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Case Report

Hemisection as a Conservative Management of Grossly Carious

Permanent Mandibular First Molar
Shweta Sharma, Rajat Sharma1, Abdul Ahad, Narinder Dev Gupta, Surendra Kumar Mishra1
Departments of Periodontics and Community Dentistry and 1Conservative Dentistry and Endodontics, Dr. Ziauddin Ahmad Dental College and Hospital, Aligarh Muslim
University, Aligarh, Uttar Pradesh, India

Abstract
Hemisection of a molar denotes removal or separation of a root along with its accompanying part of crown. It is a suitable treatment option
when the caries, resorption, perforation, or periodontal damage is restricted to one root while the other root is relatively healthy. Hemisection
of the affected tooth helps to retain the tooth structure, surrounding alveolar bone, and may also facilitate the placement of fixed prosthesis.
This case report describes the hemisection as a successful treatment method to save a grossly carious mandibular first molar with periodontal
and periapical involvement. Hemisection and prosthetic rehabilitation yielded a satisfactory result. With careful treatment planning and precise
surgical management, undesirable consequences of tooth loss were prevented.

Keywords: Furcation defect, root caries, root resection

Introduction should be considered before every molar extraction, because

it offers successful long‑term results.[3]
As a practitioner of art and science of dentistry, a clinician is
expected to provide a functional dentition for lifetime. Loss of
the posterior teeth may result in several undesirable sequelae Case Report
which requires prevention and maintenance measures. The A 20‑year‑old female was referred to the department of
treatment options for an extensively decayed and unrestorable conservative dentistry and endodontics with a chief complaint
molar are limited. The most common treatment for such tooth of pain in the lower right back tooth region for 10 days. Pain
may include extraction followed by a removable partial denture, was mild, intermittent in nature, and aggravated on mastication.
fixed partial denture, or a dental implant to replace the missing She had no relevant medical or dental history.
tooth. However, with appropriate case selection, hemisection On intraoral examination, tooth #46 was found to have a
can be a relatively simple, conservative, inexpensive treatment deep carious lesion involving distal and occlusal surfaces.
with good chances of success. The involved tooth was severely tender on percussion. On
Hemisection and root resection have now been established as probing, a periodontal pocket of 6 mm was found on the distal
successful treatment modalities. Yuh et al. assessed survival aspect. However, no mobility was observed in the affected
rates of a large number of root‑resected molars retrospectively tooth. Radiographical examination revealed carious lesion
and reported interesting findings with respect to demographic extending to the cervical third of distal root [Figure 1a].
variables. The overall survival rate for root‑resected molars was Interproximal bone loss was evident between #46 and #47
found to be 91.1%.[1] Carnevale et al. reported a survival rate along with mild haziness in the furcation area. Periapical
of about 93% over a 10‑year follow‑up among patients who
Address for correspondence: Dr. Abdul Ahad,
received hemisection as the management of furcated molars.[2] Department of Periodontics and Community Dentistry, Dr. Ziauddin
The success of hemisection depends, to a large extent, on case Ahmad Dental College and Hospital, Aligarh Muslim University,
selection and following specific endodontic, surgical, and Aligarh ‑ 202 002, Uttar Pradesh, India.
E‑mail: aahad.amu@gmail.com
restorative guidelines. It has been suggested that hemisection

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DOI: How to cite this article: Sharma S, Sharma R, Ahad A, Gupta ND,
10.4103/jnsbm.JNSBM_53_17 Mishra SK. Hemisection as a conservative management of grossly carious
permanent mandibular first molar. J Nat Sc Biol Med 2018;9:97-9.

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Sharma, et al.: Hemisection ‑ A conservative approach

