Efficiency and accuracy of augmented reality guided endodontic surgery: a systematic review

BACKGROUND: Endodontic microsurgery (EMS) is a precision-dependent procedure in which accurate localization of the root apex and controlled osteotomy are critical for successful outcomes. Despite advances in cone-beam computed tomography (CBCT), magnification, and microsurgical techniques, discrepancies between preoperative planning and intraoperative execution remain a persistent challenge, largely due to limitations in depth perception and spatial interpretation. Augmented reality (AR) technology has been introduced as an intraoperative guidance tool that enable real-time superimposition of three-dimensional anatomical data onto the surgical field, with the potential to enhance visual spatial integration and procedural accuracy. However, the effectiveness of AR-assisted EMS remains unclear due to limited and methodologically heterogeneous evidence. METHODS: A systematic review was conducted in accordance with PRISMA 2020 guidelines. Electronic searches were performed in PubMed, Scopus, and Web of Science, supplemented by citation searching. Studies evaluating AR EMS were included. Data extraction was performed using a standardized framework, and outcomes were grouped into accuracy, efficiency, safety, operator-related parameters, and treatment completeness. Risk of bias was assessed using Cochrane RoB 2 for randomized studies and ROBINS-I (version 2) for non-randomized studies. RESULTS: Three studies met the inclusion criteria, comprising one randomized simulation study, one in vitro comparative study, and one ex vivo cadaveric study. AR-assisted workflows consistently demonstrated improved spatial accuracy, reflected by reduced linear and angular deviations during osteotomy and root-end resection. Operator-related outcomes, including confidence and usability, were positively influenced. However, efficiency outcomes were inconsistent across studies, and one study reported increased residual lesion volume, indicating a potential trade-off between precision and treatment completeness. Risk of bias ranged from moderate to high, primarily due to confounding and measurement-related limitations. CONCLUSIONS: AR guided EMS demonstrates promising improvements in surgical accuracy and operator interaction however; the current evidence is limited by methodological heterogeneity and lack of clinical validation. AR should be considered a precision-enhancing adjunct rather than a replacement for conventional techniques. Further standardized and clinically relevant studies are required to establish its translational applicability in endodontic practice.