Received Date : 01-Mar-2016

Revised Date : 09-Sep-2016

Accepted Date : 12-Sep-2016
Article type : Case Report
Accepted Article
A novel method for soft tissue retraction during periapical surgery using 3D

technology: A case report.

Patel S, Aldowaisan A, Dawood, A

Department of Conservative Dentistry, King’s College London Dental Institute, London,

United Kingdom

Running title: Soft tissue retraction during periapical surgery

Keywords: apical periodontitis, endodontic microsurgery, cone beam computed tomography,

3D printing

Correspondence

Shanon Patel

Department of Conservative Dentistry, Floor 25, King’s College London Dental Institute,

London, SE1 9RT, UK

e-mail: shanonpatel@googlemail.com

Abstract:

Aim This case report describes a new approach to isolation and soft tissue retraction during

endodontic surgery using cone beam computed tomography (CBCT), computer aided design

(CAD), and three-dimensional (3D) printing.

This article has been accepted for publication and undergone full peer review but has not
been through the copyediting, typesetting, pagination and proofreading process, which may
lead to differences between this version and the Version of Record. Please cite this article as
doi: 10.1111/iej.12701
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 Summary A 53-year-old patient presented for endodontic treatment of her maxillary left

central incisor. It was decided to treat this tooth with a microsurgical approach. The data
Accepted Article
from the diagnostic CBCT scan was also used to make a physical model of the operative

site, and CAD software was used to design a soft tissue retractor to be used during the

patient’s surgery. A custom retractor was then fabricated using a 3D printer. The custom-

made retractor enhanced visualisation and soft tissue handling during the patient’s surgery.

The patient was asymptomatic at a 1-year review. No abnormalities were detected during

her clinical examination, and radiographic examination revealed complete healing of the

surgical site.

Key learning points

• The significance of proper soft tissue retraction in periapical microsurgery is under-

emphasised.

• Geometric data from CBCT scans may be harvested for a variety of uses, adding

value to the examination.

• 3D printing is a promising technology that may potentially have many uses in

endodontic surgery.

Introduction

The principle objective of endodontic therapy is to treat apical periodontitis caused by

infection of the root canal system (Ørstavik & Pitt Ford 2008). However, apical periodontitis

can still persist after primary, and even secondary root canal treatment, which may then

require surgical intervention (Barone et al. 2010).

Bacteria may remain in the apical ramifications inside and outside of a root canal making

them inaccessible to conventional root canal treatment (Siquera 2001). In addition,

periapical pathosis may also be sustained by a periapical foreign body (Nair 2006).

Endodontic surgery can treat persistent apical periodontitis by removing the infected site

thus enhancing the chances of healing (Bakland et al. 2008).

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 Endodontic surgery is now considered a microsurgical specialty with state-of-the-art

instruments (Kim & Kratchman 2006). A microsurgical approach permits clinicians to

Accepted Article
undertake endodontic surgery with more conservative osteotomies, shallower bevels,

preparation of accessory canals, retro-preparations in alignment with root canals, and more

accurate placement of biocompatible root-end filling materials (Kim & Kratchman 2006,

Saunders 2008, Setzer et al. 2010). Outcomes of endodontic microsurgery have shown

success rates ranging from 91.5-96.8% (Rubenstein & Kim 1999, Rubenstein & Kim 2002).

Cone Beam Computed Tomography (CBCT) is a promising tool to the endodontist’s

armamentarium, especially when performing surgical procedures (Patel et al. 2015). CBCT

is a three-dimensional imaging technique that appears to overcome some of the limitations

of conventional radiography, such as their two-dimensional nature (Huumonen & Ørstavik

2002), associated anatomical noise (Bender & Seltzer 1961a), and geometric distortion

(Forsberg & Halse 1994).

Use of CBCT prior to endodontic microsurgery may allow the endodontist to identify

accessory anatomy, untreated root canals, visualise the true extent of a periradicular lesion,

and prevent damage to vital anatomical structures (Low et al. 2008, Bornstein et al. 2011).

