Received: 20 January 2023

| Accepted: 8 January 2024

DOI: 10.1111/iej.14026

CASE REPORT

Dynamically guided transantral piezoelectric endodontic

microsurgery: A case report with technical considerations

Paula Andrea Villa-­Machado | Felipe Augusto Restrepo-­Restrepo |

Sergio Iván Tobón-­Arroyave

Graduate Endodontics Program, Abstract

Faculty of Dentistry, University of
Antioquia, Medellín, Colombia
Correspondence
Sergio Iván Tobón-­Arroyave, Laboratory
of Immunodetection and Bioanalysis,
Faculty of Dentistry, University of
Antioquia, Calle 70 No 52-­21, Medellín,
Colombia.
Email: stobonarroyave@gmail.com;
sergio.tobon@udea.edu.co
Aim: Endodontic microsurgery (EMS) of maxillary molars may represent a com-
plex challenge to the clinician due to the location of the roots and the proximity
of the maxillary sinus floor. This report aimed to describe the simultaneous use of
a computer-­assisted dynamic navigation (C-­ADN) system and piezoelectric bony-­
window osteotomy for the transantral microsurgical approach of a maxillary left first
molar with adequate root canal filling and symptomatic apical periodontitis.
Summary: This case report highlights the importance of C-­ADN to carry out a mini-
mally invasive buccal surgical access to palatal roots affected by apical periodontitis
and provides a practical example to help clinicians make treatment decisions based
on the available evidence. Clinical and tomographic evaluations were performed be-
fore the surgical procedure and at 24-­month follow-­up. This case was treated using a
C-­ADN system fitted to a piezotome for the buccal approach of the buccal roots, max-
illary sinus membrane lifting, and for transantral location, root-­end resection, cavity
preparation, and filling of the palatal root. The navigation system allowed to achieve
an accurate apical canal terminus location and root-­end filling of the three roots
with a minimally invasive piezoelectric crypt approach. At the 24-­month follow-­up
examination, the patient remains asymptomatic, with normal periapical structures,
and regeneration of maxillary sinus walls. It was concluded that the combination of
dynamic navigation with piezoelectric bony-­window osteotomy offers enhanced ac-
curacy, tissue preservation, diminished risk of iatrogenic complications, and could
maximize success and survival rates in transantral EMS.

KEYWORDS
bone-­lid technique, case report, computer-­assited dynamic navigation, guided endodontic
microsurgery, piezoelectric surgery

I N T RO DU CT ION by nonsurgical treatment/retreatment (Villa-­ Machado

The main goal of endodontic microsurgery (EMS) is to
remove the pathologic tissue from the periapical area by
providing a hermetic root-­end filling, thus preventing
the passage of contaminants that could not be removed
et al., 2013). Long-­term success of EMS has been quite vari-
able, with rates ranging from 78.3% to 93% after a four-­year
follow-­up period (Huang et al., 2020; von Arx et al., 2014),
and may depend in part on clinical experience, choice
of armamentarium, materials, and minimally invasive

