Salvaging an Endodontically Treated Mandibular Molar with a Furcation Perforation by Root Hemisection Followed by Fixed Prosthesis: a Case Report

British Journal of Medicine & Medical Research 20(5): 1-7, 2017; Article no.BJMMR.30891 ISSN: 2231-0614, NLM ID: 101570965

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Salvaging an Endodontically Treated Mandibular Molar with a Furcation Perforation by Root Hemisection Followed by Fixed Prosthesis: A Case Report

Sandeep Kumar Gupta 1*, Munish Goel 1, Shweta Verma 1 and Gurmeet Sachdeva 1

1Department of Conservative Dentistry and Endodontics, Himachal Dental College and Hospital, Sundernagar, Himachal Pradesh, India.

Authors’ contributions

This work was carried out in collaboration between all authors. All authors read and approved the final manuscript.

Article Information

DOI: 10.9734/BJMMR/2017/30891 Editor(s): (1) James Anthony Giglio, Adjunct Clinical Professor of Oral and Maxillofacial Surgery, School of Dentistry, Virginia Commonwealth University, Virginia, USA. Reviewers: (1) S. Anitha, JSS Dental college & Hospital, JSS University, India. (2) Mayur S. Bhattad, HSRSM Dental College and Hospital, Hingoli, Maharashtra, India. Complete Peer review History: http://www.sciencedomain.org/review-history/18197

Received 6th December 2016 rd Case Report Accepted 23 February 2017 Published 15 th March 2017

ABSTRACT

Hemisection is the splitting of a two-rooted tooth into two separate portions. This process has also been called bicuspidization in the mandibular molar because it changes a molar into two separate bicuspids. A case involving a 19-year-old patient with perforation of pulpal floor of tooth #47 and extruded gutta percha that could not be retrieved is presented. Following endodontic treatment of the distal root of #47 the tooth was hemisected and the mesial root removed. Preservation of the distal root was necessary in order to serve as abutment for restoration of the edentulous portion of mesial root and the missing #46 with fixed partial denture as tooth #48 was also missing. This article reports the procedure of hemisection of mandibular 2 nd molar and its subsequent restoration with post and core in distal root of #47 followed by fixed prosthesis using #45 as an anterior abutment.

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*Corresponding author: E-mail: [email protected];

Gupta et al.; BJMMR, 20(5): 1-7, 2017; Article no.BJMMR.30891

Keywords: Endodontics; hemisection; missing tooth; mandibular molar; prothodontic; periodontal.

1. INTRODUCTION 4. Severe destructive process: This may occur as a result of furcation or subgingival The purpose of conservative restorative dentistry caries, traumatic injury, and large root is to preserve as much as tooth structure as perforation during endodontic therapy. possible and maintain a functional dentition. Root hemisection and removal of one root involves 1.3 Contraindications careful sectioning a tooth through the root furcation add removal of the significantly 1. When loss of bone involves more than one compromised root and its associated coronal root, and the remaining roots would have structure. inadequate support. 2. When the involved tooth is an abutment Root canal treatment undergoes failure when tooth for a long bridge span. acceptable standards are not followed and leads 3. When the roots are fused. to procedural accidents such as cervical perforation, missed canal orifices, canal The results of hemisection are predictable, and blockage, ledge formation, broken instruments, success rate is high if certain basic and obstruction by previous obturating materials. considerations are carefully taken into account These problems are sometimes difficult to [2]. correct. Often a root hemisection procedure becomes the only way to preserve an otherwide 2. CASE REPORT restorable portion of a tooth.

Weine has listed the following indications for A 19-year-old male patient was referred to the tooth resection [1]. Department of Conservative Dentistry and Endodontics with a chief complaint of severe 1.1 Periodontal Indications pain of 2 weeks duration in the posterior left mandibular molar region. 1. Severe vertical bone loss involving only one root of multi-rooted teeth; 2.1 Clinical Examination 2. Through and through furcation perforation; 3. Unfavorable proximity of roots of adjacent A complete medical history was found to be non- teeth, preventing adequate hygiene contributory. maintenance in proximal areas; 4. Severe root exposure due to dehiscence. On intraoral examination it was found that #47 has undergone previous root canal treatment and 1.2 Endodontic and Restorative Indi- now was tender to percussion. There was severe cations pain to palpation on the buccal mucosa apical to the dentinoenamal junction. 1. Prosthetic failure of abutments within a splint: If a single or multirooted tooth is 2.2 Radiographic Examination periodontally involved within a fixed bridge, instead of removing the entire bridge, if the Radiographic examination revealed that remaining abutment support is sufficient, endodontic therapy had been attempted on tooth the root of the involved tooth is extracted. #47 with incompletely obturated roots and 2. Endodontic failure: Hemisection is useful in perforation in the pulpal floor. The gutta – percha cases in which there is perforation through cones had been pushed through this the floor of the pulp chamber, or pulp canal furcal perforation area with a severe orifice of the roots of an endodontically inflammatory reaction in the furcation area involved tooth which cannot be (Figs. 1 and 2). instrumented. 3. Vertical fracture of one root: The prognosis 2.3 Diagnosis of vertical fracture is hopeless. If vertical fracture traverses one root while the other A diagnosis of failed root canal therapy #47 with roots are unaffected, the offending root furcal perforation and inflammatory disease was may be amputated. established.