The European Society of Endodontology’s (ESE) CBCT position statement indicates that

CBCT should be considered in preoperative assessment and management of complex

periradicular surgery (ESE CBCT position statement 2014).

Three-dimensional printing uses Computer Aided Design (CAD) technology to create

physical models from geometric data (Dawood et al. 2015). 3D printing has found various

uses in aerospace, defence, arts, sciences, engineering, medicine, and dentistry. Use of 3D

printing in dentistry includes the fabrication of implants (Xiong et al. 2012) and their surgical

guides (Flügge et al. 2013), the fabrication of physical dental models (Liu et al. 2006), and

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 the assembly of copings and frameworks for implants and dental restorations (Miyazaki &

Hotta 2011).
Accepted Article
In endodontics, 3D printing may become of increasing significance when combined with

CBCT. Byun et al. (2015) described a novel method of root canal treatment of an

anomalous maxillary central incisor with the aid of CBCT and 3D printing. A translucent

physical tooth model with complex internal root canal anatomy was constructed and a

custom-made guide was used to aid access cavity preparation. The tooth was subsequently

treated successfully. In their case report, numerous anatomical intricacies and previous

iatrogenic errors would have made the tooth difficult to treat via conventional endodontic

techniques. Their custom-made jig allowed them safe and accurate access to the root canal

and ensured restorability of the tooth.

Zehnder et al. (2015) used CBCT and intra-oral optical scans to produce 3D printed

templates to gain guided access to root canals. In their ex vivo study, templates allowed

precise access cavity preparation and root canal negotiation of the apical third of extracted

teeth. Using similar techniques, Krastl et al. (2015) successfully treated a maxillary central

incisor with pulp canal obliteration.

In medicine, 3D printing technology has been used in the fabrication of custom-made

surgical instruments (Malik et al. 2015). Birnbaum et al. (2001) produced custom

polycarbonate templates using CAD and 3D printing to aid placement of pedicle screws in

spinal surgery. The templates conformed to bone allowing drilling to a prearranged point

marked on 3D images processed preoperatively. They found that this technique improved

accuracy and significantly decreased operative time.

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 In endodontic treatment the routine use of rubber dam is standard, yet when working in the

periapical region, moisture control is much more difficult, and moisture contamination could
Accepted Article
affect the sealing ability of retrograde root filling materials (Scarano et al. 2012). In addition,

soft tissue retraction has been traditionally viewed as the surgical assistant’s responsibility

(Kim & Kratchman 2006). Efficient and atraumatic soft tissue retraction is essential

regardless of whether apical surgery is being carried out on anterior or posterior teeth.

Inadvertant soft tissue damage suffered by inappropriate tissue elevation and reflection may

delay healing (Harrison & Jurosky 1991b).

This paper describes a novel surgical retractor, which takes advantage of 3D technology that

is becoming increasingly accessible in dentistry.

Case report

A 53 year old female patient was referred by her general dental practitioner (GDP) for root

canal treatment of her maxillary left central incisor (tooth 21). The patient presented to her

GDP with an abscess on the attached gingiva labial to tooth 21.

On presentation, the patient reported that tooth 21 was tender on biting. Medically, she was

fit and healthy. She was a regular dental attender.

She recalled that the tooth had root canal treatment over 20 years ago; her GDP confirmed

this stating that the tooth was treated by an endodontic specialist and a rubber dam was

used.

Clinical examination revealed a moderately restored dentition with good levels of oral

hygiene. Tooth 21 was restored with a well-adapted palatal direct composite resin

restoration. Periodontal probing depths were not greater than 2 mm. The tooth was tender to

percussion and to labial palpation. The remaining maxillary anterior teeth responded

positively to thermal and electric pulp testing.