© 2024 British Endodontic Society. Published by John Wiley & Sons Ltd

Int Endod J. 2024;00:1–11.  wileyonlinelibrary.com/journal/iej | 1

2 |   
crypt approach. However, EMS has significantly bene-
fited from the progressive improvement and implemen-
tation of diagnostic tools, surgical instruments, root-­end
filling materials, and protocols, making it a more effective
treatment (Ahn et al., 2018; Huang et al., 2020; Kim &
Kratchman, 2006; Tavares et al., 2020; von Arx, 2011).
In maxillary molars, however, EMS may be problem-
atical given the difficulty of accessing the surgical site not
only owing to the neighbouring of the greater palatine
vascular-­nervous bundle but also to the complexity of the
radicular anatomy of maxillary molars and their relation-
ships with the maxillary sinus floor, as well as the pres-
ence of some anatomical variants of the maxillary sinus
such as antral septa and the posterior superior alveolar
artery (Kalender et al., 2013; Kurt et al., 2014; Taschieri
et al., 2021). The palatal root of these teeth can be accessed
using palatal or buccal approaches. It has been recognized
that the palatal approach requires the use of a large palatal
flap and can be complicated by lack of direct vision, risk
of injury to the greater palatine artery or perforation of
the sinus membrane, and the difficulty for instrumenta-
tion in this area (Kurt et al., 2014, Taschieri et al., 2021).
Alternatively, the buccal or transantral approach, which
has been limited to the treatment of apical periodontitis
involving fused distobuccal and palatal roots (Setzer &
Kratchman, 2022), also involves the risk of membrane
sinus perforation, problems in locating the palatal root,
and displacement of infected dentinal shavings or foreign
materials within the sinus (Kalender et al., 2013; Kurt
et al., 2014; Setzer & Kratchman, 2022).
Considering that the perfect visualization of the sur-
gical field and the precise localization of the anatomic
landmarks bordering the periradicular area during EMS
are of utmost importance to prevent surgical complica-
tions (Kalender et al., 2013), a transantral approach for
isolated palatal roots can be very restricted by the distance
amongst the buccal cortical bone and the palatal root apex
(Setzer & Kratchman, 2022), thus requiring the use of ad-
vanced technological resources to eliminate the risk of iat-
rogenic damage.
Amongst the new developments, computer-­ assisted
dynamic navigation (C-­ADN) has arisen as an innovative
technology which integrates surgical instrumentation and
multiplanar reconstruction images of the operative area
by using an optical positioning sensor monitored through
a computerized software (Gambarini et al., 2019). C-­ADN,
initially used in cranio-­maxillofacial surgery for numerous
procedures (Demian et al., 2019; Sukegawa et al., 2018),
was subsequently introduced in dental implantology to
enhance the precision of implant placement (Mandelaris
et al., 2018; Stefanelli et al., 2019). Likewise, C-­ADN is
being used in endodontics for removal of fibre posts, the
preparation of access cavities, and location of calcified
TRANSANTRAL ENDODONTIC MICROSURGERY
root canals (Chong et al., 2019; Jain et al., 2020; Villa-­
Machado et al., 2022; Zubizarreta-­Macho et al., 2020), and
has been applied with success in EMS by some clinicians
(Gambarini et al., 2019) who have reported that could as-
sist the endodontist's work and reduce the risk of iatro-
genic injury, decreasing post-­operative discomfort for the
patient, and improving healing. Basically, C-­ADN system
comprises a computer with the planning/guidance soft-
ware, a position sensor (Micron Tracker stereoscopic cam-
era), an optically marked jaw attachment (Jaw-­Tracker),
and an optically marked handpiece attachment (Drill
Tag) (Chong et al., 2019; Gambarini et al., 2019; Stefanelli
et al., 2019). During surgical procedure, the C-­ADN sys-
tem tracks the position of a surgical device, mapping it to
a pre-­acquired cone-­beam computed tomography (CBCT)
scan of the jaw to afford real-­time cutting. As the surgical
device approaches the previously mapped surgical area,
the system shows a target view on the computer screen
to guide the clinician to accurately locate the tip in the
multiplanar reconstructions of the patient's CBCT, mod-
ify the device orientation, cut to the planned dimensions,
or change the osteotomy pathway throughout the surgery
(Stefanelli et al., 2019).
In parallel, piezoelectric bony-­window osteotomy, ini-
tially introduced as a technique for maxillary sinus floor
