Gregori M. Kurtzman 1, Lanka Mahesh2, Irfan Qureshi3
1 Private Practice, Silver Spring Maryland USA
2 Private Practice, New Delhi, India.
3 Assistant Professor,Altamash Institute of Dental Medicine, Karachi, Pakistan, Private Practice
Correspondence: GregoriM. Kurtzman
How to CITE:
Kurtzman GM,Mahesh L, Qureshi I. Hemisection as an alternative treatment for the vertically fractured mandibular molar J PakDentAssoc. 2012; 21(03) :177 – 181
Hemisection ofmandibularmolars may be a viable treatment optionwhenVertical root fracture has occurred in one of the roots and the other root is healthy. Acasewill be presented discussing the techniques involved in hemisection and restoration of the remaining tooth.
Hemisection, vertical root fracture, post and core
he treatment of severe furcal bone loss may require the removal of a portion of the anatomic crown and its associated root or resection of only one root from a multirooted tooth. This resection type of surgical therapy is a definitive treatment because it predictably enables clinicians to better access the remaining tooth structure for periodontal and subsequent prosthetic therapy. However, adherence to guidelines for necessary tooth preparation for root resection, in this case hemisection, is paramount to facilitate the patient’s ability to accomplish optimal long term maintenance of this affected area. Prosthetic therapy and restorative sequencing is often complicated when periodontal attachment loss, caries or tooth fracture involves the furcation area of the multirooted molar. Although such involvement invariably diminishes the long-term prognosis of the affected teeth, extraction is not necessarily an option. Hemisection, which involves removal of the involved root and its associated crown portion, is one of several treatment modalities that can be used in such cases.Therefore, it is important for dentists to know the necessary indications/contraindications, surgical techniques, and prosthetic management for successful hemisection. This predicative treatment modality has a high degree of success if some basic considerations are followed. For example in the case presented, fracture of the root of a mandibular molar may not doom the remaining unaffected portion of the tooth to extraction. When the health of the other root is sound it may be utilized to provide a premolar shaped restoration.
A40 year old male presented with the complaint of a rough area on the lower right first molar. Examination revealed a vertical fracture of the distal root. The tooth had undergone prior Endodontic therapy and was asymptomatic. Radiographically, it was evident that the distal root had a fracture separating the root into two independent portions. (Figure 1)
apical tip coronally to the furcation. Surprisingly, neither tooth portion demonstrated any mobility. (Figure 2) The mesial root lacked pathology and tested negative for percussion. The only other mandibular teeth missing were the right second molar and third molars bilaterally. Periodontal health was normal and no other restorations or decaywas present on the remaining teeth.
Treatment options were discussed and due to financial considerations it was decided to save and restore the mesial root of tooth 30. Future treatment when finances allow will include placement of an implant distal to the restored mesial root and restoration with a fixed single crown. The patient returned eight months after the initial consultation to initiate treatment as finances had improved and he now had insurance benefits. Clinically and radiographically no changes had occurred and the patient indicated the area remained symptom free. Local anesthetic was applied via a mental block and PDL injection with 4% Septocaine with 1:100,000 epinephrine (Septodont, New Castle, DE). A coarse tapered diamond was utilized in a highspeed handpeice with water to place a cut fromthe buccal to the lingual thru the furcation. (Figure 3) Periotomes (Zoll Dental, Chicago, IL) were used to luxate the most distal root fragment by gently apical directed force into the periodontal ligament space. The segment was then removed with a ronguer. Theperiotomes were then introduced into the cut placed at the furcation, the remaining root moved distally and removed with the ronguer. (Figure 4&5)
The diamond was utilized to remove the lip at the furcation on the mesial root and eliminate any undercut that might trap plaque. The old composite core was removed and the orifices for the mesial buccal and mesial lingual canals identified. A Bident bipolar (Biden_Philadelphia, PA) unit was used to trough the sulcus around the remaining root to expose more root structure and improve the ferrule affect for the future crown. Bleeding on themesial papillawas additionally controlled with theBident unit. (Figure 6)
