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| Year : 2023 | Volume
: 26
| Issue : 3 | Page : 355-358 |
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| Hemisection: Partial preservation of compromised tooth |
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Ishani Saluja1, Annapoorna K Kamath1, Sreelakshmi Pradeep1, Ravi Gupta1, Kanika Duggal2
1 Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Karnataka, India
2 Kennedy Dental and Orthodontics, Brampton, Canada
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| Date of Submission | 11-Jan-2023 |
| Date of Decision | 11-Feb-2023 |
| Date of Acceptance | 21-Feb-2023 |
| Date of Web Publication | 16-May-2023 |
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 Abstract | | |
One of dentistry's primary objectives is the long-term maintenance of teeth. Hemisection may be the best line of action when only one root is decayed and the other one is intact. This case report outlines and depicts a situation in which the deteriorated terminal abutment was part of a cantilevered fixed prosthesis. Hemisection and prosthesis rehabilitation had successful outcomes.
Keywords: Hemisection; mandibular molar; tooth root
How to cite this article:
Saluja I, Kamath AK, Pradeep S, Gupta R, Duggal K. Hemisection: Partial preservation of compromised tooth. J Conserv Dent 2023;26:355-8 |
How to cite this URL:
Saluja I, Kamath AK, Pradeep S, Gupta R, Duggal K. Hemisection: Partial preservation of compromised tooth. J Conserv Dent [serial online] 2023 [cited 2023 Jun 5];26:355-8. Available from: https://www.jcd.org.in/text.asp?2023/26/3/355/376908 |
| Introduction | |  |
Modern dentistry has made it possible to have a healthy dentition for life.[1] Losing posterior teeth leads to tooth migration, loss of masticatory function, and reduction in arch length. Hence, maintenance of posterior teeth is important.[2]
Bacteria are responsible for a variety of dental health disorders, including dental caries and periodontal disease. Extraction of the teeth and replacement with a prosthesis are the only options for treating periodontally affected molars with severe decay.[3]
However, resective therapies are an effective treatment option for maintaining natural tooth structure and can offer the patient a fair substitute in a variety of pressing clinical circumstances. Success rates can be quite high and comparable to other treatment options when done correctly and the patient maintains a good oral hygiene.[4]
Hemisection is the separating of multirooted teeth with their crown portion, resulting in the loss of periodontal attachment, to retain the natural tooth structure and make space for a fixed prosthetic appliance. The word “hemisection” is a treatment option that enables the preservation of tooth structure and alveolar bone. It is also a synonym for tooth sectioning, bisection bicuspidization, odontosection, or tooth separation.[5]
Indications for hemisection
- A multirooted tooth has one root damaged by caries, fracture, or root perforation
- The remaining root can be treated endodontically
- A post and core restoration can be supported by the remaining root
- For the ensuing fixed prosthetic restoration, the remaining root is suitably positioned to provide for a sufficient draw
- The root morphology that allows for good surgical accessibility and periodontal maintenance of the definitive restoration.[6]
Using a tooth's root as an abutment has the following drawbacks
- Poorly shaped roots
- Poor endodontic candidates
- Patient unwilling to undergo dental procedures.[6]
| Case Report | | |
A 55-year-old female patient came to the department of conservative dentistry and endodontics complaining of decay and pain in the lower right back tooth area over the previous week. The patient reported of pain which was dull and continuous and aggravated on biting in relation to offending tooth. No relevant medical/family history was reported. The patient was conscious, cooperative, and well-oriented to time, place, and person. Clinical examination of the right mandibular first molar revealed the presence of a large disto-occlusal carious lesion extending subgingivally which was tender on vertical percussion. A periodontal probing around the tooth revealed normal alveolar bone architecture, normal sulcular depth, no pockets, and mobility within physiological bounds. Pulp sensibility test resulted in a severe, lingering pain, and electric pulp testing revealed an exaggerated reaction when compared with #36. IOPAR with respect to 46 revealed coronal radiolucency involving enamel, dentin, and pulp with loss of lamina dura. Distal root appeared to be bulkier suggestive of hypercementosis. The final diagnosis was symptomatic irreversible pulpitis with symptomatic apical periodontitis with respect to 46 [Figure 1]a. | Figure 1: IOPAR with respect to 46 reveals. (a) Obliteration of the distal root of tooth by decay, (b) Endodontically treated mesial canals, (c) Immediately after hemisection, (d) 1-month follow-up, (e) 3-month follow-up, (f) 3-year follow-up
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Following potential treatment plans were discussed
- Fixed prosthesis using the mesial portion of the mandibular first and second premolars
- Fixed prosthesis with the mesial part of the mandibular first molar and an inlay type restoration on the adjacent tooth (second molar)
- Fixed prosthesis with the mesial part of the mandibular first molar and an occlusal rest on the adjacent tooth (second molar)
- Extraction followed by implant.
