Case study

endodontic microsurgery

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Endodontic microsurgery of an anatomically challenging zone using Navident’s dynamic navigation by Dr Paula Villa, Columbia 

Dynamic Navigation technology has been used in Endodontic Microsurgery to guide cutting instruments, including piezotomes, in real time, to perform osteotomies and apicoectomies. Dynamic Navigation systems map the patient’s jaws to their cbCT scan by trace registering landmarks on teeth of the jaw to be treated. The system’s stereoscopic camera recognises optical markers attached to the jaw to be treated and the instrument to be used and monitors the drill or saw position during the surgery. Unlike static navigation guides, Dynamic Navigation procedures are not constrained to a predetermined path, there is no risk of distortion, and the inability to work in restricted areas of the mouth due to the bulk of the guide is obviated.

Case Report

A 50-year-old male patient presented with moderate pain associated with a previously treated maxillary right second premolar (tooth #1.5). The tooth had been endodontically treated and restored with a cast post/core and full crown. The patient’s scan (cbCT) revealed two separate roots, an intact buccal plate and an apical lesion associated with the palatal root. The tooth was moderately sensitive to vertical percussion, periodontal probe depths and mobility were within normal limits. After consultation, the patient chose to have treatment done with Navident’s Dynamic Navigation.

The proximity of the palatal root apex to the sinus floor raised the issue of an existing sinus perforation or the risk of iatrogenic creation. Dynamic Navigation enabled real-time feedback of the position of the instrument tip in a z axis as it accessed the palatal root apex and the floor of the sinus. Lidocaine 2% with 1:80,000 epinephrine (New Stetic, Guarne, Ant. Colombia) was used to achieve profound local anesthesia and a full thickness mucoperiosteal flap with a vertical releasing incision was elevated. 

Three landmarks (up to 6 can be used) were marked on teeth displayed in the patient’s scan in a non-colinear array. A Head Tracker (optical marker) was secured to establish jaw position, a tracer tag attached to a tracer tool and a stentless trace registration of the maxilla done by creating a cloud of points around the landmarked teeth thus accurately mapping the avatar maxilla on the CBCT.

endodontic microsurgery

An accuracy check was performed to verify the trace registration, a drill tag (optical marker) was secured to the Piezotome® Cube handpiece by an adapter, the LC2 saw secured to the handpiece and the saw tip calibrated. The Dynamic Navigation software algorithms enable the micron tracker (stereoscopic camera) to identify the avatar saw tip as it cuts the periphery and depth of the cortical window. The position of the saw at the periphery of the palatal root resection can be precisely tracked thus preventing a sinus communication (Figs 3A, 3B). The retro-preparations were done using a E30RD ultrasonic tip (USA – NSK-Nakanishi International). Post-surgical CBCT confirms the precision of the saw cuts resulting in accurate resection of both roots without complications ensuant from an iatrogenic tear of the sinus membrane.


Dynamic Navigation is an exciting and promising adjunct for enhancing positive outcomes in contrast to the efficacy of static navigation guides. The real-time feedback feature of the Navident technology mitigates risk in areas close to anatomic structures. Selective and controlled osseous dissection is enhanced. The ability to alter the surgical pathway provides for an improved margin of accuracy and degree of safety.  

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