Endodontic Treatment Failure, Periapical Periodontitis, Periradicular Lesion, Postoperative Wound Healing
Conditions
Keywords
Static surgical guide, Endodontic surgery, Apicoectomy, Cone Beam Computed Tomography, Trephine bur, Well-Root PT, Structural accuracy, Bone healing outcomes
Brief summary
The goal of this clinical trial is to evaluate the surgical accuracy and healing outcomes of endodontic surgery performed with the assistance of a 3D-printed static surgical guide in patients requiring apicoectomy. The main questions it aims to answer are: 1. What is the level of positional and angular accuracy of the actual root-end resection compared to the virtual planning when utilizing a static surgical guide? 2. What are the postoperative pain and swelling levels reported by patients at 1, 3, and 7 days after undergoing guided endodontic surgery? 3. What are the clinical success rates and CBCT-based radiographic healing outcomes at 6 months postoperatively? Participants will: * Undergo a preoperative digital workflow combining CBCT data and intraoral surface scans to design a customized static surgical guide. * Undergo targeted endodontic surgery where a 4.5-mm trephine bur is guided through the static template to perform the osteotomy and a 3-mm root-end resection in a single step. * Receive retrograde root-end cavity preparation via ultrasonic tips and root-end filling using calcium aluminosilicate bioceramic paste (Well-Root PT). * Complete self-evaluation forms regarding pain and swelling on postoperative days 1, 3, and 7. * Return for follow-up examinations at 1 week (for suture removal) and at 6 months for definitive clinical evaluations, as well as follow-up multi-planar CBCT imaging to evaluate both periapical bone healing and surgical accuracy via superimposition with the baseline preoperative plan.
Detailed description
This prospective, single-arm, longitudinal clinical trial evaluates the accuracy and healing results of targeted endodontic surgery guided by 3D-printed static templates. The study aims to determine whether a fully digital workflow can standardize root-end resection, minimize bone removal, and provide favorable clinical outcomes. Each eligible participant undergoes a standardized preoperative digital preparation. High-definition CBCT imaging data (DICOM format) and intraoral surface scan data (STL format) are acquired and imported into the Realguide software (version 5.0). After precise registration using three anatomical landmarks, the surgical path is planned. A virtual cylinder representing a 4.5-mm diameter trephine bur is positioned perpendicular to the root axis, calculated to achieve an exact 3-mm apicoectomy length. A teeth-supported static surgical guide with a 4.6-mm internal diameter sleeve and verification windows is then designed and fabricated using Stereolithography (SLA) 3D printing technology with biocompatible resin. On the day of surgery, after administering local anesthesia (2% lidocaine with 1:100,000 epinephrine) and reflecting a full-thickness mucoperiosteal flap, the static surgical guide is securely positioned on the dental arch. Cortical plate osteotomy and root-end resection are executed in a single step through the guide sleeve using a 4.5-mm trephine bur at a speed of 800 rpm under continuous sterile saline irrigation. Following guide removal and periapical lesion debridement, a 3-mm deep retrograde cavity is prepared along the root canal axis using dedicated ultrasonic tips. The root end is then sealed with Well-Root PT bioceramic material, and the flap is secured using 5-0 nylon sutures. Postoperative medications including amoxicillin, ibuprofen, and paracetamol are prescribed uniformly. Patient-centered outcomes (pain and swelling intensity) are self-recorded using a 6-point modified Visual Analog Scale (VAS) on days 1, 3, and 7 post-surgery. Sutures are removed at day 7. At the 6-month follow-up milestone, patients undergo comprehensive clinical evaluations based on the Gutmann & Harrison (1994) criteria. Concurrently, a postoperative CBCT scan is performed using identical exposure parameters to quantify periapical lesion volume reduction and grade structural bone healing (cortical plate, resection plane, and peri-radicular space regeneration) according to the Azim (2021) criteria. The cumulative digital data sets are superimposed to calculate the linear distance (mm) and angular deviations (degrees) between the planned and actual surgical paths, thereby establishing the structural accuracy of the static guided technique.
Interventions
DEVICE3D-Printed Static Surgical Guide and Trephine Bur
A personalized dental template constructed from surgical guide clear resin via SLA technology, incorporating a guide sleeve to orient a 4.5-mm trephine bur for single-step cortical plate perforation and 3-mm root-end resection.
DEVICEUltrasonic Retrograde Preparation and Bioceramic Retrograde Obturation
Preparation of a 3-mm deep root-end cavity using specialized ultrasonic tips driven by a piezo-ultrasonic surgical unit, followed by retrograde obturation with Well-Root PT calcium aluminosilicate bioceramic paste
Sponsors
University of Medicine and Pharmacy at Ho Chi Minh City
Study design
Allocation
NA
Intervention model
SINGLE_GROUP
Primary purpose
TREATMENT
Masking
NONE
Masking description
Clinical and radiographic outcome assessments will be conducted by an independent dental clinician who was not involved in the surgical procedures. To minimize detection bias, all patient data and CBCT DICOM files will be anonymized and coded prior to evaluation. The assessor will remain blinded to the patients' clinical postoperative profiles (pain and swelling progression) when grading bone healing outcomes.
