Review Article

Outcome of Crown and Root Resection: A

Systematic Review and Meta-analysis of the
Literature
Frank C. Setzer, DMD, PhD, MS,* Haochang Shou, PhD,† Pacharee Kulwattanaporn, DDS, MS,‡
Meetu R. Kohli, BS, DMD,* and Bekir Karabucak, DMD, MS*

Abstract
Introduction: A systematic review and meta-analysis Large-scale randomized controlled trials should be conducted to strengthen the
were conducted to report combined and individual evidence. (J Endod 2019;45:6–19)
weighted pooled outcome rates for crown resection
(CR) and root resection (RR) procedures. Methods: Key Words
Three electronic databases (PubMed [MEDLINE], Sco- Crown resection, meta-analysis, outcome, root resection, success, survival, systematic
pus, and the Cochrane Library) were searched to iden- review
tify human studies in 12 languages on CR (hemisection,
trisection, and premolarization) and RR (amputations
and RRs without removal of crown portions). Five
peer-reviewed journals, references of relevant publica-
R oot amputation dates
back to Farrar in
1884 (1) as treatment for
Significance
No previous study provided cumulative outcome
tions, and reviews were hand searched. Assessment by rates for crown and root resection procedures.
multirooted teeth with
3 independent reviewers was based on the following The knowledge gained from this investigation will
furcation involvement,
predefined Population, Intervention, Comparison, help the practitioner with treatment planning and
Gottlieb and Orban in
Outcome, Study Design question: “For teeth in patients decision making for cases with indication for crown
1933 (2), and Messinger
undergoing surgical therapy by CR versus RR, what is or root resection.
and Orban in 1954 (3).
the expected probability of survival according to longi- Today, a distinction is
tudinal studies with strictly defined outcome measure- made between root resection (RR) and crown resection (CR) procedures. RR includes
ments and inclusion/exclusion criteria?” Clinical root amputation or any RR at the level of the cementoenamel junction without removal
investigations with at least 12 months of follow-up of portions of the crown. CR addresses hemisection, trisection, and premolarization
were included. Studies and level of evidence were (bicuspidization). This includes all procedures in which a dissection transverses
appraised using the Newcastle-Ottawa Scale and through the furcation and the crown of a multirooted tooth in such a way that a root
Grading of Recommendations, Assessment, Develop- and the associated portion of the crown may be removed (hemisection or trisection)
ment and Evaluations. Results: Thirty-four articles or all root/crown sections are being retained (premolarization or bicuspidization).
were obtained for final analysis. Data could be ex- The primary indication for resective therapies is class III furcation involvement.
tracted from 19 studies (CR and RR OVERALL: Other reasons may include deep class II furcation involvement, localized severe bone
N = 2667 [19 studies], CR: n = 111 [3 studies], and loss involving 1 individual root, vertical root fractures, subgingival root caries, persisting
RR: n = 1127 [9 studies]). A random effects model periapical pathology, root resorptions, and iatrogenic root perforations (4, 5) as well as
showed weighted mean survival rates of 85.6% the preservation of teeth with a high strategic value or when anatomic situations
(95% confidence interval [CI], 76.7–91.5) for CR and preclude implant placement (6). A detailed overview of all possible indications is pro-
RR procedures OVERALL. Individual data showed vided in Supplemental Table S1 (available online at www.jendodon.com).
weighted mean survival rates of 81.9% (95% CI, Renewed interest has emerged to preserve natural teeth (7, 8). Although tooth
72.0–88.8) for CR and 87.2% (95% CI, 71.7–94.8) extraction and replacement with dental implants were described as being regarded
for RR. There was no statistically significant difference as a panacea (9), recent studies provided new, previously missing evidence on the
between CR and RR (P = .89, odds ratio calculation) long-term outcome of implants versus natural teeth (10) and the incidence and nature
or between maxillary and mandibular molars of implant-related complications (11, 12). Considering a patient’s life span, resective
(P = .81, Fisher exact test). Conclusions: Overall, CR therapies may provide means to prolong the life of a tooth, postponing implant
and RR procedures showed good outcome rates. placement to later stages.

From the *Department of Endodontics, School of Dental Medicine and †Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Phil-
adelphia, Pennsylvania; and ‡Department of Operative Dentistry, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand.
Address requests for reprints to Dr Frank C.Setzer, School of Dental Medicine, University of Pennsylvania, 240 S 40th Street, Philadelphia, PA 19104. E-mail address:
fsetzer@upenn.edu
0099-2399/$ - see front matter
Copyright ª 2018 American Association of Endodontists.
https://doi.org/10.1016/j.joen.2018.10.003

