CBCT-guided endodontics for calcified canals: accuracy, efficiency, safety, and tooth preservation: a systematic review and meta-analysis

Guided endodontic access is increasingly used for severely calcified or obliterated canals, but most comparative evidence remains experimental and the extent to which technical advantages translate into clinical benefit is uncertain. This review evaluated the accuracy, efficiency, safety, and tooth-structure preservation of CBCT-based guided endodontic access. PubMed/MEDLINE, Scopus, Web of Science Core Collection, and Embase were searched from inception to 15 August 2026. Analytical clinical and experimental studies were distinguished from contextual clinical/safety reports. Static, dynamic, and robotic/haptic guidance were treated as separate intervention classes. Compatible outcomes were synthesized using outcome-appropriate meta-analytic methods, with HKSJ inference for few-study continuous random-effects analyses. Confidence in clinical inference was assessed using a GRADE-informed framework. Seventy-nine eligible reports were included: 32 reports representing independent analytical studies and 47 contextual clinical/safety reports. Twenty-five of the 32 analytical studies were non-clinical, and all primary meta-analyses concerned static guidance. Static guidance was associated with less tooth-structure loss (MD − 35.29 mm 3 , 95% HKSJ CI − 62.24 to − 8.33; I 2 = 98.2%) and shorter measured access/procedure time (MD − 13.72 min, 95% HKSJ CI − 18.88 to − 8.55; I 2 = 59.4%). Canal-access failure was less frequent with static guidance (OR 0.082, 95% CI 0.031–0.216), with similar relative estimates in laboratory and clinical strata. No perforations occurred in 157 static-guided preparations compared with 18/162 conventional preparations. Angular deviation showed no consistent advantage; the favourable apical-deviation estimate remained heterogeneous. Dynamic-navigation and robotic/haptic evidence was substantially more limited. Static guidance shows technical advantages under predominantly experimental conditions, particularly for canal access, measured procedure time, and tooth-structure preservation. Current evidence does not establish the magnitude of patient-level clinical benefit or complication reduction. Comparative clinical evidence for static guidance remains limited, while evidence for dynamic and robotic/haptic systems is less mature.