BASIC RESEARCH – TECHNOLOGY

3-Dimensional Accuracy of Sameer D. Jain, BDS, MS,

MSD,* Caroline K. Carrico,
PhD,† and Ido Bermanis,
Dynamic Navigation DMD, MSc‡

Technology in Locating
Calcified Canals

ABSTRACT
SIGNIFICANCE
Introduction: This study aimed to present a novel dynamic navigation method to attain
minimally invasive access cavity preparations and to evaluate its 3-dimensional (3D) Novel dynamic navigation
accuracy in locating highly difficult simulated calcified canals among maxillary and technology with high-speed
mandibular teeth. Methods: Three identical sets of maxillary and mandibular 3D-printed jaw drills has the potential to
models composed of 84 teeth in their anatomic locations with simulated calcified canals (N 5 achieve minimally invasive
138 canals) were set up on dental manikins. The Navident dynamic navigation system access cavities in locating
(ClaroNav, Toronto, Ontario, Canada) was used to plan and execute access preparations highly difficult calcified canals.
randomly with high-speed drills by a board-certified Endodontist. Two-dimensional (2D) and Newer upgrades in dynamic
3D horizontal, ver-tical, and angulation discrepancies between the planned and placed navigation technology
access preparations were digitally measured using superimposed cone-beam computed facilitates clinical feasibility in
tomographic scans. Analysis of covariance models were used to evaluate the associations nonsurgical drilling to mitigate
and the interaction between tooth type and jaw, the canal orifice depth, and the iatrogenic errors.
discrepancies between planned and prepared access cavities. The significance level was
set at .05. Results: The mean 2D horizontal deviation from the canal orifice was 0.9 mm,
and it was significantly higher on maxillary compared with mandibular teeth (P , .05). The
mean 3D deviation from the canal orifice was 1.3 mm, and it was marginally higher on
maxillary teeth in comparison with mandibular teeth (P .05). The mean 3D angular deviation
was 1.7 degrees, and it was significantly higher in molars compared with premolars (P , .05).
The 3D and 2D discrepancies were independent of the canal orifice depths (P . .05). The
average drilling time was 57.8 seconds with significant dependence on the canal orifice
depth, tooth type, and jaw (P , .05). Conclusions: This study shows the potential of applying
dynamic 3D navigation technology with high-speed drills to preserve tooth structure and
accurately locate root canals in teeth with pulp canal obliteration. (J Endod 2020;-:1–7.)

KEY WORDS
Access cavity; calcified canals; dynamic navigation; guided endodontics; minimally
invasive endodontics; Navident
From the Departments of
*Endodontics and †Dental Public
Pulp canal obliteration (PCO) or calcific metamorphosis as a sequela of dental trauma may occur in up Health and Policy, School of
to 40% of cases
1–3
. Endodontic therapy is only indicated in 7%–27% of PCO cases if the tooth presents Dentistry, Virginia Commonwealth
1,4–7
University, Richmond, Virginia; and
with symptoms or radiographic pathology consistent with apical periodontitis . PCO may also occur ‡
Claronav Inc, Toronto, Canada
8
as a sequelae to dental caries, tooth surface loss or vital pulp therapies, orthodontic treatment . Severe
Address requests for reprints to Dr
physiologic PCO in geriatric patients may occur from the apposition of secondary or tertiary dentin or
Sameer D. Jain, Department of
9,10
from the regular intake of systemic statins . Despite the application of high-magnification and cone- Endodontics, School of Dentistry,
beam computed tomographic (CBCT) imaging, access cavity preparation for such cases is prone to Virginia Commonwealth University, 520
procedural errors that may lead to a substantial loss of dentin structure, thereby reducing the long-term North 12th Street, Box 980566,
11 Richmond, VA 23298-0566.
prognosis . Therefore, the American Association of Endodontists categorized the treatment of teeth
12 E-mail address: sdjain@vcu.edu
with PCO as a high difficulty level .
0099-2399/$ - see front matter
Recent clinical reports and in vitro studies have proposed using a static computed tomographic–
Published by Elsevier Inc. on behalf of
based stereolithographic drill guide system to increase accuracy for surgical and nonsurgical cavity
13–18
American Association of Endodontists.
preparations . Some of its perceived limitations include additional treatment time, cost of CBCT and https://doi.org/10.1016/
intraoral scan acquisition, template fabrication, use of larger-diameter slow-speed drills with the j.joen.2020.03.014

