Indian J Stomatol 2015;6(1):33-36

Hemisection of Multirooted Tooth: A Case Report

1 2 3 4
Pratibha Agrawal , Sanjeev Kunhappan , Shruti Saha , Shweta Singh

Abstract
Mandibular first molars are the most commonly extracted teeth due to dental caries and periodontal disease. These teeth are the
major standpoint for occlusion, and also have a wide peri-cemental area. Hence, any defect in the root either mesial or distal, ex-
traction is the most common treatment planned. Under specific conditions, only the diseased part of the tooth can be extracted
after an endodontic treatment. Hemisection may be a valuable form of treatment for molar teeth when caries has progressed to
the furcation, or where there is an extensive carious lesion extending subgingivally in one area of the root, making it impossible
to place an adequate restoration in that area and the root is considered unrestorable. Hemisection and prosthetic rehabilitation yi-
elded a satisfactory result.

Keywords: Extraction; hemisection; dental caries; periodontal diseases; furcation.

Introduction
Modern advances in all phases of dentistry have provided
the opportunity for patients to maintain a functional dentit-
ion for lifetime. Therapeutic measures performed to ensure
retention of teeth vary in complexity. The treatment may
involve combining restorative dentistry, endodontics and
periodontics so that the teeth are retained in whole or in
part. A molar tooth with extensive root caries may be uns-
uitable for restoration. In such cases, the treatment options
are limited and may include a partial denture or a dental im-
plant to replace the missing tooth. Alternatively, if the dec-
ay is limited to one root, a hemisection procedure may be
possible. Hemisection (removal of one root) involves rem-
oving significantly compromised root structure and the as-
sociated coronal structure through deliberate excision.1
Hemisection of the affected tooth allows the preservation
of tooth structure, alveolar bone and cost savings over oth-
er treatment options.2 Weine has listed the following indic-
ations for tooth resection:3
Periodontal indications
1. Severe vertical bone loss involving only one root of mu-
lti-rooted teeth.
2. Through and through furcation destruction.
3. Unfavourable proximity of roots of adjacent teeth, prev-
enting 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 fix-
ed bridge, instead of removing the entire bridge, if the rem-
aining abutment support is sufficient, the root of the invol-
ved tooth is extracted.
2. Endodontic failure: Hemisection is useful in cases in wh-
ich there is perforation through the floor of the pulp cham-
ber, 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 fr-
acture is hopeless. If vertical fracture traverses one root
while the other roots are unaffected, the offending root may
1
Department of Conservative Dentistry and Endodontics, Ambikapur Medical College, Ambikapur, 2Government Dental College, Raipur,
3
Chhattisgarh Dental College and Research Institute, Rajnandgaon, 4Department of Orthodontia, Government Dental College, Raipur,
Chattisgarh, India. Correspondence: Dr. Pratibha Agrawal, email: prati15.agrawal@gmail.com
be amputed.
4. Severe destructive process: This may occur as a result of
furcation or subgingival caries, traumatic injury, and large
root perforation during endodontic therapy.
a. Strong adjacent teeth available for bridge abutments as
alternatives to hemisection.
b. Inoperable canals in root to be retained.
c. Root fusion-making separation impossible.
Contraindications
1. Poorly shaped roots or fused roots.
2. Poor endodontic candidates or inoperable endodontic
roots.
3. Patient unwilling to undergo surgical and endodontic tr-
eatments and undertake care or the resulting restoration.
Case report
A 40-year-old male patient reported to the Department of
Conservative Dentistry and Endodontics, with the chief
complains of pain and food lodgement in lower left back
region of the jaw since 15 days. Patient was relatively asy-
mptomatic before then. He developed intermittent and thr-
obbing pain in this region, which got aggravated during
mastication. Patient gave past dental history of root canal
treatment in 36 approximately a year back. Patient's medi-
cal history was non contributory. On intra-oral examinat-
ion, 36 was found to be grossly carious with dislodged res-
toration (Figure 1). On vertical percussion 36 was found to
be sensitive. No deep pocket was found in relation to 36.
On radiographic examination improper root canal treatme-
nt with distal root of 36 and secondary caries extending to
cervical third of the distal root and even approaching to
furcation area of the 36 was observed (Figure 2). In the
view of above findings, hemisection of distal root of 36
while retaining the mesial root (as adequate bone support
was present) followed by crown with 36 mesial root. Hem-
isection was carried out in relation to36 with vertical cut
method (Figure 3). A long shank, taper fissure carbide bur
in high speed handpiece was placed along the buccal groo-

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 Indian J Stomatol 2015;6(1):33-36

Figure 1: Preoperative clinical photograph 36 Figure 2: Preoperative IOPA x-ray 36

Figure 3: Composite restoration of 36 Figure 4: IOPA x-ray of crown

sectioning of 36

Figure 5: Hemisection of distal root of 36 Figure 6: IOPA x-ray after hemisection of 36

