|Year : 2022 | Volume
| Issue : 1 | Page : 17-23
Use of dynamic navigation system in endodontics: A literature review
Sanchit Vilas Mujumdar, Anamika Chetan Borkar, Sayali Anil Maral, Nikhil Babaji Nighot, Sanket Dilip Aras
Department of Conservative Dentistry and Endodontics, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||25-Aug-2021|
|Date of Decision||30-May-2022|
|Date of Acceptance||11-Apr-2022|
|Date of Web Publication||4-Jul-2022|
Dr. Sanchit Vilas Mujumdar
E302, Mont vert Seville, Pink City Road, Wakad, Pune, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Over the years, traditional endodontic approaches performed have caused significant loss of healthy tooth structure. Clinical approach became relatively predictable following the introduction of cone-beam computed tomography, Digital Imaging and Communications files, and dental operating microscopes. Despite these advances, mishaps such as excessive dentin loss and/or perforations may still occur during freehand preparations affecting the tooth's prognosis. Following the developments in surface scanning and three-dimensional printing, static guidance systems were introduced. However, they too had multiple drawbacks. Dynamic navigation systems (DNSs) were introduced following to overcome them. DNS is based on computer-aided navigation technology analogous to the Global Positioning System (GPS) navigation. New minimally invasive preparations have been put forward claiming to be the future of endodontics which can be achieved with the help of DNS. The review thus aims at evaluating the possible use of DNS in planning and executing these minimally invasive preparations without unnecessary loss of healthy tooth structure.
Keywords: Cone-beam computed tomography, Digital Imaging and Communications, dynamic navigation system, jaw tracking, ultraconservative access cavities
|How to cite this article:|
Mujumdar SV, Borkar AC, Maral SA, Nighot NB, Aras SD. Use of dynamic navigation system in endodontics: A literature review. J Int Clin Dent Res Organ 2022;14:17-23
|How to cite this URL:|
Mujumdar SV, Borkar AC, Maral SA, Nighot NB, Aras SD. Use of dynamic navigation system in endodontics: A literature review. J Int Clin Dent Res Organ [serial online] 2022 [cited 2022 Aug 14];14:17-23. Available from: https://www.jicdro.org/text.asp?2022/14/1/17/349757
| Introduction|| |
The American Association of Endodontics has classified treatment of calcific metamorphosis or pulp canal obliterations (PCOs) as a high difficulty level index. Pulp canal obliterations can occur as a result of trauma, wearing of tooth surface, caries, orthodontic treatment or phyiologic changes in geriatric population., The dental operator almost always faces a difficult decision when PCO is diagnosed mainly because endodontic treatment is indicated only in about 7%–27% of those patients if the teeth are symptomatic with any symptoms or radiographic pathology that is in line with apical periodontitis. However, if treatment is indicated, it poses a great challenge to the endodontist as histologically PCO is usually presented with very narrow root canal, the location of which becomes difficult in many circumstances due to increased risk of procedural errors in the form of perforations, and aggressive loss of sound dentin. Care is to be taken while initiating root canal treatment including performing access cavity preparation and negotiating canal and its instrumentation for a good long-term prognosis.
Traditional endodontic access cavities have been performed over the decades without any significant change following a straight-line access to the main canal. This, however, caused significant loss of internal tooth structure in addition to the previous pathology. Lately, new preparations which are less invasive in the form of small-sized access cavities have been put forward. These have been described as ultraconservative access cavities (UCACs),, interpreted as “Ninja or Truss access.” It is a minimally invasive approach which focuses on conserving the pericervical dentin.,
Clinical approach became more predictable since the introduction of dental operating microscopes and three-dimensional (3D) evaluation in the form of cone-beam computed tomography (CBCT) for estimation of root canal anatomy. This is mainly due to the possible chances of avoiding mishaps and complications that are caused by missed, hidden canals or other distinctive features., However, even with these advances, excess dentin loss and/or perforation can still occur negatively influencing the tooth's prognosis.
