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 Table of Contents  
CASE REPORT
Year : 2012  |  Volume : 3  |  Issue : 4  |  Page : 159-163

A ray of hope for the hopeless: Hemisection of mandibular molar with socket preservation


1 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, I.M.S, Banaras Hindu University, Varanasi, Uttar Pradesh, India
2 Department of Periodontics, Faculty of Dental Sciences, I.M.S, Banaras Hindu University, Varanasi, Uttar Pradesh, India

Date of Web Publication5-Feb-2013

Correspondence Address:
Pushpendra K Verma
Senior Resident, Faculty of Dental sciences, I.M.S, Banaras Hindu University, Varanasi- 221 005, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2155-8213.106844

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  Abstract 

Introduction: The management, treatment and long-term retention of mandibular molar teeth with furcation involvement have always been a challenge in periodontal therapy. Hemisection has been used successfully to retain teeth with furcation involvement. The term hemisection refers to the sectioning of a molar tooth, with the removal of an unrestorable root which may be affected by periodontal, endodontic, structural (cracked roots), or caries. Case Report : This case report describes a simple procedure of hemisection in a mandibular molar with socket preservation with help of an alloplastic bone graft and subsequent restoration of the tooth with fixed prothesis. Discussion: Hemisection represents a form of conservative procedure, which aims at retaining as much of the original tooth structure as possible. It may be a suitable alternative to extraction. Hemisection of the affected tooth allows the preservation of tooth structure, alveolar bone and cost savings (time and money) over other treatment options. The preservation of posterior abutment teeth permits oral rehabilitation with fixed bridges instead of removable prosthesis. Conclusion: The keys to long term success appear to be thorough diagnosis followed by interdisciplinary approach with endodontic, surgical and prosthetic procedures. Preservation of a hopeless tooth is possible by selecting patients with good oral hygiene, and careful surgical and restorative management.

Keywords: Fixed partial denture, furcation involvement, hemisection


How to cite this article:
Verma PK, Srivastava R, Baranwal HC, Gautam A. A ray of hope for the hopeless: Hemisection of mandibular molar with socket preservation. Dent Hypotheses 2012;3:159-63

How to cite this URL:
Verma PK, Srivastava R, Baranwal HC, Gautam A. A ray of hope for the hopeless: Hemisection of mandibular molar with socket preservation. Dent Hypotheses [serial online] 2012 [cited 2017 Mar 25];3:159-63. Available from: http://www.dentalhypotheses.com/text.asp?2012/3/4/159/106844


  Introduction Top


Advances in dentistry have made it possible to maintain a functional dentition for a lifetime. The terms 'hemi-section' and 'root amputation' are known collectively as 'root resection'. [1] Hemisections have been used in cases of advanced bone loss in furcation involvements. Hemisection refers to sectioning of a molar into two halves followed by removal of the diseased root and its coronal portion. The retained root is endodontically treated and the furcation area is made self-cleansable. The success rate of this type of endo-perio furcation lesions is most likely related to the anatomical characteristics of furcation area interfering with adequate instrumentation. Since hemisected teeth fail by root fractures, it is important to restore them adequately by an extra-coronal restoration. [2] This treatment can produce predictable results as long as proper case selection is followed by interdisciplinary approach with endodontic, surgical and prosthetic procedures. [3] Weine has listed the following indications for tooth resection [4]

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
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

  1. Poorly shaped roots or fused roots
  2. Poor endodontic candidates or inoperable endodontic roots
  3. Patient unwilling to undergo surgical and endodontic treatments In this article, a case of hemisection is presented as a treatment option for a tooth where only the distal root of a mandibular molar was affected. The decision was taken to hemisect the distal root, as the mesial bone and furcation bone was relatively unaffected. This procedure represents a form of conservative dentistry, aiming to preserve as much tooth structure as possible rather than sacrificing the whole tooth. [5]