lifting (Vercellotti et al., 2001), is an advanced technique
of bone surgery which has been gaining interest in EMS
to prepare a bone window when the involved tooth has
an intact or near-­intact cortical bone (Hirsch et al., 2016).
Once the microsurgical endodontic instrumentation has
been completed, the obtained bone lid is repositioned in
the initial site (Hirsch et al., 2016; Lee et al., 2020; Sivolella
et al., 2017; Younes et al., 2017), thus resulting in minimal
bone loss whilst the bone lid acts as an autologous cortical
graft that may promote the regeneration of periradicular
tissues (Lee et al., 2020).
The aim of this clinical case report is to present the out-
come of the simultaneous use of the C-­ADN system and
piezoelectric bony-­window osteotomy for the transantral
microsurgical approach of a maxillary left first molar with
adequate root canal filling and symptomatic apical peri-
odontitis after a 24-­month radiographic follow-­up. The
manuscript is written in accordance with the Preferred
Reporting Items for Case reports in Endodontics (PRICE)
guidelines (Nagendrababu et al., 2020).
REPORT
A timeline with the core elements associated with man-
aging the case according to the PRICE guidelines can be
found in Figure 1. A 58-­year-­old male was referred to the
outpatient clinic of the present authors for assessment and
VILLA-­MACHADO et al.
F I G U R E 1 Timeline of events describing the flowchart of the
case according to case report guidelines.
management of a maxillary left first molar with pain on bit-
ing and tenderness to percussion and palpation in the api-
cal region. The medical history did not reveal risk factors,
medications, or underlying systemic diseases that would
compromise the treatment. Two years earlier, root canal
treatment had been carried out for prosthodontic reasons.
   | 3
CBCT imaging evaluation revealed the presence of a sat-
isfactory full-­coverage all-­ceramic restoration along with
well-­defined, and periapically confined, hypodensities
involving the apex of the three roots, which showed ade-
quate root canal fillings as defined by the close adaptation
to the dentinal walls, absence of voids, and length <2 mm
from the radiographic apex. In addition, the tooth had di-
vergent roots, an additional mesiobuccal (MB2) canal, and
signs of buccal root fenestration. Concurrently, the maxil-
lary sinus revealed a prominent mucosal thickening and
displacement of the floor toward the roots (Figure 2a–d).
Upon examination, tenderness to percussion and palpa-
tion, adequate crown margins, and mild gingival recession
were noted and, although a narrow band of keratinized
tissue was present, sulcus depths around the involved
teeth did not exceed 3 mm (Figure 2e). The case was di-
agnosed as symptomatic apical periodontitis of tooth 26.
The patient was offered crown removal/non-­surgical re-
treatment or surgical intervention as treatment alterna-
tives. Given the presence of an adequate root canal filling
and the good quality of the coronal restoration, the patient
agreed to the surgical approach and signed the informed
consent form after receiving complete information on
methods, risks, and possible discomfort.
SURGICAL TECHNICAL
CONSIDERATIONS
The surgical procedure was conducted by two trained en-
dodontists (P.A. V-­M. and F.A. R-­R.) following the general
protocol described below, with the aid of an operating mi-
croscope (Zumax oms 3200®, Zumax Medical, Suzhou New
District, China) and using a C-­ADN system (Navident®,
ClaroNav®, Ontario, Canada) fitted to a Piezotome® Cube
Handpiece (Acteon®, Merignac, France).
A presurgical CBCT scan, acquired with a Planmeca
ProMax 3D Classic (Planmeca®, Helsinki, Finland) unit
set at 88 kVp, 11 mA, 8 × 5 cm of field vision, voxel size
0.150 × 0.150 × 0.150 mm, 12-­ 8 bits, and 15 s of expo-
sure time, was analysed using Romexis Viewer 5.2.0R
(Planmeca®). The scans were exported in Digital Imaging
and Communications in Medicine (DICOM) format to the
Navident® planning software to map the presurgical imag-
ing of the patient's dentition.
Before the surgical approach, a preoperative antiseptic
mouth-­rinse was done for 2 min with 15 mL of a low dose
chlorhexidine solution (PerioGard®, Colgate-­ Palmolive,
Cali, Colombia) and the anaesthesia was reached infiltrat-
ing lidocaine 2% with epinephrine 1:80 000 (New Stetic,
Guarne, Colombia) applied on the right mucobuccal
sulcus and the palatal mucosa. The CBCT images were
matched by using a Jaw Tracker, that is, a support fixed
4 |    TRANSANTRAL ENDODONTIC MICROSURGERY