Gupta et al.; BJMMR, 20(5): 1-7, 2017; Article no.BJMMR.30891

Japan). Thorough cleaning and debridement of the distal canal of #47 was completed using hand NiTi files (Denstply Maillefer, Ballaigues, Switzerland). Alternating irrigation with saline 0.9% w/v (Alkem Laboratories Ltd., India) and 5.2% sodium hypochlorite (Surya Fine Chemicals Ltd., India) was used to dissolve and flush residual pulp tissue from the canal. Biomechanical preparation of the distal root of #47 was completed followed by obturation of the distal root with gutta-percha cones (Dentsply Maillefer, Ballaigues, Switzerland)and sealer Fig. 1. Pre-operative radiograph Sealapex (Kerr Corporation, CA, USA) using cold lateral condensation. The quality of obturation was verified radiographically and was found to be satisfactory.

Post space preparation was initiated two weeks later by removing gutta-percha from distal canal of #47 with peezo reamers nos.1, 2, and 3 (Mani, Japan). (Figs. 3 and 4)) Access was with RVG (Kodak 5100 India).

Fig. 2. Pre-operative photograph

2.4 Treatment Plan

As the patient was very young it was decided to save and conservatively retreat # 47 by:

1. Endodontic retreatment of distal root of #47. 2. Hemisection of #47. 3. Extraction of mesial root of #47. Fig. 3. Post space preparation 4. Placement of post in the distal root of #47 for additional support. 5. Restore the edentulous space of mesial root of #47& #46 by fixed prosthesis using tooth #45 and distal root of #47 as anterior and posterior abutments respectively.

2.5 Treatment

Treatment plan and postoperative consequences were explained to the patient. An informed written consent was signed following which the patient was scheduled for a subsequent Fig. 4. Post insertion appointment. To begin paralleling the post, a Para Post X 2.6 Procedure (Coltene, Whaledent, Switzerland) drill with a 0.90 mm x 0.036 inch diameter (Brown) was During first visit the gutta-percha was removed used which corresponds to last peezo-reamer from the distal root of #47using solvent drill no. #3. This drill was used with a slow-speed (Endosolv, Septodont, France) and H files (Mani, contra-angle (750 - 1,000 RPM) keeping it in

Gupta et al.; BJMMR, 20(5): 1-7, 2017; Article no.BJMMR.30891

continuous clockwise rotation parallel to the long The compromised and non-restorable mesial root axis of the root. The post space created was of tooth #47 was extracted (Figs. 7 and 8). irrigated with saline. A post was selected accordingly and placed in the post space, Gutta-percha in the furcation area was removed checked with RVG, and cemented with GIC Type with a pick-up forceps and the socket was I ( GC America Inc.). A core build-up was made irrigated adequately with sterile saline to remove with ParaCore (Coltene,Whaledent,Switzerland) bony chips and debris. The retained root was a dual-cured, radiopaque, glass–reinforced, trimmed and smoothened to ensure that no composite resin system to maintain a good seal spicules were present to cause periodontal and allow interproximal contouring during irritation. The extraction site was again irrigated, surgical separation. debrided, and sutured with 3-0 silk suture (Sutures India Pvt Ltd., India) (Fig. 9). Extraction of the mesial root of tooth #47 was carried out under antibiotic coverage with 1000 mg amoxicilin (Abbott. Health Care Pvt Ltd., India) and 400 mg Diclomol Sp (Win-Medicare Pvt Ltd., India) administered one hour before the procedure to prevent infection and possible postoperative pain. On the day of procedure routine sterilization of operation theater and instruments was performed and patient was draped. The mouth was rinsed with Betadine gargle (Win-Medicare Pvt Ltd., India) and a proper schedule of surgical disinfection was followed. 2% lignocaine hydrochloride (Lignox Fig. 6. Verticle cut 2%, Indoco- Remedies Ltd., India) was administered to anesthetize the inferior alveolar, lingual and long buccal nerves supplying tooth #47.