Figure 7: Tooth preparation of 36 Figure 8: Teeth in occlusion after

crown cementation of 36

34

ve and a cut was made. The cut was channeled towards the
center of the tooth. The bur was moved in the lingual and
apical direction until the furcation area was reached. Once
the bur had severed the floor of the pulp chamber, root was
separated from the remaining portion of the tooth. A fine
probe was passed through the cut to ensure separation (Fig-
ure 4). After separation, the severed portion of the distal ro-
ot was removed with a extraction forceps (Figure 5, 6). The
socket was irrigated with sterile saline to remove bony chi-
ps and debris The remaining portion of the mesial tooth
was trimmed to remove any ledges or sharp spicules, as
these structures are potentially detrimental for periodontal
maintenance. Patient was recalled after 7 days, then the pe-
rmanent restoration followed by crown was done with 36
(Figure 7, 8).
Discussion
The terms "root amputation" and "hemi-section" are kno-
wn collectively as "root resection.4 Root amputation/hem-
isection is an useful alternative procedure to save those
multi-rooted teeth which have been indicated for extract-
ion. Before selecting a tooth for hemisection, patient's oral
hygiene status, caries index and medical status should be
considered. Also, accessibility of root furcation for easy se-
paration as well as good bone support for the remaining ro-
ot should be assessed.
The loss of posterior teeth can result in several undesirable
sequelae, hence a guiding principle should be followed to
try and maintain what is present. This case study presents a
treatment available in cases of extensive iatrogenic perfor-
ations in the floor of molars. Hemisection has been used su-
ccessfully to retain teeth with perforation involving furca-
tion. Various resection procedures described are:
a) Root amputation
b) Hemisection
c) Radisection
d) Bisection
Root amputation refers to removal of one or more roots of
multirooted tooth while other roots are retained. Hemisec-
tion denotes removal or separation of root with its accom-
panying crown portion of mandibular molars. Radisection
is a newer terminology for removal of roots of maxillary
molars. Bisection/bicuspidization is the separation of mes-
ial and distal roots of mandibular molars along with its cro-
wn portion, where both segments are then retained individ-
ually.3
A guiding principle should be to try and maintain what is
present.5 The use of hemisection to retain a compromised
tooth offers a prognosis comparable to any other tooth with
endodontic treatment.
Endodontic phase: Endodontic treatment was performed
first because in case, if the tooth cannot be treated endodo-
ntically or if there is an endodontic failure, the case will be
contraindicated for hemisection.
Periodontic phase: 4 critical factors in selecting molar for
hemisection are:6
1) Root divergence: Ideally the resected root should have
generous root divergence, as close root proximity will ma-
ke surgery difficult.
2) Root form: Roots of mandibular molars show concavity,
35
Indian J Stomatol 2015;6(1):33-36
mostly on mesial root. Therefore, odontoplasty should be
performed to provide a proper contour.
3) Location of furcation: Closer the furcation opening to
the cemento-enamel junction, better the prognosis for reta-
ined root.
4) Remaining root attachment is critical to evaluate; as cyl-
indrical, ovoid, long root serves as an excellent abutment.
Objectives:
1) To facilitate maintenance.
2) To prevent further attachment loss.
3) To obliterate furcation defects as a periodontal mainten-
ance problem.
Prosthodontic phase: When the tooth has lost part of its
root support, it will require a restoration to permit it to fun-
ction independently or serve as an abutment for Fixed Par-
tial Denture or splint. Thus, restoration is required for fun-
ction and stabilization of occlusion.
In the present case hemisection was carried out by vertical
cut method followed by crown with 36. Saad et al., have al-
so 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 por-
tion of tooth can very well act as an abutment.1
With recent refinements in endodontics, periodontics and
restorative dentistry, hemisection has received acceptance
as a conservative and dependable dental treatment and tee-
th so treated have endured the demands of function.7
According to Buhler et al., hemisection should be conside-
red before every molar extraction, because this procedure
can provide a good absolute biological cost savings with
good long-term success. In addition, he reported that the
failure rates of single-tooth alloplastic (titanium) implants
and hemisections are not substantially different.8
Langer et al., reviewed records of 100 patients who had un-
dergone root resection over a 10 year period. They reported
a failure rate of 38%, of which 15.8% occurred within the
9
first 5 years after surgery. Most failures involved mandib-
ular teeth and occurred for reasons other than inflammat-
10
ory periodontal disease. There are only few long term stu-
dies on the survival of teeth after hemisection and root am-
putation published. These investigations often lack infor-
mation about case selection and subsequent restoration.
Furthermore there are conflicting data about the survival of
the remaining fragment (3-38% for 10 years.) and a wide
range of reasons for failure of hemisection.11
The keys to long term success include thorough diagnosis,
selection of patients with good oral hygiene, careful surgi-
cal and restorative management. Hemisection may be a su-
itable alternative to extraction and implant therapy and sh-
ould be discussed with patients during consideration of tre-
atment options.
Conclusion
Hemisection as a treatment option to conserve the tooth str-
ucture and use it as an abutment is still very relevant. The
decision of hemisectioning the tooth should be based on
the extent and pattern of bone loss, root trunk and root len-
gth, ability to eliminate the osseous defects and endodo-
ntic restorative consideration. This treatment can produce
predictable results as long as proper diagnostic, endodont-

ic, surgical and prosthetic procedures are performed. The
prognosis for hemisection is the same as for routine endo-
dontic procedures provided that case selection has been co-
rrect, the endodontics has been performed adequately, and
the restoration is of an acceptable design relative to the oc-
clusal and periodontal needs of the patient.
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