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 A periapical radiograph using a beam aiming device and a digital charge coupled device

(Schick Technologies, New York, NY, USA) revealed that the tooth had been previously root
Accepted Article
filled, had a periapical radiolucency 3 mm in diameter, and a shortened root end (Fig 1a).

With the consent of the patient, a small volume CBCT scan (3D Accuitomo 80; J Morita

Manufacturing, Kyoto, Japan) with exposure parameters 80 kV, 3.0 mA and 17.5 s was

taken of the area of interest. The reconstructed images from the CBCT scan revealed that

periapical radiolucency was 5 mm in diameter, had not perforated the palatal cortical plate

and that the incisive foramen was not in close proximity (Fig 1b, c).

A diagnosis of chronic periapical periodontitis associated with an existing root filling and

external inflammatory resorption was reached for tooth 21. After discussing the various

treatment options with the patient, it was decided to treat the tooth with a microsurgical

approach.

The volumetric data from the CBCT scan was exported as a Digital Imaging and

Communications in Medicine (DICOM) file. As a starting point in the retractor design process,

the DICOM file was converted into a stereolithography (STL) file using CAD software

(Mimics, Materialise, Lueven, Belgium). The STL file was then uploaded to an industrial

design and 3D printing studio (www.digits2widgets.com), and a resin 3D printed model of

the surgical site ordered (Fig 2a). To convey the intended design of the retraction device to

the designer, a ‘mock-up’ of the device was formed in dental wax on the resin model of the

surgical site (Fig 2b). This sketch design was then reinterpreted by the industrial designer at

the 3D print studio against the 3D model in a software environment using CAD software

(Spaceclaim, Concord, Massachusetts, USA) (Fig 2c, d). A variety of screenshots of the

device were then sent for approval, and minor adjustments made. At the end of this

collaborative iterative design process, the STL file of the device was printed in an

autoclavable nylon material, and its fit confirmed against the anatomical model (Fig 2e).

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 On the day of surgery, local anaesthetic was administered via labial and palatal infiltration.

A full thickness mucoperiosteal flap with distal releasing incisions was raised from tooth 12
Accepted Article
to tooth 22. The autoclaved custom retractor clipped onto the incisal edges of the teeth and

was used to hold the flap into place and keep it away from the operating area (Fig 2f).

Treatment was carried out with the aid of a dental operating microscope (3 step entreé;

Global, St Louis, MO, USA). An osteotomy was created with a long tapered diamond bur in a

surgical high-speed handpiece (Twinpower 47, J Morita), after which all visible granulation

tissue was removed. Due to the already short nature of the root, a 2 mm apical root

resection with a shallow bevel was carried out on tooth 21. There were no signs of root

fracture on the resected root surface. A 3 mm root-end cavity was prepared on the tooth with

an ultrasonic tip (KiS ID, Obtura Spartan, Il, USA) and was sealed with IRM (Dentsply

DeTrey GmbH, Konstanz, Germany), (Fig 3a). The flap was repositioned and sutured (5/0

Ethilon, Ethicon Inc, Somerville, NJ, USA). Verbal and written post-operative instructions

were given to the patient following the procedure. The patient was reviewed 3 days later.

The surgical site was healing well; the patient did not report any postoperative pain or

discomfort and the sutures were removed.

At a 1 year review the patient was asymptomatic. Clinical examination was unremarkable.

Radiographic examination revealed completed healing of the surgical site (Fig 3b).

Discussion

Persistent apical periodontitis is preferably treated by root canal retreatment (Barone et al.

2010). However, post-treatment failure can still occur when treatment has been performed to

a good standard (Siqueira et al. 2001). Apical periodontitis may persist because of

extraradicular infections, and/or due to intra-radicular infection (Nair 2006). The infected

site(s) may not be accessible by conventional therapy, and therefore may require surgical

intervention. Patient preference, and benefit-risk analysis may also favour management of

persistent apical periodontitis by periapical surgery instead of root canal retreatment

This article is protected by copyright. All rights reserved.

