Endodontic Microsurgery Utilizing an Autonomous Robotic System for the Maxillary Second Molar: A Case Report

Endodontic Microsurgery Utilizing an Autonomous Robotic System for the Maxillary Second Molar: A Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Endodontic Microsurgery Utilizing an Autonomous Robotic System for the Maxillary Second Molar: A Case Report Minting Wan, Lishan Huang, Xiaoxing Li, Siyu Li, Qingsong Wu, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6838364/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 27 Oct, 2025 Read the published version in BMC Oral Health → Version 1 posted 9 You are reading this latest preprint version Abstract Background Endodontic microsurgery (EMS) is a widely utilized technique for addressing periapical periodontitis that is unresponsive to conventional root canal treatment. Nevertheless, achieving precise root apex location and resection can pose significant challenges for surgeons, particularly in complex anatomical situations. The inherent difficulties in accessing and the restricted visualization typically render EMS infeasible in the second molar region. The autonomous robotic (ATR) system, characterized by its automation, precision, and stability, is anticipated to address the limitations inherent in manual operations within complex EMS scenarios. Herein, this report details the successful application of robot-assisted EMS in a maxillary second molar. Case presentation: A 26-year-old female patient presented to our hospital with chronic periapical periodontitis following a previous history of root canal treatment in the right maxillary second molar. The patient data were imported into DentalNavi software to design the drilling path for precise resection while avoiding damage to the maxillary sinus. Through the integration of an optical pose tracking mechanism and the computerized operational system, the robot arm completed the autonomous resection task of the mesiobuccal root according to the preoperative plan, providing a position reference for the free-hand operation of the distal buccal root. No complications were reported during the surgery. Clinical and radiographic assessments at a six-month follow-up indicated satisfactory outcomes. Conclusions The ATR system offers an accurate, safe, and minimally invasive technique for osteotomy and apicoectomy. This technology demonstrates potential as a reliable and clinically effective technique for managing complex and anatomically challenging EMS procedures. Endodontic microsurgery autonomous robotics second molar root-end resection osteotomy Figures Figure 1 Figure 2 Figure 3 Figure 4 Background The pathogenesis of refractory periapical periodontitis is usually related to external root surface microbial infections and abnormal root canal anatomy, which usually cannot be resolved through conventional root canal treatment (RCT)[ 1 ]. With the advancements in cone beam computed tomography (CBCT), microsurgical instruments, and bioceramic materials, modern endodontic microsurgery (EMS) has become a frequently employed intervention for preserving natural teeth following unsuccessful RCT[ 2 , 3 ]. However, posterior molars present significantly greater surgical challenges than anterior teeth, often resulting in less favorable outcomes[ 4 , 5 ]. The anatomical positioning of the second molar poses substantial challenges for precise localization and root-end resection due to the limited accessibility of instruments, obstruction by soft tissue, and a restricted visual field, even for experienced surgeons[ 3 , 6 , 7 ]. Additionally, the proximity of the root apex of maxillary molars to the maxillary sinus necessitates careful attention to potential sinus perforation, thereby increasing the technical sensitivity and risk of complications[ 8 ]. Static navigation (SN), grounded in the concept of digital-guided therapy, was introduced into EMS[ 9 ]. This technique employs a computer-designed, 3D-printed template to guide osteotomy and apicoectomy, resulting in more precise and minimally invasive surgical outcomes than freehand surgery[ 10 ]. However, the inherent bulk of the navigation template inevitably limits its application in areas with restricted access, particularly concerning the second molars. In contrast, Dynamic navigation (DN), with its optical tracking system, offers real-time visualization and is better suited for managing complex EMS cases[ 11 ]. Despite its advantages, DN has limitations, including the high demands on hand-eye coordination, the potential for deviation due to the absence of physical constraints, and the impact of additional hand accessories on operator tremors and fatigue[ 12 ]. These factors collectively constrain the efficacy of DN in procedures involving the second molars and increase the risk of iatrogenic injury[ 7 ]. The piezoelectric "bone window" technique offers an adequate view of the surgical area in the EMS of mandibular second molars[ 6 ]. However, the preparation and repositioning of the bony lid also underscore the importance of clinical experience and skill. Regardless of the technology employed, the critical aspects of a surgical procedure are still executed manually by surgeons, where human factors can influence the accuracy of the surgery. Consequently, further exploration of more promising alternative surgical options for second molars is warranted. In recent years, surgical robotics have achieved significant advancements in refinement, intelligence, and autonomy[ 13 ]. The autonomous robotic (ATR) system is an advanced technology that has been demonstrated to enhance accuracy and mitigate risks during implant surgeries[ 14 – 16 ]. This technique employs an optical pose tracking mechanism and a computerized operational system to direct the robotic arm in executing autonomous movements and drilling tasks according to the preoperative plan[ 15 ]. Owing to the precision and task autonomy of the robotic arm, robot-assisted endodontic microsurgery (RA-EMS) holds promise for increased accuracy and predictability in osteotomy and apicoectomy, potentially minimizing the risk of human error and improving surgical prognosis[ 17 , 18 ]. Isufi et al.[ 19 ] and Liu et al.[ 20 ] have reported the precise application of RA-EMS in treating premolars and a first molar with intact buccal cortical bone, respectively. These findings suggest the potential advantages of dental robotics in the management of EMS. Therefore, utilizing autonomous and fatigue-free robotic systems offers a promising alternative to address the limitations inherent in manual operations, particularly in complex anatomical scenarios that require enhanced precision and safety in access procedures. This article presents a case of RA-EMS successfully performed on a maxillary second molar adjacent to the maxillary sinus, with satisfactory healing observed at a six-month follow-up. Case presentation A 26-year-old female presented at the Affiliated Stomatology Hospital of Guangzhou Medical University, complaining of chewing pain in the left maxillary second molar for two weeks. Teeth #13 and #15 had previously received fixed partial denture restoration, which was later removed, and then underwent RCT of Tooth #15 in our department 7 months ago. During treatment, the second mesiobuccal (MB2) canal and the apical portion of the MB canal were found to be