F I G U R E 2 Maxillary left first molar underwent prosthodontic treatment with apical periodontitis following initial root canal treatment.
(a) Pre-­operative sagittal CBCT view showing two isolated periapical hypodensities <5 mm in diameter located around the apexes of the
buccal roots and a flat maxillary sinus mucosal thickening. (b) Axial and (c, d) coronal magnified CBCT views showing divergent roots
with adequate root canal fillings, projection of the sinus floor toward the roots, bone defects confined to periapical region, a MB2 in the
mesiobuccal root, and signs of buccal cortical disruption (yellow arrows). (e) Clinical inspection showed a narrow band of keratinized tissue
and mild gingival recession.

on the crown either of the involved tooth or the neigh-
bouring tooth to the surgical field with a dual-­cure resin
cement (Grandio® Core Dual Cure, VOCO, Germany),
which can be detected and tracked by the Navident® cam-
era (Figure 3a–e). Matching was accomplished using the
trace registration method. In this step, a calibrated tracer
tool coupled to a Tracer Tag and monitored by the Micron
Tracker camera is displaced through the tooth surfaces. As
a result, the software captures a series of points obtained
over this trajectory to three-­dimensionally orientate the
tool tag, thus mapping the patient's maxillary segment of
interest to the CBCT image. Calibration defines the ge-
ometry and the limits of the surgical approach. The trace
registration step was completed by a full accuracy check
achieved by touching all tooth surfaces again with the
tracer tool. The synchronized mapping steps are depicted
in Figure 4a–d. Measurements of ±0.03 mm were used to
corroborate the precision of the trace in the three orthog-
onal dimensions.
Afterwards, an optical tracking tag (Drill Tag) was fit-
ted to the Piezotome® Cube handpiece (Acteon®), with a
10 mm length and 3 mm width LC2 saw insert attached.
The Piezotome® was also calibrated as aforementioned to
obtain an optical triangulation tracking with the stereo-
scopic camera (Figure 5a). After calibration, a submar-
ginal mucoperiosteal flap with a mesial vertical releasing
incision was prepared with a #15C surgical blade (Salvin
Dental Specialties®, Latrobe, PA, USA) and reflected ex-
posing the area around the involved tooth and the two
adjacent teeth (Figure 5b). During osteotomy, Navident®
system may estimate in real time the deviation between
the planned location and the actual position of the piezo-
electric saw as it cuts the cortical bone both in extent and
depth to create a rectangular bone window consisting of
two vertical and two horizontal osteotomies (Figure 5c).
Root-­end resection of buccal roots perpendicular to the
long axis of the root was simultaneously performed at this
stage with the same Piezotome® saw tip.
Once the sectioned bone lid was lifted off with a
curved osteotome, the resected buccal root-­ end seg-
ments were discarded and the granulomatous tissue was
removed. The bone lid was stored in 0.9% saline solu-
tion at room temperature to keep it hydrated until use.
Resected buccal root-­ end surfaces were stained with
1% methylene blue to be inspected under high magni-
fication (×16) with the aid of the operating microscope
VILLA-­MACHADO et al.    | 5

F I G U R E 3 Intraoperative workflow of C-­ADN surgical procedure showing the patient registers obtained with the tracer tool. (a) After
flap reflection, the Jaw Tracker was fixed on the crown either of the involved tooth or the neighbouring tooth to the surgical area to be
detected by the Navident's camera. (b) When the scan was imported into Navident® system, the clinician is prompted to draw a jaw centre
line which generated the panorama which was used for alignment of the surgical instrument (arrow). (c–e) The 3D view can be reoriented
in all directions to control the location, orientation, and depth of the cut during the root-­end resection of the palatal root.

