Conservative Dentistry Journal Vol. 10 No.

1 January-June 2020; 23-26

Case Report

Hemisection of a severely decayed mandibular molar: a case report

Cendranata Wibawa Ongkowijoyo, Latief Mooduto, Deavita Dinari and Riski Setyo Avianti
Department of Conservative Dentistry,
Faculty of Dental Medicine, Universitas Airlangga,
Surabaya, Indonesia

ABSTRACT
Background: Dental implants gained popularity as the treatment to replace grossly decayed teeth. However, with the
increasing evidence and the difficulty to manage complications associated with dental implants, clinicians are pushed
to opt for a more conservative approach. Case: A male patient with a chief complaint of frequent food impaction in a
severely decayed mandibular molar wished to retain his tooth. Upon thorough examination, the carious lesion extended
to furcal area that rendered the distal root unsalvageable. However the mesial root can be retained; thus, hemisection
was proposed. Case Management: Root canal treatment was carried out in the mesial canals. Then, the tooth was split
mesio-distally. The distal root was extracted, and the mesial root was retained. Subsequently, the tooth was restored with
PFM crown. Conclusion: Hemisection with subsequent prosthetic rehabilitation can be a viable alternative to retain
severely decayed mandibular molar.

Keywords: Hemisection; root resection; compromised tooth

Correspondence: Latief Mooduto, Department of Conservative Dentistry, Faculty of Dental Medicine, Universitas Airlangga. Jl.
Mayjend. Prof. Dr. Moestopo No. 47 Surabaya 60132, Indonesia. E-mail: latiefmdt@yahoo.co.id

INTRODUCTION patient reported no pain associated with the offending tooth.

General medical history was non-contributory.
The decision to extract or to retain grossly decayed tooth Upon clinical examination, there was no extraoral and
is not always a straightforward task. In the past decades, intraoral tissue abnormality. The offending tooth number 36
compromised teeth were more likely to be extracted and presented with an extensive carious lesion distally, with a
replaced with dental implants; thus, dental implants gains subgingival margin, and a little remaining of temporary filling
more popularity among dentists.1–3 material. No pain reported after percussion and bite test.
However, due to increasing evidence of dental implant Radiographic examination revealed a large distal
biological and technical complications and the difficulty to carious lesion extending to furcal area of 36. There was
manage those complications, clincians are pushed to opt no periapical lesion associated with both mesial and distal
for a more conservative approach, which is to postpone roots. According to AAE classification, 36 was diagnosed
extraction and to retain teeth.1,4,5 In endodontics discipline, a as “previously treated tooth”.
compromised tooth can be retained with various endodontic According to clinical and radiographic examination, the
surgery approaches. For example, with apex resection, distal root of 36 was unsalvageable. However, the mesial
bicuspidization, surgical extrusion, and hemisection.6 In root along the mesial part of crown was intact. The patient
this case report, the management of a severely decayed wished to retain the tooth. Therefore, root canal treatment
mandibular molar up to furcation level with hemisection of mesial canals, hemisection and extraction of distal roots,
and prosthetic restoration will be presented. followed by porsthetic restoration with porcelain fused to
metal (PFM) crown was proposed. The patient agreed with
the proposed treatment plan.
CASE REPORT

A 45-year-old male patient came to the Conservative CASE MANAGEMENT

Dentistry Department, Dental Hospital of Universitas
Airlangga with a chief complaint of a frequent food 1st visit – endodontic treatment: Tooth 36 was isolated with
impaction in the region of left mandibular molar. The rubber dam. Conservative access opening was performed
tooth was treated previously but remain unfinished. The to preserve sound tooth structure. 2 orifices (MB and ML)

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 Conservative Dentistry Journal Vol. 10 No. 1 January-June 2020; 23-26