calcified, while the other canals were treated effectively. Clinical examination during this visit revealed that tooth #15 had been crown-prepared and restored with resin (Fig. 1A). Tooth #15 exhibited tenderness to percussion and palpation, no response to pulp sensitivity testing, physiological mobility, normal probing depth, with no sinus tract observed. Radiological examinations revealed radiolucency associated with the MB and distobuccal (DB) roots. The DB canal, palatal canal, and the upper portion of the MB canal were obturated. However, the MB2 canal and the apical portion of the MB canal were not visible and unfilled (Fig. 1B-E). The apices of tooth #15 were in close proximity to the maxillary sinus, with the minimum distance from the MB apex to the sinus floor measuring 1.4 mm (Fig. 1D). Additionally, the buccal cortical bone plate was intact (Fig. 1E). Tooth #15 was diagnosed with chronic periapical periodontitis following a previous history of RCT. Considering the limited efficacy of retreatment options and the complexity of the surgical intervention, it was recommended that the patient undergo EMS assisted by the ATR system (Yakebot; Yakebot Technology Co, Ltd, Beijing, China). The patient's informed consent was duly obtained. Data Acquisition The patient's jaw data were acquired using a CBCT scan (Carestream Health Inc, Rochester, NY, USA) and exported in Digital Imaging and Communications in Medicine format (Fig. 2A). An intra-oral scanner, Cerec Omnicam (Sirona, Bensheim, Germany), was employed to capture the data of the teeth and soft tissues, which were then stored in Standard Tessellation Language format (Fig. 2B). Surgical Planning The data were imported into DentalNavi software (Yekebot Technology Co, Ltd, Beijing, China) to reconstruct a 3D model and generate a virtual patient (Fig. 2C). The surgical plan was developed to position a virtual bone trephine bur to resect 3 mm of the MB root-end perpendicularly (Fig. 2D-G). A 3.5 mm diameter, 10 mm length bone trephine bur was selected (Fig. 2H). The drilling path was meticulously designed to avoid the maxillary sinus. Due to limited traction of the cheek mucosa, the DB apex was treated freehand during surgery, using the target point of the MB apex as a reference. Personalized surgical accessories were 3D printed, and the visual marker was designed to be parallel to the patient's sagittal plane (Fig. 2I and J). Surgical Procedure On the surgery day, the robotic instrument was positioned near the surgical site. The robotic arm, trephine bur, and probe tip were calibrated sequentially (Fig. 3A and B). Anesthesia was administered to the surgical area using 1.7 mL 4% articaine and epinephrine 1/100,000. The surgery was performed by an endodontic specialist with more than 10 years of experience in EMS. A rectangular flap was designed and implemented to ensure full exposure of the surgical area (Fig. 3D). Subsequently, the surgical accessories equipped with a visual marker were affixed to the anterior dentition of the surgical dental arch. The intraoral registration was performed by calibrated probe (Fig. 3C). The manual guided path of the robotic arm was recorded. Ultimately, the robot system transitioned the autonomous mode to prepare for tissue resection. The surgeon used the foot pedal to control the autonomous procedure and monitored the process via the DentalNavi interface during entire process. The robotic arm automatically performed osteotomy and root-end resection with sterile saline irrigation, following the recorded path at a rotational speed of 800-1200rpm (Fig. 3E and F). Once the trephine bur reached the preset depth of the osteotomy, the robotic arm stopped drilling and exited to its original position. After resecting the MB root-end, the surgeon enlarged the bone cavity under a microscope (OPMI Proergo; Carl Zeiss, Göttingen, Germany) and resected the DB root-end by 3mm (Fig. 3G and H). Careful periapical curettage was performed. No maxillary sinus floor injury was observed. The resected root surface showed no cracks, but the MB2 apical foramen was not found. The 3 mm depth of the MB and DB root ends was prepared with an ultrasonic tip (Obtura Spartan, Fenton, MO) and filled with iRoot BP Plus (Innovative Bioceramics, Vancouver, BC, Canada) (Fig. 3I and J). Concentrated growth factors (CGF) were prepared from 20 ml of the patient's venous blood, pressed into a film, and placed in the bone cavity (Fig. 3K). The 6 − 0 monofilament sutures were used for flap suturing (Fig. 4A). Results An immediate postoperative radiological examination confirmed the precise resection of the root ends (Fig. 4B). Sutures were removed a week post-surgery. The patient was asymptomatic, exhibiting only slight redness and swelling in the soft tissue of the surgical area (Fig. 4C and D). Follow-up evaluations at six months demonstrated satisfactory clinical outcomes, with radiological evidence indicating a recovery in periapical bone density (Fig. 4E and F). Discussion To our knowledge, this is the first case report of RA-EMS involving the maxillary second molar. EMS of the second molar presents substantial challenges for clinicians due to the limitation in accessing and obtaining direct visualization of the apex area, which requires high technical sensitivity[ 5 , 6 ]. Excessive bone resection due to difficulty in apex localization often affects the healing and increases the patient's postoperative pain[ 21 ]. The anatomical relationship between the maxillary sinus and the apices of the maxillary molar roots is frequently related to dental complications during EMS. Most studies suggest that the MB root apex of the maxillary second molar is generally nearer to the sinus compared to other molars[ 8 , 22 , 23 ], accompanied by a high risk of maxillary sinus perforation during surgical procedures[ 24 ]. In this case, the buccal bone plate remains intact, necessitating a complete resection distance of up to 9.6 mm at the MB root, which is located near the maxillary sinus. These factors present significant challenges to the stability and tactile feedback of manual procedures. Consequently, the ATR system may serve as a more advantageous approach, offering enhanced accuracy and reduced invasiveness in such complex anatomical scenarios. The robotic arm, with six degrees of freedom, facilitated flexible entry and exit movements in the maxillary second molar region, demonstrating distinct advantages in terms of accessibility. A handpiece with a 30° contra-angle was employed to cope with the narrow posterior space of the oral cavity. In this case, the RA-EMS achieved the precise osteotomy and apicoectomy of the MB root according to the pre-designed trajectory without causing damage to adjacent vital structures. Although the DB root was performed freehand due to the obstruction caused by the patient's cheek, the ATR system still provided a reference for its relative position and a visual surgical field for accurate freehand localization and resection. This case's shortcoming lies in the failure to identify the MB2 apical foramen during surgery. The CBCT revealed diffuse calcification along the path of the MB2 canal, and the inherent anatomical constraints of the region still pose significant difficulties for surgical operations. Additionally, the most apical part of the main root canal, as well as the apical ramifications