  Case Report Top


A 46 year old male patient, reported in the Faculty of Dental Sciences, IMS, BHU, Varanasi, Uttar Pradesh, India with the chief complaint of pain and sensitivity in left, lower, posterior region, since 3 months. The pain occurred on mastication and was relieved, once the stimulus was removed. Past dental history suggested an uneventful extraction of 37, which was carious. The patient did not give any significant medical history, but he was a tobacco chewer since 10 years. On intraoral examination, the probing depth of 13 mm was found on buccal and distal surfaces, along with grade III furcation involvement in tooth 36 [Figure 1]. Also, the tooth showed grade I mobility and was sensitive to percussion. IOPA radiograph revealed periodontal bone loss which obliterated the coronal third of the distal root as compared with mesial root and periapical rarefaction with both the roots [Figure 2]. Periodontal support of mesial root of 36 was good. Periodontal prognosis with 36 was good and the vitality test was positive. Thus, it was diagnosed as 'chronic generalized gingivitis and localized periodontitis, associated with lower left mandibular 1st molar'. Treatment options included extraction of 36, followed by placement of implant, a fixed partial denture or a removable partial denture. The patient did not wish to have the tooth removed, so conservative treatment was selected, which included hemisection of the distal root of 36, followed by prosthetic replacement. The whole procedure was explained to the patient and a thorough scaling and root planing was done. Gingival and periodontal status was reevaluated after 2 weeks. Intentional root canal treatment was done in 36. After local anesthesia, a mucoperiosteal flap was reflected to expose the area of hemisection. Hemisection was carried out in 36 [Figure 3], [Figure 4] and [Figure 5]. Distal root was extracted and the defect was packed with bone graft (Perio bone-G, alloplastic graft) [Figure 6]. The flap was repositioned and sutured with 3-0 silk non-resorbable interrupted sutures [Figure 7]. Periodontal dressing was placed [Figure 8]. Antibiotics and analgesics were prescribed for one week. The sutures were removed 10 days later. The patient was monitored on a weekly schedule, postoperatively, to ensure good oral hygiene in the surgerized area [Figure 9]. The tooth had good bone support after 8 months and it was decided to give him a fixed prosthesis involving 35,36,37,38. Occlusally, the tooth 36 was contoured as a molar on hemisected tooth, which provided more surface area for occlusal table. Patient was followed up by regular recall visits and oral prophylaxis. He had good masticatory efficiency with the prosthesis and was very satisfied with the treatment outcome.
Figure 1: Pre-Operative tooth

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Figure 2: IOPA radiograph

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Figure 3: Hemisection of tooth done

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Figure 4: Hemisected tooth

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Figure 5: Hemisected tooth portion

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Figure 6: Bone graft placed in the defect

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Figure 7: Sutures placed

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Figure 8: Periodontal Dressing

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Figure 9: Post-operative view with fixed prosthesis

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  Discussion Top


Regeneration of periodontal hard and soft tissues, including formation of a new attachment apparatus is the main aim of regenerative therapy. The management of a periodontal-endodontic defect includes nonsurgical debridement of root canals, as well as surgical approaches that provide better access to clean the root surfaces and apical lesions. Bone loss caused by pulpal disease is reversible, whereas, advanced bone loss caused by periodontal disease is usually irreversible. [6] Multirooted, periodontally involved molars can be maintained for long periods of time with hemisection depending on their extent of bone destruction. The necessity of periodontal surgical therapy is most likely because the periodontal bone loss was more advanced and less likely to resolve after non-surgical therapy alone. [7] The hemisection is a technique sensitive procedure. [8] One must be careful throughout the processes of case selection, and endodontic, periodontal, restorative and maintenance therapies. It has been shown that vital root resections are possible, especially in the maxilla, with symptoms not being manifested until several weeks after the placement of a sedative dressing of choice. In our case, there was bone loss till periapical region in the distal root of 36. Since, there was good bone support on the mesial side of 36 along with fair inter radicular bone, extraction was not considered. Hemisection as a treatment option was perfectly suited to the case. There were other missing teeth like 37 which needed prosthetic replacement. The patient wanted to conserve as much tooth structure as possible. The hemisected 36 could be used as an abutment for replacement of 37 with fixed prosthesis. The decision of hemisecting the tooth should be based on the extent and pattern of boneloss, root trunk and root length, ability to eliminate the osseous defects and endodontic-restorative consideration, which were all considered. [9] When choosing to perform a hemisection procedure, consideration should be given to the morphology, clinical length and shape of the roots of a multirooted tooth. [3] It is important to take into account the divergence of the roots while making a case selection. Affected teeth with roots spread apart facilitate the clinician's ability to carry out root resection. Teeth with closely approximated or fused roots are not good choices to receive hemisection therapy.

