Journal of Conservative Dentistry
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Year : 2023  |  Volume : 26  |  Issue : 1  |  Page : 113-117
Real-time guided endodontics: A case report of maxillary central incisor with calcific metamorphosis

1 Department of Conservative Dentistry and Endodontics, Vishnu Dental College and Hospital, Bhimavaram, Andhra Pradesh, India
2 Department of Conservative Dentistry, Karnavati University, Gandhinagar, Gujarat, India
3 Department of Conservative Dentistry, Vishnu Dental College and Hospital, Bhimavaram, Andhra Pradesh, India

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Date of Submission14-Sep-2022
Date of Decision22-Sep-2022
Date of Acceptance23-Sep-2022
Date of Web Publication08-Dec-2022


Dental trauma results in various complications and poses an enigma to the practitioner. Calcific metamorphosis is one of the sequelae of trauma. A female patient of 35 years visited the specialty clinic of endodontics for the management of a discolored tooth. Clinically, discolored 21 was observed with no pain on palpation and percussion. The pulp sensibility test revealed a negative response. Radiographic examination revealed pulp canal obliteration with an apical radiolucency of Peri Apical Index (PAI 4). The tooth was diagnosed as necrotic pulp with asymptomatic apical periodontitis. Attempt to negotiate the canal under a Dental Operating Microscope (LABOMED, Los Angeles, CA, USA) and ultrasonics (Satelec, Acteon, France) was futile. Cone-beam computed tomography image revealed a patent canal in the apical third. Using real-time guided endodontics with a dynamic navigation system (Navident, ClaroNav, Toronto, ON, Canada), the protocol of plan, trace, and place was followed, and successful canal negotiation was achieved. After radiographic confirmation, root canal treatment was completed.

Keywords: Calcific metamorphosis; cone-beam computed tomography; dynamic navigation system; navident; real-time guided endodontics; root canal therapy

How to cite this article:
Panithini DB, Sajjan GS, Kinariwala N, Medicharla UD, Varma K M, Kallepalli M. Real-time guided endodontics: A case report of maxillary central incisor with calcific metamorphosis. J Conserv Dent 2023;26:113-7

How to cite this URL:
Panithini DB, Sajjan GS, Kinariwala N, Medicharla UD, Varma K M, Kallepalli M. Real-time guided endodontics: A case report of maxillary central incisor with calcific metamorphosis. J Conserv Dent [serial online] 2023 [cited 2023 Jun 7];26:113-7. Available from:

   Introduction Top

Pulp canal obliteration (PCO) or calcific metamorphosis (CM) presents a crucial and difficult procedural step during root canal treatment and may happen in up to 40% of traumatic dental instances. Only in 7%–27% of PCO instances, the endodontic therapy is necessary if the tooth exhibits radiographic disease or signs of apical periodontitis. PCO may also develop as a result of orthodontic treatment, vital pulp therapies, tooth surface loss, or dental cavities.[1]

It can be demanding for clinicians to treat CM or PCO. Contemporary techniques for the management of PCO are associated with multiple angulation radiographs, the use of 1% methylene blue dye, and a “champagne bubble” test with sodium hypochlorite and endosonics. During the treatment, multiple intraoperative radiographs are advised to assess the orientation of the drill tool to avoid procedural mishaps.[2] In spite of this, often, the negotiation would not be successful, and also procedural errors could make the tooth structurally compromised.[3] The treatment of teeth with PCO is therefore considered to be of a high difficulty level by the American Association of Endodontists (AAE).[1]

Numerous calcification instances have benefited greatly from the application of cone-beam computed tomography (CBCT), magnification with illumination, and ultrasonics.[4],[5] However, despite these developments, excessive dentin removal or even perforation can still happen often and compromise the survival of the tooth.[6]

Every area of dentistry, especially endodontics, has succeeded from the use of CBCT and three-dimensional (3D) printing, which paved the way for guided endodontics.[3] It is a relatively new technology that navigates a cavity preparation tool inside the root canal. This leads to a cautious preparation of the apically extended access preparation for finding obliterated root canals. Static guides have limitations, such as difficulties or impossibility to be employed in posterior teeth due to restricted interocclusal space, despite the great accuracy shown by numerous studies.[7]

The dynamic navigation system (DNS), a distinct technique adopted from implant dentistry, has been used for both surgical and nonsurgical endodontic therapies. Using an optical tracking device managed by a special computer interface, DNS combines CBCT and spatial positioning technologies.[7]

This prolific computer-guided technology, Trace and Place (TaP), has been designed for DNS protocol. TaP replaces the fiducial stent and enhances the precision of penetration. Optical tracking tags, namely, Jaw Tracker and a Drill-Tag connected to the patient's jaw and instrument, respectively, are tracked by an optical tracking device.[8] The present case report elaborates on the successful clinical procedure assisted with DNS for locating the calcified root canal.