6 Setzer et al. JOE — Volume 45, Number 1, January 2019

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 Review Article
For proper treatment planning, the general outcome rates of indi- repeated for “Review Articles.” The PubMed (MEDLINE) and Scopus
vidual dental procedures must be part of the consideration (13), with search covered the time frame from 1966 to March 15, 2018. The Co-
the highest level of evidence being desirable (14). Large-scale random- chrane Library was searched from 1992 to March 15, 2018.
ized controlled trials are accepted as the gold standard, but they are not Bibliographies of 5 relevant clinical journals (Periodontology
available in the literature for all dental interventions and treatment mo- 2000, Journal of Periodontology, Journal of Prosthetic Dentistry,
dalities (15). In the absence of randomized controlled trials, meta- Journal of Clinical Periodontology, and Journal of the American
analyses of the available data are an alternative and provide the best Dental Association) were hand searched from 1966 or the earliest
available evidence. In endodontics, systematic reviews and meta- available issue thereafter to March 2018. The reference sections of
analyses exist for the outcome of primary endodontic treatment (15, all publications identified for full-text review and of all relevant review
16), nonsurgical endodontic retreatment (17), surgical endodontic articles were cross-referenced. ClinicalTrials.gov was searched for
treatment (18), and the comparison of endodontically treated teeth planned, ongoing, or completed investigations. Three experts in the
versus dental implants (9, 16). However, no study has established field were contacted to identify any gray literature sources or currently
the overall cumulative outcome rates for CR and RR procedures or a planned clinical trials. The authors were prepared to contact study au-
comparison of the outcome rates between CR versus RR procedures. thors if questions arose throughout the investigation. The PROSPERO
The aim of this systematic review was to provide the best available database of systematic review protocols was accessed to identify any
evidence on the outcome of CR and RR procedures. Preparation for this related reviews currently being undertaken.
study revealed no specific success criteria for resective procedures. PubMed (MEDLINE), Scopus, and the Cochrane Library were
Tooth loss or extraction recommendation has been accepted as failure searched first. A title search was conducted independently by 2 calibrated
of CR or RR; therefore, tooth survival was chosen as the outcome param- reviewers (P.K. and F.S.) followed by abstract review and full-text review
eter for success in this investigation. by 3 calibrated, independent reviewers (M.K., P.K., and F.S.). Hand
A meticulous review of the literature was undertaken for 12 lan- searches and cross-referencing was conducted subsequently. Cohen
guages to include a large quantity of available information by raw kappa statistical analysis was obtained after full-text review.
data extraction and subsequent statistical analysis. The following
research question was defined before conducting the literature search Inclusion and Exclusion Criteria
to identify both cumulative and individual outcome rates for CR versus The inclusion criteria were as follows:
RR procedures following the Population, Intervention, Comparison,
Outcome, Study Design format: “For teeth in patients undergoing sur- 1. An original study investigating the clinical outcome of root/crown
gical therapy (Population) by CR (Intervention) versus RR (Compari- resective therapies for endodontically treated teeth in humans
son), what is the expected probability of survival (Outcome) 2. The outcome evaluation was described in the study
according to longitudinal studies with strictly defined outcome mea- 3. A minimum of a 12-month follow-up
surements and inclusion/exclusion criteria (Study Design)?” The hy- 4. Raw data can be extracted from the article or obtained by personal
pothesis was that there was no significant difference in the outcome communication with the principal authors
comparing CR with RR procedures. 5. A randomized controlled trial, a prospective study with concurrent
control, or a prospective or retrospective case study
Materials and Methods The exclusion criteria were as follows:
This systematic review and meta-analysis to determine the
1. An original study but not investigating the clinical outcome of root/
outcome of CR and RR were prepared and conducted according to
crown resective therapies for endodontically treated teeth in humans
the Preferred Reporting Items for Systematic Reviews and Meta-
2. A review or opinion article
Analyses guidelines (19). The study was added to the PROSPERO data-
3. A follow-up period <12 months
base (CRD42018091840).
4. Raw data cannot be extracted from the article or obtained by per-
sonal communication with the principal authors
Identification of Studies 5. Case reports or case series with <10 as a sample size
Based on the Population, Intervention, Comparison, Outcome,
Study Design question, 3 electronic databases (ie, PubMed [MEDLINE], The 3 calibrated, independent reviewers resolved any discrep-
Scopus, and the Cochrane Library) were searched for topic-related ancies regarding study inclusion by discussion.
studies. The term ([crown lengthening OR tooth root/surgery OR
root resection OR tooth resection OR furcation/involvement OR furca- Data Extraction
tion involvement OR furcation/therapy OR furcation therapy OR furca- A custom-designed spreadsheet was used for data extraction. Dis-
tion/surgery OR furcation surgery OR furcation OR furcation plasty OR crepancies were resolved by discussion. The following information was
hemisection OR premolarization OR trisection OR root amputation OR sought from the selected articles: title, publication year, language, sam-
root separation OR rhizotomy OR rhizectomy OR ampudontology OR ple size (overall), follow-up period (years), follow-up rate (%), age of
odontogenous resection OR dissection OR radectomy OR odontosec- participants, resection type (RR or CR), type of procedures (root ampu-
tion OR root resective therapy OR periodontal surgery] AND [outcome tation, hemisection, trisection, or premolarization), outcome criteria
assessment OR success OR treatment outcome OR prognosis]) was (definition), outcome (survival [N/%] or failure/loss [N/%]), study
applied. For PubMed (MEDLINE), the search was limited to “dental design and quality (best, better, good, average, fair, and unknown
journals,” specific article types (“Classical Article, Clinical Trial, following the protocol by Iqbal and Kim [16] and the Newcastle-
Controlled Clinical Trial, Historical Article, Journal Article, Multicenter Ottawa Scale [NOS] for observational studies [20]), practitioner
Study, Observational Study, Pragmatic Clinical Trial, and Randomized (student/resident, general practitioner, periodontal specialist/oral sur-
Controlled Trial”), human subjects, and publications in 12 languages geon, or endodontic specialist), indications for procedure (endodontic
(Chinese, English, French, German, Hebrew, Hindi, Japanese, Korean, pathology [apical periodontitis, root fracture, perforation, and so on],
Portuguese, Spanish, Thai, and Turkish). In addition, the search was periodontal bone loss >6 mm [deep pocket or periodontic-endodontic