Intervention model description
This is a single-arm, prospective clinical trial in which a single cohort of eligible participants consecutively receives targeted endodontic surgery assisted by a 3D-printed static guide, with each patient serving as their own baseline for healing evaluations, and actual surgical paths compared against virtual plans for accuracy assessments.
Eligibility
Sex/Gender
ALL
Age
16 Years to No maximum
Healthy volunteers
No
Inclusion criteria
1. Patient is aged 16 years or older. 2. Patient possesses a healthy or stable systemic physical status classification (ASA I or II). 3. Presence of at least one permanent tooth displaying a distinct clinical indication for apical endodontic surgery. 4. The estimated post-resection crown-to-root ratio of the target tooth remains \<= 1. 5. The periapical radiolucency features a well-defined maximum radiographic dimension of \>= 5 mm on CBCT. 6. The target tooth has no history of previous surgical root-end resection procedures. 7. The lesion does not directly involve or impinge upon hazardous adjacent anatomical structures (e.g., the inferior alveolar nerve canal, the maxillary sinus floor, or the mental foramen). 8. The presence of at least three stable, non-mobile permanent teeth within the same dental arch to serve as reliable anchor units to support the surgical template. 9. Patient is fully capable and willing to provide signed written informed consent.
Exclusion criteria
1. Women who are currently pregnant or breastfeeding. 2. History of known allergy or systemic hypersensitivity to amide local anesthetics, epinephrine co-agents, or any structural resins and bioceramic materials utilized in this protocol. 3. Extensive metal restorations, crowns, or massive fixed partial dentures adjacent to the target site that generate severe radiographic scattering artifacts, compromising CBCT measurement quality. 4. Target tooth displays clinical evidence of a vertical root fracture, non-restorable structural crown destruction, or advanced localized periodontitis. 5. Massive periapical pathology requiring a root-end resection length exceeding 3 mm, or necessitating excessive mechanical field widening beyond the template boundaries to achieve surgical curettage. 6. Inadequate stability, rocking, or poor fit of the printed surgical guide during the intraoral verification phase. 7. Patient demonstrates non-compliance or is unable to return for scheduled longitudinal follow-ups and imaging appointments.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Linear Positional Deviation of Apicoectomy | 6 months postoperatively | The absolute vertical distance deviation (measured in millimeters) between the virtually planned root-end resection path and the actual resection plane achieved clinically. This measurement is quantified by superimposing the 6-month postoperative CBCT data onto the baseline preoperative planning model. |
| Angular Deviation of Apicoectomy | : 6 months postoperatively | The angular difference (measured in degrees) between the long axis of the planned virtual surgical trajectory and the actual surgical track created by the trephine bur, measured across the structural plane containing the root axis |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Postoperative Pain Scores | Postoperative days 1, 3, and 7 | Patient-reported pain intensity measured via a 6-point modified Visual Analog Scale (VAS) where 0 indicates no pain and 5 indicates severe, incapacitating pain requiring complete bed rest. |
| Postoperative Swelling Scores | Postoperative days 1, 3, and 7 | Patient-reported tissue swelling measured via a 6-point modified VAS where 0 indicates no swelling and 5 indicates severe facial swelling accompanied by limited mouth opening (trismus). |
| Volumetric Change of Periapical Lesion | Baseline and 6 months postoperatively | The quantitative volumetric reduction of the periapical radiolucency (calculated in cubic millimeters, mm³) determined by comparative three-dimensional rendering software on CBCT scans acquired at baseline and follow-up. \[Time Frame: Baseline and 6 months postoperatively\] |
| Clinical Healing Success Status | 6 months postoperatively | The proportion of cases achieving 'Complete Clinical Healing' defined according to the Gutmann \& Harrison (1994) criteria, requiring the total absence of pain, clinical tenderness to percussion or palpation, sinus tract formation, pathologic tooth mobility, or deep localized periodontal pockets. |
| Radiographic Healing Score (CBCT Evaluation) | 6 months postoperatively | The composite score (ranging from 0 to 6 points) derived by evaluating three distinct anatomical layers on multi-planar CBCT reconstructions: Cortical Plate remodeling (C), Resection Plane periodontal ligament space regeneration (R), and Peri-radicular lesion size and bone density (P), with each layer scored from 0 (no healing) to 2 (complete healing) according to the Azim (2021) criteria |
Countries
Vietnam
Contacts
CONTACTNguyen Le Nguyen, DDS
STUDY_DIRECTORSon Hoang Le, DDS, PhD
Department of Oral Surgery, Faculty of Odonto-Stomatology, University of Medicine and Pharmacy at Ho Chi Minh City
Outcome results
None listed