And 1st treatment option (fixed prosthesis using the mesial portion of mandibular first and second premolars) was carried out.
Clinical procedure
Root canal treatment was initiated after obtaining the informed consent from the patient. During the first visit, access opening was performed using Endo Access Bur (no. 2). Initial glide path was created using #10 K file. Isolation was done using rubber dam. Ingle's radiographic technique was used to determine the working length (mesiolingual = 20 mm and mesiobuccal = 19.5 mm). Apical enlargement was done up to #25 K file. Root canal instrumentation (crown-down technique) was completed using ProTaper Universal files with canal lubricant up to #F2 (Endoprep-RC, Anabond Stedman). Copious irrigation with saline and 3% sodium hypochlorite was done. Tooth was temporized with cotton pellet and ZnOE. Temporary restoration was removed.
During the second visit, isolation was achieved with rubber dam. Initial irrigation was done using saline and 3% sodium hypochlorite. To ensure the master cone fit, a radiograph was taken. Final irrigation was performed using saline, 3% sodium hypochlorite, and 17% ethylenediaminetetraacetic acid (1–2 min). Using absorbent paper tips, the canal was dried. Using a single-cone technique, obturation was carried out using a zinc oxide eugenol sealant and the corresponding master cone (#F2). To ensure a good seal, the canal orifices were sealed with glass ionomer cement (GIC), and the chamber was restored with composite. [Figure 1]b.
After administration of local anesthesia, interdental papilla and gingival margins were reflected with a periosteal elevator extending from the second premolar to the first molar (45, 46). A tapered fissure carbide bur was used to cut a vertical segment from the buccal to the lingual. The bur was positioned more distally than mesial. A probe was passed after resection, to make sure the two roots were separated. The tooth's distal portion was removed, and sterile saline was used to irrigate the extracted site [Figure 2]a, [Figure 2]b. Final shaping of retained segment was done to obtain a smooth surface. With 3-0 silk nonresorbable sutures, the interdental papilla and gingival borders were realigned and repaired [Figure 3]a. Tooth was kept out of occlusion. [Figure 1]c. | Figure 2: Clinical pictures. (a) Diseased crown and root sectioned off and removed, (b) Extracted distal root, (c) Postoperative picture (FPD w.r.t 46). FPD: Fixed partial denture
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 | Figure 3: Occlusal view of tooth 46. (a) Hemisection of the tooth, (b) Composite core build up and tooth prepared for fixed partial prosthesis, (c) Fixed partial prosthesis with respect to 46
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Alginate impressions of the arches were taken for the fabrication of special tray. The putty index was made. Tooth preparations were carried out with respect to 45 and 46. Shoulder finish line was given labially using TF30, and chamfer finish line was given lingually using TR12. Shoulder finish line of width 2 mm and overall reduction of 2–2.5 mm was done [Figure 3]b. Double-mix double-impression was taken of the mandibular arch using putty impression material with light body impression material (Aquasil Soft Putty, Dentsply, and Reprosil Light Body Dentsply). Protemp crown was cemented using temporary cement (PROVICOL) with respect to 45 and 46. A3 shade was selected with respect to 45, and A3.5 shade was selected with respect to 46. Fixed partial denture (FPD) with respect to 45 and 46 cemented with type I GIC [Figure 2]c and [Figure 3]c.[7]
The absence of periodontal ligament widening and bone development at an extraction was shown by radiographic success at 1, 3, 6 months, and 3 years, following the recall visit. [Figure 1]d, [Figure 1]e, [Figure 1]f.