(Figure 5d). Following apical canal termini location,
root-­end cavity preparations of about 3 mm depth were
made in the distobuccal (DB), mesiobuccal 1 (MB1)
and MB2 canals using a 6 mm length, 0.3 mm width,
and 9% taper diamond-­coated AS6D ultrasonic micro-
surgical tip (Newtron® Acteon®), connecting the extent
amongst the MB1 and MB2 canals during root-­end cav-
ity preparation (Figure 5e). After rinse, haemostasis was
reached using racemic-­epinephrine pellets (Racellet®,
Pascal Dental, Bellevue, WA, USA), and the root-­
end preparation was dried with Stropko dryer (Vista
Dental®, Racine, WI, USA). Afterwards, root-­end fillings
(Figure 5f) using EndoSequence® Root Repair Material
BC Fast Set Putty (ESRRM Putty; Brasseler, Savannah,
GA, USA) were placed with a carrier device MRFL®
(Hu-­Friedy®, Chicago, IL, USA) and condensed with a
Buchanan plugger PLGRF1® (Hu-­Friedy®). Next, taking
into account that the sinus mucosa was very thin and not
properly visible in CBCT scans, the Navident® system
was not used for its detachment and lifting because this
would mean a great deviation from path to palatal apex
and might increase the tearing risks. Instead, a Kramer-­
Nevins sinus lift instrument (Hu-­Friedy®, Chicago, IL,
USA) was used under direct microscopic visualization,
to push the sinus membrane upward and inward to ex-
pose the buccal bone cortex of the palatal root and lo-
cate, with the assistance of the Navident® system, the
palatal apex (Figure 5f). Piezoelectric osteotomy was
performed to gain access and to complete the root-­end
resection, cavity preparation, and filling of the palatal
root apex (Figure 6a–c).
Ten millilitres of blood were obtained from the pa-
tient's antecubital vein using a 15 mL glass tube, which
was immediately centrifuged at 3.000 rpm for 10 min with
no anticoagulant in a Duo Quattro PRF Centrifuge® (PRF
Process medical, Nice, France). Platelet-­Rich Fibrin (PRF)
membranes were removed from the tube and inserted
into the bone crypt to ensure the accurate repositioning
and stabilization of the bone lid (Figure 6d,e). Given the
presence of the cortical disruption, and additional PRF
membrane was used for covering the bone lid as bar-
rier (Figure 6f). Finally, the flap was sutured back to its
6 |    TRANSANTRAL ENDODONTIC MICROSURGERY

F I G U R E 4 Trace registration for planning EMS access with the C-­ADN system. (a, b) The tracer tool was calibrated at a distance of no
more than 50 mm from the Micron Tracer. (c) Landmarks were placed on 3–6 teeth (non-­collinear). The tracer tool tip was slid around all
surfaces of the teeth thus creating a cloud of points that mapped the patient's jaw to the CBCT scan. When both the Jaw Tracker and the
Tracer Tag were detected by the Micron Tracker stereoscopic camera, the tracing signal on the monitor screen appeared in white for both
tools as observed in the left lower panel. (d) An accuracy check was done on all tooth surfaces to ensure that trace registration had been
successful.