and lateral canals, are the most common areas of bacterial persistence[ 1 , 21 ]. Successful resection and obturation of MB and DB root ends are expected to achieve effective infection control. This was corroborated by the satisfactory healing observed at the 6-month follow-up. The stability of drilling and the real-time feedback of patient micromovement are critical factors influencing the resection accuracy in RA-EMS. The infrared-based optical tracking system precisely tracks the head movements of the patient in real-time[ 13 ]. During the operation, the patient's head was tilted right. This position made tracking conventional visual markers, which are typically perpendicular to the patient's sagittal plane, difficult for the infrared camera. We have specifically designed a visual marker parallel to the sagittal plane, thereby accommodating the unique anatomical position of the second molar region. The operational software system employs visual servo and force feedback mechanisms to guide the micromovements of the robotic arm[ 25 ] and compensate for force deformation caused by lateral force during drilling[ 13 ], thereby ensuring precise and safe positioning. With its stability and precision operating mechanism, the robotic arm complements and extends the surgeon's cognitive and sensory capabilities, even surpassing the experience limitations. This technique eliminates the impact of tremors, fatigue, and skill deficits of manual operation, thus minimizing the risk of inadvertent damage to the adjacent sinus[ 25 ]. Recent studies have shown that the RA-EMS exhibits greater accuracy and enhanced time efficiency compared with the SN and DN technology[ 17 , 26 ]. The system's visualized computer interface delivers real-time feedback on the accuracy of the autonomous drilling path, ensuring safe and predictable surgical outcomes[ 15 ]. The surgeon maintains discrete control of the ATR system, thereby enabling flexible monitoring and adjustment of the drilling program to accommodate complex surgical conditions[ 14 , 27 ]. Moreover, this technique diminishes the reliance on hand-eye coordination skills and reduces the burden on surgeons, making the operation and learning process relatively easier. Intentional replantation is also a common approach for treating second molars with refractory periapical periodontitis[ 28 , 29 ]. However, it is necessary to carefully consider the challenges associated with minimally invasive tooth extraction[ 30 ], as well as the effects of granulation tissue curettage on the periodontal ligament for the tooth in this case[ 28 ]. With limited access and proximity to critical anatomical structure, the ATR provides precise surgical procedures, potentially mitigating the technique sensitivity of performing EMS on the maxillary second molar. However, RA-EMS on the maxillary second molar imposes more stringent requirements for mouth opening and buccal mucosa traction. The precision of RA-EMS necessitates further clinical validation. Simplifying preoperative preparation and incorporating machine learning is essential. Moreover, further investigation is required to develop a compact drilling system for the restricted space in the posterior region. Conclusion We present a pioneer report evaluating the feasibility and efficacy of implementing an ATR system for the EMS on the maxillary second molar. RA-EMS offers an accurate, safe, and minimally invasive technique for osteotomy and apicoectomy in challenging anatomical areas within this case's constraints. This advancement is anticipated to address challenges in the field of EMS that have proven difficult to resolve through manual operation technology, thereby ultimately improving and promoting patient-centered healthcare quality. Abbreviations EMS Endodontic microsurgery ATR Autonomous robotic RCT Root canal treatment SN Static navigation DN Dynamic navigation RA-EMS Robot-assisted endodontic microsurgery MB2 Second mesiobuccal MB Mesiobuccal DB Distobuccal CGF Concentrated growth factors Declarations Ethics approval and consent to participate This study did not involve experiments with human or animal subjects, and therefore, no ethical approval was required. The clinical trial number is not applicable. The patient provided written consent to receive treatment and authorized the use of their information for medical research purposes. Consent for publication The patient gave the written informed consent for the publication of this case report and any accompanying images. Availability of data and materials The datasets used and/or analysed during this study are available from the corresponding author on reasonable request. Competing interests The authors deny any conflicts of interest related to this study. Funding This work was supported by the Natural Science Foundation of Guangdong Province (No. 2023A1515012777), the Science and Technology Planning Project of Guangzhou (No. 202201020203, 202201020117), Featured Clinical Technique of Guangzhou (No.2023C-TS58), and the Plan on enhancing scientific research in GMU (No.GMUCR2024-02024). Authors' contributions Manuscript writing and Investigation: MW; Data collation and analysis: LH; Supervision and validation: XL; Resources and investigation: SL and QW; Methodology and validation: CG and YL; Conceptualization, writing – review and editing, supervision, project administration and funding acquisition: XY. All authors read and approved the final manuscript. MW and LH are joint first authors and contributed equally to the paper. Acknowledgements Not applicable. References Nair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249–81. 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Cite Share Download PDF Status: Published Journal Publication published 27 Oct, 2025 Read the published version in BMC Oral Health → Version 1 posted Editorial decision: Revision requested 16 Jul, 2025 Reviews received at journal 09 Jul, 2025 Reviewers agreed at journal 02 Jul, 2025 Reviews received at journal 01 Jul, 2025 Reviewers agreed at journal 26 Jun, 2025 Reviewers invited by journal 26 Jun, 2025 Editor assigned by journal 16 Jun, 2025 Submission checks completed at journal 16 Jun, 2025 First submitted to journal 06 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6838364","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":477093242,"identity":"839df82b-2349-4d29-b0c9-45e9eb5a3164","order_by":0,"name":"Minting Wan","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Minting","middleName":"","lastName":"Wan","suffix":""},{"id":477093243,"identity":"07ec3c94-6d8a-4bef-bb76-f272c6f3ddd2","order_by":1,"name":"Lishan Huang","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Lishan","middleName":"","lastName":"Huang","suffix":""},{"id":477093244,"identity":"39bd859f-bbec-4318-9d62-aa5a0baf10f0","order_by":2,"name":"Xiaoxing Li","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xiaoxing","middleName":"","lastName":"Li","suffix":""},{"id":477093245,"identity":"dd6ddb1f-efb9-4742-b219-b321ff968170","order_by":3,"name":"Siyu Li","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Siyu","middleName":"","lastName":"Li","suffix":""},{"id":477093246,"identity":"5cb6bbfc-99f0-4064-ba4e-e48a87223fc0","order_by":4,"name":"Qingsong Wu","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Qingsong","middleName":"","lastName":"Wu","suffix":""},{"id":477093247,"identity":"0b4bdba5-aee8-4556-9f5c-00e33a5ad675","order_by":5,"name":"Chengji