JOE — Volume 45, Number 1, January 2019 Outcome of Crown and Root Resection 7
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Review Article
lesion], furcation problem, or restorative reasons [root proximities , mandibular teeth were evaluated by applying Pearson and Fisher exact
crown and bone contouring]), reasons for failure (progressive gener- tests. SPSS v15.0 (SPSS Inc, Chicago, IL), Minitab v15.0 (Minitab Inc,
alized periodontal disease, progressive localized periodontal disease, State College, PA), and Excel 2007 (Microsoft Corporation, Redmond,
endodontic reasons [abscess or nonhealing apical periodontitis], or WA) were used for all descriptive and inferential analyses.
restorative reasons [fractures, recurrent decay, and so on]), restora-
tion type (permanent [full coverage where indicated] or temporary Assessment of Methodological Quality
[buildup, no full coverage where indicated]), maintenance (regular Two reviewers (M.K. and F.S.) independently assessed the quality
professional care or individual home care only), and maintenance fre- of the included studies using 2 scales. Iqbal and Kim (16) stratified
quency (not applicable, once per year, or at least twice per year). studies into 6 categories: best (randomized controlled trial, double-
blind), better (prospective study with concurrent controls), good (pro-
Statistical Analysis spective study with historic controls), average (prospective case study),
A meta-analysis was performed using both a fixed effects (FE) fair (retrospective case study), or unknown. The NOS was used for
model and a random effects (RE) model to obtain the final effect sizes detailed appraisal of observational studies (20). NOS assigns a
and 95% confidence intervals (CIs) incorporating within- and between- maximum of 4 points for selection, 2 points for comparability, and 3
study heterogeneity. t2 and I2 statistics were used to evaluate heteroge- points for exposure or outcome. NOS scores of 7–9 are considered
neity among trials. An estimate >50% was considered to be substantial high-quality and 5–6 moderate-quality observational studies (20).
heterogeneity. The data were quantitatively synthesized as weighted
pooled outcome rates for the combined interventions of CR and RR Grading of Recommendations, Assessment,
(OVERALL). Where data could be isolated appropriately, weighted Development and Evaluations Evidence Synthesis
pooled outcome rates were also calculated for CR and RR, respectively. Levels of evidence quality were estimated according to
The odds ratio (OR) based on the pooled proportions for each proced- Grading of Recommendations, Assessment, Development and Evalua-
ure was calculated. The differences in outcome between maxillary and tions (GRADE) guidelines (21), which allow the inclusion of

Figure 1. A flowchart of the review search and study identification.

8 Setzer et al. JOE — Volume 45, Number 1, January 2019

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 Review Article
observational studies in the absence of randomized controlled trials sion at each screening phase is shown in Figure 1. An electronic
(22), as appraised using the NOS. The strength of the recommendation database search resulted in a total of 3962 citations, with 3588
followed the GRADE overall evidence grade categories as follows: 1, deriving from PubMed (MEDLINE), 320 from Scopus, and 54
high grade (further research is unlikely to change confidence in the ef- from the Cochrane Library. The search for review articles revealed
fect estimate); 2, moderate grade (further research is likely to alter con- 564 citations, of which 15 were previously unidentified (23–37),
fidence in the effect estimate and may change the estimate), 3, low grade relevant to the subject, and obtained together with earlier
(further research is likely to significantly alter confidence in the effect identified reviews for cross-referencing (6, 38–42). A hand search
estimate and to change the estimate); and 4, very low grade (any effect of the 5 journals resulted in 16 additional references and cross-
estimate is uncertain). referencing of the review articles in 7 additional references. After
duplicate elimination, 4 studies were included. Of these combined
3966 citations, 84 abstracts were acquired after title review. Abstract
Results review eliminated a further 50 references (6, 38, 40–87) (Table 1).
Search Findings The remaining 34 publications were obtained for full-text assessment,
A Preferred Reporting Items for Systematic Reviews and Meta- after which 19 studies were deemed eligible for inclusion
Analyses flow diagram depicting study selection, inclusion, and exclu- (88–106). Table 1 details the reasons for the exclusion of 15 studies