original place with 6-­0 Ethilon® monofilament sutures
(Ethicon®, Somerville, NJ, USA) while applying gentle
pressure. The patient received amoxicillin 500 mg three
times a day for 7 days, meloxicam 7.5 mg twice a day for
5 days, and 1.2% chlorhexidine mouthrinse 30 cc three
times a day for 7 days. Postoperative instructions included:
apply ice pack for 15 min four times the first day; the next
day apply warm compresses for 15 min, three times a day,
for a minimum of 3 days; do not perform physical exercises
for a week; avoid chewing from the surgical site; and do
not pulling up their lips or cheeks to avoid flap disruption.
Given that the integrity of sinus membrane was preserved,
further postoperative instructions related to the maxillary
sinus care were not required following the surgery. The
sutures were removed 5 days after surgery and the patient
was scheduled for recall appointments every 3 months.
At the 24-­month recall examination, the patient con-
tinues to be asymptomatic. Follow-­up CBCT scans showed
normal periapical structures and regeneration of maxil-
lary sinus walls with just an inconspicuous thickening of
the sinus membrane (Figure 6g,h). Additionally, details of
the healing of periapical tissues surrounding each of the
roots, as observed through the different multiplanar tomo-
graphic reconstructions, are shown in parallel with refer-
ence to the preoperative periapical status in Figure 7a–f.
The patient is closely monitored at 6-­month intervals and
will be kept under long-­term review to evaluate treatment
success and to check any evidence of signs and/or symp-
toms of inflammation.
DISC USSION
It has been acknowledged that a minimally invasive access
in EMS must be performed with a 3 mm root-­end resection
and a bevel approaching zero degrees, while providing
sufficient space to perform the root-­end cavity prepara-
tion and root-­end filling procedures (Hawkins et al., 2020;
Kim & Kratchman, 2006). This approach ensures a clear
evaluation of the periphery of the resected root surfaces in
order to detect fractures, isthmuses, and anatomic intrica-
cies. Notwithstanding, in the maxilla, where the maxillary
sinus membrane could be perforated, the optimal pres-
ervation of the surrounding bone tissue is of paramount
importance (Nino-­Barrera et al., 2018; Zahedi et al., 2018).
Considering that EMS of the palatal root of a maxillary
first molar by the palatal approach requires a relatively in-
vasive and time-­consuming procedure due to the need to
prepare a large palatal flap, a difficult osteotomy, and the
risk of significant haemorrhage from the greater palatine
VILLA-­MACHADO et al.    | 7

F I G U R E 5 Microsurgical approach to the buccal roots. (a) The piezoelectric saw tip is calibrated and detected by the optical
triangulation track prior to the osteotomy. (b) After submarginal flap reflection, both a MB root fenestration and a disruption of the cortical
plate on the DB root were evident. (c) Real time feedback provided by the Jaw Tracker during surgery enabled a minimally invasive
piezoelectric bony window allowing the simultaneous piezoelectric root-­end resection to proceed at an angulation of <10°. (d) Methylene
blue was used to outline the periphery of the buccal resected root-­end surfaces and to detect the presence of isthmuses and/or fracture lines.
Yellow arrow shows the preservation of sinus membrane integrity. (e) Root-­end cavity preparation was completed with ultrasonic diamond-­
coated tips connecting an isthmus detected amongst the MB1 and MB2. (f) Root-­end filling was performed using ESRRM Putty and sinus
membrane was elevated carefully.