radiolucency surrounding the apex of both roots of #46 was socket of the distal root filled with bone graft  [Figure 1c].
also found. On the basis of history, clinical and radiographic Sutures were removed after 2 weeks.
examination, a diagnosis of chronic apical periodontitis was
At 1‑month recall visit, healing was found to be satisfactory,
made with respect to tooth #46. Since the extent of decay
while mobility was absent [Figure 2d]. Tooth preparation of
rendered the tooth nonrestorable, the patient was explained
the mesial portion of the first permanent molar and second
about the condition and prognosis of tooth with feasible
molar was performed followed by porcelain‑fused‑to‑metal
treatment options including extraction and placement of dental
prosthesis [Figure 3a and b]. Radiographs at 3 months and
implant. However, she opted for hemisection followed by fixed
9 months suggested progressive formation of bone in the
dental prosthesis over other treatment options.
extraction socket along with resolution of radiolucency around
The periodontal prognosis of the mesial root was fair the mesial root of #46 [Figure 3c and d].
with good bone support. After completion of endodontic
treatment that also included removal of all carious tooth
structures [Figure 1b], hemisection of distal root was
Discussion
performed under local anesthesia. Full‑thickness flaps were Loss of posterior teeth may result in several undesirable
elevated on the buccal and lingual aspects of the involved tooth. sequelae such as mesial drifting, loss of arch length, and loss of
Upon reflection of the flap, crater‑like bony defect along the masticatory function. As previously discussed, treatment options
distal root became more evident. Degranulation was performed for an extensively decayed and nonrestorable molar are limited.
using surgical curettes (Hu‑Friedy, Chicago, IL, USA) to A clinician must decide a treatment option based on the patient’s
expose the bone. A low‑speed surgical length fissure carbide age, medical history, and the ability to maintain oral hygiene.
bur was used under saline irrigation to make vertical cut toward Consideration of the cost of treatment and available clinical
the furcation area. A fine probe was passed through the cut to evidence of success of different modalities is indispensable.
ensure separation [Figure 2a]. In the present case, all possible treatment options were
After completion of the sectioning, the root was elevated explained to the patient, including hemisection, as the decay
from its socket using a periosteal elevator and removed. was limited to distal root. Since the patient was young, she was
Granulation tissue was curetted out of the distal socket using reluctant to lose her tooth. In addition, her financial conditions
surgical curettes. The socket was irrigated adequately with made her to reject the option of dental implant.
sterile normal saline [Figure 2b]. Scaling and root planing The long‑term success of hemisected molar depends on a
of the remaining root surfaces was performed with Gracey number of interrelated factors: periodontal condition of tooth,
curettes (Hu‑Friedy, Chicago, IL, USA). The distal root socket root anatomy, maintenance therapy, endodontic and restorative
and crater‑like bony defect were grafted with alloplastic bone therapy, and the surgical procedure itself.[3]
graft (hydroxyapatite and β‑tricalcium phosphate) [Figure 2c].
Flap was approximated and sutured with 3‑0 braided silk. From periodontal aspect, the amount of bone support and
The occlusal table was minimized to redirect the forces along degree of furcation involvement are major determinants for
the long axis of the mesial root. Immediate postoperative case selection and prognosis. Studies have found that the
radiograph showed the well‑retained mesial root and extraction

a b
a b

c c d
Figure 1: (a) Preoperative radiograph showing the extent of carious Figure 2: (a) Clinical photograph showing line of resection through
lesion and periapical radiolucency. (b) Radiograph after completion of furcation area. (b) Surgical field after removal of resected half of
root canal treatment and removal of carious tooth structure. (c) Immediate tooth structure. (c) Alloplastic graft placed in the socket of distal root.
postoperative radiograph showing extraction socket filled with bone graft (d) One‑month postoperative photograph showing healing of soft tissue

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Sharma, et al.: Hemisection ‑ A conservative approach

concluded that both molar root resection and molar implant

placement with appropriate restoration demonstrated a high
degree of success in function. However, Bühler reported that
failure rates of two treatment alternatives were not substantially
different with an average reported failure rate of 13.1%
among hemisected teeth.[12] In contrast to this, Zafiropoulos
a b et  al. reported that, in periodontitis patients, hemisected
mandibular molars were more prone to complications than
dental implants.[13] While both procedures demonstrate high
and low success rates depending on the appropriately applied
treatment plan and presence of deleterious factors, they are
not interchangeable in clinical situations.

c d Conclusion
Figure 3: (a) Occlusal view of porcelain‑fused‑to‑metal prosthesis. Conservative management of grossly carious multirooted
(b) Buccal view of porcelain‑fused‑to‑metal prosthesis. (c) Postoperative teeth in young patients not only preserves the dentition but
radiograph at 3 months. (d) Postoperative radiograph at 9 months also reduces the financial burden, psychological trauma, and
occlusal dysfunction associated with tooth loss. Hemisection
long‑term prognosis of molars with Grade III furcation is poor seems to be a reliable treatment option for saving a
when compared to molars with a lesser degree of furcation nonrestorable molar which otherwise needs to be extracted.
involvement.[4,5] It indicates that root resection or hemisection Financial support and sponsorship
performed at the incipient stage of furcation invasion is more Nil.
likely to result in successful outcome. Considering these factors,
favorable result in the present case may be attributed to minimal Conflicts of interest
extent of furcation involvement at the time of surgery. Moreover, There are no conflicts of interest.
socket preservation at the site of extracted root done in this case
contributed to maintain the original topography of alveolar ridge. References
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