JOE Volume -, Number -, - 2020 3D Accuracy of Dynamic Navigation Technology 1

possibility of dentinal microcrack formation inability to be used in posterior teeth because a straight path to the apical target point, lack
and a rise in temperature of the periodontium, of the lack of interocclusal space, the need for of real-time visualization, and inability to
change the predetermined drill position during
14,15,19
the procedure .
Novel dynamic optically driven guidance
systems allow clinicians to visualize the position
and angulation of implant preparation during the
osteotomy drilling sequence, which can be
adjusted in real time
20
. This technique has the
potential to be applied in endodontics for
conservative access cavity preparation without
the limitations of static guided endodontics.
Studies with the newer-generation dynamic
navigation systems with slow-speed drills have
demonstrated their superior accuracy over
freehand implant placement 21. However, no
study has been conducted to date to investigate
the
3-dimensional (3D) accuracy of dynamic
navigation for access cavity preparation in
locating calcified canals using high-speed
drills. The aim of this study was to present a
novel dynamic navigation method to attain
minimally invasive access cavity preparations
and to evaluate its 3D accuracy in locating the
simulated calcified canals among maxillary
and mandibular teeth.
MATERIALS AND METHODS
In this study, stereolithographic images were
generated of anatomically precise human teeth
replicas (TrueTooth; DELendo, Santa Barbara,
CA) including anteriors, bicuspids, and molars
such that the root canal orifice started at a
distance of 5 mm above the apex for anterior
teeth and 2 mm below the cementoenamel
junction for premolars and molars.
Three identical sets of maxillary and
mandibular jaw models composed of 84
teeth (N 5 138 canals) were 3D printed to
simulate calcified anatomy on multi-ink
simulated training replicas of human jaws
(TrueJaw, DELendo). The treatment was
performed by a board-certified Endodontist
after undergoing training sessions of over
20 samples with the dynamic navigation
system. The Navident workflow in Figure
1A–Z outlines 3 representative canals with
challenging placement (tooth #25), extreme
canal orifice depth (tooth #22), and
frequently missed anatomy (second
mesiobuccal canal of tooth #3).
The Navident protocol was performed
in
4 steps:
1. Scan: a preoperative CBCT scan (CS 8100 3-
D; Carestream Health Inc, Rochester,
2 Jain et al.
NY) with a minimum voxel size of 75 mm
was performed separately for each of the
jaw models and stored as a Digital Imaging
and Communications in Medicine (DICOM)
file. These files were imported into the
Navident (ClaroNav, Toronto, Ontario,
Canada) implant/access planning software
to map the dentition.
2. Plan: the CBCT image data served as a
guide to plan nonsurgical virtual 3D access
cavity/paths of 1.0-mm diameter and depths
ranging from 9.5–21 mm. The entry point
started from the incisal edge/occlusal table to
the point of negotiation of the canals in 3
dimensions. Each canal was entered through
its own access opening. For instance, upper
molars with 4 canals ended up with four 1-mm
openings in their occlusal surfaces.
3. Trace: the CBCT images were matched
with the mounted TrueJaw, through the Jaw
Tracker installed on it, by registering the
CBCT scan to the model. The matching is
done through the “trace registration”
technique; a calibrated tracer (like a stylus
pen) tracked by the Micron Tracker camera
is slid along the tooth surface while the
system samples point along its path. The
collected “cloud of points” is then
automatically matched in the best possible
way with the outer surface of the teeth in
the CBCT scan. A full accuracy check was
performed in all 3 directions
(anteroposterior, laterolateral, and
occlusogingival) to verify registration
accuracy in all 3 axes.
4. Place (navigated access): each jaw was
mounted onto a dental manikin. A latex face
with limited mouth opening simulated limited
visibility and pressure caused by facial soft
tissues. Teeth were isolated using a dental
dam. Navigated access cavity preparation for
canals within a jaw set was performed in a
randomized order. Precision microendodontic
(tip diameter 5 0.28 mm) high-speed access
burs (Endoguide EG3; SSWhite, Lakewood,
NJ) were used for the initial access in
combination with surgical-length (tip diameter
5 0.21 mm) tapered diamond carbide burs
(859 FGSL; KometUSA, Rockhill, SC) for the
remaining depth of the access cavity
