TOOTH HEMISECTION RATHER THAN EXTRACTION OF A MUTILATED MOLAR-A 2 YEAR FOLLOW UP CASE REPORT

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TOOTH HEMISECTION RATHER THAN EXTRACTION OF A MUTILATED MOLAR-A 2 YEAR FOLLOW UP CASE REPORT

Siddhi Dhadda *, Deepak Raisingani, Prachi Mittal and Ashwini B. Prasad

Mahatma Gandhi Dental College and Hospital, Ramchandpura, Rajasthan, India.

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ABSTRACT: Modern breakthroughs in dentistry have created the opportunity for people to maintain a functional dentition for lifetime. Hemisection is a conservative approach of maintaining tooth. This is an endodontic treatment that involves removing one or more roots as well as the current crown structure in order to promote tooth retention and address nonfunctional dental roots that cannot be maintained. As they are prone to fracture it is critical to replace them using an extracoronal restoration. A 35-year-old male patient complaint of mild intermittent pain in relation to the lower left back tooth region since 15 days. The teeth were tender to percussion. A diagnosis of symptomatic irreversible pulpitis with symptomatic apical abscess with a treatment plan of hemisection in relation to #36 was made. 18 months clinical and radiographic follow-up depicts adequate radiographic healing, high lighting in achieving retention of mesial half of tooth structure and its supporting periodontium.

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Keywords: Hemisection, Prosthetic Rehabilitation, Resorption

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INTRODUCTION: Progressive enhancement in all parts of dentistry have enabled people to maintain a functional dentition throughout their lives. Therapeutic measures used to ensure tooth retention vary in complexity. The treatment may include a combination of restorative dentistry, endodontics, and periodontics to preserve the teeth in whole or in part ¹. The success rate for endo-surgery ranges from 73% to 99% but indicated only in less than 5% of all endodontic patients ². The prognosis depends on diagnosing factors, case selection, indications, contraindications, treatment procedures, periodic evaluations and statistical analysis ³.

The resection methods are described: root amputation, hemisection, radisection, and bisection ⁴. If the bone loss is restricted to a single root, the procedure named hemisection may be implemented ⁵. It is the splitting of a mandibular molar into two halves, followed by the removal of the damaged root and coronal region. The retained root is endodontically treated, and the furcation area is made self-cleansable by carefully removing the root's lip. As they are prone to fracture it is critical to replace them using an extracoronal restoration ⁵. Preffered when one of the molar roots is unsalvageable due to caries, periodontitis or iatrogenic issues. Preserves the tooth structure, alveolar bone, and costs less than alternative treatment choices ⁶. Thus a conservative with a favourable prognosis ⁵.

Indications for a hemisection, according to Weine are:

1. Furcation destruction.
2. Severe vertical bone loss involving only one root of multirooted teeth.
3. Proximity of unfavorable roots.
4. Severe root exposure due to dehiscence.
5. Perforation pulp chamber, or pulp canal of one of the roots.
6. Prosthetic failure of abutments within a splint.
7. Vertical fracture of one root.
8. Severe destruction as a result of furcation or subgingival caries ⁷.

Contraindications are:

1. Deep furcation perforation.
2. Conjoined roots that cannot be restored.
3. Teeth that have short or unsuccessful canal treatments ^{8, 9}.

Rather than extracting the tooth in toto, this kind of conservative procedure helps preserve as much of the tooth structure as possible ¹⁰.

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 distal 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 of tooth was eliminated ¹¹.

Case Report: A 35-year-old male patient reported to the department of Conservative Dentistry and Endodontics with the chief complaint of mild intermittent pain in relation to lower left back tooth since 15 days. On taking the history, the pain was sudden in onset, mild and aggravates on consuming cold beverages. No relevant medical history was noted. Clinical examination revealed distoproximal caries involving distal root and furcation in lower left molar (tooth #36). Cold testing of #tooth 36 elicited an intense lingering pain. The tooth was tender to percussion with grade I mobility and pocketdepth of 4-5 mm on the distal side of the tooth. A preoperative IOPA revealed distoproximal caries involving distal root and periapical radiolucency at the furcation Fig. 1. From the clinical and radiographic findings, a diagnosis of symptomatic irreversible pulpitis with symptomatic apical abscess in relation to tooth #36 was established. Since the patient was reluctant for extraction, a conservative course of treatment was chosen, involving the hemisection of tooth #36 followed by prosthetic replacement.

Endodontic Phase: In the first visit, local anesthesia was administered using 1.8mL of 2% lidocaine with 1:80,000 epinephrine [Lignox 2% ADR INJ, Indoco Remedies Ltd. (Warren, Pharma), Mumbai, MH, India] via inferior alveolar nerve block technique. Under rubber dam isolation and magnification (6x) the caries were excavated using large BR#31 round bur (Mani, Inc., Utsunomiya, Japan).