 (Friedman 2002). In this case, the tooth was previously treated by an endodontic specialist

under aseptic conditions.

Accepted Article
The patient consented to have endodontic microsurgery performed after being informed of

the risks and benefits of all treatment options, which included conventional root canal

retreatment. The healing observed in this case demonstrates the effectiveness of

microsurgical techniques, especially when compared with traditional methods (Setzer et al.

2010). As the patient initially had the root canal treatment carried out under rubber dam by

an endodontist it was felt that her choice of treatment was justifiable.

This case report presents a novel technique for soft tissue retraction during periapical

surgery. The relevance of adequate and atraumatic soft tissue retraction in periapical

microsurgery is often under-emphasised. Improved access and soft tissue handling will

ultimately improve the efficiency of treatment as well as the predictability of soft tissue

healing (Cortellini & Tonetti 2001). Microsurgery alone will not enhance epithelial healing

rates, but optimal tissue adaptation of wound edges can create smaller distances for

epithelial migration during the healing process; more rapid soft tissue healing is a result of

decreased tissue trauma and improved wound closure during microsurgical procedures

(Velvart & Peters 2005). Frequent slippage of a retractor during surgery is one of the major

causes of postoperative tissue swelling and can trigger transient parasthesia in the

mandibular molar/premolar region (Kim & Kratchman 2006). The 3D printed retractor used in

this case provided stable soft tissue retraction, and was easily sterilised beforehand to

reduce contamination of the surgical field.

Many endodontic surgical failures have been attributed to poor visibility and ability to treat

the microscopic causes of apical disease (Setzer et al. 2010). The retractor described in this

case report was designed in such a way to provide a clear “window” to perform an

osteotomy and root-end surgery. This allowed the operator to ensure that the osteotomy site

was kept as small as practically possible, and in this case both the operator and patient

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 benefited from improved visualisation, soft tissue handling, and moisture control. Rubinstein

& Kim (1999) demonstrated that there was a correlation between the size of the osteotomy
Accepted Article
and the time of healing. They showed that smaller osteotomies tended to heal faster using

radiographic changes as evidence.

Regardless of whether endodontic surgery is being planned on anterior or posterior teeth

atraumatic handling of soft tissues is essential to increase the likelihood of successful

healing and plays a significant role in the aesthetic outcome of endodontic surgery (Velvart &

Peters 2005). Therefore the use of a custom made retractor was felt to be justified in this

case.

Fabrication of a retractor using CBCT and 3D printing may ultimately be used to improve the

microsurgical management of posterior teeth. Mandibular molars, in particular, are more

difficult to treat with a microsurgical approach (Bornstein et al. 2011). Periradicular surgery in

mandibular molars is associated with complications such as challenging access to the roots

as a product of the posterior location, depth of the buccal cortical plate (Rud et al. 2001),

and closeness of the roots or pathologic processes to the mandibular canal (Littner et al.

1986). In a prospective study involving two district general hospitals, 20%–21% of patients

experienced sensory disorders of the lower lip after periradicular surgery on mandibular

molars (Wesson & Gale 2003). Fabrication of a custom made retractor may provide

surgeons better vision and more stable soft tissue retraction during surgical treatment of

mandibular premolars and molars. This may help prevent soft tissue trauma and damage to

adjacent sensory nerves.

Prospective clinical trials have demonstrated that there was no significant difference

between MTA and IRM as root-end filling materials in the outcome of endodontic surgery

when modern microsurgical techniques were used (Chong et al. 2003, Lindeboom et al.

2005). Zuolo et al. (2000) reported a success rate of 91.2% using contemporary surgical

This article is protected by copyright. All rights reserved.

 techniques and IRM as a root-end material in their prospective clinical study. IRM was used

in this case due to its ease of handling.