preparation. After calibration of the handpiece
and bur, the drilling time was recorded for
each attempt.
The high-speed handpiece and the jaws
were tracked via the attached optical tracking
tags (DrillTag and JawTracker, respectively).
The tags are constantly and simultaneously
detected by the high-precision optical
positioning sensor (the built-in Micron Tracker
camera), providing optical triangulation
tracking. This allows for an accurate real-
time representation of the drill tip location
and trajectory in relation to the anatomy on
the model’s CBCT image and the planned
virtual access cavity. The navigation was
performed by the primary investigator. The
tip of the bur was directed to be precisely
oriented, and the progression was visually
controlled by checking the planned cavity in
“target” view (Fig. 1R–Z). The depth of the
bur was monitored and indicated by a
green bar on the depth gauge; when within
1 mm of the desired depth, the bar’s color
changed from green to yellow. It changed
to red when the correct depth was reached.
Postoperative CBCT scans with
access burs in the prepared access cavities
were acquired with similar exposure
parameters as the preoperative CBCT
scans. Superimposition of the preoperative
scan with planned access templates and
the postoperative scan was performed
using EvaluNav (ClaroNav) software. The
planned and prepared access cavities were
compared to isolate their 2D and 3D
discrepancies (Fig. 2A–G).
Statistical Methods
Analysis of covariance models were used to
evaluate the discrepancies between planned
and prepared access cavities for tooth type
(anterior, premolar, and molar), jaw (maxilla
and mandible), and the interaction between
tooth type and jaw while accounting for the
canal orifice depth and the discrepancies
between the planned and prepared access
cavities. The discrepancies were measured in
the 2D entry, 2D horizontal and vertical
deviation from the canal orifice, 3D deviation
from the canal orifice, and 3D angular
deviation. In addition to the discrepancies, a
model for the total time was also fit with the
same predictors. The significance level was
set at P 5 .05. Backward elimination was used
to reach a parsimonious model. Only terms
with P , .05 were considered for the final
model. Post hoc pair-wise comparisons were
adjusted using the Tukey adjustment. The null
hypothesis was that the discrepancies and
drilling time were independent of the tooth
type, jaw, and canal orifice depth.
RESULTS
A total of 138 canals were drilled, 78 on
maxillary teeth and 60 on mandibular teeth. Of
these, 36 were anterior teeth, 30 were from
premolars and 72 were from molars. The
average drilling time was 57.8 seconds, and
the average canal orifice depth was 12.4 mm.
The overall mean 3D deviation from the canal
JOE Volume -, Number -, - 2020
FIGURE 1 – The NAVIDENT workflow. (A and B ) Scan: a preoperative CBCT scan of the custom TrueJaw model is acquired. Plan: the CBCT scan is imported into
Navident, and the 3D virtual access trajectories are planned. The CBCT coronal and sagittal views of (C–F ) tooth #25, (G–J ) tooth #22, and (K–N ) the second mesiobuccal
canal of tooth #3 serving as a guide to plan nonsurgical virtual 3D access cavity/paths of 1.0-mm diameter. Trace: 6 landmarks (starting points for tracing) selected on the 3D
rendered image on each of the (O ) maxillary and (P ) mandibular models on the screen. (Q ) Clinical tracing on the jaw model with a tracer tool to register the CBCT scan to
the model for the following navigation steps. Place (navigated access): the bur orientation and the drilling guided by “target” views on the computer screen for (R–T ) tooth
#25, (U–W ) tooth #22, and (X–Z ) the second mesiobuccal canal of tooth #3. The depth of the burs was monitored and indicated by the green bar of the depth gauge; the
color changed from green to yellow when within 1 mm of the desired depth and from yellow to red when the correct depth was reached.
JOE Volume -, Number -, - 2020 3D Accuracy of Dynamic Navigation Technology 3
FIGURE 2 – Three-dimensional accuracy measurements. (A ) Representation of accuracy measurements on EvaluNav software through superimposition of planned
(yellow ) and prepared (red ) access cavity positions. Postoperative CBCT scans of prepared cavities and superimpositions of planned and prepared access cavities in axial,
coronal, and sagittal CBCT views on (B and C ) tooth #25, (D and E ) tooth #22, and (F and G ) the mesiobuccal canal of tooth #3 on EvaluNav software.