Developments in 3D printing and scanning led to the introduction of static guidance systems. These systems carry information regarding the predetermined access drill path from the patient's CBCT scans to a stent or guide. However, there have been multiple drawbacks for the same. Dynamic navigation system (DNS) was introduced following to overcome them. It was first introduced in the field of implantology in dentistry to make implant insertion easier and with more accuracy. This new dynamic guidance system allows the operator to visualize the position and angulation during implant site preparation while doing the osteotomy procedure adjustments to which can be made in real time. Through a clinically applicable interface that provides real-time display, these systems guide users to drill into the targeted position according to the output of the preoperative planning software., This technique can be used for making conservative endodontic preparations without the drawbacks of static-guided systems.
This review aims at exploring the possibility of the use of DNS in conservative endodontic preparations and accuracy of locating access in calcified canals.
| Navident DNS Software (claroNav)|| |
DNS makes possible computer guidance in real time using CBCT data set that is imported in the form of a Digital Imaging and Communications (DICOM) file. This is like the use of GPS and satellite navigation. A Canadian company called ClaroNav has developed a computer-aided technology, Trace and Place (TaP). TaP prevents the need for a stent that was used in static navigation with increased accuracy of dento-osseous penetration. An optical tracking device [Figure 1] tracks a Jaw Tracker, the optical tracking tag that is connected to the jaw of the patient, and a drill tag, which is the optical tracking tag connected to an instrument specific to the procedure. The tip is overlayed on the CBCT scan, which is mapped to the jaw of the patient.
The increased accuracy of TaP technology enhances the facility of treatment for restricted access cavity preparation and minimizes the size of cortical window osteotomies. Ultrasonic tips used during apicoectomy procedures for preparation of apical third can also be traced using the DNSs.
| TaP Procedure|| |
Before the appointment
- The first step of the procedure includes the transfer CBCT scan data in the form of a DICOM file into the DNS planning software to map and visualize the dentition,
- The software screen shows the 3D reconstruction, wide view, axial, buccolingual, mesiodistal section views, and the depth indicator [Figure 2].
- Planning is done for the entry of the access point, the orientation of axis, and the depth of the access preparation. In the case of microsurgical procedures, the course of the peizotome is dependent on the extent of bone pathology that surrounds the apex of the root [Figure 3]a, [Figure 3]b, [Figure 3]c
- Planning can be done at any time before the treatment begins, given that the 3D scan corresponds with the present dental condition
- As a preparatory step before the next step, 3–6 landmarks are selected and marked on the teeth that can be approached easily and are evident
- When the computer cursor is positioned over the 3D model, its cross-scan be seen. A reddish crosshair attaches to the landmark with its center on the exterior [Figure 4]
- The system indicates to the operator if suspected that the landmark is in an incorrect location.
|Figure 2: three-dimensional reconstruction, panoramic view, axial view, buccolingual view, and mesiodistal view|
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|Figure 3: (a) planned axis and angulation of virtual drill. (b) Redline reflecting off-angle positioning. (c) Peizotome planning|
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- The Jaw Tracker (mandible or maxilla) or Head Tracker (maxilla) is secured to the jaw being treated [Figure 5]
- The Jaw Tracker can be positioned at a distance from the rubber dam, unlike a Jaw Tracker attached to a stent that is more restricted due to its position
- After the three landmarks are decided, the optical tracking sensor tracks the Terminology as it is moved around the landmarks on the buccal, lingual, and occlusal surfaces in a manner similar to applying etchant/bonding solutions [Figure 6]
- The number of points contacted is shown as a percentage in the software.
Calibration of the drill
- Calibration of the drill axis and its tip is done after attachment of drill tag to the handpiece [Figure 7]
- The drill tag is being continuously tracked by the optical tracking sensor, and the drill position is shown on the software [Figure 8] ,
- A warning will be issued if the drill tag goes behind the camera view [Figure 9]a and [Figure 9]b.