Objectives of hemisection:

  1. To facilitate maintenance
  2. To prevent further attachment loss
  3. To obliterate furcation defects as a periodontal maintenance problem
In the present case, the above mentioned indication for case selection in performing hemisection was optimum as the roots were not closely approximated or fused. The tooth had to be endodontically treated before hemisection. Appropriate endodontic therapy must be performed before hemisection to avoid intrapulpal dystrophic calcification and postoperative tooth sensitivity. [10] In this particular case, the hemisected tooth was observed for 8 months for bone support and a fixed prosthesis involving 35,36,37,38 was given only after that. According to Shin-Young Park, resected molars used as intermediate abutments of a fixed bridge, had a higher survival rate. [11] This might be because the occlusal loads on the intermediate abutment are smaller than on terminal abutments and single abutments. Amount of occlusal forces is significant for the long term success of the fixed bridge, and root fractures were frequently reported in resected molars with higher occlusal loads. Furthermore there are conflicting data about the survival of the remaining fragment (3-38% for ten years) and a wide range of reasons for failure of hemisection. [12] Root fracture is the main cause of failure after hemisection, so occlusal modifications are required to balance the occlusal forces on the remaining root. Hence, the use of hemisection to retain a compromised tooth offers a prognosis comparable to any other tooth with endodontic treatment.


  Conclusion Top


With recent refinements in endodontics, periodontics and restorative dentistry, hemisection has received acceptance as a conservative dental treatment for a hopeless tooth. This article presents a technique to maintain tooth structure in a compromised tooth. The keys to long term success appear to be thorough diagnosis, selection of patients with good oral hygiene, careful surgical and restorative management. It was shown that such teeth can function successfully for long periods.

 
  References Top

1.Basaraba N. Root amputation and tooth hemisection. Dent Clin North Am 1969;13:121-32.  Back to cited text no. 1
    
2.Newell DH. The role of the prosthodontist in restoring root resected molars: A study of 70 molar root resections. J Prosthet Dent 1991;65:7-15.  Back to cited text no. 2
    
3.Kurtzman GM, Silverstein LH, Shatz PC. Hemisection as an alternative treatment for vertically fractured mandibular molars. Compend Contin Educ Dent 2006;27:126-9.  Back to cited text no. 3
    
4.Weine FS. Endodontic Therapy, 5 th ed. St. Louis: Mosby; 1996  Back to cited text no. 4
    
5.Kost WJ, Stakiw JE. Root amputation and hemisection. J Can Dent Assoc 1991;57:42-5.  Back to cited text no. 5
    
6.Verma PK, Srivastava R, Gupta KK, Srivastava A. Combined endodontic-periodontal lesion: A clinical dilemma. J Interdiscip Dentistry 2011;1:119-24.  Back to cited text no. 6
  Medknow Journal  
7.Joshipura V. Hemisection-A relevant, practical and successful treatment option. J Int Oral Health 2011;3:43-8.  Back to cited text no. 7
    
8.Akki S, Mahoorkar S. Tooth hemisection and restoration an alternative to extraction-A case report. Int J Dent Clin 2011;3:67-8.  Back to cited text no. 8
    
9.Agrawal VS, Kapoor S, Shah NC. An innovative approach for treating vertically fractured mandibular molar-hemisection with socket preservation. J Interdiscip Dentistry 2012;2:141-3.  Back to cited text no. 9
  Medknow Journal  
10.Vivekanada Pai AR, Khosla M. Root resection under the surgical field employed for extraction of impacted tooth and management of external resorption. J Conserv Dent 2012;15:298-302.  Back to cited text no. 10
    
11.Park SY, Shin SY, Yang SM, Kye SB. Factors influencing the outcome of root-resection therapy in molars: A 10-year retrospective study. J Periodontol 2009;80:32-40.  Back to cited text no. 11
    
12.Park JB. Hemisection of teeth with questionable prognosis. Report of a case with seven-year results. J Int Acad Periodontol 2009;11:214-9.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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