artery (Kurt et al., 2014), for the current case presentation
the palatal approach was discarded and the surgery was
performed by a dynamically guided buccal access.
In order to perform accurate presurgical planning, gain
access to locate apexes, and avoid vital anatomical struc-
tures (Pinsky et al., 2007), in recent years, surgical guide
templates using computer-­aided design/computer-­aided
manufacturing (CAD/CAM) and 3D printing have been
used for the creation of minimally invasive approaches in
EMS by means of a guided osteotomy that defines the pe-
rimeter of the surgical site (Ahn et al., 2018; Gargallo-­Albiol
et al., 2019; Pinsky et al., 2007; Strbac et al., 2017; Tavares
et al., 2020). However, the manufacturing process of these
templates has risks of distortion and time delay. These
guide templates are cumbersome, spatially restrictive, and
the pathway of the osteotomy cannot be altered during
the surgical procedure. Alternatively, the novel C-­ADN
incorporates a stereoscopic tracking camera that identi-
fies the position of the patient's jaw in relation to the tip
of the instrument used for the surgical procedure. It al-
lows the operator to precisely direct the instrument in the
axial, coronal, and sagittal fields-­of-­view with an accuracy
8 |   
of less than 1 mm (Gambarini et al., 2019). In addition,
whereas the primary advantage of the C-­ADN system over
the static guides is the possibility to modify the plan at any
time during the clinical procedure (Gambarini et al., 2019;
Stefanelli et al., 2019), the trace registration protocol also
eliminates the need of moulded thermoplastic templates,
which is of significant value in posterior EMS and in the
treatment of patients with limited opening.
Some prognostic factors related to the outcome of EMS
include a small osteotomy for access to the crypt, per-
pendicular resection of the root apex, and pre-­treatment
planning to avoid iatrogenic damage to anatomic struc-
tures (von Arx, 2011). In this sense, piezoelectric bony-­
window osteotomy was developed in order to obtain
major levels of precision and safety during bone sur-
gery compared with standard bur and saw instruments
(Landes et al., 2008). The microvibrations generated by
the piezoelectric ultrasonic osteotome allow a selective
cutting action of only mineralized structures, without
impinging upon or damaging soft tissues even in situa-
tions of unintended contact (Abella et al., 2014; Landes
et al., 2008; Younes et al., 2017). Therefore, piezosurgery
TRANSANTRAL ENDODONTIC MICROSURGERY
F I G U R E 6 Transantral approach
to the palatal root and guided bone
regeneration. (a) Palatal root-­end was
resected at 3 mm level from the apical
terminus with a bevel angle <10° and
removed using surgical pliers. (b)
Ultrasonic root-­end cavity preparation.
(c) Root-­end filling with ESRRM Putty
was placed in the palatal root. (d) The
bony crypt was filled with PRF obtained
from the patient's blood before the start
of the surgical procedure to promote
guided bone regeneration. (e) The bone
lid is repositioned and held in place with
the PRF coagulum. (f) A PRF membrane
is placed over the bone lid to avoid
the migration of the epitheliums and/
or connective tissue to the bony crypt
throughout the disrupted cortical bone.
(g, h) CBCT examination at 24 months
after surgery revealed reformation of
periodontal space of normal width in
each root, an inconspicuous thickening
of the sinus membrane, and complete
regeneration of maxillary sinus walls. The
outcome was classified as healed.
is advantageous when bone must be transected near to
underlying soft tissues, such as blood vessels, nerves,
and the maxillary sinus membrane, or when mechanical
or thermal damage must be avoided (Abella et al., 2014).
At the same time, micrometric vibration reduces intra-
operative bleeding owing to the air-­ water cavitation
effect of the coolant being used, thus providing bet-
ter visibility of the operative field (Hirsch et al., 2016;
Landes et al., 2008; Vercellotti et al., 2001). With this
technique, a defined and optimized osteotomy coupled
with stable placement of the bone lid in its original site
may allow a better bone regenerative process (Sivolella
et al., 2015). When repositioned, the bone lid works as
a rigid autogenous barrier with osteogenic potential,
thus preventing the entry of non-­osteogenic cells (Lee
et al., 2020; Sivolella et al., 2017) while minimizing buc-
cal bone depression (Younes et al., 2017) and optimizing
the immediate structural reconstruction of the defect
(Lee et al., 2020, Sivolella et al., 2017). Moreover, fol-
lowing the basic principle of guided bone regeneration,
the bone lid technique also contributes to create and
maintain an isolated volume where a blood clot could
VILLA-­MACHADO et al.    | 9

