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Authors: Dr. Neelam Mittal, Dr. Anoop Mohandas

ABSTRACT

The advancement in dentistry showers a lot of conservative approaches that provide the opportunity for patients to maintain their functional dentition for decades or life time. Hemisection is a simple procedure that refers to removal and separation of the root with its accompanying crown portion of two-rooted tooth especially mandibular molars. It is an interdisciplinary approach of endodontics, periodontics and restorative dentistry. This case report presents retaining a periodontally affected mandibular second molar with subgingival caries by hemisection and further crown placement.

INTRODUCTION


The advancement in dentistry showers a lot of conservative approaches that provide the opportunity for patients to maintain their functional dentition for decades or life time. The treatment modalities to ensure retention of the tooth in the arch varies in complexity and combines interdisciplinary approaches involving restorative dentistry, endodontics, periodontics and prosthodontics.

Tooth resection procedures preserve as much tooth structure as possible without extracting the whole tooth.1 Resection procedures introduces the terms root amputation, hemisection, radisection and bicuspidization which should be clearly understood. Root amputation is the removal of one or more roots of a multirooted tooth with retention of other tooth.2 Hemisection refers to the surgical seperation of a multi-rooted tooth with extraction of one root along with the overlying crown and most likely on mandibular molars.3 Removal of roots of maxillary molars is denoted by a new term radisection. Bicuspidization or bisection is the sepaeration of the roots of madibular molars along with their crown portion and retaining them as individual units.4 The indications for root resection suggested by Weine5 are
 
Pre op iopa showing subgingival caries Iopa After Endodntic Treatment of Mesial Roots
 
Fig.3,4
VERTICAL SPLIT THROUGH THE FURCATION AREA FOR SEPERATION OF TOOTH EXTRACTION SOCKET OF DISTAL ROOT AFTER HEMISECTIONING


Periodontal indications
 
  1. Severe vertical bone loss involving only one root of multi-rooted teeth
  2. Through and through furcation destruction
  3. Unfavourable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance in proximal areas
  4. Severe root exposure due to dehiscence
 
Fig.5,6
REMOVED DISTAL ROOT WITH CARIES PROSTHETIC REHABILITATION OF RETAINED MESIAL ROOT WITH CROWN


Endodontic and restorative indications
 
  1. Prosthetic failure of abutments within a splint: If a single or multirooted tooth is periodontally involved within a fixed bridge, instead of removing the entire bridge, if the remaining abutment support is sufficient, the root of the involved tooth is extracted.
  2. Endodontic failure: Hemisection is useful in cases in which there is perforation through the floor of the pulp chamber, or pulp canal of one of the roots of an endodontically involved tooth which cannot be instrumented.
  3. Vertical fracture of one root: The prognosis of vertical fracture is hopeless. If vertical fracture traverses one root while the other roots are unaffected, the offending root may be amputed.
  4. Severe destructive process: This may occur as a result of furcation or subgingival caries, traumatic injury, and large root perforation during endodontic therapy. Contraindications for hemisection includes fused roots where separation is impossible, roots where endodontic therapy is not feasible and patient unwillingness. This case reports presents retention of a mandibular molar with subgingival caries on the distal root by hemisectioning that root followed by a full coverage restoration.
 
Fig.7
6 MONTH REVIEW IOPA
CASE REPORT.

A fifty five year old male patient reported to our department of conservative dentistry and endodontics with pain in relation to lower left back region for last 2months. On clinical examination there was distal caries on the second molar that extends subgingivally and tooth had mild tenderness on percussion. The tooth had grade 2 furcation involvement. IOPA showed radiolucency extending from distal of 37 below cementoenamel junction to beyond half of the distal root and furcation radiolucency. There was a pocket depth of 4 mm on the buccal aspect of tooth with no mobility.

The treatment options were extraction of the tooth or hemisection of the distal root followed by prosthetic rehabilitation. The patient wanted to save the tooth and so the later one was choosen. The mesial root canals had undergone endodontic therapy with step back and lateral condensation techniques. The access cavity was sealed with composite after giving glass ionomer lining. Then under local anesthesia, a full thickness flap was elevated around second molar. For sectioning of the distal root, vertical cut method using a long shank tapered fissure bur was done in the bifurcation area.

The separation was confirmed by passing a fine probe. A straight elevator was used to luxate and remove the distal root from the socket. The exposed root surface were scaled and root planned. The socket was debrided and irrigated with plenty of normal saline. The flap was sutured back with 3-0 black silk suture. The occlusal table of the retained potion was minimized to reduce the masticatory forces along the long axis. After one and half months healing of the tissues,the retained mesial part was prosthetically rehabilitated with metal ceramic crown.

