The use of cone beam computed tomography in piezosurgery and static navigation (PRESS)

Abstract

Treatment of a failing endodontic procedure via microsurgical revision presents better outcomes due, in part, to the integration of the surgical operating microscope (SOM) and CBCT into clinical practice. But challenges still remain with respect to the operational locations and the techniques required to address them. Posterior sites, with substantial cortical plate thicknesses and sensitive anatomy, present the dichotomy of visualization versus post-surgical regeneration of bone. The bony lid technique bridges the gap between these two concepts, and the application of Piezosurgery renders a precise and biocompatible osseous incision. The primary evolution of the bony lid technique relied on the transfer of measurements from defined landmarks in the CBCT volume to the cortical plate of the surgical site. The secondary evolution utilized a vacuformed stent fabricated with pertinent fiducial markers in gutta-percha defining the surgical site parameters, and a scan exposed with the stent in place. The third and final evolution utilized the digital workflow to virtually plan the surgical procedure, integrating STL and DICOM files to create 3-dimensional guides with exacting resection locations, levels, and angles. Export of the virtually planned guide in post-production generates the precision endodontic surgical stent (PRESS). The progression from crude on-site measurements to elegant and precise surgical guides enabled the access and manipulations of difficult surgical sites without compromising visibility, post-operative osseous regeneration or patient comfort.