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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 9  |  Issue : 3  |  Page : 206-209

Hemisection: A conservative approach


1 Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana, India
2 Department of Conservative Dentistry and Endodontics, Maharana Pratap College of Dentistry and Research Centre, Gwalior, Madhya Pradesh, India

Date of Web Publication7-Aug-2017

Correspondence Address:
Anshul Arora
Department of Conservative Dentistry and Endodontics, Faculty of Dental Sciences, SGT University, Gurgaon, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJDS.IJDS_7_17

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  Abstract 

Hemisection denotes the removal of compromised root and the associated crown portion with the loss of periodontal attachment and is performed to maintain the original tooth structure and attain the fixed prosthesis. The success rate of such procedure is high. The present case report demonstrates the successful management of hemisection of 46 with occlusal rehabilitation. It was a conservative approach aiming to retain as much original tooth structure as possible against the option of extraction of the natural tooth.

Keywords: Furcation, hemisection, mandibular molar, resection


How to cite this article:
Arora A, Arya A, Singhal RK, Khatana R. Hemisection: A conservative approach. Indian J Dent Sci 2017;9:206-9

How to cite this URL:
Arora A, Arya A, Singhal RK, Khatana R. Hemisection: A conservative approach. Indian J Dent Sci [serial online] 2017 [cited 2020 Aug 3];9:206-9. Available from: http://www.ijds.in/text.asp?2017/9/3/206/212402


  Introduction Top


Modern advances in all phases of dentistry have provided the opportunity for patients to maintain a functional dentition for lifetime.[1] Today's dentistry is based on conservation. The aim of any treatment modality is to preserve the natural, but proper periodontic, prosthetic, and endodontic assessment for appropriate selection of cases is important. Thus, the root resection procedures are used to preserve as much tooth structure as possible, in a tooth involving peri-furcation infection as opposed to a routine root canal therapy that has delayed and/or questionable prognosis in such teeth. The other treatment modality is extraction and subsequent prosthetic rehabilitation. Root resection is the process by which one of the roots of a tooth is removed at the level of the furcation, presenting with an opportunity to remove the infected part, and preserve the relatively healthy portion of the tooth, while maintaining its integrity within the socket; therefore, one-half of the crown and the associated infected root is removed while leaving the healthy portion of the crown and its associated root in function.[2]

Root canal therapy with its rationale of canal debridement and disinfection, following adept chemomechanical preparation, involving shaping and cleaning procedures, and obturation is carried out as an adjunct but imperative procedure, to maintain the endodontic inertness of the remaining portion of the hemisected tooth, with the aim of controlling infection and subsequently healing the periradicular lesion, while maintaining form and function of the tooth.

Weine F has listed the following indication for root resection.[3]

Periodontal indications

  1. Severe vertical bone loss involving only one root of multirooted teeth
  2. Through and through furcation destruction
  3. Unfavorable 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 amputated
  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. Strong adjacent teeth available for bridge abutments as alternatives to hemisection
  2. Inoperable canals in root to be retained
  3. Root fusion-making separation impossible.



  Case Report Top


A 30-year-old male patient reported to the department with the complaint of pain in the left mandibular first molar. On examination, the tooth was tender on percussion and was grossly carious [Figure 1]. On probing the area, there was a deep periodontal pocket around the mesial root of the tooth. On radiographic examination, furcation involvement was evident, and there was a periapical radiolucency associated with the mesial root. The bony support of distal root was completely intact [Figure 2]. The second premolar showed deep caries involving pulp. It was decided that the mesial root should be resected after the completion of endodontic therapy of the tooth. The patient was informed about the treatment plan, and consent was obtained before the procedure. Root canal procedure was carried out in the distal root of mandibular molar and premolar [Figure 3] under rubber dam, an access was created using endo access burs (Dentsply Maillefer), on obtaining straight line access, working length was determined using radiographic methods and confirmed on the apex locataor (ProApex–II), (0.5 mm from the perceivable apex). Biomechanical shaping and cleaning were done, with rotary files (ProTaper Next, Dentsply Maillefer) up to file size F4, under passive mechanical irrigation with saline and 4% w/v sodium hypochlorite solution, a calcium hydroxide interappointment intracanal dressing was given for 21 days, after which obturation was completed using cold lateral compaction technique with appropriate gutta-percha points and AH Plus resin base sealer.
Figure 1: Preoperative

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Figure 2: Preoperative radiograph

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Figure 3: Obturation irt 35 and distal root of 36

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Hemisection of the mesial root and crown was carried out using the vertical cut method, in the subsequent appointment. After vertical and crevicular incision, full thickness mucoperiosteal flap was reflected. The mesial root was sectioned at the level of the furcation using long-tapered fissure diamond. The mesial root was atraumatically extracted [Figure 4],[Figure 5],[Figure 6], and the socket was irrigated adequately with normal saline and subsequently filed with a bone file to remove bony chips and irregularities. The flap was replaced, and simple interrupted sutures were placed, using vicryl (3-0) suture material. The occlusion was relieved and adjusted to redirect the forces along the long axis of the distal root. The surgical site was covered with a periodontal dressing (Coe-Pak ™ GC America Inc., Alsip, IL, USA), and postoperative instructions were given to the patient.
Figure 4: Hemisection done (mesial root removed)

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Figure 5: Mesial root extracted

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Figure 6: Radiograph with mesial root extracted

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Four weeks following surgery, complete healing at the surgical site was observed, clinically and radiographically.