Gong","email":"","orcid":"","institution":"Beijing YakeBot Technology Co., Ltd","correspondingAuthor":false,"prefix":"","firstName":"Chengji","middleName":"","lastName":"Gong","suffix":""},{"id":477093248,"identity":"a4d760fb-657e-45be-b397-732e1fdb9ad1","order_by":6,"name":"Yufei Li","email":"","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":false,"prefix":"","firstName":"Yufei","middleName":"","lastName":"Li","suffix":""},{"id":477093249,"identity":"a6e4f052-dda1-47aa-ba13-2d9f43e888be","order_by":7,"name":"Xuechao Yang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA3UlEQVRIiWNgGAWjYPACGwYGCTCDmWgtaaRrOUyCFoPjZww/F/w6bzd/dneaBEOFdWID+9kDeLVI9uQYS8/su53cOOfsNgmGM+mJDTx5CXi18EvwGEjz9txOZpbI3SbB2HY4sQEoglcLmwSP8W/ennPJbGAt/4jQArTFTJrnxwE7HrCWBiK0SPaklVnzNiQnSEjkbrZIOJZu3MaTg1+LwfHDm2/z/LGzl5+Ru/HGhxpr2X72M/i1MDBwGDAwtjEkNoDYCSDfEVAPBOwPGBj+MNgTVjgKRsEoGAUjFgAAId5AXkiX3ncAAAAASUVORK5CYII=","orcid":"","institution":"Guangzhou Medical University","correspondingAuthor":true,"prefix":"","firstName":"Xuechao","middleName":"","lastName":"Yang","suffix":""}],"badges":[],"createdAt":"2025-06-06 15:53:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6838364/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6838364/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12903-025-06964-6","type":"published","date":"2025-10-27T15:57:40+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85824642,"identity":"b3bafc37-ba55-459f-b8f8-2b61505479d8","added_by":"auto","created_at":"2025-07-02 07:04:24","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":312682,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative examination. (A) Preoperative photograph. (B) Preoperative periapical radiography. (C) Coronal view of preoperative CBCT. (D) Sagittal view of preoperative CBCT, showing MB apex distance 1.4mm from maxillary sinus. (E) Axial view of preoperative CBCT, showing intact buccal cortical plate and the resection depth was 9.6 mm from the MB root's lingual surface to the cortical bone.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6838364/v1/d6173dac77ee2f59591a7c07.jpeg"},{"id":85823964,"identity":"875d2cfc-d907-48ed-8669-35e93f4650b2","added_by":"auto","created_at":"2025-07-02 06:56:24","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":131529,"visible":true,"origin":"","legend":"\u003cp\u003ePreoperative preparation. (A)Jaw data obtained by a CBCT scan. (B) Intraoral scan data including teeth and soft tissues. (C) Fit CBCT and intraoral scan data to reconstruct the 3D model. (D-H) Design drilling path. (I-J) Design and manufacture surgical personalized accessories and visual marker component.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6838364/v1/515c602f0c7f8a90b0821997.jpeg"},{"id":85824643,"identity":"4f72dec1-f72d-43a6-b497-74a430c1a67a","added_by":"auto","created_at":"2025-07-02 07:04:24","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":308054,"visible":true,"origin":"","legend":"\u003cp\u003eCalibration, registration,and surgical procedure. (A-B) Calibration of robotic arm, trephine bur, and probe tip. (C) Intraoral registration. (D) Rectangular flap. (E-F) Implementing bone and root-end resection of MB root by the ATR system. (G) Bone and root-end resection of DB root. (H) Resection completed. (I) Retrograde preparation. (J) Retrograde filling. (K) CGF membrane placement.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6838364/v1/ac28aa2d40b982a5ff38609d.jpeg"},{"id":85826208,"identity":"e33a75a7-2d7e-43bb-8b38-a69073ba0fa7","added_by":"auto","created_at":"2025-07-02 07:12:25","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":112726,"visible":true,"origin":"","legend":"\u003cp\u003ePostoperative examination results. (A-B) Immediate postoperative photograph and radiological examination. (C) 1-week follow-up intraoral photography. (D) Sutures removal. (E-F) 6-month follow-up.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-6838364/v1/3159757ec47e1be239cc6fbd.jpeg"},{"id":95040578,"identity":"6b4fa262-da50-4608-a63d-b3314aba1c10","added_by":"auto","created_at":"2025-11-03 16:09:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1329885,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6838364/v1/7811367b-8158-4162-935a-9352234e1633.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Endodontic Microsurgery Utilizing an Autonomous Robotic System for the Maxillary Second Molar: A Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eThe pathogenesis of refractory periapical periodontitis is usually related to external root surface microbial infections and abnormal root canal anatomy, which usually cannot be resolved through conventional root canal treatment (RCT)[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With the advancements in cone beam computed tomography (CBCT), microsurgical instruments, and bioceramic materials, modern endodontic microsurgery (EMS) has become a frequently employed intervention for preserving natural teeth following unsuccessful RCT[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. However, posterior molars present significantly greater surgical challenges than anterior teeth, often resulting in less favorable outcomes[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The anatomical positioning of the second molar poses substantial challenges for precise localization and root-end resection due to the limited accessibility of instruments, obstruction by soft tissue, and a restricted visual field, even for experienced surgeons[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Additionally, the proximity of the root apex of maxillary molars to the maxillary sinus necessitates careful attention to potential sinus perforation, thereby increasing the technical sensitivity and risk of complications[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eStatic navigation (SN), grounded in the concept of digital-guided therapy, was introduced into EMS[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. This technique employs a computer-designed, 3D-printed template to guide osteotomy and apicoectomy, resulting in more precise and minimally invasive surgical outcomes than freehand surgery[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, the inherent bulk of the navigation template inevitably limits its application in areas with restricted access, particularly concerning the second molars. In contrast, Dynamic navigation (DN), with its optical tracking system, offers real-time visualization and is better suited for managing complex EMS cases[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Despite its advantages, DN has limitations, including the high demands on hand-eye coordination, the potential for deviation due to the absence of physical constraints, and the impact of additional hand accessories on operator tremors and fatigue[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These factors collectively constrain the efficacy of DN in procedures involving the second molars and increase the risk of iatrogenic injury[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The piezoelectric \"bone window\" technique offers an adequate view of the surgical area in the EMS of mandibular second molars[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the preparation and repositioning of the bony lid also underscore the importance of clinical experience and skill. Regardless of the technology employed, the critical aspects of a surgical procedure are still executed manually by surgeons, where human factors can influence the accuracy of the surgery. Consequently, further exploration of more promising alternative surgical options for second molars is warranted.