   Case Report Top

A female patient of 35 years was referred to the postgraduate endodontic clinic with the complaint of discoloration in the upper maxillary central incisor (21) for the past 10 years. The patient reported no relevant medical history. Past dental history included orthodontic treatment with few restorations.

On clinical examination, tooth 21 showed a discoloration that was not sensitive to percussion and palpation. Pulp sensibility using an electric pulp tester (Gentle-Pulse, Parkell Electronics Division) and a cold test (Coltene Whaledent, Switzerland) yielded a negative response. The periapical radiograph revealed an obliterated pulp chamber, a calcified root canal with periapical radiolucency of PAI 4 (apical periodontitis with the well-defined radiolucent area) [Figure 1]a, and the management was considered a high difficulty level of treatment according to the AAE. Tooth 21 was diagnosed as necrotic pulp with asymptomatic apical periodontitis. The radiographic classification of CM was total obliteration. In this case, CM might be a result of previous orthodontic treatment.[1] The tooth was planned for nonsurgical root canal therapy. After having her queries and worries addressed, the patient consented to the advised course of action.
Figure 1: Workflow of the procedure (a) Preoperative radiograph (b) CBCT scan imported into Navident, and the planned 3D virtual access trajectories. (c) Clinical tracing of the landmarks with a tracer tool to register the CBCT scan. (d) Calibration of the drill tip. (e) Accuracy check (f) Placing the bur orientation and drilling guided by target views on the computer (g) Angular deflection after superimposition of the data (h) Postobturation radiograph. CBCT: Cone-beam computed tomography. 3D: Three-dimensional

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A local anesthetic was administered with lignocaine and adrenaline (1:80,000) (LIGNOX 2% A Santacruz, Mumbai, India). Under a rubber dam (Coltene Whaledent, Switzerland), isolation access cavity was prepared under DOM (LABOMED, Los Angeles, CA, USA) with a diamond access bur (Dentsply Sirona 851012 FG safe end bur). Calcification was evident. Ultrasonic handpiece (Satelec, Acteon, France) with Endodontic Treatment Exploration Ball Diamond Tip ultrasonic tip (Satelec P5® Piezo) was used in endo mode. In spite of the good effort, the canal was not negotiated. As the patient expressed a desire to preserve the natural tooth, an alternative treatment plan was suggested. The treatment plan included negotiation of PCO with real-time guided endodontics using DNS (Navident, ClaroNav, Toronto, ON, Canada).

A preoperative CBCT (Cranex 3D Sordex, Tuusula, Finland) scan was completed operating at 90 kVp, 8 mA with a field of view of 10 cm × 10 cm and voxel size 0.13 mm, and saved as Digital Imaging and Communications in Medicine file (ON DEMAND 3D server tuusula, Finland). Maxillary and mandibular impressions were made, and positive replicas were prepared. The plaster casts were scanned using a high-resolution optical scanner (Medit® Seoul, Korea), as instructed by the manufacturer, with an accuracy of <7 μ. The implant/access planning software in Navident (ClaroNav, Toronto, Ontario, Canada) was used to import these files and map the dentition. Since there was no built-in guided endodontics function, access cavity depth, access point of entry, and axis orientation and angle were all planned. A planned implant shape of 1 mm diameter was used as the access cavity guide. The panoramic view, target view, depth indicator, buccolingual and mesiodistal section views, as well as the streaming video were all shown on the screen [Figure 1]b.

In the following appointment, a local anesthetic with lignocaine and adrenaline (1:80,000) was administered. The patient's head was securely fastened to the head tracker. CBCT images were matched with the trace registration technique.

