|Year : 2016 | Volume
| Issue : 2 | Page : 104-107
Hemisection-saving by Slicing
Kunjan Joshi, Vatsala Singh, Preeti Kambalyal
Department of Periodontology, Darshan Dental College and Hospital, Udaipur, Rajasthan, India
|Date of Web Publication||12-Sep-2016|
Department of Periodontology, Darshan Dental College and Hospital, Loyara Village, Ranakpur Road, Udaipur - 313 001, Rajasthan
Source of Support: None, Conflict of Interest: None
The progressing inflammatory periodontal disease, if untreated, ultimately results in tooth loss. This inflammatory process can also affect the bifurcation or trifurcation of multi-rooted teeth. A mandibular molar with Grade III furcation and an endodontic involvement has always been a challenge for treatment, management and long-term prognosis. Hemisection refers to the removal or separation of root with its accompanying crown portion of two-rooted teeth, most likely mandibular molars. It is one of the treatment options for preserving the remaining part of the molar having sound periodontium. The present case report demonstrates the successful management of Grade III furcation involvement by hemisection procedure in mandibular molar using a vertical cut method and rehabilitation with fixed prosthesis.
Keywords: Dental caries, furcation defects, molar
|How to cite this article:|
Joshi K, Singh V, Kambalyal P. Hemisection-saving by Slicing. Adv Hum Biol 2016;6:104-7
| Introduction|| |
Furcation is the region that is present in multi-rooted teeth which is an area of complex anatomy and morphology. Furcation involvement is defined as bone resorption and attachment loss in the inter-radicular space that results from plaque-associated periodontal disease. According to Glickman classification of furcation involvement, Grade III furcation involvement with endodontic lesion in mandibular molar always has a questionable prognosis. Multidisciplinary approach is being taken so that teeth are retained in whole or in part for a long time. Indications of extraction of a tooth include severe bone loss with endodontic involvement. In some cases of mandibular molar, one root will be with advanced bone loss while the other root can be saved, here hemisection can be a treatment alternative. Hemisection refers to surgical separation of a multi-rooted tooth with the extraction of one root along with the overlying crown.
Appropriate case selection is mandatory with periodontic, prosthodontic and endodontic assessment. From a periodontal perspective, hemisection is indicated if there is severe bone loss limited to one root or involvement of a Grade III furcation that could produce a stable root after the procedure.
Other indications include extensive exposure of the roots because of dehiscence, and if the patient is unable to maintain appropriate oral hygiene in the area. It can also be performed where there is poor prognosis of an abutment tooth within a fixed prosthesis provided a portion of the tooth can be retained to act as the abutment for the prosthesis. Endodontic failures such as perforations and broken instruments are another indication for hemisection. Other indications include vertical root fracture or any severe destructive process that is confined to a single root including caries, external root resorption and trauma. Contraindications include strong abutment tooth adjacent to the proposed hemisected tooth, inoperable remaining tooth and fusion or proximity of the roots that prevent their separation. This procedure represents a form of conservative management to retain the maximum tooth structure as possible. Following hemisection, socket preservation procedure helps retain the available bone and soft tissue for better function and aesthetics.
In endo-perio lesions, pulpal necrosis precedes periodontal changes. A periapical lesion originating in pulpal infection and necrosis may drain to the oral cavity through the periodontal ligament, resulting in destruction of the periodontal ligament and adjacent alveolar bone. This represents clinically as a localised, deep, periodontal pocket extending to the apex of the tooth. Pulpal infection may also drain through accessory canals, especially in the furcation area and may lead to furcation involvement through the loss of clinical attachment and alveolar bone. This case report describes a patient who had complained of pain in the lower left back tooth region. The treatment plan involved initial endodontic therapy, followed by hemisection of the mesial half of the first molar. After a month, when healing was found satisfactory, a fixed prosthesis was given which served the dual purpose of acting as a splint as well as restoring the masticatory function of tooth. Thus, prognosis of tooth improved, and the need for extraction was eliminated.
| Case Report|| |
An 18-year-old female reported to the Department of Periodontology, Darshan Dental College and Hospital, with the complaint of pain in the lower left back tooth region. On examination, the second premolar and the first molar had carious pulp involvement with Grade III furcation involvement of the first molar. Exudation/pus discharge was negative, probing pocket depth was 4–5 mm and mobility was absent. Radiographic examination revealed caries extending to the pulp with vertical bone loss involving mesial root of the first molar extending into the furcation area [Figure 1]. The first molar showed the presence of three roots. The treatment plan was decided to hemisect the mesial root of the first molar after endodontic treatment followed by prosthesis. The canals were obturated with lateral condensation method using Gutta-percha points, and the chamber was filled with silver amalgam to maintain a good seal and allow interproximal area to be properly contoured during surgical separation [Figure 2] and [Figure 3].
|Figure 3: Pre-operative radiograph showing well-obturated 35, 36 (with 3 roots).|
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Under local anaesthesia, full-thickness flap was reflected by giving a crevicular incision from the first premolar to the second molar [Figure 4]. The vertical cut method was used to resect the crown with mesial root. Granulation tissue was removed. Using long shank-tapered fissure carbide bur, the vertical cut was made from occlusal surface towards the furcation area, and the mesial root along with crown portion was separated [Figure 5].