F I G U R E 7 Comparison of
preoperative and postoperative
multiplanar tomographic reconstructions
of periapical tissues of the maxillary left
first molar underwent transantral EMS.
The sagittal view shows: (a) preoperative
MB and DB roots exhibiting periapical
hypodensities confined to the retro-­
alveolar spongiosa; and (b) follow-­up MB
and DB roots showing replacement of
the lesions with new bone. The coronal
view shows: (c) preoperative MB root
with a periapical lesion in contact with
the sinus floor; and (d) follow-­up MB
root displaying complete resolution of
the periapical lesion. The coronal view
depicts: (e) preoperative DB and palatal
roots demonstrating periapical defects
confined to the apical region of the roots;
and (f) follow-­up DB and palatal roots
showing complete apical healing with
bone fill.

form and ultimately lead to a complete bone healing
(Younes et al., 2017). On the other hand, although it has
been stated that piezo-­driven root-­end resection may in-
duce micro-­fracture formation (Jadun et al., 2019) and
result in rougher surfaces (Bernardes et al., 2009) than
free-­hand root-­end resection using carbide burs, in the
present case report the use of C-­ADN system helped the
operator to precisely position the piezoelectric saw with
the correct angulations to perform the root-­end resec-
tions with great accuracy without evidence of collateral
damage at operative microscopic assessment.
As a final point, there are some cost and time consid-
erations associated with the use of the C-­ADN and piezo-
electric systems for EMS. Whilst, the financial outlay to
the acquisition of expensive equipment may constitute
the main limitation, and the time for case preparation and
planning is something greater than that of the free-­hand
surgery, the use of this technology in the clinical practice
has the potential of shortening the actual surgical time.
Additional drawbacks related to the dynamic navigation
system used in this clinical case include the fact that it is
bulky and requires different extra-­oral devices as well as
some level of skill, visuomotor coordination, and practice
to achieve accurate instrument placement from entry point
to target display on the computer screen (Villa-­Machado
et al., 2022). Notwithstanding, it is important to point out
that Navident® system has the advantage over other sys-
tems such as X-­Guide® (X-­Nav® Technologies, Lansdale,
Pennsylvania) in that it is handpiece-­independent. This
fact provides great flexibility to the clinician not only to
perform osteotomy, root-­end resection, and lifting of the
sinus floor all with one device, but also to fit different de-
vices such as a high-­speed or a low-­speed handpiece, a
piezoelectric device, and others during the surgical proce-
dure (Stefanelli & La Rosa, 2021).
CONCLUSION
The combination of C-­ ADN system with piezoelectric
bony-­window osteotomy offers enhanced accuracy, tissue
preservation, diminished risk of iatrogenic complications,
and could maximize success and survival rates in transan-
tral EMS.
AUTHOR CONTRIBUTION
Villa Machado P.A. and Restrepo-­Restrepo F.A performed
the surgical procedure, accomplished the CBCT imaging
analyses, recording of tomographic data, analysis of the
results, and were involved in drafting the manuscript.
10 |    TRANSANTRAL ENDODONTIC MICROSURGERY
Tobón-­Arroyave S.I. handled the work concepts and de-
sign, supervised the acquisition of the data, accomplished
the interpretation of data, and critically evaluated and
supplemented the manuscript.
CONFLICT OF INTEREST STATEMENT
The authors declare that they have no competing financial
interests in the products used in this work.
DATA AVAILABILITY STATEMENT
Data sharing not applicable to this article as no datasets
were generated or analysed during the current study.
ETHICS STATE MENT
The University of Antioquia does not require ethical ap-
proval for reporting individual case reports. The patient
involved has given written informed consent to publica-
tion of case datails and images.
ORCID
Sergio Iván Tobón-­Arroyave https://orcid.
org/0000-0002-4628-7743
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How to cite this article: Villa-­Machado, P.A.,
Restrepo-­Restrepo, F.A. & Tobón-­Arroyave, S.I.
(2024) Dynamically guided transantral
piezoelectric endodontic microsurgery: A case
report with technical considerations. International
Endodontic Journal, 00, 1–11. Available from:
https://doi.org/10.1111/iej.14026