Three landmarks on the maxillary jaw were selected and brushed on incisal, labial, and cusp tips with Tracer-Tag/Tracer-Tool. The percentage of points contacted was displayed by the software [Figure 1]c and was tracked by an optical tracking sensor. A drill tag was fastened to the slow-speed contra-angle handpiece, which needed to be tracked and navigated by an adapter. A size #1 Munce bur (CJM Engineering Tech, CA, USA) of 0.5 mm diameter was secured to the handpiece. Both the drill tip and handpiece were calibrated using a calibrator [Figure 1]d. An accuracy check was done with the drill tip [Figure 1]e. As the optical tracking sensor continuously tracks the Drill-Tag, the program shows the bur's location. As soon as the calibrated device moved toward the patient's jaw, the navigation screen became active. The length of the planned access penetration depth, bur, and the direction of the bur in the handpiece was displayed in the target view. This was displayed as a static white target, a moving black cross, and the cone. Now the real-time navigation started. When the bur was within the vicinity of 1 mm of the plan, the depth indicator turned yellow. On further orientation by visualizing in all three sections, the bur reached the planned path within 0.5 mm with an angle of >3° the depth indicator and the cone turned green. Now the drilling was commenced till the desired planned depth [Figure 1]f.

A size 10 C file (Dentsply Maillefer) was introduced into the canal to verify the successful location and negotiation of the canal. A radiograph was acquired for confirmation after the use of an electronic apex finder (J Morita, Germany) to determine the canal's indicated working length. A postoperative CBCT scan was performed to evaluate the angular deflections and linear deviations.

Isolation of the tooth was done using a rubber dam. HyFlex CM file system (Coltene Whaledent) was used for biomechanical preparation until 25, 0.04 taper, along with 3% sodium hypochlorite (Septodont Healthcare PVT LTD, India), 17% ethylenediaminetetraacetic acid (RC help, Prime Dental PVT LTD, India), and saline as intermittent irrigation. U-files (Satelec, Acteon, France) were used for ultrasonic activation, after which a calcium hydroxide (Viola, Ivoclar Vivadent AG) dressing was applied, and an interim restoration (CAVIT, 3M ESPE Dental AG, Germany) was positioned. In the next session, the root canal was sealed with gutta-percha (Coltene Whaledent, Switzerland) and bioceramic sealer, EndoSequence BC (Brasseler USA), using a warm vertical compaction technique [Figure 1]h.

A minimum intervention access to a calcified canal was offered by dynamic navigation. The ability to receive real-time feedback allowed the root structure to be preserved without weakening the walls. The patient was totally asymptomatic, and the periapical lesion was in remission at the end of the course of treatment.

From the pre- and postoperative CBCT data, the remaining dentin thickness was calculated, and the average reduction and deviation were estimated at the level of the cementoenamel junction (CEJ) and the level of the drilling point [Figure 2]a.[9]
Figure 2: (a) Schematic view of calculation of linear deviation (b) Dentin thickness at CEJ level (c) Dentin thickness at canal level. CEJ: Cementoenamel junction

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At the end of the case, the linear deviation was measured as:

Mesiodistal (MD) deviation= [(X1-X1*)-(X2-X2*)] [(2.43 − 1.74)-(1.69 − 1.65)]

Buccopalatal (BP) deviation= [(Y1-Y1*)-(Y2-X2*)] [(3.76 − 2.84)-(2.98 − 2.43)]

The MD linear deviation was about 0.65 mm, and the BP linear deviation was about 0.37 at the CEJ level [Figure 2]b.

The MD linear deviation was about 1.46 mm, and the BP linear deviation was about 0.01 at the drilling level [Figure 2]c.

The angular deflection was also measured by the superposed preprocedural and postprocedural CBCT images using integrated software from Navident. The highest angle formed by the planned and prepared access paths was instantly calculated and displayed as a 4° deviation [Figure 1]g.

   Discussion Top

In scenarios like the treatment of PCO, guided endodontics is an accurate approach that preserves more dental tissue while extending the longevity of a treated tooth.[10] A systematic review regarding guided endodontics concluded that it is a viable and reliable method with a reduced possibility of iatrogenic errors for treating teeth with calcified canals and complicated anatomy or for facilitating surgical root canal therapy.[11] The propensity to monitor the preparation drill in real-time during the procedure also enables modifications to be made to the original plan. In contrast to static endodontic guides with no feasibility of path alteration, this is a significant advantage. Studies comparing the precision of computer-assisted surgery (dynamic navigation) to freehand and static-guided revealed that dynamic navigation is more accurate than the other modalities.[12] According to the research by Jain et al., the location of extremely challenging simulated calcified canals can be done with minimally invasive access cavities using high-speed drills under dynamic navigation. They attained a mean horizontal deviation from the canal orifice of 0.9 mm in 2D and 1.3 mm in 3D. They came to the conclusion that a 2D variation of 0.9 mm for apically extended access cavity preparations was relatively safe.[1]

