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An Update on Endodontic Microsurgery of Mandibular Molars: a Focused Review

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An Update on Endodontic Microsurgery of Mandibular Molars: a Focused Review medicina Review An Update on Endodontic Microsurgery of Mandibular Molars: A Focused Review Sun Mi Jang 1, Euiseong Kim 1 and Kyung-San Min 2,3,4,* 1 Microscope Center, Department of Conservative Dentistry and Oral Science Research Center, Yonsei University College of Dentistry, Seoul 03722, Korea; [email protected] (S.M.J.); [email protected] (E.K.) 2 Department of Conservative Dentistry, School of Dentistry, Jeonbuk National University, Jeonju 54896, Korea 3 Research Institute of Clinical Medicine, Jeonbuk National University, Jeonju 54907, Korea 4 Biomedical Research Institute, Jeonbuk National University Hospital, Jeonju 54907, Korea * Correspondence: [email protected]; Tel.: +82-63-250-2764 Abstract: Endodontic microsurgery is a highly predictable treatment option in most cases when conventional endodontic treatment is not feasible. Nevertheless, mandibular molars are still con- sidered by clinicians to be the most difficult type of teeth, with the lowest success rate. In recent years, endodontic microsurgery has been attempted more frequently with the emergence of modern cutting-edge technologies such as dental operating microscopes, various microsurgical instruments, and biocompatible materials, and the success rate is increasing. This review describes the current state of the art in endodontic microsurgical techniques and concepts for mandibular molars. Notably, this review highlights contemporary equipment, technology, and materials. Keywords: endodontic; microsurgery; mandibular; molar; update Citation: Jang, S.M.; Kim, E.; Min, K.-S. An Update on Endodontic 1. Introduction Microsurgery of Mandibular Molars: A Focused Review. Medicina 2021, 57, Endodontic treatment aims to disinfect the root canal system, followed by sealing 270. https://doi.org/10.3390/ this space to prevent recontamination [1]. For this purpose, nonsurgical endodontic treat- medicina57030270 ment is the first option in most cases, but a surgical approach may be indicated when peri-radicular pathosis cannot be solved by a nonsurgical method [2]. Surgical endodontic Academic Editor: Vita Maciulskiene treatment has evolved considerably owing to new technological advances such as den- tal operating microscopes, cone-beam computed tomography (CBCT), computer-aided Received: 28 January 2021 design/computer-aided manufacturing (CAD/CAM), and three-dimensional printing Accepted: 12 March 2021 technology. Most endodontists now consider the above equipment essential for surgical Published: 16 March 2021 endodontic treatment. Nevertheless, clinicians still consider mandibular molars to be the most difficult Publisher’s Note: MDPI stays neutral targets. The success rate for mandibular molars is lower than that for any other type of with regard to jurisdictional claims in teeth in the oral cavity [3]. The difficulty posed by mandibular molars is their anatomical published maps and institutional affil- location in the posterior areas of the oral cavity. Even in a retrospective study that used a iations. 15-year database obtained in the 21st century, molars showed a higher probability of failure than anterior teeth, and tooth type might be the only factor contributing to the outcomes of microsurgery [4]. Therefore, microsurgery of mandibular molars requires an adequate evaluation of the surgical access and the relationship of the roots to anatomical structures Copyright: © 2021 by the authors. such as the mental foramen and mandibular canal [5]. Licensee MDPI, Basel, Switzerland. However, within the limitation of our knowledge, there has been no focused review This article is an open access article regarding endodontic microsurgery of mandibular molars in the past 10 years, although distributed under the terms and considerable technical advances have occurred. Therefore, the purpose of this review was conditions of the Creative Commons to present an update on endodontic microsurgical techniques and concepts for mandibular Attribution (CC BY) license (https:// molars. creativecommons.org/licenses/by/ 4.0/). Medicina 2021, 57, 270. https://doi.org/10.3390/medicina57030270 https://www.mdpi.com/journal/medicina Medicina 2021, 57, x FOR PEER REVIEW 2 of 15 Medicina 2021, 57, 270 to present an update on endodontic microsurgical techniques and concepts for mandibu-2 of 15 lar molars. 