\u003c/p\u003e \u003cp\u003eIn recent years, surgical robotics have achieved significant advancements in refinement, intelligence, and autonomy[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The autonomous robotic (ATR) system is an advanced technology that has been demonstrated to enhance accuracy and mitigate risks during implant surgeries[\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This technique employs an optical pose tracking mechanism and a computerized operational system to direct the robotic arm in executing autonomous movements and drilling tasks according to the preoperative plan[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Owing to the precision and task autonomy of the robotic arm, robot-assisted endodontic microsurgery (RA-EMS) holds promise for increased accuracy and predictability in osteotomy and apicoectomy, potentially minimizing the risk of human error and improving surgical prognosis[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Isufi et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] and Liu et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] have reported the precise application of RA-EMS in treating premolars and a first molar with intact buccal cortical bone, respectively. These findings suggest the potential advantages of dental robotics in the management of EMS.\u003c/p\u003e \u003cp\u003eTherefore, utilizing autonomous and fatigue-free robotic systems offers a promising alternative to address the limitations inherent in manual operations, particularly in complex anatomical scenarios that require enhanced precision and safety in access procedures. This article presents a case of RA-EMS successfully performed on a maxillary second molar adjacent to the maxillary sinus, with satisfactory healing observed at a six-month follow-up.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eA 26-year-old female presented at the Affiliated Stomatology Hospital of Guangzhou Medical University, complaining of chewing pain in the left maxillary second molar for two weeks. Teeth #13 and #15 had previously received fixed partial denture restoration, which was later removed, and then underwent RCT of Tooth #15 in our department 7 months ago. During treatment, the second mesiobuccal (MB2) canal and the apical portion of the MB canal were found to be calcified, while the other canals were treated effectively. Clinical examination during this visit revealed that tooth #15 had been crown-prepared and restored with resin (Fig. 1A). Tooth #15 exhibited tenderness to percussion and palpation, no response to pulp sensitivity testing, physiological mobility, normal probing depth, with no sinus tract observed. Radiological examinations revealed radiolucency associated with the MB and distobuccal (DB) roots. The DB canal, palatal canal, and the upper portion of the MB canal were obturated. However, the MB2 canal and the apical portion of the MB canal were not visible and unfilled (Fig. 1B-E). The apices of tooth #15 were in close proximity to the maxillary sinus, with the minimum distance from the MB apex to the sinus floor measuring 1.4 mm (Fig. 1D). Additionally, the buccal cortical bone plate was intact (Fig. 1E). Tooth #15 was diagnosed with chronic periapical periodontitis following a previous history of RCT. Considering the limited efficacy of retreatment options and the complexity of the surgical intervention, it was recommended that the patient undergo EMS assisted by the ATR system (Yakebot; Yakebot Technology Co, Ltd, Beijing, China). The patient\u0026apos;s informed consent was duly obtained.\u003c/p\u003e\n\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\n \u003ch2\u003eData Acquisition\u003c/h2\u003e\n \u003cp\u003eThe patient\u0026apos;s jaw data were acquired using a CBCT scan (Carestream Health Inc, Rochester, NY, USA) and exported in Digital Imaging and Communications in Medicine format (Fig.\u0026nbsp;2A). An intra-oral scanner, Cerec Omnicam (Sirona, Bensheim, Germany), was employed to capture the data of the teeth and soft tissues, which were then stored in Standard Tessellation Language format (Fig.\u0026nbsp;2B).\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003eSurgical Planning\u003c/h3\u003e\n\u003cp\u003eThe data were imported into DentalNavi software (Yekebot Technology Co, Ltd, Beijing, China) to reconstruct a 3D model and generate a virtual patient (Fig. 2C). The surgical plan was developed to position a virtual bone trephine bur to resect 3 mm of the MB root-end perpendicularly (Fig. 2D-G). A 3.5 mm diameter, 10 mm length bone trephine bur was selected (Fig. 2H). The drilling path was meticulously designed to avoid the maxillary sinus. Due to limited traction of the cheek mucosa, the DB apex was treated freehand during surgery, using the target point of the MB apex as a reference. Personalized surgical accessories were 3D printed, and the visual marker was designed to be parallel to the patient\u0026apos;s sagittal plane (Fig. 2I and J).\u003c/p\u003e\n\u003ch3\u003eSurgical Procedure\u003c/h3\u003e\n\u003cp\u003eOn the surgery day, the robotic instrument was positioned near the surgical site. The robotic arm, trephine bur, and probe tip were calibrated sequentially (Fig.\u0026nbsp;3A and B).\u003c/p\u003e\n\u003cp\u003eAnesthesia was administered to the surgical area using 1.7 mL 4% articaine and epinephrine 1/100,000. The surgery was performed by an endodontic specialist with more than 10 years of experience in EMS. A rectangular flap was designed and implemented to ensure full exposure of the surgical area (Fig.\u0026nbsp;3D).\u003c/p\u003e\n\u003cp\u003eSubsequently, the surgical accessories equipped with a visual marker were affixed to the anterior dentition of the surgical dental arch. The intraoral registration was performed by calibrated probe (Fig.\u0026nbsp;3C). The manual guided path of the robotic arm was recorded. Ultimately, the robot system transitioned the autonomous mode to prepare for tissue resection.\u003c/p\u003e\n\u003cp\u003eThe surgeon used the foot pedal to control the autonomous procedure and monitored the process via the DentalNavi interface during entire process. The robotic arm automatically performed osteotomy and root-end resection with sterile saline irrigation, following the recorded path at a rotational speed of 800-1200rpm (Fig.\u0026nbsp;3E and F). Once the trephine bur reached the preset depth of the osteotomy, the robotic arm stopped drilling and exited to its original position.\u003c/p\u003e\n\u003cp\u003eAfter resecting the MB root-end, the surgeon enlarged the bone cavity under a microscope (OPMI Proergo; Carl Zeiss, G\u0026ouml;ttingen, Germany) and resected the DB root-end by 3mm (Fig. 3G and H). Careful periapical curettage was performed. No maxillary sinus floor injury was observed. The resected root surface showed no cracks, but the MB2 apical foramen was not found. The 3 mm depth of the MB and DB root ends was prepared with an ultrasonic tip (Obtura Spartan, Fenton, MO) and filled with iRoot BP Plus (Innovative Bioceramics, Vancouver, BC, Canada) (Fig. 3I and J). Concentrated growth factors (CGF) were prepared from 20 ml of the patient\u0026apos;s venous blood, pressed into a film, and placed in the bone cavity (Fig. 3K). The 6\u0026thinsp;\u0026minus;\u0026thinsp;0 monofilament sutures were used for flap suturing (Fig. 4A).