TABLE 1. The Reasons for Study Exclusions after Abstract and Full-text Review
Authors, publication year Authors, publication year
Exclusion Exclusion
Excluded after abstract review Language criteria Excluded after full-text review Language criteria
Abrams & Trachtenberg, 1974 (43) English 2 Ross et al, 1980 (107) English 1
Guldener, 1976 (44) German 2 Baima, 1987 (108) English 2
Johnson, 1976 (45) English 2 Baima, 1987 (109) English 2
Gerstein, 1977 (38) English 2 Wilson et al, 1987 (110) English 1
Reetz, 1979 (46) German 2 Ariga, 1987 (111) Japanese 2
Waerhaug, 1980 (47) English 2 Lachner et al, 1989 (112) German 1
Adriaens & de Boever, 1981 (48) German 2 Hellden et al, 1989 (113) English 5
Rossi & Bustamante, 1982 (49) Spanish 2 Handtmann et al, 1989 (114) German 1
Kryshtalshyj, 1986 (50) English 2 Bu€ hler, 1991 (115) German 3
Erpenstein, 1986 (51) English 2 Bu € hler, 1994 (39) English 2
Schmitt & Brown, 1989 (52) English 2 Mu€ ller et al, 1995 (116) English 1
Novaes & Novaes, 1993 (53) English 2 Northway, 2004 (117) English 1
Leonard & Gutmann, 1995 (54) English 5 Ribeiro et al, 2011 (118) English 1
Berkey et al, 1995 (55) English 1 Oh, 2012 (119) English 5
Hempton & Leone, 1997 (40) English 2 Johansson et al, 2013 (120) English 1
Oates & Kalkwarf, 1997 (56) English 2
Kinsel et al, 1998 (41) English 2
Fugazzotto, 1999 (57) English 2
Fugazzotto, 1999 (58) English 2
Saenz De Nasr & Nasr, 2001 (42) English 2
Becker et al, 2001 (59) English 1
Serino et al, 2001 (60) English 1
Hildebrand, 2003 (61) English 2
Bohnenkamp & Garcia, 2004 (62) English 2
Minsk & Polson, 2006 (6) English 2
Hoffmann et al, 2006 (63) English 1
Carnevale et al, 2007 (64) English 1
Checchi et al, 2008 (65) English 5
Santana et al, 2009 (66) English 1
Park, 2009 (67) English 5
Hayakawa et al, 2011 (68) English 1
Saito et al, 2011 (69) English 1
Cortellini & Tonetti, 2011 (70) English 1
€umer et al, 2011 (71)
Ba English 1
Cortellini et al, 2011 (72) English 1
Silvestri et al, 2011 (73) English 1
Hayakawa et al, 2012 (74) English 1
Horwitz & Gabay, 2012 (75) Hebrew 2
Cesar-Neto et al, 2012 (76) English 5
Floratos & Kratchman, 2012 (77) English 5
Levin & Kessler-Baruch, 2012 (78) Hebrew 2
Briguglio et al, 2013 (79) English 1
Molna r et al, 2013 (80) English 1
Mishra et al, 2013 (81) English 1
Aljateeli et al, 2014 (82) English 1
Kurt et al, 2014 (83) English 1
Anitha & Rao, 2015 (84) English 5
Sanz et al, 2015 (85) English 2
Tahmooressi et al, 2016 (86) English 5
Rattanasuwan et al, 2017 (87) English 1

JOE — Volume 45, Number 1, January 2019 Outcome of Crown and Root Resection 9
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 10

Review Article
TABLE 2. An Overview of Study Characteristics and Outcome Data according to OVERALL, Crown Resection (CR), and Root Resection (RR) and Maxillary Versus Mandibular Molars
Outcome of all procedures Outcome Maxillary Mandibular
Setzer et al.

(OVERALL) of CRs Outcome of RRs molars molars

Authors, Follow- Age Weight
publication Follow- up rate range Type of Sample Failure Sample Failure Sample Failure Sample Sample (RE) Study Study quality
%
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year Language up (y) (%) (y) procedures size Survival (loss) % size Survival (loss) % size Survival (loss) size Survival size Survival (%) design Iqbal & Kim [NOS]