orifice was 1.3 mm, and the mean 3D
angular deviations was 1.7 . The mean 2D
entry and horizontal and vertical deviation
from the canal orifices were 1.1, 0.9, and
1.0 mm, respectively. Descriptive summary
statistics and results from analysis of
covariance analysis are provided in Tables
1 and 2, respectively.
The drilling time was dependent on
the canal orifice depth (P 5 .0007), tooth
type, and jaw, with the differences in tooth
type dependent on the jaw (P , .0001). For
a 1-mm increase in the canal orifice depth,
the drilling time increased by 7.6 seconds
(95% confidence interval [CI], 3.26–11.91).
The 2D entry deviations were higher
on the mandible (1.23 vs 0.85; 95% CI on
difference, 0.11–0.65). 2D horizontal
deviation from the canal orifice was
significantly higher for maxillary teeth
compared with the mandibular (P 5 .0206).
The average deviation for the maxillary was
0.97 mm compared with 0.70 mm on the
mandibular, with an average difference of
0.27 mm (95% CI on difference, 0.04–0.50).
The 2D vertical deviation from the canal
orifice was dependent on the tooth type
(P 5 .0344). Post hoc pair-wise
comparisons found that molars had
significantly higher average deviation than
premolars (adjusted P 5 .0270).
The 3D canal orifice deviation was
marginally significantly different between the 2
jaws (P 5 .0523). The average deviation was
higher on the maxilla at 1.4 mm compared
with 1.2 mm for the mandible (95% CI on
difference, 0.00–0.44).
Overall, 3D angular deviation was
dependent on the tooth type (P 5 .0288). The
average deviation for molars was 1.9 mm,
which was significantly higher than the 1.4-
mm average for premolars (adjusted P value 5
.0403; 95% CI on difference, 0.02–1.00).
The average for anterior teeth (1.5 mm)
was not significantly different from molars
(adjusted P value 5 .1633) or premolars
(adjusted P 5 .7943).

TABLE 1 - A Summary of Time, Depth and Discrepancy Measures by Jaw and Tooth Type (Mean, Standard Deviation)

Jaw Tooth type

Time, depth and discrepancy measures Overall Maxilla Mandible Anterior Premolar Molar
Total time (s) 57.8, 61.91 45.6, 41.2 67.2, 72.89 142.1, 63.46 18.2, 8.11 32.2, 21.14
Canal orifice depth (mm) 12.4, 4.04 13.6, 3.71 11.5, 4.08 18.8, 1.83 10.2, 1.84 10.2, 0.89
2D deviation - entry (mm) 1.1, 0.80 0.9, 0.65 1.2, 0.87 1.0, 0.80 1.2, 0.82 1.0, 0.80
2D horizontal - canal orifice (mm) 0.9, 0.69 1.0, 0.78 0.7, 0.51 0.8, 0.57 0.8, 0.60 0.9, 0.77
2D vertical - canal orifice (mm) 1.0, 0.64 0.9, 0.68 1.0, 0.60 0.9, 0.63 0.7, 0.52 1.1, 0.66
3D deviation - canal orifice (mm) 1.3, 0.65 1.2, 0.57 1.4, 0.70 1.3, 0.59 1.1, 0.56 1.4, 0.71
3D angular deviation - canal orifice ( ) 1.7, 0.98 1.7, 0.90 1.7, 1.04 1.5, 0.78 1.4, 0.62 1.9, 1.14
2D, 2-dimenisonal; 3D, 3-dimensional.