After adequate healing of the tissue, the prosthetic phase of therapy is initiated by planning a porcelain fixed partial denture involving mandibular premolar and the retained distal half of mandibular first molar. The teeth in involved were prepared using diamond points, after which a putty-light body impression was made using polyvinyl siloxane impression material. Provisional restoration was fabricated using indirect technique and was cemented in place. To enhance the oral hygiene maintenance, modified sanitary pontic design was selected. Porcelain metal bridge was fabricated subsequently and cemented in place [Figure 7].
Figure 7: Fixed partial denture

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  Discussion Top


Hard and soft-tissue regeneration, including the formation of new attachment housing, serves as 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 as an adjunct or an alternative. Bone loss caused by pulpal disease is reversible, whereas, advanced bone loss caused by periodontal disease is usually irreversible.[4] Multirooted, periodontally involved molars can be maintained for long periods of time with hemisection depending on their extent of bone destruction justifying that periodontal surgical therapy is required in cases where advanced periodontal bone loss has occurred and is less likely to resolve after nonsurgical therapy alone. The success of the root resection procedure depends to a large extent on proper case selection. The hemisection is a useful alternative treatment to extraction to save the multirooted tooth with periodontal, endodontic, restorative, or prosthetic problems. The literature on the distal root resection in mandibular is limited as compared to mesial root because of its anatomical structure.[5],[6] Hemisection of mandibular molar may be viable treatment modality when one root has poor treatment prognosis, and the other root is healthy and that portion of tooth can be act as abutment. The treatment, management, and long-term retention of mandibular molar teeth exhibiting such invasions have always been a challenge to the dental specialist. 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. 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 case selection criteria for performing a 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. The case demonstrates successful management of tooth with endo-perio lesion and furcation involvement by hemisecting the mesial root. Root fracture is the main reason for failure after hemisection, so occlusion modifications are required. Occlusion contacts were positioned more favorably. Lateral forces were reduced by making cuspal inclines, less incline, and limiting balance incline contacts, according to Shin-Young Park, resected molars used as intermediate abutments of a fixed bridge, had a higher survival rate,[7] this might be because the occlusal loads on the intermediate abutment are smaller than on terminal abutments and single abutments. The 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.

Bhuler (1988) observed 32% failure rate in hemisection case due to endodontic pathology and root fracture while long-term studies have shown greater success.[8],[9],[10] In the present case, 6 months follow-up showed good prognosis with the absence of mobility and healthy periodontal condition. Thus, the hemisection can be considered as an effective and conservative treatment against extraction of the tooth with extensive caries.

Clinical significance

This treatment can produce predictable results as long as proper case selection is followed by interdisciplinary approach with endodontic, surgical, and prosthetic procedures and is a viable alternative, conservative in approach, while maintaining form and function, as opposed to extraction procedures.


  Conclusion Top


Hemisection is an alternative, effective, and conservative treatment modality over conventional procedure or extraction of periodontally and endodontic affected teeth.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  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.
Shah N, Gupta YK. Endodontic miscellany: Hemisection and full coverage to relieve crowding and lingual displacement of pulpo-periodontally involved mandibular first molar. Endodontology 2000;12:1283-5.  Back to cited text no. 2
    
3.
Weine FS. Endodontic Therapy. 5th ed. St. Louis, USA: Mosby; 1996. p. 154-68.  Back to cited text no. 3
    
4.
Verma PK, Srivastava R, Gupta KK, Srivastava A. Combined endodontic-periodontal lesion: A clinical dilemma. J Interdiscip Dent 2011;1:119-24.  Back to cited text no. 4
    
5.
Saad MN, Moreno J, Crawford C. Hemisection as an alternative treatment for decayed multirooted terminal abutment: A case report. J Can Dent Assoc 2009;75:387-90.  Back to cited text no. 5
    
6.
Shafiq MK, Javaid A, Asaaad S. Hemisection. An option to treat apically fractured and disloged part of a mesial root of a molar. J Pak Dent Assoc 2011;20:183-6.  Back to cited text no. 6
    
7.
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. 7
    
8.
Radke U, Kubde R, Paldiwal A. Hemisection: A window of hope for freezing tooth. Case Rep Dent 2012;2012:390874.  Back to cited text no. 8
    
9.
Shah S, Modi B, Desai K, Duseja S. Hemisection – A conservative approach for a periodontally compromised tooth – A case report. J Adv Oral Res 2012;3:31-5.  Back to cited text no. 9
    
10.
Weine FS, editor. Root amputation. Endodontic Therapy. 6th ed. Osaka: Mosby-Year Book, Inc.; 2004.  Back to cited text no. 10
    


    Figures

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



 

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Abstract
Introduction
Case Report
Discussion
Conclusion
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