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eAn immediate postoperative radiological examination confirmed the precise resection of the root ends (Fig.\u0026nbsp;4B). Sutures were removed a week post-surgery. The patient was asymptomatic, exhibiting only slight redness and swelling in the soft tissue of the surgical area (Fig.\u0026nbsp;4C and D). Follow-up evaluations at six months demonstrated satisfactory clinical outcomes, with radiological evidence indicating a recovery in periapical bone density (Fig.\u0026nbsp;4E and F).\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo our knowledge, this is the first case report of RA-EMS involving the maxillary second molar. EMS of the second molar presents substantial challenges for clinicians due to the limitation in accessing and obtaining direct visualization of the apex area, which requires high technical sensitivity[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Excessive bone resection due to difficulty in apex localization often affects the healing and increases the patient's postoperative pain[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. The anatomical relationship between the maxillary sinus and the apices of the maxillary molar roots is frequently related to dental complications during EMS. Most studies suggest that the MB root apex of the maxillary second molar is generally nearer to the sinus compared to other molars[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], accompanied by a high risk of maxillary sinus perforation during surgical procedures[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. In this case, the buccal bone plate remains intact, necessitating a complete resection distance of up to 9.6 mm at the MB root, which is located near the maxillary sinus. These factors present significant challenges to the stability and tactile feedback of manual procedures. Consequently, the ATR system may serve as a more advantageous approach, offering enhanced accuracy and reduced invasiveness in such complex anatomical scenarios. The robotic arm, with six degrees of freedom, facilitated flexible entry and exit movements in the maxillary second molar region, demonstrating distinct advantages in terms of accessibility. A handpiece with a 30\u0026deg; contra-angle was employed to cope with the narrow posterior space of the oral cavity. In this case, the RA-EMS achieved the precise osteotomy and apicoectomy of the MB root according to the pre-designed trajectory without causing damage to adjacent vital structures. Although the DB root was performed freehand due to the obstruction caused by the patient's cheek, the ATR system still provided a reference for its relative position and a visual surgical field for accurate freehand localization and resection. This case's shortcoming lies in the failure to identify the MB2 apical foramen during surgery. The CBCT revealed diffuse calcification along the path of the MB2 canal, and the inherent anatomical constraints of the region still pose significant difficulties for surgical operations. Additionally, the most apical part of the main root canal, as well as the apical ramifications and lateral canals, are the most common areas of bacterial persistence[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Successful resection and obturation of MB and DB root ends are expected to achieve effective infection control. This was corroborated by the satisfactory healing observed at the 6-month follow-up.\u003c/p\u003e \u003cp\u003eThe stability of drilling and the real-time feedback of patient micromovement are critical factors influencing the resection accuracy in RA-EMS. The infrared-based optical tracking system precisely tracks the head movements of the patient in real-time[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. During the operation, the patient's head was tilted right. This position made tracking conventional visual markers, which are typically perpendicular to the patient's sagittal plane, difficult for the infrared camera. We have specifically designed a visual marker parallel to the sagittal plane, thereby accommodating the unique anatomical position of the second molar region. The operational software system employs visual servo and force feedback mechanisms to guide the micromovements of the robotic arm[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e] and compensate for force deformation caused by lateral force during drilling[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e], thereby ensuring precise and safe positioning. With its stability and precision operating mechanism, the robotic arm complements and extends the surgeon's cognitive and sensory capabilities, even surpassing the experience limitations. This technique eliminates the impact of tremors, fatigue, and skill deficits of manual operation, thus minimizing the risk of inadvertent damage to the adjacent sinus[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Recent studies have shown that the RA-EMS exhibits greater accuracy and enhanced time efficiency compared with the SN and DN technology[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The system's visualized computer interface delivers real-time feedback on the accuracy of the autonomous drilling path, ensuring safe and predictable surgical outcomes[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. The surgeon maintains discrete control of the ATR system, thereby enabling flexible monitoring and adjustment of the drilling program to accommodate complex surgical conditions[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Moreover, this technique diminishes the reliance on hand-eye coordination skills and reduces the burden on surgeons, making the operation and learning process relatively easier.\u003c/p\u003e \u003cp\u003eIntentional replantation is also a common approach for treating second molars with refractory periapical periodontitis[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. However, it is necessary to carefully consider the challenges associated with minimally invasive tooth extraction[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], as well as the effects of granulation tissue curettage on the periodontal ligament for the tooth in this case[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWith limited access and proximity to critical anatomical structure, the ATR provides precise surgical procedures, potentially mitigating the technique sensitivity of performing EMS on the maxillary second molar. However, RA-EMS on the maxillary second molar imposes more stringent requirements for mouth opening and buccal mucosa traction. The precision of RA-EMS necessitates further clinical validation. Simplifying preoperative preparation and incorporating machine learning is essential. Moreover, further investigation is required to develop a compact drilling system for the restricted space in the posterior region.