Bergenholtz et al, English 1–11 Not 16–63 Root amputation, 45 42 3 93.3 15 Not reported 30 Not reported 5.5 Retrospective fair [high]
1972 (88) reported hemisection
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Hamp et al, 1975 English 5 Not Not Root amputation 87 87 0 100 87 87 0 100 39 Not reported 44 Not reported 6.3 Retrospective fair [moderate]
(89) reported reported
Langer et al, 1981 English 10 Not Not Root amputation, 100 62 38 62 50 37 50 25 5.1 Retrospective fair [moderate]
(90) reported reported hemisection,
premolarization
Erpenstein et al, English 1–7 Not 27–71 Hemisection 34 27 7 79.4 34 27 7 79.4 7 Not reported 27 Not reported 4.3 Retrospective fair [moderate]
1983 (91) (mean reported
2.9)
B€
uhler et al, 1988 English 10 89.3 20–59 Root amputation 28 19 9 67.9 28 19 9 67.9 3.5 Retrospective fair [high]
(92) (mean =
50.1)
Kuhrau et al, 1990 German 4–8 100 Not Root amputation 25 20 5 80 25 20 5 80 3.8 Retrospective fair [high]
(93) reported
Carnevale et al, English 3–11 97.6 20–69 Root amputation, 488 470 18 96.3 6.3 Retrospective fair [high]
1991 (94) hemisection
Basten et al, 1996 English 2–23 100 25–77 Root amputation 49 45 4 91.8 49 45 4 91.8 32 30 17 15 5.5 Retrospective fair [high]
(95)
Babay et al, 1996 English 4 100 30–45 Root amputation 14 13 1 92.9 14 13 1 92.9 14 13 0 0 4.3 Retrospective fair [high]
(96) (mean =
38)
€ f et al,1997
Blomlo English 3–10 91.8 34–75 Root amputation 146 112 32 76.7 146 112 32 76.7 111 Not reported 35 Not reported 5.6 Retrospective fair [high]
(97)
Carnevale et al, English 10 100 21–62 Root amputation, 175 163 12 93.2 6.1 Prospective average [high]
1998 (98) hemisection,
trisection
Hou et al, 1999 (99) English 5–13 100 26–67 Root amputation, 52 50 2 96.2 29 27 23 23 5.9 Retrospective fair [high]
hemisection,
trisection
Sv€
ardstr€
om et al, English 9.5 81 14–73 Root amputation, 58 52 6 89.7 5.4 Retrospective fair [high]
2000 (100) (mean = hemisection,
44.9) trisection
Fugazzotto et al, English 1–15 Not 22–79 Root amputation, 701 678 23 96.7 21 20 1 95.2 680 658 22 96.8 335 323 366 355 6.3 Retrospective fair [high]
2001 (101) reported hemisection,
premolarization
Polson & Blieden, English 10–18 100 30–45 Root amputation 30 27 3 90.0 30 27 3 90.0 25 22 5 5 4.9 Retrospective fair [high]
2002 (102) (mean = (mean =
12.4)* 47.3)
Zafiropoulos et al, English 4 Not 35–73 Hemisection 76 61 15 80.4 56 45 11 80.4 0 0 76 61 5.2 Retrospective fair [high]
2009 (103) reported
Park et al, 2009 English 2–7 Not 50.8  11.4 Root amputation, 342 240 102 70.2 186 138 156 102 5.9 Retrospective fair [high]
JOE — Volume 45, Number 1, January 2019

(104) reported hemisection,

premolarization
Lee et al, 2012 English 1–24 Not 47.3 Root amputation, 149 60 89 40.3 89 31 60 29 5.4 Retrospective fair [high]
(105) reported hemisection
De Beule et al, English 1–27 Not Not Root amputation 68 34 34 50.0 68 34 34 50.0 4.6 Retrospective fair [high]
2017 (106) reported reported
2667 2262 403 111 92 19 1127 1015 110 100

RE, random effect.

*Polson and Blieden (102) reported the follow-up period of a larger population investigated for the outcome of periodontal disease treatment, of which the root resection cohort is a subgroup.
 TABLE 3. Detailed Study Characteristics
JOE — Volume 45, Number 1, January 2019

Authors,
publication Outcome Procedure Type of Reasons for Restoration Maintenance
year Practitioner criteria group procedures Indications failure type Maintenance frequency
Bergenholtz Not reported Survival RR/CR Root amputation, Endodontic Localized Permanent Not reported Not reported
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et al, 1972 hemisection pathology, periodontal

(88) periodontal disease,
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bone loss >6 mm, endodontic

furcation reasons
problem,
restorative
reasons
Hamp et al, Not reported Survival RR Root amputation Furcation problem Not reported Permanent Not reported Not reported
1975 (89)
Langer et al, Not reported Survival* RR/CR Root amputation, Furcation problem Generalized and Not reported Not reported Not reported
1981 (90) hemisection, localized
premolarization periodontal
disease,
endodontic and
restorative
reasons
Erpenstein et al, Not reported Survival CR Hemisection Endodontic Localized Permanent, Regular At least twice per
1983 (91) pathology, periodontal temporary professional care year
periodontal disease,
bone loss >6 mm, endodontic
furcation reasons
problem,
restorative
reasons, other
€ hler et al,
Bu Not reported Survival RR Root amputation Periodontal bone Localized Permanent Regular Once per year, at
1988 (92) loss >6 mm, periodontal professional care least twice per
furcation disease, year
problem endodontic and
restorative
reasons
Kuhrau et al, Not reported Survival RR Root amputation Periodontal bone Endodontic and Not reported Regular Once per year
1990 (93) loss >6 mm, restorative professional care
furcation reasons
problem
Carnevale et al, Not reported Survival† RR/CR Root amputation, Endodontic Not reported Permanent Regular At least twice per
Outcome of Crown and Root Resection

1991 (94) hemisection pathology, professional care year

periodontal
bone loss >6 mm,
furcation
problem,
restorative

Review Article
reasons
Basten et al, Periodontal Survival RR Root amputation Periodontal bone Endodontic and Permanent Regular At least twice per
1996 (95) specialist/oral loss >6 mm, restorative professional care year
surgeon furcation reasons
problem
(continued )
11
 12

Review Article
TABLE 3. (continued )
Authors,
Setzer et al.