|Figure 9: (a) central incisor: (1) Drill is green; (2) central axis of glide path/osteotomy; (3) depth indicator; (4) angle between drill and central axis of planned osteotomy; (5) depth indicator turning yellow when drill and central axis overlap. (b) Maxillary molar: Planned canal location is on target|
Click here to view
Dento-osseous real-time navigation
- The navigation screen is active when the system identifies the calibrated instrument approaching the patient's jaw
- The distance between the instrument tip and the central axis of the planned access penetration point, the glide path, or the osteotomy is measured by the target view
- The length of the central axis that is planned is represented by the center of the static white target, and the drill tip is represented by the moving black cross following its movement
- A cone represents the real-time direction of the drill in the head of the handpiece [Figure 9]a and [Figure 9]b
- During the drilling, the moving cross and cone are tracked. The cone will change to green as the instrument tip reaches within 0.5 mm with an angle of <3° to the planned glide path or osteotomy
- The depth indicator changes to yellow when the drill tip reaches within 1 mm of the apical or horizontal extent of the landmark for planned depth.,
| Applications of the Dynamic Navigation System|| |
The DNS can be used in applications including:
- Location of calcified canals
- Ultraconservative access cavity preparations
- Endodontic microsurgeries.
| Location of Calcified Canals|| |
Jain et al. in 2020 conducted a study to evaluate the 3D accuracy of DNS in locating incredibly difficult calcified canals that were simulated in maxillary and mandibular teeth. The Navident DNS (ClaroNav) was used along with high-speed drills to plan and prepare the access cavities randomly. They followed the similar Navident protocol of scan, plan, trace, and place.
The optical tracking tags were used to track the high-speed handpiece and the jaws that are continually and simultaneously detected by the high-accuracy optical positioning sensor (MicronTracker camera) and provide an optical triangulation tracking. Thus, an accurate real-time representation of the drill tip location and trajectory can be made in association with the anatomy on the model's CBCT scan and the planned virtual access cavity. A software EvaluNav (ClaroNav) was used for superimposing the preoperative scan with planned access templates and the postoperative scan. The planned and prepared access cavities were compared for isolation of their 2D and 3D discrepancies.
The average 2D horizontal and 3D deviation was 0.9 mm and 1.3 mm from the canal orifice, respectively. Both the 2D and 3D deviations were higher on maxillary teeth than the mandibular teeth. The average angular deviation in 3D was 1.7° and was significantly higher in molars than premolars (P < 0.05), with an average drilling time of 57.8 s.
Dianat et al. in 2020 conducted a study determining the accuracy and efficiency of DNS for location of calcified canals when compared to the freehand (FH) preparations. Sixty human single-rooted teeth with PCO were selected. Based on their CBCT scans, virtually planning of the drilling path and depth was done using the X-Guide software. It was found that the time required for preparation of access cavities and the number of mishaps in the DNS group were significantly less as compared to the FH group. It was concluded that the DNS was more accurate and efficient than the FH preparations in location of calcified canals in human teeth and this novel technique can help the operator minimize or avoid mishaps during access cavity preparations in calcified teeth.
Jain et al. conducted another study comparing the speed, precision quality, and amount of tooth substance lost with FH and DNS access cavity preparation techniques for root canal location in 3D printed teeth with simulated calcified root canals. Access preparations which were dynamically navigated resulted in significantly less tooth substance loss in than the FH technique (27.2 vs. 40.7 mm3, P < 05) and also had higher optimal precision (drill path centered) for location of calcified canals than the FH preparations (75% vs. 45%, P < 05). There was a negligible difference with mandibular tooth substance loss between the two techniques (19.0 vs. 19.1 mm3, P < 05). However, qualitatively the FH preparation was still prone to 30% higher chance of less than optimal precision (drill path transported) in location of calcified canals. Furthermore, dynamically navigated access cavities were prepared significantly faster than FH preparations.
| Ultraconservative Access Cavity Preparation|| |
Gambarini et al. conducted a study to evaluate the possible use of DNS (ClaroNav) in planning and preparation of UCACs and its precision in vitro when compared to a manual FH approach.
Twenty radiopaque, artificial teeth replicas were selected and divided into two groups and scanned using CBCT. In the first group, a micro endodontic bur was used to reach MB1 canal orifice. In the second group, dynamic navigation was used to plan and carry out a direct, straight-line access. After cavity preparation, another CBCT was taken and the scans were compared.
A significant difference was found between the two groups. The DNS group showed significantly more precision, showing smaller mean values in the angulation (4.8°) and in the maximum distance from the ideal position (0.34 mm) in comparison to the manual approach (mean values were 21.2° and 0.88 mm, respectively).
