Virtual surgical planning with dual-stage guide using internal irrigation for cortical plate access and apicectomy

Endodontic microsurgery (EMS) performed on mandibular molars poses complex challenges due to difficult accessibility, thick mandibular plate of bone, and poor visibility. The aim of this case report is to present the clinical application of virtual surgical planning with a novel dual-stage surgical guide featuring integrated internal irrigation, used to facilitate cortical plate access and apicectomy of a mandibular molar. A 64-year-old healthy male patient was referred with the chief complaint of constant ache and discomfort associated with the endodontically treated mandibular right first molar. Clinically, the tooth was tender to percussion. Intraoral periapical radiograph revealed periapical radiolucency associated with the tooth. The tooth was diagnosed with previous endodontic treatment with symptomatic apical periodontitis. EMS was performed on the mesial root, utilizing a dual-stage surgical guide with internal irrigation. The guide enabled controlled corticotomy and apicectomy, followed by retrofilling and repositioning of the bony window. Cone-beam computed tomography at 12 months revealed excellent osseous healing, with only minor remodeling at the mesial cortical plate. The image also demonstrated a clearly defined trephine cutting angle, indicating precise guidance by the second-stage component. The surgical guide design mitigated critical risks by protecting the adjacent distal root, enabling accurate apical third resection, and maintaining effective irrigation throughout the procedure. This case report emphasizes the potential of guided microsurgical techniques in managing complex posterior cases, improving accuracy, safety, and efficiency – while empowering less experienced clinicians with greater procedural confidence.