4 Jain et al. JOE Volume -, Number -, - 2020

TABLE 2 - Results from the Analysis of Covariance Model Me 95% CI P
an v
 alue* 26
preparation . The second-generation
2D deviation - entry Navident system facilitates calibration of high-
Jaw .0054 speed handpieces and drills, unlike its
Mandible 0.85 0.65, 1.05 a predecessor, which was only geared toward
Maxilla 1.23 1.05, 1.4 b slow-speed drills for implant placements. A
2D vertical - canal orifice high-speed handpiece with precision
Tooth type .0344 microendodontic burs, as used in our study,
Anterior 0.92 0.71, 1.13 a,b
was more efficient and effective to penetrate
Premolars 0.71 0.48, 0.93 b
enamel and maintain an accurate minimally
Molars 1.06 0.92, 1.21 a
invasive straight-line path in apically extended
3D deviation - canal orifice
access cavity preparation. We recommend
Jaw .0523
Mandible 1.17 1.00, 1.33 a these burs to conserve pericervical dentin and
Maxilla 1.39 1.24, 1.53 b mitigate unnecessary removal of dentin
3D angular deviation - canal orifice around the path of planned access.
Tooth type .0288 Our initial pilot investigations to compare
Anterior 1.53 1.21, 1.85 a,b static guides for posterior teeth had to be aborted
Premolars 1.38 1.03, 1.72 b because of the lack of interocclusal space to
Molars 1.89 1.66, 2.11 a accommodate the additional 10 mm of drill or bur
Total time length required by the guide ring position over the
Canal depth (1-unit increase) 7.59 2.26, 11.91 .0007 tooth. Using simulated calcifications in all
†
Jaw*/tooth type ,.0001 posteriors highlighted additional advantage of
Mandible dynamic navigation in patients with restricted
Anterior 51.28 19.94, 82.63 a
mouth opening or canals with an ergonomically
Premolars 13.99 -1.97, 29.95 a
challenging entry angle. Our results found no
Molars 37.35 25.12, 49.59 a
significant difference in 2D or 3D discrepancies
Maxilla
with increasing orifice depths using dynamic
Anterior 136.69 107.3, 166.08 a
Premolars 48.79 28.61, 68.98 b navigation. Unlike static guidance, the ability to
Molars 57.78 43.25, 72.31 b attain real-time verification and validation of
positional accuracies enhances clinical
2D, 2-dimensional. transparency and accountability to optimize
*P value from the analysis of covariance model; levels with the same letter were not statistically significantly
different at the Tukey adjusted .05 level. patient outcomes 27.
†
For interaction term, tooth type was only compared within the jaw.
Slow-speed burs through a static-
guided approach in simulated calcified canals
required on an average 11 minutes compared
with an average drilling time of 58 seconds in
22
All 2D and 3D discrepancies canal location in natural teeth is absent in 3D- our study . In 2 extensive meta-analyses
were independent of the canal orifice printed teeth. Thus, the use of 3D-printed teeth with static guidance for implant placement,
depths (P . .05). can place the freehand technique at a slight there was a mean deviation of 1.4 mm at
disadvantage. Based on our pilot investigation, the implant’s apex and an angular deviation of
28,29
the freehand techniques to precisely locate 3.5 . Studies on in vitro models for
DISCUSSION
canals on simulated calcified root canals implant placement indicate that dynamic
This is the first study that shows and evaluates inherently generated errors in all parameters navigation systems with slow-speed drills have
the potential use of high-speed drills and that led to a higher substance loss or a mean entry deviation approximating 1.2 mm
precision microendodontic high-speed burs with perforations. Thus, we eliminated the variable and a mean angular deviation error
dynamic navigation to effectively prepare 30
of operator error regarding dependency on approximating 4 . The 2D horizontal
conservative access cavities in anteriors, anatomic landmarks and focused on deviation from the canal orifice acquires more
premolars, and molars with simulated calcified evaluating just the accuracy of dynamically significance for endodontic applications
root canals to depths as high as 21 mm. A navigated access cavities to the virtual because increased drilling depths could lead to
previous study comparing freehand and static
planned cavities. loss of tactile guidance. In such an event,
navigation for access cavity preparation in
Static-guided accesses prepared with horizontal deviations can cumulatively increase