publication Outcome Procedure Type of Reasons for Restoration Maintenance

year Practitioner criteria group procedures Indications failure type Maintenance frequency
Babay et al, Periodontal Survival‡ RR Root amputation Periodontal bone Localized Not reported Individual home Not reported
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1996 (96) specialist/oral loss >6 mm, periodontal care only

surgeon, furcation disease
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endodontic problem
specialist
€ f et al,
Blomlo Periodontal Survival RR Root amputation Periodontal bone Generalized and Not reported Regular At least twice per
1997 (97) specialist/oral loss >6 mm, localized professional care year (68% of pts)
surgeon furcation periodontal (68% of pts)
problem disease,
endodontic and
restorative
reasons
Carnevale et al, Not reported Survival RR/CR Root amputation, Endodontic Generalized and Permanent Regular At least twice per
1998 (98) hemisection, pathology, localized professional care year
trisection periodontal periodontal
bone loss >6 mm, disease,
furcation endodontic and
problem restorative
reasons
Hou et al, 1999 Periodontal Survival RR/CR Root amputation, Periodontal bone Not reported Permanent Regular Not reported
(99) specialist/oral hemisection, loss >6 mm, professional care
surgeon trisection furcation
problem,
restorative
reasons
€rdstro
Sva €m Not reported Survival RR/CR Root amputation, Periodontal bone Restorative Not reported Regular Not reported
et al, 2000 hemisection, loss >6 mm, reasons, other professional care
(100) trisection furcation
problem
Fugazzotto Periodontal Survival RR/CR Root amputation, Not reported Generalized and Permanent Regular Once per year
et al, 2001 specialist/oral hemisection, localized professional care
(101) surgeon premolarization periodontal
disease,
endodontic and
restorative
reasons
Polson & Periodontal Survival RR Root amputation Periodontal bone Endodontic reasons Not reported Regular At least twice per
JOE — Volume 45, Number 1, January 2019

Blieden, 2002 specialist/oral loss >6 mm, professional care year

(102) surgeon furcation
problem
Zafiropoulos Periodontal Survival CR Hemisection Furcation problem Localized Permanent Regular At least twice per
et al, 2009 specialist/oral periodontal professional care year
(103) surgeon disease,
restorative
reasons
 Review Article
(39, 107–120) after full-text review. Cohen kappa statistics showed

Carnevale et al (94): failures according to study included cement washout, caries, abutment fracture, root fracture, untreatable endodontic problem, and probing depth >5 mm. The study recorded a total of 28 failures, of which 10 were retained. Numbers extracted from the study
At least twice per
70.6% agreement at this stage before arbitration.

Once per year, at

least twice per

Once per year

ClinicalTrials.gov (121) was accessed March 20, 2018, resulting
year

year
in 806 citations. Four trials warranted further evaluation. Two of the 4
trials were currently recruiting and were related to periodontal therapy.
The other 2 were completed and investigated the treatment of furcation
defects and immediate versus delayed periodontal surgery, respectively.
All 4 reports were disregarded. A report from the 3 experts in the field
professional care

professional care

professional care
did not identify any gray literature or any other ongoing investigation.
(254 selected

The PROSPERO database search returned 70 results but none relevant

molars)
Regular

Regular

Regular
to the study subject.

Characteristics of the Included Studies

Tables 2 and 3 describe the characteristics of all 19 included
studies. All studies investigated both males and females ranging in
Not reported
temporary
Permanent,
Permanent

age from 14–79 years. Data could be extracted for the combined
group (OVERALL [CR and RR]) for 2679 teeth from all 19 studies,
for CR for 111 teeth from 3 studies, and for RR from 1127 teeth
from 9 studies (Table 2). Of all of the studies, 18 identified “furcation
problem” as an indication for the procedure, 15 “periodontal bone loss
>6 mm,” 6 “endodontic pathology,” and 5 “restorative reasons”
endodontic and

endodontic and
reasons, other
Generalized and

periodontal

periodontal
restorative

restorative

Not reported

(Table 3). As causes for failure, 11 studies listed “generalized and/or

Generalized
localized

disease,

disease,

reasons

localized periodontal disease” and 13 studies “endodontic and/or

restorative reasons” (Table 3). Restoration of the resected tooth was
described by 12 studies; 16 investigations shared information about
the type of maintenance, of which 13 also included the frequency
(Table 3).
bone loss >6 mm,

bone loss >6 mm,

Periodontal bone
periodontal

periodontal

loss >6 mm,

pathology,

pathology,
restorative
furcation

furcation

furcation
Endodontic

Endodontic
problem,

problem

problem
reasons

Effects on Tooth Survival after Resective Therapies

*Langer et al (90): loss of resected teeth or periodontal, endodontic, and restorative failures that led to extraction after the follow-up visit.

Meta-analyses for proportions of tooth survival were separately

calculated for the OVERALL, CR, and RR groups using log odds as out-
comes. To allow for statistical evaluation, for Hamp et al (89), where the
success proportion was 100%, a 1/2 count was added to the number of
premolarization
Root amputation,

Root amputation,

Root amputation

failure events so that the success rate became 99.5%. For each of the 3
hemisection,

hemisection

groups, the individual effect sizes (log-transformed odds) and corre-

sponding variances were estimated, and the weighted overall success
probabilities were calculated using inverse probability weights.
Babay et al (96): extraction after follow-up visit because of nonsavable periodontal condition.