They concluded that UCAC preparations showed more advantages after using DNS by reducing the potential risk of iatrogenic weakening of tooth structure and minimizing the negative influences to shaping procedures.
Gambarini et al. conducted another study to describe and classify four different types of point endodontic access cavities and to check if DNS could allow planning and accurate execution of these cavities in vitro. They concluded that the digital design of dynamically navigated access cavities offers the possibility of visualizing the exact area where the chamber should be opened before executing. Dynamic navigation allowed to perform very precise cavities with minimal procedural errors in association with any possible inclination of the drill for reaching orifices of canals. These results support the clinical use of DNS also in endodontics, especially when minimally invasive cavities are planned, as recently suggested by some dental practitioners.
| Endodontic Microsurgeries|| |
Gambarini et al. published a case report showing the use of the Navident DNS (ClaroNav) for bone cavity preparation and root-end resection in the surgical endodontic treatment of a lesion in an upper lateral incisor.
The DNS allowed the precise localization of the root and precise apicoectomy with a minimal invasive cavity preparation. The osteotomy and root-end resection were performed by the operator with a minimally invasive approach accurately without any iatrogenic mishaps.
| Benefits of Dynamic Over Static|| |
The stage of pretreatment planning has been transformed by the emergence of CBCT and 3D printing., DICOM files are converted into stereolithic files that are further used to create static navigation stents/templates manufactured using CAD/CAM process. These templates guide the access cavity preparation and microsurgical orientation, minimizing the removal of excess tooth and bone structure. However, each type of navigation system has its drawbacks. When using free hand navigation clinical judgement and the need for dento-alveolar access surgery is the most important factor. Manual approach depends on visualization of the anatomy from information provided by casts and radiographs. Thus, time required is significantly increased with a FH navigation technique in comparison to a guided technique. Determination of the canal position and pathway is more difficult.
In the case of static navigation technique, stereolithic stents are used, and they require a CBCT scan with medium field of view. Polyvinyl siloxane impressions of the arch are made and poured in stone. Then, a digital 3D scan of the stone model is made and integrated with the patient's DICOM files. The use of an intraoral scanner is recommended and required for this purpose. However, any flaw in the process of stent fabrication can result in inaccurate image acquisition.
Real-time navigation is a viable alternative to stereolithic stent (static)-guided surgery as it offers the operator some advantages. With the use of dynamic navigation, the need for fabrication of a stent can be avoided resulting in an economical treatment alternative. Since the navigation is considered a dynamically guided system, changes to the treatment can be easily made during the operating procedure. Furthermore, the tactile feeling while drilling as well as the manual control is still present.
Zubizarreta-Macho et al. conducted a study to compare the accuracy of computer-aided dynamic navigation versus computer-aided static procedure and manual procedure for endodontic access cavities in 30 single-rooted anterior teeth. Teeth selected were distributed randomly into three groups based on the navigation system used. According to the results, the endodontic access cavities showed more accuracy with the dynamic navigation group as compared to the static group at the deviation angle and the horizontal deviation (measured at the coronal entry point and the apical endpoint) in absolute value.
Thus, the benefits include:
- Flexibility – Plan can be changed at any time after viewing the CBCT data, even during treatment
- Immediacy – Guidance is immediately available following planning – as stent fabrication is not needed
- Predictability – More predictable due to immediate detection and correction of the stent problem
- Safety – As accuracy check is always available, large errors can be avoided by observing and immediate addressal
- Simplicity – Planning process is user-friendly as there is no need to design the guide
- Economy – Cost per procedure much lower compared to static systems as no expensive kits or specific drills are required.
| Conclusion|| |
Ultraconservative and minimally invasive access cavities are the future of endodontics. DNS is a value-added and important addition to the digital workflow. Digital access cavity design in endodontics offers the advantage of visualizing the exact area where the access opening should be performed before the preparation is started. The 3D computer-aided DNS can achieve minimally invasive access cavities with high-speed drills while locating difficult calcified canals with a significantly less tooth substance loss along with optimal and efficient precision when compared to other navigation systems.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]