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe present a pioneer report evaluating the feasibility and efficacy of implementing an ATR system for the EMS on the maxillary second molar. RA-EMS offers an accurate, safe, and minimally invasive technique for osteotomy and apicoectomy in challenging anatomical areas within this case's constraints. This advancement is anticipated to address challenges in the field of EMS that have proven difficult to resolve through manual operation technology, thereby ultimately improving and promoting patient-centered healthcare quality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eEMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eEndodontic microsurgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eATR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eAutonomous robotic\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRCT\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRoot canal treatment\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eStatic navigation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDN\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDynamic navigation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eRA-EMS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eRobot-assisted endodontic microsurgery\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMB2\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSecond mesiobuccal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMesiobuccal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDistobuccal\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCGF\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eConcentrated growth factors\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study did not involve experiments with human or animal subjects, and therefore, no ethical approval was required. The clinical trial number is not applicable.\u003c/p\u003e\n\u003cp\u003eThe patient provided written consent to receive treatment and authorized the use of their information for medical research purposes.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe patient gave the written informed consent for the publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during this study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors deny any conflicts of interest related to this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the Natural Science Foundation of Guangdong Province (No. 2023A1515012777), the Science and Technology Planning Project of Guangzhou (No. 202201020203, 202201020117), Featured Clinical Technique of Guangzhou (No.2023C-TS58), and the Plan on enhancing scientific research in GMU (No.GMUCR2024-02024).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eManuscript writing and Investigation: MW; Data collation and analysis: LH; Supervision and validation:\u0026nbsp;XL; Resources and investigation: SL\u0026nbsp;and QW; Methodology and validation: CG and YL; Conceptualization, writing \u0026ndash; review and editing, supervision, project administration and funding acquisition: XY. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eMW and LH are joint first authors and contributed equally to the paper.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNair PN. On the causes of persistent apical periodontitis: a review. Int Endod J. 2006;39(4):249\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsesis I, Rosen E, Taschieri S, Telishevsky Strauss Y, Ceresoli V, Del Fabbro M. Outcomes of surgical endodontic treatment performed by a modern technique: an updated meta-analysis of the literature. J Endod. 2013;39(3):332\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSetzer FC, Kratchman SI. Present status and future directions: Surgical endodontics. Int Endod J. 2022;55(Suppl 4):1020\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYoo Y-J, Cho E-B, Perinpanayagam H, Gu Y, Zhu Q, Noblett WC, Kum K-Y. Endodontic Microsurgery Outcomes over 10 Years and Associated Prognostic Factors: A Retrospective Cohort Study. J Endod. 2024;50(7):934\u0026ndash;43.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePallar\u0026eacute;s-Serrano A, Glera-Suarez P, Tarazona-Alvarez B, Pe\u0026ntilde;arrocha-Diago M, Pe\u0026ntilde;arrocha-Diago M, Pe\u0026ntilde;arrocha-Oltra D. Prognostic Factors after Endodontic Microsurgery: A Retrospective Study of 111 Cases with 5 to 9 Years of Follow-up. J Endod. 2021;47(3):397\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBi C, Zhou M, Zhang Y, Zheng P. Endodontic Microsurgery of Mandibular Second Molars Using the Bony Lid Approach: A Case Series. J Endod. 2022;48(12):1533\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFu W, Chen C, Bian Z, Meng L. Endodontic Microsurgery of Posterior Teeth with the Assistance of Dynamic Navigation Technology: A Report of Three Cases. J Endod. 2022;48(7):943\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLavasani SA, Tyler C, Roach SH, McClanahan SB, Ahmad M, Bowles WR. Cone-beam Computed Tomography: Anatomic Analysis of Maxillary Posterior Teeth\u0026mdash;Impact on Endodontic Microsurgery. J Endod. 2016;42(6):890\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAnderson J, Wealleans J, Ray J. Endodontic applications of 3D printing. Int Endod J. 2018;51(9):1005\u0026ndash;18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZubizarreta-Macho \u0026Aacute;, Castillo-Amature C, Montiel-Company JM, Mena-\u0026Aacute;lvarez J. Efficacy of Computer-Aided Static Navigation Technique on the Accuracy of Endodontic Microsurgery. A Systematic Review and Meta-Analysis. J Clin Med. 2021;10(2):313.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi X, Huang L, Li S, Lao S, Yan N, Wu H, Yang X. Endodontic Microsurgery with the Aid of Dynamic Navigation System Using Minimally Invasive Incision Approach in Anatomically Complex Scenarios: A Case Series. J Endod. 2024;50(12):1777\u0026ndash;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C, Zhang R, Zhang W, Wang F, Wang Z, Qin L, Bian Z, Meng L. Analysis of the accuracy of a dynamic navigation system in endodontic microsurgery: A prospective case series study. J Dent. 2023;134:104534.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Liu Y, Xie R, Li Z, Bai S, Zhao Y. The evolution of robotics: research and application progress of dental implant robotic systems. Int J Oral Sci. 2024;16(1):28.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Z, Xie R, Bai S, Zhao Y. Implant placement with an autonomous dental implant robot: A clinical report. J Prosthet Dent. 2023;S0022\u0026ndash;3913(23):00124\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJia S, Wang G, Zhao Y, Wang X. Accuracy of an autonomous dental implant robotic system versus static guide-assisted implant surgery: A retrospective clinical study. J Prosthet Dent. 2023;S0022\u0026ndash;3913(23):00284\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang W, Xu H, Mei D, Zhou C, Li X, Han Z, Zhou X, Li X, Zhao B. Accuracy of the Yakebot dental implant robotic system versus fully guided static computer-assisted implant surgery template in edentulous jaw implantation: A preliminary clinical study. Clin Implant Dent Relat Res. 2024;26(2):309\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen C, Qin L, Zhang R, Meng L. Comparison of Accuracy and Operation Time in Robotic, Dynamic, and Static-Assisted Endodontic Microsurgery: An In Vitro Study. J Endod. 