2.2. Anatomical ConsiderationsConsiderations 2.1.2.1. Thickness of thethe BuccalBuccal BoneBone TheThe buccalbuccal bonebone ofof thethe mandibularmandibular molarmolar areaarea isis thickerthicker thanthan inin otherother areas.areas. TheThe thicknessthickness ofof thethe posteriorposterior buccalbuccal corticalcortical plateplate isis generallygenerally 2–32–3 mmmm on average ((FigureFigure1 1a).a ). Furthermore,Furthermore, thisthis thicknessthickness maymay increaseincrease posteriorlyposteriorly (oblique(oblique ridge),ridge), limitinglimiting accessaccess toto thethe molarmolar rootsroots (Figure(Figure1 1b).b). While While the the mesial mesial root root of of the the mandibular mandibular first first molar molar is is reasonably reasonably closeclose toto thethe buccalbuccal corticalcortical plate,plate, thethe distaldistal rootroot isis centrallycentrally locatedlocated inin thethe bonebone andand thethe rootsroots ofof thethe secondsecond molarmolar areare significantlysignificantly closercloser toto thethe linguallingual corticalcortical plateplate [[6].6]. Therefore, mandibularmandibular molarsmolars with with a thicka thick buccal buccal bone bone plate plate pose pose a challenging a challenging problem problem in endodontic in endo- surgery,dontic surgery, especially especially for precise for root-endprecise root-end localization. localization. FigureFigure 1.1. Anatomical features ofof thethe mandibularmandibular molar area.area. (a) Thick buccal bone of the mandible (white(white triangle).triangle). ((bb)) ObliqueOblique ridgeridge inin thethe secondsecond mandibularmandibular molarmolar areaarea (red(red triangle).triangle). Recently,Recently, BiBi etet al.al. [[7]7] reportedreported aa sophisticatedsophisticated approachapproach thatthat reducedreduced thethe distancedistance betweenbetween thethe rootsroots andand thethe buccalbuccal corticalcortical plateplate byby orthodonticorthodontic movement.movement. ByBy orthodonticorthodontic movementmovement towardtoward the the buccal buccal aspect aspect for for 2 2 months, months, the the distance distance between between the the two two anatomical anatom- structuresical structures was decreasedwas decreased from from 4.5 mm 4.5 to mm 1.5 to mm 1.5 (mesial mm (mesial root) and root) 7.1 and mm 7.1 to mm 4.5 mm to 4.5 (distal mm root).(distal Therefore,root). Therefore, the surgical the surgical procedure procedure became became easier easier and and the the results results were were successful. success- Furthermore,ful. Furthermore, Ahn Ahn et al. et [8 al.] performed [8] performed osteotomy osteotomy and apexand apex localization localization effectively effectively using us- a CAD/CAM-guideding a CAD/CAM-guided surgical surgical template template in a mandibular in a mandibular molar molar with a with thick a buccalthick buccal bone platebone (Figureplate (Figure2). Indeed, 2). Indeed, the surgical the surgical template temp manufacturedlate manufactured by using by CAD/CAM using CAD/CAM technology tech- combinednology combined with CBCT with can CBCT determine can determine the three-dimensional the three-dimensional extent of extent the required of the required cortical bonycortical window. bony window. Therefore, Therefore, with this with guide, this the guide, surgical the approach surgical approach to the apical to regionthe apical is less re- invasivegion is less and invasive less traumatic and less so traumatic that minimizes so that boneminimizes loss in bone comparison loss in comparison to the traditional to the osteotomytraditional techniquesosteotomy techniques [9]. However, [9]. evenHowever, with thiseven static with technique, this static clinicianstechnique, may clinicians have problemsmay have regardingproblems regarding the instrumentation the instrumentation during the during surgical the procedure. surgical procedure. In this respect, In this mostrespect, recently, most recently, dynamic dynamic navigation navigation systems forsystems dental for implant dental positioningimplant positioning were applied were toapplied endodontic to endodontic microsurgery microsurgery [10]. This [10]. dynamic This dynamic navigation navigation integrates integrates surgical surgical procedure pro- andcedure radiologic and radiologic images images by using by an using optical an optical positioning positioning device device controlled controlled by a dedicated by a ded- computerizedicated computerized interface. interface. Consequently, Consequently, with the with help the of cutting-edgehelp of cutting-edge guiding guiding technologies, tech- cliniciansnologies, canclinicians perform can a safeperform and lessa safe traumatic and less surgical traumatic procedure surgical in procedure the mandibular in the molar man- area,dibular and molar unfavorable area, and complications unfavorable includingcomplications increased including postoperative increased pain,postoperative delayed healing,pain, delayed and nerve healing, damage and nerve can be damage avoided. can be avoided. Medicina 2021, 57, 270 3 of 15 Medicina 2021, 57, x FOR PEER REVIEW 3 of 15 Medicina 2021, 57, x FOR PEER REVIEW 3 of 15 Figure 2. Clinical case using a computer-aided design/computer-aided manufacturing FigureFigure 2. Clinical2. Clinical case
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