OVERALL Outcome for CR and RR Procedures

RR/CR

RR/CR

Figure 2A summarizes the meta-analysis evaluating the overall

RR

outcome of CR and RR from all 19 studies included in the investigation

(N = 2679). In-between study heterogeneity was quantified
(t2 = 1.5136; I2 = 95.2% [range, 93.7%; 96.4%], P < .01). The RE
Survival

Survival

Survival

model showed weighted mean survival rates of 85.61% (95% CI,

76.66–91.51) for CR and RR procedures combined. The funnel plot
for the assessment of publication bias of all of the studies included in
Student/resident,
specialist/oral

specialist/oral

specialist/oral
periodontal
endodontic

the OVERALL group is shown in Figure 3A.

Periodontal

Periodontal
specialist
surgeon,

Surgeon
surgeon

CR, crown resection; RR, root resection.

CR Outcome for CR Subgroup

Figure 2B details the meta-analysis evaluating the outcome of CR
procedures from the 3 studies that allowed for detailed subgroup anal-
Park et al, 2009

ysis (n = 111). In-between study heterogeneity was quantified

De Beule et al,
Lee et al, 2012

reflect the survival rate.

2017 (106)

(t2 = 0.0399; I2 = 14.0% [0.0%; 91.1%], P = .3125). The RE model

showed weighted mean survival rates of 81.87% (95% CI, 71.95–
(104)

(105)

88.83) for CR procedures. The funnel plot for the assessment of pub-
lication bias of the studies included in the CR group is shown in
Figure 3B.
†

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Review Article

Figure 2. Forest plots depicting weighted pooled outcome rates and individual study weights for groups: (A) OVERALL (crown and root resection), (B) CR, and
(C) RR. Events = tooth survival. Success/failure refers to the statistical outcome proportions and does not relate to any clinical criteria.

RR Outcome for RR Subgroup analysis (n = 1127). In-between study heterogeneity was quantified
Figure 2C shows the meta-analysis evaluating the outcome of RR (t2 = 1.9337; I2 = 93.9% [90.5%; 96.1%], P < .01). The RE
procedures from the 9 studies that allowed for detailed subgroup model showed weighted mean survival rates of 87.20% (95% CI,

14 Setzer et al. JOE — Volume 45, Number 1, January 2019

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 Review Article

Figure 4. CR versus RR. (A) A forest plot of the included studies. Success/
failure refers to the statistical outcome proportions and does not relate to
any clinical criteria. (B) A funnel plot of the included studies.

across the 3 CR and 9 RR studies. Results indicated that there was no

significant difference between CR and RR (P = .89) (Fig. 4A and B).

Comparison between Maxillary and Mandibular Molars

Nine studies allowed for data extraction to assess the comparison
of the outcome of maxillary versus mandibular molars (90, 95, 96, 99,
101–105). In the maxilla, 584 of 710 teeth (82.3%) survived, and in the
mandible 590 of 703 teeth (83.9%) survived. There was no statistically
significant difference between the 2 arches (Fisher exact test, P = .81).
Figure 3. Funnel plots visualizing the estimated treatment effects (log odds of Five studies allowed for data extraction regarding specific procedures in
tooth survival) for each study (x-axis) against their corresponding measures of individual arches, including root amputation in the maxilla (95, 101,
study precision (standard error, y-axis) for the assessment of publication bias. 102) with 397 of 406 teeth surviving (97.8%), root amputation in
(A) OVERALL (crown and root resection), observed asymmetry around the the mandible (95, 96, 101, 102) with 355 of 367 teeth surviving
vertical lines suggesting publication bias or a systematic difference in the effect (96.7%), and mandibular hemisection (101, 103) with 65 of 77
sizes between studies; (B) CR; and (C) RR. teeth (84.4%) surviving. There was no statistically significant
difference in survival between root amputation in the maxilla versus
the mandible (Pearson test, P = .92) or between root amputation
71.68–94.82) for RR procedures. The funnel plot for the assessment of
versus hemisection in the mandible (P = .46).
publication bias of the studies included in the RR group is shown in
Figure 3C.
Quality Assessment of the Studies
Comparison between CR and RR Table 4 details the study quality according to the assessment scale
For the comparison of CR versus RR, an OR based on the pooled by Iqbal and Kim (16). All included studies were observational. One
proportions for each procedure was calculated. The OR was estimated study was found to be of “average” quality (97); the remaining 18
to be 0.87 based on the FE model and 0.66 based on the RE model. To studies were judged as being of “fair” quality. The NOS was used for
test for its significance, the uncertainty of the pooled estimates was taken the detailed methodological quality assessment of these observational
into account by conducting a 2-sample test based on the pooled log studies (20) (Supplemental Table S2 is available online at www.
odds ratio between CR and RR. Using the pooled standard errors jendodon.com). NOS scores of 7–9 (high-quality observational study)
demonstrated P = .30 based on the FE model estimates and P = .40 were found for 16 studies and scores of 5–6 for 3 studies (moderate-
from the RE model estimates. In addition, a meta-regression was calcu- quality observational study) (Supplemental Table S2 is available online
lated comparing the effect sizes (log-transformed odds), taking into ac- at www.jendodon.com), resulting in an average NOS score of 7.4 for all
count the procedure (CR or RR) as a study-specific moderator variable 19 studies.