Pulp chamber was explored using DG16 endo explorer (Hu-Friedy, Chicago, Illinois, USA). The patency was confirmed with the SS hand 10k file (Mani, Japan) Working length was determined using an apex locator (Root ZX Mini; J Morita, Japan) and confirmed radiographically Fig. 2. The cleaning and shaping was done with the 20k SS hand files (Mani, Japan), followed by rotary instrumentation up to 25-4% in both the canals. Subsequently, the canals were irrigated with 2.5% sodium hypochlorite (NaOCl) (Prime Dental Products, India) and normal saline solution (0.9%).

The master cone radiograph was confirmed and checked for tugback Fig. 3. The root canals were dried with paper points and obturated with lateral compaction technique using AH Plus sealer (De Trey; Dentsply, Konstanz, Germany) Fig. 4.

Periodontic Phase: Local anaesthesia was administered and crevicular incision from the region of the first premolar to the second molar was made followed with elevation of full thickness mucoperiosteal flap. Further curettage and debridement were performed due to the obvious bone defect. The distal root was extracted by making a vertical cut faciolingually towards the bifurcation area using a long shank tapered fissure carbide bur (Mani, Japan).

When extracting the distal root, great care was taken to avoid damaging the nearby tooth and bone and was further confirmed radiographically Fig. 5. Comprehensive root planing of the mesial root was carried out with curette in conjunction with debridement and irrigation of the socket. The surgical dressing was completed, and sutures were inserted without any occlusal load on the mesial root followed with core build up by dental amalgam was done Fig. 6. One month later, fixed partial denture was planned for the rehabilitation of the hemisected tooth with respect to teeth #36 and 37.

Prosthodontic Phase: Tooth preparation was carried out for porcelain fused to metal crown on teeth #36 and 37.

Impression was recorded followed by cementation of the crown. Periodically, recall was carried out to ensure the restoration's success and healing Fig. 7.

24 months follow up radiograph showed a good bone fill in relation to distal root indicative of good healing and probing pocket depth was reduced with no mobility Fig. 8.

FIG. 1: PRE OPERATIVE RADIOGRAPH

FIG. 2: WORKING LENGTH DETERMINATION

FIG. 3: MASTER CONE RADIOGRAPH  

FIG. 4: OBTURATION RADIOGRAPH

FIG. 5: HEMISECTIONED TOOTH                  

FIG 6:  POST ENDODONTIC RESTORATION WITH AMALGAM

                                                                                             

FIG 7: CORONAL PROSTHESIS    

FIG 8: 24 MONTHS FOLLOW UP RADIOGRAPH

DISCUSSION: Nowadays, people want to keep their natural teeth for a lifetime ¹². Crack and dental caries extending to the root often present with restorative treatment challenges ¹³. Assessing periodontal, prosthodontic, and endodontic conditions is crucial for choosing the right patients. Before any molar extraction, according to Buhler, hemisection should be taken into consideration as it offers a reliable, cost-effective, and biologically sound option with good long-term success ¹⁴. A periodontal-endodontic defect is treated with root canal debridement and, as an adjunct, surgical techniques that provide improved access for cleaning the root surfaces and apical diseases ^{15, 16}. The patient's caries index, medical condition, and level of oral hygiene should all be taken into account before choosing a tooth for hemisection ¹.

However, it is associated with some disadvantages such as:

1. Any surgical procedure, it can lead to pain.
2. Root surfaces that are reshaped by grinding in the furcation are more susceptible to caries.
3. Remaining roots must undergo endodontic therapy and the crown must undergo restorative management ¹⁷.

Park SY applied root excision therapy to 691 molars in 579 patients. After reviewing from 342 out of 402 molars for more than a year, it was determined that the prognosis for periodontal disease was better with root excision than it was for non-periodontal disease ¹. ^*According to recent findings by Park et al. ⁷, if the patient practices good dental hygiene, hemisection of molars with dubious prognosis may be able to preserve the teeth without causing noticeable bone loss over an extended period of time. According to Saad et al. (2008), hemisection of a mandibular molar may be an appropriate course of therapy if the decay is limited to one root and the other root is in good health, allowing the remaining tooth to potentially function as an abutment ¹. When hemisection is used to keep a challenged tooth in place, the prognosis is similar to that of any other tooth that receives endodontic therapy ¹⁸.

The Following four Criteria are Crucial for Choosing a Molar for Hemisection ¹⁹: Root Form, Root Divergence, Furcation Location, and Remaining Root Attachment. In order for the tooth to continue functioning on its own after losing some of its root support, a restoration is required for function and stabilization of occlusion ¹⁸.