A periodontal probe was passed through the cut to ensure separation. The mesial half portion of the tooth was extracted and the socket was irrigated adequately with sterile saline to remove amalgam debris. The extraction site was irrigated and debrided. The crater-like bony defect was grafted with hydroxyapatite bone graft (G Bone™) and guided tissue regeneration collagen membrane (Healiguide™). Then, the flap was repositioned and sutured with 3-0 black silk sutures. The occlusal table was minimised to redirect the forces along the long axis of the distal root during tooth preparation. Radiograph showed the well-retained distal root and extraction socket of the mesial root filled with bone graft. After 1 week, sutures were removed, and the area was irrigated. Healing was uneventful [Figure 6]. After 1 month healing of the tissues, fixed bridge was fabricated involving retained distal half and root canal (RC)-treated 35 [Figure 7]. Six-month follow-up radiograph showed a good bone fill in relation to mesial root indicative of good healing and probing pocket depth was reduced with no mobility [Figure 8].
|Figure 6: Radiograph shownig well-retained distal root with hemisected mesial half.|
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Regeneration of periodontium, including formation of new attachment apparatus, is the main aim of regenerative surgery. Treatment of an endodontic-periodontal lesion includes non-surgical RC debridement as well as surgical approach to clean the root surface and apical lesion. Bone loss caused by advanced periodontal disease is usually irreversible. Multi-rooted molars with Grade III furcation involvement can be managed by hemisection. Buhler stated that hemisection should be considered before every molar extraction because it provides a good, absolute and biological cost-saving alternative with good long-term success. Success of this procedure depends on careful case selection. Clinical prediction of a long-term prognosis is crucial. This requires proper diagnosis, treatment planning and execution by all the clinicians involved in the inter-disciplinary approach.
The divergence of the roots is an important factor as tooth with roots spreads apart, facilitating the clinician to perform the procedure. The present case showed the mandibular first molar with three roots. With proper knowledge of tooth anatomy and careful execution of procedure, hemisection was a success. The second premolar was also showing endodontic involvement. Teeth were treated with RC therapy before hemisection of molar. The remaining tooth structure was restored with composite restoration and used as an abutment for crown and bridge after repositioning the occlusal contacts in a favourable position. Park et al. performed root resection therapy on 691 molars in 579 patients. The associated factors were examined from 342 of 402 molars that had been followed up for >1 year. They concluded that root resection to treat periodontal problems had a better prognosis than for non-periodontal problems. To achieve a good result, it was important that the remaining roots had >50% bone support. This guideline may help improve the predictability of root resection therapy. Saad et al. have also concluded that hemisection of a mandibular molar may be a suitable treatment option when the decay is restricted to one root and the other root is healthy and remaining portion of tooth can very well act as an abutment.
Akki and Mahoorkar  reported a case with missing mandibular left first premolar and Grade I mobility of the mandibular left first molar with 9 mm deep periodontal pocket on the distal root. Distal root was extracted. The treated teeth were successfully used as abutments for small bridges.
Bollineni and Karunakar  concluded that increasing the life of tooth by the process of hemisection has become a successful treatment option. This treatment can produce predictable results as long as proper diagnostic, endodontic, surgical and prosthetic procedures are performed. This procedure is a form of conservative approach to retain as much tooth structure as possible.
| Conclusion|| |
Whenever furcation defects have reached Grade III, resective procedure is advocated. Root resection is a valid treatment option for the molars with Grade III furcation involvement as it has shown better prognosis in the management of periodontal problems. This case report shows the treatment of an endodontically and periodontically compromised tooth by multidisciplinary approach. The six-month follow-up success also supports the fact that proper treatment planning, meticulous supportive periodontal care and excellent home care can provide long-term solutions to such challenging clinical situations. Root amputation and hemisection should be considered as another weapon in the arsenal of the dental surgeon, determined to retain and not remove the natural teeth. The results of hemisection are predictable, and success rates are high if certain basic considerations are taken into account.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]