Peeso burs were used to prepare a post space in both canals to a diameter of 1.25mm and a depth of 10mm. An adhesive (Bond1, Pentron Clinical Technologies, Wallingsford, CT) was applied into each post preparation and all exposed dentin. Excess adhesive was removed with paper points. Cement-it Universal C&B (Pentron Clinical Technologies, Wallingsford, CT) was injected into the post spaces and a Fibrekor post (Pentron Clinical Technologies, Wallingsford, CT) was inserted to length. Excess luting agentwas removed fromaround the posts by application of airwith the air/water syringe. Acontrasting color dual cure resin core material (Build-it FR, Pentron Clinical Technologies, Wallingsford, CT) was injected around the posts and built up coronally. (Figure 7) Following set of the materials, the excess length of fiber post was reduced and the core shaped keeping the restoration out of occlusion. (Figure 8&9)
The patient returned after four weeks post surgical healing. The soft tissue had healed at the distal root and the mesial root remained asymptomatic. Preparation of the mesial root was made to accept a porcelain fused to _ metal crown. The contrasting color of the core material assisted in ensuring adequate ferrule in the preparation. Retrac (Centrix, Shelton, CT) was injected into the sulcus and a cotton Comprecap (Coltène/Whaledent Inc., Cuyahoga Falls, OH) placed over the preparation. The patient was instructed to bite into the Comprecap and occlusion was maintained for 5 minutes to provide better capture of the margins. A light body polyvinyl siloxane was subsequently injected around the preparation and a full arch impression tray filled with medium body polyvinyl siloxane (Correct Quick, Pentron Clinical Technologies, Wallingford, CT) was inserted. An opposing full arch impression and bite were taken. Atemporary crown was fabricated using Revotec (GC America, Alsip, IL) and temporarily luted with Tempcem (Pentron Clinical Technologies,Wallingsford,CT). The patient returned several weeks later for completion of treatment on tooth 30.The temporary crown was removed and the final restoration tried in. Occlusion was checked and the porcelain fused to metal crown luted withCement-itUniversalC&B.(figure10& 11)
In situations where resective endodontic surgery is planned, prior initiation of conventional endodontic treatment simplifies the surgical procedure. This is often the case because tooth preparation can invade the pulp chamber and jeopardize control of the coronal seal of the endodontic access opening, thereby complicating the completion of endodontic therapy. when choosing to performa hemisection procedure c should be given to the morphology, clinical length and shape of the roots of a multirooted tooth. The divergence of the roots is indeed an important indication. Those affected teeth with roots spread apart facilitate the clinician’s ability to perform a root resection, whereas teeth with closely approximated or fused roots should not receive hemisection therapy.Conversely the contraindications to performing hemisection include a “non-physiologic” post surgical architecture thatwould preclude good home care, or an inadequate amount of alveolar bone remaining to support the existing root structure. Also, if cleaning and shaping cannot be adequately performed in the canal system of the roots to be retained or this segment of the tooth is nonrestorable. Following resection therapy is the post resection restorative rehabilitation. The present prosthetic guidelines for rehabilitation include a confluence of the root and the prosthetic crown contours. In addition, the axial tooth contours of the restored resected teeth should have a physiologic contour, which implies that the restoration emerges from the root with a zero degree emergence profile. These transgingival areas should therefore exhibit a flat prosthetic contour at the gingival margin, producing a more hygienic, less plaque retentive regionwhen compared to a tooth restoredwith a cervical bulge at the gingival portion of the prosthesis
The removal of a root and the overlaying anatomic crown is referred to as a hemisection. Hemisection of either amaxillary ormandibular molar is often ameans of retaining teeth needed for restorative abutments or occlusal support. This treatment can produce predicable results as long as proper diagnostic, endodontic, surgical and prosthetic procedures are performed.
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Dr.Kurtzman is in private general practice in Silver Spring, Maryland, USA and a former Assistant Clinical Professor at University of Maryland. He has lectured internationally on the topics of Restorative dentistry, Endodontics and Implant surgery and prosthetics, removable and fixed prosthetics, Periodontics and has over 215 published articles.He has earned Fellowship in the AGD, AAIP, ACD, ICOI, Pierre Fauchard, ADI, Mastership in the AGD and ICOI and Diplomat status in the ICOI and American Dental Implant Association (ADIA). Dr. Kurtzman has been honored to be included in the “Top Leaders in Continuing Education” by Dentistry Today annually since 2006. He can be reached at dr_kurtzman@marylandimplants. com.