DISCUSSION

The success of the hemisection procedures are solely dependant on proper case selection as the procedure is technique sensitive.6 The objectives of hemisection procedure is to obliterate the furcation defects, prevention of attachment loss and maintaining the alveolar bone. Various factors have to be considered by the clinician before arriving to the final decision of hemisection procedures.7,8 Local factors include that related with tooth are tooth anatomy, crown –root ratio, tooth mobility, severity of attachment loss, and occlusal relationships. For example a molar that is tilted in any direction is a poor candidate. Closely approximated and fused roots are contraindicated.

Long and straight roots are good candidates than short and conical roots. Patient factors include health of the patient, importance of the tooth, cost and time. Lastly is the clinician factors which involves a good case selection, diagnostic and treatment planning and clinical skill. The present case is a clear indication for hemisection as the subgingival caries involves half of the distal root and clear furcation involvement is present. The patient is also willing to save his tooth.

Carnevale9 suggested the sequence of treatment to be endodontic therapy of the part to be retained followed by surgical sectioning of the involved root and crown part. Then the retained part has to be prosthetically rehabilitated and maintenance of the hygienic measures. Eventhough hemisection is a successful treatment option in furcation involvement cases it is associated with some disadvantages. It involves surgical part that is associated with pain and anxiety. Root surfaces that are grinded in the furcation area and hemisection site are more susceptible to caries. Any failure in the endodontic therapy may lead to failure of this procedure. An improper prosthetic therapy may hamper the success of this procedure.

Prosthetic part is also very important in the hemisection procedure. The tooth has already lost a part of its root support, so it requires a restoration to function independently or as an abutment. The prosthethic rehabilitation has a dual role of splinting the tooth as well as rehabilitating the masticatory role of tooth.The occlusal part of the prosthesis should be in such a way to reduce the masticatory forces especially the lateral component. The occlusal contacts should be reduced in size as well as repositioned.

The cuspal inclines should be less steep and balancing incline contacts should be eliminated to reduce lateral forces. The margins should be proper without any overhangs or plaque retentive features to prevent further periodontal destruction. Shin-Young Park reported that resected molars as intermediate abutments have more survival rate compared with terminal and single abutments.10 This may be due to smaller occlusal load.

A study for quality of resection by Newell 11 in 70 root resected molars showed 30% of cases were faulty when subgingival, residual roots, furcal lips and/or ledges were present. Maxillary molars (33.3%) showed more failure than mandibulars (22.7%). Secondary decay after treatment may hamper a favourable result. Failure of procedure occurs if failure of endodontic therapy happens due to any reason.

Buhler’s 10 year study on 34 resected molars reported a 32 % failure with main causes as endodontic failure and root fracture.12 Park J et al suggested by maintaining oral hygiene and proper follow up molars with questionable prognosis can be maintained for a long time by hemisection without further bone loss.7 Shin-Young Park concluded root resection to treat periodontal problems have a good prognosis than for non periodontal problems and remaining roots should have more than 50 % support for better results.10

CONCLUSION

Hemisection is treatment option that retains the natural tooth for long time that solely depends on proper case selection. The prognosis of the case is good if endodntic therapy is adequately performed and the prosthetic rehabilitation favours the occlusal and periodontal needs of the patient.

REFERENCES
 
  1. Basaraba N. Root amputation and tooth hemisection. Dent Clin of N Amer 1969; 13: 121
  2. Parmar G , Vashi P. Hemisection: A Case report and review. Endodontology, vol 15. 2003 26-29
  3. Bandu Napte, Srinidhi Surya Raghavendra. Management of periodontally compromised mandibular molar with hemisectioning: A case report. J of Int Clinical Dental Reasearch Org. july dec 2014, vol 6 issue2 130-133
  4. Ammons WF Jr, Harrington GW. Furcation : Involvement and treatment, Carranza’s Clinical Periodontology, 10 th ed 991.1004
  5. Weine FS. Endodontic therapy 5th ed. St. Louis: Mosby 1996
  6. Akki S, Mahoorkar S. Tooth hemisection and restoration an alternative to extraction: A case report . Int J Dent Clin 2011. 3. 67-8
  7. Park J. Hemisection of teeth with questionable prognosis. Report of a case with seven-year resultsa. J of Int Academy of Periodontology 2000 1995; 9 : 69-78
  8. Vaibhavi Joshipura. Hemisection- A relevant, practical and successful treatment option. JIOH : 2011; 3(6): 43-8
  9. Carnevale G, Pontoreiro R, Hurzeler MB, Management of furcation involvement. Periodontol 2000 1995 9, 69-89
  10. Park S Y, Shin S Y, Yang S M, Kye SB, Factors influencing the outcome of root-resection therapy in molars: A 10 year retrospective study. J Periodontol 2009; 80
  11. 32-40

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