2024;50(10):1448\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi Y, Inamochi Y, Wang Z, Fueki K. Clinical application of robots in dentistry: A scoping review. J Prosthodont Res. 2024;68(2):193\u0026ndash;205.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIsufi A, Hsu TY, Chogle S. Robot-Assisted and Haptic-Guided Endodontic Surgery: A Case Report. J Endod. 2024;50(4):533\u0026ndash;e539531.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Liu X, Wang X, Liu Y, Bai Y, Bai S, Zhao Y. Endodontic Microsurgery With an Autonomous Robotic System: A Clinical Report. J Endod. 2024;50(6):859\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006;32(7):601\u0026ndash;23.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePei J, Liu J, Chen Y, Liu Y, Liao X, Pan J. Relationship between maxillary posterior molar roots and the maxillary sinus floor: Cone-beam computed tomography analysis of a western Chinese population. J Int Med Res. 2020;48(6):300060520926896.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiao WC, Chang SH, Chang HH, Chen CH, Pan YH, Yeh PC, Jeng JH, Chang MC. An analysis of the relevance and proximity between maxillary posterior root apices to the maxillary sinus and the buccal cortical bone plate. J Dent Sci. 2024;19(4):1972\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang S, Wang X, Jiang J, Tiwari SK, Xiao Y, Ye L, Peng L. Relationship between the Surgical Access Line of Maxillary Posterior Teeth and the Maxillary Sinus Floor. J Endod. 2022;48(4):509\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eXie R, Liu Y, Wei H, Zhang T, Bai S, Zhao Y. Clinical evaluation of autonomous robotic-assisted full-arch implant surgery: A 1-year prospective clinical study. Clin Oral Implants Res. 2024;35(4):443\u0026ndash;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLiu C, Wang X, Liu Y, Ma D, Wu Z, Wang H, Bai S, Zhao Y. Comparing the accuracy and treatment time of a robotic and dynamic navigation system in osteotomy and root-end resection: An in vitro study. Int Endod J. 2025;58(3):529\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu XY, Shi JY, Qiao SC, Tonetti MS, Lai HC. Accuracy of robotic surgery for dental implant placement: A systematic review and meta-analysis. Clin Oral Implants Res. 2024;35(6):598\u0026ndash;608.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOng TK, Lim D, Singh M, Fial AV, FACTORS INFLUENCING THE TREATMENT, OUTCOME OF INTENTIONAL REPLANTATION ON TEETH WITH PERIAPICAL PERIODONTITIS. A SYSTEMATIC REVIEW AND META-ANALYSIS. J Evid Based Dent Pract. 2022;22(4):101722.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJaved F, Zafar K, Khan FR. Outcome of intentional replantation of endodontically treated teeth with periapical pathosis: A systematic review and meta-analysis. Aust Endod J. 2023;49(Suppl 1):494\u0026ndash;507.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePisano M, Di Spirito F, Martina S, Sangiovanni G, D'Ambrosio F, Iandolo A. Intentional Replantation of Single-Rooted and Multi-Rooted Teeth: A Systematic Review. Healthc (Basel). 2022;11(1):11.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Endodontic microsurgery, autonomous robotics, second molar, root-end resection, osteotomy","lastPublishedDoi":"10.21203/rs.3.rs-6838364/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6838364/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEndodontic microsurgery (EMS) is a widely utilized technique for addressing periapical periodontitis that is unresponsive to conventional root canal treatment. Nevertheless, achieving precise root apex location and resection can pose significant challenges for surgeons, particularly in complex anatomical situations. The inherent difficulties in accessing and the restricted visualization typically render EMS infeasible in the second molar region. The autonomous robotic (ATR) system, characterized by its automation, precision, and stability, is anticipated to address the limitations inherent in manual operations within complex EMS scenarios. Herein, this report details the successful application of robot-assisted EMS in a maxillary second molar.\u003c/p\u003e\u003ch2\u003eCase presentation:\u003c/h2\u003e \u003cp\u003eA 26-year-old female patient presented to our hospital with chronic periapical periodontitis following a previous history of root canal treatment in the right maxillary second molar. The patient data were imported into DentalNavi software to design the drilling path for precise resection while avoiding damage to the maxillary sinus. Through the integration of an optical pose tracking mechanism and the computerized operational system, the robot arm completed the autonomous resection task of the mesiobuccal root according to the preoperative plan, providing a position reference for the free-hand operation of the distal buccal root. No complications were reported during the surgery. Clinical and radiographic assessments at a six-month follow-up indicated satisfactory outcomes.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eThe ATR system offers an accurate, safe, and minimally invasive technique for osteotomy and apicoectomy. This technology demonstrates potential as a reliable and clinically effective technique for managing complex and anatomically challenging EMS procedures.\u003c/p\u003e","manuscriptTitle":"Endodontic Microsurgery Utilizing an Autonomous Robotic System for the Maxillary Second Molar: A Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-02 06:56:20","doi":"10.21203/rs.3.rs-6838364/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-16T04:54:56+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T14:13:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258650567679178258395213463468127541540","date":"2025-07-02T14:22:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-01T10:58:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"228416827168739410315630009582694778617","date":"2025-06-27T00:06:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-26T20:09:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-16T08:10:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-16T08:09:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Oral Health","date":"2025-06-06T15:43:49+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-oral-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ohea","sideBox":"Learn more about [BMC Oral Health](http://bmcoralhealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ohea/default.aspx","title":"BMC Oral Health","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a764bcc0-c953-4e3d-b775-a50f90b1ad71","owner":[],"postedDate":"July 2nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:06:30+00:00","versionOfRecord":{"articleIdentity":"rs-6838364","link":"https://doi.org/10.1186/s12903-025-06964-6","journal":{"identity":"bmc-oral-health","isVorOnly":false,"title":"BMC Oral Health"},"publishedOn":"2025-10-27 15:57:40","publishedOnDateReadable":"October 27th, 2025"},"versionCreatedAt":"2025-07-02 06:56:20","video":"","vorDoi":"10.1186/s12903-025-06964-6","vorDoiUrl":"https://doi.org/10.1186/s12903-025-06964-6","workflowStages":[]},"version":"v1","identity":"rs-6838364","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6838364","identity":"rs-6838364","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}