simulated calcified root canals found successful 31
slow-speed drills were comparable with post the risk of perforations or iatrogenic errors .
canal location in only 41.7% using the
space preparation, which can significantly The results of our study found a mean 2D
22
conventional freehand technique . The failure to reduce the structural biomechanical properties horizontal deviation of 0.9 mm from the canal
clinically locate canals in post-traumatically of the root along with the temperature rise that orifice with high-speed drills, which could be
23,24
reduced pulpal lumen varied from 20%–71% . can negatively affect the periodontium 11,22,25. considered relatively safe for deep endodontic
In our study 3D-printed teeth were used to attain A recent pilot investigation used a freehand access cavity preparations.
a high level of standardization that ensured high-speed drill to create an initial punch to The indirect method of locating the
comparability; one must consider that the regional penetrate the enamel followed by the use of prepared access cavity through the placement
variation in color or consistency in anatomic an older generation dynamically guided slow- of drills in the cavities for the postoperative
landmarks that may guide the clinician during speed handpiece for drilling the underlying CBCT scan may have included possible errors
traditional dentin that led to a stepped access cavity from image acquisition and bur positioning.
JOE Volume -, Number -, - 2020
These errors can be cumulative and
interactive, impacting all of the parameters.
Future studies using sophisticated
segmentation techniques, 3D image
processing (micro–computed tomographic
imaging), and analysis to quantify the
difference between the planned and the
prepared access cavities are warranted for
detecting higher 3D accuracy
32
. from the canal orifice, and a mean 3D
A certain level of technical skill, hand-
eye coordination, and manual dexterity must
be maintained from the drilling entry point to
reaching the target while looking at the
computer screen. Clinical success can be
dependent on the hand skills of the operator
because of inaccuracies of hand tremor and
perception of 0.25 mm and 0.5 involved with
33
bur and handpiece tracking . Simulation of
dynamic navigation shortened the learning
curve for clinicians performing colonoscopy
and improved training of novice endoscopists
34
. Novice operators have demonstrated a
significant improvement of implant placement
skills with dynamic navigation with as low as 3
attempts to up to
3D Accuracy of Dynamic Navigation Technology 5
21,35
20 attempts . The operator in this study CONCLUSION
practiced on over 20 samples and Optically driven, computer-aided, 3D dynamic
developed a stable and consistent workflow
navigation technology with high-speed drills can
to minimize the influence of the learning
achieve minimally invasive access cavities in
curve and operator-induced error.
locating highly difficult simulated calcified canals
The updated second-generation trace
with mean 2D horizontal deviation of 0.9
registration system can perform registration
mm and a mean 3D deviation of 1.3 mm
with preexisting small field of view CBCT
scans, thereby reducing the amount of
angular deviations of 1.7 .
radiation exposure. This is distinctively
different from the first-generation navigation
system, which requires additional CBCT scans
with thermoplastic stents and radiographic
26
ACKNOWLEDGMENTS
fiducial markers . The cost and time
The authors thank Dr George Deeb
considerations associated with thermoplastic
(Department of Oral and Maxillofacial Surgery,
stent fabrication and errors associated with it
Virginia Commonwealth University) for
can be eliminated, making it clinically feasible
for endodontic procedures. Future studies on allowing access to the NaviDent system.
the application of this technology in the areas Supported by a Virginia
of endodontic retreatment and microsurgery Commonwealth University School of
may unlock new synergies and minimize Dentistry faculty grant (Sameer D. Jain).
iatrogenic errors. With the recent upgrades in Dr Sameer D. Jain and Dr Caroline
this technology, it enhances chairside clinical K. Carrico deny any conflict of interest
feasibility, which may lead to efficient patient related to this study. Dr Bermanis is an
care and predictable outcomes. employee of ClaroNav Inc.

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