was found in the mesial root. Negotiation was performed 2nd visit - hemisection: Prior to surgery, extraoral and
with D-finder 10 (Mani, Japan), apical patency and glide intraoral soft tissue were rubbed with chlorhexidine 2%
path were achieved with the same instrument. Working antiseptic solution. Mandibular block anesthesia was done
length was determined with electronic apex locator and was with lidocaine + 1:80.000 adrenaline (Pehacaine, Phapros,
confirmed with periapical radiograph (20mm). Indonesia).
The canals were flooded with NaOCl 2.5%. Protaper Before hemisection, the separation site was determined
Next X1 and X2 (Denstply, USA) were used to shape in mesio-distal and apico-coronal aspect to achieve a precise
the canals with crown down technique. Root canal separation. With long thin coarse diamond bur, the distal
cleaning was done with 30G side vented irrigation needle and mesial roots of 36 was separated right at the furcation
(OneMed, Indonesia) with the following protocol: EDTA level.
17% for 1 minute, flushed with sterile aquadest; and Surgical elevator was used to engage between the roots
NaOCl 2.5% + activation with Endoactivator (Dentsply, and ascertain separation is complete7. Then, the distal root
USA) for 30 seconds, repeated 3 times, flushed with was elevated and extracted.
sterile aquadest. Furcal roof was subsequently probed and smoothened
The canals were subsequently dried with endo-suction with fine diamond bur to eliminate any roughness present.
and obturated with Protaper Next X2 gutta percha (Dentsply, The extraction socket was then irrigated with saline to
USA) and AH-Plus sealer (Dentsply, USA). Resin remove debris. 5,8 Carbonate apatite block (Gamacha,
composite (Z 350 XT, 3M, Germany) was used as coronal Indonesia) was applied as bone graft material and covered
sealing material. with native collagen membrane (Botiss, Germany).

Figure 1. Pre-operative clinical & radioraph. Figure 5. Separation of mesial & distal roots.

Figure 2. Isolation, access opening, and working length Figure 6. Extraction of distal root.
determination.

Figure 3. Shaping and cleaning. Figure 7. Smoothening and irrigation.

Figure 4. Obturation and coronal sealing.

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Figure 8. Bone graft and membrane. Figure 11. Full coverage crown preparation.

Figure 9. Suturing and periapical radiograph. Figure 12. Isolation & PFM crown insertion.

Figure 10. Suture removal. Figure 13. After PFM crown cementation.

Gingiva was sutured to secure bone graft and membrane multirooted tooth, usually a mandibular molar, through
in place. Periapical radiograph was taken to evaluate the the furcation in such a way that a root and the associated
hemisection procedure. The patient was given prescription portion of the crown may be removed or retained.”9
of antibiotics and antiinflammatory medications as well as Hemisection is one of the arsenals within endodontics
post-hemsiection instructions. discipline which utilizes both conservative and surgery
3rd visit – suture removal: 1 week after hemisection, measures to retain compromised teeth. Indications and
the soft tissue healed unevently. Sutures were removed. contraindications of hemisection are:5,7,8,10–13 Patient wishes
4th visit – full coverage crown preparation: 3 months after to retain the tooth; Multirooted teeth in which one or
hemisection. The soft tissue and bone healed uneventfully. more of the roots can be retained due to sound hard and
The remaining mesial part of tooth 36 was prepared for periodontal tissue, but the other cannot be retained due to;
full coverage PFM crown. Mesial marginal ridge of 37 was Extensively decayed; Fractured; Severely resorbed; Large
also prepred for mesial rest, providing additional support iatrogenic perforation; Severe root proximity with adjacent
for the PFM crown. tooth inadequate for a proper embrassure space; Involved
Impression for working cast was made with PVS in with an extensive periodontal disease which compromises
double-step technique. Prepared tooth 36 was subsequently the periodontal support; and Symptomatic and persistent
temporised. Lab instructions was then sent for PFM crown periapical lesion which cannot be endodontically treated due
fabrication with 3M 3 shade. to blockage, ledges, or presence of separated instruments.
5th visit – PFM crown try in & cementation: Temporary Hemisection is a very valuable treatment modality where
crown was removed and PFM crown was tried and evaluated a part of multirooted tooth acting as a terminal abutment
for its marginal fit, proximal fit, and occlusion. Isolation of a short-span bridge fails.8,14,15 Contraindications:5,7,8,10–13
was carried out using split dam technique. Tooth 36 and 37 Patient does not wish to retain the tooth; Single rooted teeth;
was then cleaned prior to cementation. Subsequently, PFM Multirooted teeth in which the roots are fused; Multirooted
crown was cemented with RMGIC cement. teeth in which the furcation is located far apical from the
alveolar crest (taurodontism); The root to be retained cannot
be endodontically treated due to blockage, ledge, or presence
DISCUSSION separated instrument; The root to be retained does not have
adequate sound tooth structure due to excessive endodontic
According to American Association of Endodontics, instrumentation previously; Inadequate periodontal support
hemisection is defined as: “The surgical separation of a surrounding the root to be retained; Unfavorable crown:root

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 Conservative Dentistry Journal Vol. 10 No. 1 January-June 2020; 23-26

ratio within the root to be retained; Multirooted teeth located treatment modality to save an extensively decayed
outside proper arch form; and other considerations which mandibular molar.
necessitate complete extraction of the tooth.
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With careful case selection, hemisection with subsequent

rehabilitation with prosthetic crowns can be a viable

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