Points to Consider while Fabricating a Prosthesis: If nonocclusal surfaces lack physiologic form or if margins are flawed, restoration may exacerbate periodontal disease. An occlusal contact area that is not adequately designed changes permissible forces into destructive forces, which ultimately results in hemisection failure. In order to have an insertion path that is compatible with the anterior abutment, hemisected abutments are tapered more than 6 to 10 degrees. To make up for this, the abutment is fitted with buccal and lingual grooves. To lessen the stresses on the retained hemisected root, the occlusal table is shrunk in size.In order to decrease nonworking contacts and lessen laterally directed stresses, cuspal inclines are made less steep. Premolar restoration of the retained root assisted in lowering the masticatory burden. According to Stein, "the sanitary pontic is the best design for posterior region, aesthetic permitting ²⁰.

Good and managed thriving restoration is essential for the success of periodontal health. Using a crown splinter as a retainer in abutment teeth can be an alternative. The preparation crown splinter is similar to inlay preparation, which is more conservative and less damaging hard tissue in vital teeth. Furthermore, the crown splinter more preserves periodontal health while causing minor pulpal damage ²¹.

Long-term success depends on careful patient selection with good oral hygiene, meticulous surgical and restorative management, and a thorough diagnosis. Hemisection should be discussed as a possible alternative to extraction and implant therapy when patients are thinking about their treatment options ¹⁸.

"Root resection" is the combined term for "root amputation" and "hemi-section." Newell claims that keeping part or all of the tooth is an advantage of amputation, hemisection, or bisection. The crown must have restorative treatment performed on it, and endodontic therapy must be administered to any surviving root or roots ²². Remaining tooth structure was restored with crown splinter PFM after repositioning the occlusal contacts in a favorable position because occlusion modifications are required after hemi section because root fracture is the main reason for failure ²³. Newell evaluated the quality of 70 root-resected molars from 62 patients. In 21 (30%) of the resections, the presence of subgingival, residual roots, furcal lips, and/or ledges was deemed to be problematic. Maxillary molar failure rates were higher than mandibular molar rates (22.7%) ²⁴.

On 34 resected molars, Buhler observed a 32% failure rate after ten years. Once more, periodontal collapse resulted in the extraction of only one tooth, although endodontic disease and root fracture were the primary causes of failure. In a follow-up conducted three to ten years later, Blomlof et al. ⁸ discovered the same failure rate ²⁵.

579 patients had 691 molars treated with root excision therapy by Shin-Young Park. Of the 402 molars that had been followed up on for more than a year, 342 had their associated factors investigated. They came to the conclusion that patients with periodontal issues had a better prognosis from root excision than those without it. It was crucial that the remaining roots had more than 50% bone support in order to get the desired outcome. This recommendation could enhance the predictability of treatment including root excision ²⁶. In an academic setting, >50% of teeth remained functional after 9 years of root resection therapy ²⁷.

According to a study by Atul Jain, hemisection was performed with the removal of the mesial root and crown in a case of significant loss of the mesial root due to external root resorption and a decent quantity of the distal root remaining with appropriate bone support. After moving the occlusal contacts into a more advantageous location, the remaining tooth structure was repaired using composite and utilised as an abutment in a crown and bridge ¹. According to a review article by Saraf et al. outcomes of several studies reveal success rates ranging from 62% to 100% with follow up periods of 1 to 23 years and they came to the conclusion that when hemisection is performed, an overall success rate of approximately 88% can be predicted ²⁸. Kumar performed a hemisection procedure on a 45-year-old male patient. It had a persistent chronic sinus tract associated with a periodontal pocket in relation to an endodontically treated and crowned lower right first molar. Following a provisional diagnosis of vertical root fracture in relation to mesial root of 46, exploratory surgery was done. The mesial root was extracted. Socket preservation was done by grafting the extraction site with a mixture of the demineralized freeze-dried bone allograft ²⁹.

Basten et al. found that 92% of all hemisected molars sustained over a period of 12 years, with failures attributed to recurrence of caries, endodontic and strategic issues ³⁰.

CONCLUSION: The case study highlights the significance of specialised knowledge and professional communication through its therapeutic planning, surgical sequencing, and pluridisciplinarity. A baton used for tooth extraction is called a hemisection. The procedure's long-term success is determined by the careful selection of cases.

ACKNOWLEDGEMENT: The author would like to express their gratitude towards researchers and research scholars in the field whose work laid the foundation for this review. They would like to thank editorial team members and reviewers for their constructive feedback and their valuable suggestions during the review process. The inclusion of their input has substantially improved the clarity and coherence of this article.

CONFLICTS OF INTEREST: The author declares no conflict of interest.

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    How to cite this article:

    Dhadda S, Raisingani D, Mittal P and Prasad AB: Tooth hemisection rather than extraction of a mutilated molar-a 2 year follow up case report. Int J Pharm Sci & Res 2025; 16(2): 516-21. doi: 10.13040/IJPSR.0975-8232.16(2).516-21.

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