| Discussion | | |
Hemisection requires the elimination of one or more roots with the corresponding coronal structure. This surgery is typically carried out as an alternative to total extraction when a patient's molar prognosis could be improved by eliminating roots that are severely weakened.[8]
The main justification for restoring these teeth was that “fixed” teeth are generally more functional than “removable” teeth and more cosmetically pleasing than “no” teeth.[9] Due to the patient's reluctance to tooth extraction and inability to pay for an implant, hemisection was the treatment of choice.
According to Park, as long as the patient practices an excellent oral hygiene, hemisection of molars with an uncertain prognosis can preserve the teeth without detectable bone loss for a long period of time.[10] According to Saad et al., when damage is limited to one root and the other root is healthy, hemisection of a mandibular molar may be a wise therapeutic option. In such circumstances, the residual part of the tooth might potentially serve as an abutment. Due to the anatomical configuration of the mandibular molars, there is less information available on distal root resection than there is for mesial root.[11]
A three-unit bridge was made available to restore the occlusal function involving the second premolar and the mesial root of the mandibular first molar. [Figure 2]a and [Figure 2]b. Studies conducted in the laboratory have shown that using this type of prosthetic design results in a nearly normal recovery of biting force [Figure 3]a.[12] Due to the second molar's preservation, this design has assisted to keep the prosthesis' size minimal. Smaller prostheses are stronger and more desirable since they survive longer and build up less plaque than larger ones.[11] Two abutment teeth are required for the cantilevered FPD. This cantilevered FPD also obeys Ante's law which states that “the total periodontal membrane area of the abutment teeth must equal or exceed that of the teeth to be replaced.”[13]
Correct case evaluation is a key to this treatment's success. This technique can be used if the bone support around the root is sufficient, but adequate root size is also necessary for a good prognosis and course of therapy. Whether there is more root than bone, supporting the fixed prostheses is another aspect of restoration success to take into account.[11]
In our case, the patient exhibited improved oral hygiene around the prosthesis during the 3-year follow-up appointment. At the 3-year follow-up, the radiograph of our patient showed stable bone levels in addition to acceptable dental hygiene.
Hemisection is important from the standpoint of conservative dentistry to keep the tooth from being extracted. We consider that hemisection, a multidisciplinary approach to treatment that combines endodontic, restorative, and prosthodontic procedures, represents an additional option for maintaining teeth and bone structure.[14],[15]
| Conclusion | | |
In light of this, we recommend that patients should have the choice of hemisection or root resection as opposed to extraction when keeping a tooth's portion appears to prolong the life of prosthesis.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 10. | Park JB. Hemisection of teeth with questionable prognosis. Report of a case with seven-year results. J Int Acad Periodontol 2009;11:214-9. |
| 11. | 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. |
| 12. | Semeniuk VM, Guts AK, Putalova IN, Artiukhov AV. Biomechanical grounds for use of lower molar segments after tooth preservation operations. Stomatologiia (Mosk) 2004;83:23-5. |
| 13. | Ante IH. The fundamental principles of abutment. Michigan Dent Soc Bull 1926;8:14-23. |
| 14. | Agüloğlu S, Emrah AY, Özdemir E. A fibre-reinforced fixed partial denture on a hemisectioned tooth: A case report. Int Dent Res 2011;1:38-41. |
| 15. | Nowokowski AT, Serebnitski A, Pesun IJ. Hemisection as a treatment option: A case report. Oral Health 2010;100:83. |
Correspondence Address:
Dr. Sreelakshmi Pradeep
Department of Conservative Dentistry and Endodontics, Manipal College of Dental Sciences, Mangalore, Affiliated to Manipal Academy of Higher Education, Light House Hill Road, Mangalore - 575 001, Karnataka
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcd.jcd_31_23
[Figure 1], [Figure 2], [Figure 3] |
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