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Review Article
GRADE Summary of Evidence

model proportion
Random effects

0.86 (0.77–0.92)

0.82 (0.72–0.89)

0.87 (0.72–0.95)
The GRADE summary of findings, including the study event rates,
RE model proportions, and the strength of evidence for the respective
(95% CI)
interventions, is shown in Table 4. Based on the observational designs
Summary of findings

of the included studies, the initial category of low on the GRADE scale
was determined for the OVERALL group as well as the CR and RR sub-
groups. OVERALL and the RR subgroup were downgraded for serious
inconsistency based on the study heterogeneities as evidenced from the
4BBB Very low 2262/2667 (84.8)

4BBB Very low 1015/1127 (90.1)

t2 and I2 statistics, and some publication bias was detected for the
92/111 (82.3)
Study event
rates (%)

OVERALL group in the funnel plot (Fig. 3A). The subgroup CR was
downgraded because of a serious risk of bias and serious imprecision.
Hence, the quality of evidence according to GRADE for the OVERALL,
CR, and RR groups was determined to be very low. The quality of evi-
dence and summary of findings are summarized in Table 4.
4BBB Very low

Crown resection was downgraded because of a serious risk of publication bias and imprecision caused by the limited evidence published because of the small number of small trials and the limited sample size.
Overall quality
of evidence

Discussion
This meta-analysis presented overall cumulative outcome rates
for resective procedures and confirmed the original hypothesis that
there was no significant difference in outcome between CR and RR.
The latter was despite the fact that the cumulative survival rate for
CR was estimated at 81.2%, lower than the cumulative survival for
considerations

RR at 87.2%. This may be because there were only 3 CR studies, all

*The OVERALL group and the root resection subgroup were downgraded for serious inconsistency based on the study heterogeneities as evidenced from the t2 and I2 statistics.

of small sample size, and because large variations existed among RR

Other

None

None

None

studies, both in terms of sample size and the individual survival rates.
TABLE 4. Grading of Recommendations, Assessment, Development and Evaluations Quality of Evidence and Summary of Findings

Both the individual survival rates of maxillary versus mandibular mo-

lars as well as the individual survival rates for the procedures root
amputation and hemisection in the respective arches may have been
affected by one disproportionately large study (101).
Undetected

Undetected
Publication

Not serious

Reviewing the highest level of evidence, together with patients’

bias

preferences and the operators’ skills, is adamant for best evidence-

based dentistry as defined by the American Dental Association
(122). In the absence of high-level studies, meta-analyses of the exist-
Imprecision

Not serious

Not serious

ing body of literature serve as the best available evidence (11). Ran-
Serious†

domized clinical trials for the outcome of CR and RR may be

Quality assessment

difficult to design. Both procedures are often a last effort to preserve

a natural tooth. Although endodontic microsurgery is a minimally inva-
sive technique only resecting a small portion of the apex (123), CR or
RR is usually indicated when an entire root is irreversibly damaged. The
indirectness

indirectness

indirectness
Indirectness

only alternative may then be the extraction of the entire tooth, leaving
No serious

No serious

No serious

either healthy contralateral teeth or replacement options to serve as a

control group. Healthy contralateral teeth may often be unavailable and
not provide information on the outcome of tooth replacement options.
Today, dental implants are considered the gold standard for tooth
replacement in most situations. However, replacement should only be
Inconsistency

performed after inevitable tooth loss in a later stage of a person’s life,

Not serious
Serious*

Serious*

rather than an early replacement for an existing tooth, particularly with

implants (7, 8). This paradigm also aided in the decision not to
compare the outcome of resective procedures with the outcome of
dental implants for the purposes of this study. Although CR and RR
Overall, crown and root resection

procedures may seem to be similar procedures, they differ greatly in

Not serious

Not serious
Serious†
Risk of

postoperative crown preparation design, the approaches to long-

bias

term periodontal management, and hygiene control for both the dental
team and the patient. One of the primary goals of additional periodontal
treatments, such as furcation plasty or variations of CRs and RRs, is to
No. of participants

improve the accessibility for proper root debridement and to facilitate

Crown resection
observational

observational

observational

posttreatment plaque control (124, 125). However, RRs create

Follow-up

Root resection
(studies)

undercuts below the crown, which may complicate access for dental
2667 (19

studies)

studies)

studies)
1127 (9

hygiene. On the other hand, coronal preparation after CR is more

111 (3

extensive with chamfered axial walls cut deeply into existing

furcations, sacrificing more tooth structure but allowing for better
coronal contours for hygiene requirements (126). Within its general
†

16 Setzer et al. JOE — Volume 45, Number 1, January 2019

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 Review Article
limitations, this study presents the best available evidence for the 4. Basaraba N. Root amputation and tooth hemisection. Dent Clin North Am 1969;13:
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