Accepted Article
The use of CAD CAM technology has become commonplace in the dental laboratory, and

many now have their own scanners and milling units (van Noort 2012). In the dental surgery,

intra-oral and CBCT scanners are becoming more mainstream, and dental professionals are

becoming well acquainted and adept at working with large volumes of digital data (Dawood

et al. 2015).

3D printing offers another form of output for dental CAD software, making it possible to

develop complex components and objects in an array of different materials (Liu et al. 2006).

3D printing technologies have been readily available for more than a decade (Petzold et al.

1999). However, developments and access to scanner technology and CAD software have

made this technology easier to use (Malik et al. 2015, van der Meer et al. 2016). In addition,

commercial and public interest has made 3D printing more affordable, raised awareness,

and improved access to resources (Cohen et al. 2009, Condino et al. 2011, Duan et al.

2013)

In this case, sintered nylon was selected as the material of choice, as it is robust, flexible,

and autoclavable, but other options might include titanium, stainless steel and other plastic

materials (Dawood et al. 2015). 3D printed retractors may be customised to suit the nature

of their intended purpose.

The use of CBCT in this case significantly enhanced the management of this surgical case,

allowing the determination of bone thickness, the nature of the periapical lesion, and the

inclination of the root, which are all pertinent factors in preoperative assessment for

endodontic surgery (Patel et al. 2015). The fabrication of the 3D printed model and the

custom retractor show how patient management may be further improved from an existing

CBCT scan.

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 It is essential that the radiation dose is optimized and kept As Low as Reasonably

Achievable (ALARA) when exposing patients to ionising radiation (Farman 2005). Use of
Accepted Article
CBCT must be justified and only be utilised when it enhances the management of a case

(ESE CBCT position statement 2014). The smallest field of view suitable for the clinical

situation should be used to decrease radiation doses (Patel et al. 2015). This is even more

relevant for younger patients, who are more sensitive to the stochastic effects of radiation

(Verdun et al. 2008). The effective dose of the CBCT scanner (3D Accuitomo; J Morita Mfg.

Corp) used in this case was approximately 13 μSv (Loubele et al. 2009), which is in the
same magnitude of 2–3 standard periapical exposures (Arai et al. 2001, Mah et al. 2003).

Conclusion

The use of CBCT in this case not only assisted in the diagnostic process, but also enabled

the production of a custom 3D printed soft tissue retractor, which improved access to the

surgical site, whilst also improving treatment efficiency and minimizing soft tissue damage.

Acknowledgments

The authors acknowledge Mr. Tom Mallinson of www.digits2widgets.com for design and

production of the device.

Conflict of Interest statement

The authors have stated explicitly that there are no conflicts of interest in connection with

this article.

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Accepted Article
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Accepted Article
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Accepted Article
Figure Legends

Figure 1 (a) Preoperative radiograph of tooth 21 revealed a periapical radiolucency

associated with this tooth. (b) Preoperative coronal and (c) sagittal reconstructed cone beam

computed tomography (CBCT) images showed that the periapical lesion was approximately

5 mm in diameter with no perforation of the palatal cortical plate, and that the incisive

foramen was not in close proximity.

Figure 2 (a) A surface model of the area of interest was fabricated from CBCT DICOM data.

The location of the lesion was marked in red wax as a reference point for the retractor’s

design. (b) A ‘mock-up’ retractor was made in dental wax on the anatomical model to convey

the intended design to the technician prior to 3D printing. (c-d) The preliminary design was

reinterpreted and modified by an industrial designer at a 3D print studio against the 3D

model using CAD software. (e) The retractor was tried in on the model to check fit and

access. (f) The custom retractor improved soft tissue management and access during the

patient’s periapical microsurgery.

Figure 3 (a) An immediate postoperative radiograph of tooth 21 was taken after the patient’s

surgery to ensure proper root resection and compaction of the IRM retrofilling. (b) 1 year

follow-up radiograph of tooth 21 demonstrated complete healing of the surgical site.

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Accepted Article

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Accepted Article

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