This technology has the ability to minimize the drill's angular and linear deviations during the preparation of the access, removal of dentin inside the canal and at the CEJ level, intraoperative time, and complications such as perforation and transportation. The outcomes demonstrated enhanced success in terms of angular deflection and linear deviation in all directions. According to a study by Dubey et al. evaluating the accuracy of DNS, the DNS samples had a success rate of 96.6%, whereas the freehand samples had an 83.3% success rate.[13] According to a systematic evaluation, the DNS showed improved perfection in comparison to the free-handed technique, and with sufficient device training, can be useful in managing challenging endodontic patients.[14] The treatment of metamorphosed, sclerotic, and occult canals requires a paradigm change that can only be achieved by applying this technology in endodontics.

   Conclusion Top

Dynamic navigation, in this case, enabled the precise development of a less invasive access path using the real-time feedback from the drilling device. Dynamic navigation can preserve the remaining tooth structure and prevention of mishaps in a single appointment. However, a steep learning curve and initial investment are the limitations. Early adoption is osmotic, but diffusion leads to widespread acceptance.

Declaration of patient consent

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

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Conflicts of interest

There are no conflicts of interest.

   References Top

Jain SD, Carrico CK, Bermanis I. 3-dimensional accuracy of dynamic navigation technology in locating calcified canals. J Endod 2020;46:839-45.  Back to cited text no. 1
Smadi L, Khraisat A. Detection of a second mesiobuccal canal in the mesiobuccal roots of maxillary first molar teeth. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:e77-81.  Back to cited text no. 2
Nikhil V. Dynamic navigation system: A real-time guide to endodontists. J Endod 2020;46:1286-90.  Back to cited text no. 3
Johnstone M, Parashos P. Endodontics and the ageing patient. Aust Dent J 2015;60 Suppl 1:20-7.  Back to cited text no. 4
Kiefner P, Connert T, ElAyouti A, Weiger R. Treatment of calcified root canals in elderly people: A clinical study about the accessibility, the time needed and the outcome with a three-year follow-up. Gerodontology 2017;34:164-70.  Back to cited text no. 5
Dianat O, Gupta S, Price JB, Mostoufi B. Guided endodontic access in a maxillary molar using a dynamic navigation system. J Endod 2021;47:658-62.  Back to cited text no. 6
Lang H, Korkmaz Y, Schneider K, Raab WH. Impact of endodontic treatments on the rigidity of the root. J Dent Res 2006;85:364-8.  Back to cited text no. 7
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.  Back to cited text no. 8
  [Full text]  
Dianat O, Nosrat A, Tordik PA, Aldahmash SA, Romberg E, Price JB, et al. Accuracy and efficiency of a dynamic navigation system for locating calcified canals. J Endod 2020;46:1719-25.  Back to cited text no. 9
Connert T, Weiger R, Krastl G. Present status and future directions – Guided endodontics. Int Endod J 2022;1-8.  Back to cited text no. 10
Moreno-Rabié C, Torres A, Lambrechts P, Jacobs R. Clinical applications, accuracy and limitations of guided endodontics: A systematic review. Int Endod J 2020;53:214-31.  Back to cited text no. 11
Bardales-Alcocer J, Ramírez-Salomón M, Vega-Lizama E, López-Villanueva M, Alvarado-Cárdenas G, Serota KS, et al. Endodontic retreatment using dynamic navigation: A case report. J Endod 2021;47:1007-13.  Back to cited text no. 12
Dubey D, Mandal TK, Verma K, Mitra R, Raj M, Gosh M. The accuracy and efficiency of a dynamic 3D navigation system for negotiating calcified canals. Int J Oral Care Res 2021;9:107.  Back to cited text no. 13
  [Full text]  
Jonaityte EM, Bilvinaite G, Drukteinis S, Torres A. Accuracy of dynamic navigation for non-surgical endodontic treatment: A systematic review. J Clin Med 2022;11:3441.  Back to cited text no. 14

Correspondence Address:
Dr. Durga Bhavani Panithini
Department of Conservative Dentistry and Endodontics, Vishnu Dental College and Hospital, Bhimavaram - 534 202, Andhra Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcd.jcd_506_22

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