A vertical cut to resect the crown of tooth #47 into halves was made using a long shank tapered fissure carbide bur (Mani, Japan). The vertical cut made was in a buccolingual direction joining the buccal developmental groove with the lingual developmental groove and deep enough to just reach the bifurcation area (Figs. 5 and 6).

A fine probe was passed through the cut to check for complete separation of both the mesial Fig. 7. Extraction of mesial root and distal segments and so as to not injure soft tissue in furcation area.

Fig. 5. Verticle cut Fig. 8. Extracted root

Gupta et al.; BJMMR, 20(5): 1-7, 2017; Article no.BJMMR.30891

prosthesis were used. Final prosthesis was cemented (Fig. 12) using Glass ionomer cement type I (GC America Inc).

Fig. 9. Post-operative photograph

The healing was evaluated at one month post- extraction and found to be satisfactory (Fig. 10).

Fig. 12. Final prosthesis (w.r.t.)#45,46,47

Post-operative instructions were given for periodontal maintenance. The recall follow-ups were made for every 3 months to evaluate oral hygiene, sulcular depth, gingival recession, occlusion, thickness of periodontal ligament, and for clinical or radiologic evidence of root resorption. All of these parameters were found to be normal, indicative of adequate healing.

Fig. 10. After one month 3. DISCUSSION

Crown preparation for fixed prosthesis on (written Case selection is very important and based on a out here) (w.r.t.) #45 and the built up core of thorough periodontal, prosthodontics, and distal root of #47 (Fig. 11). (NOTE: Please define endodontic assessment. Buhler stated that w.r.t. first then use the abbreviation initials hemisection should be considered instead of afterwards). molar extractions because it provides a good, absolute, and biological cost saving alternative with good long-term success [4]. Hemisection provides an opportunityfor retaining as much of the original tooth structure as possible. Already stated in the first line.

3.1 Endodontic Phase

Proper endodontic treatment should be planed prior to hemisection. Weine [5] has suggested that in the cases with pulpal involvement, the Fig. 11. Crown preparation (w.r.t.) #45 and #47 pulp should be extirpated and the canals measured prior to the surgical appointment. This Final impressions were made using putty further verifies that the roots to be retained will (Coltene, Whaledent, Switzerland) and models be negotiable and treatable at a later date. It is obtained [3]. Bite registration was made using very undesirable to have a retained root that bite registration wax and the models articulated. proves to be endodontically untreatable when Metal coping were tried in the patient’s mouth amputation procedures on the same tooth have involving #45, #46 and #47 to check for marginal already been performed. Following this initial adaptation and occlusal clearance prior to endodontic treatment, the access is sealed ceramic application. This was followed by temporarily with ZOE or Cavit. Moreover, it might ceramic build up w.r.t #45 and 46 only on the be difficult to perform endodontic treatment with tried metal copings. Because of less clearance severe contamination of the pulp by through an and less height w.r.t distal root of #47 only metal open site due to the resection. In the above case

Gupta et al.; BJMMR, 20(5): 1-7, 2017; Article no.BJMMR.30891

endodontic treatment and core restoration was furcation roof and thus creating a concave completed prior to hemisection and extraction. shaping of the root trunk and crown. Such a shape may not offer an ideal surface for oral 3.2 Periodontal Phase: [6] hygiene procedures; patients should therefore pay special attention to these areas when Four critical factors in selecting molar for performing oral hygiene procedures. In contrast, hemisection are: Stein noted that, “esthetics permitting”, a sanitary pontic is the best design for the posterior region” 1) Root divergence- Ideally the resected root [8] Finished margins are placed supra-gingivally should have wide root divergence, as close root in order to maintain gingiva self-cleansing. proximity will make surgery difficult.

2) Root form- Roots of mandibular molars are 3.4 Clinical Significance concave, mainly on the mesial root. Therefore, odontoplasty should be performed in order to The above case clearly shows that if carefully provide a proper contour. selected and executed, hemisection gives the patient a more comfortable and long lasting 3) Location of furcation- The closer the option for fixed prosthesis compared to furcation opening is to the cemento-enamel removable partial dentures and a more financially junction, the better the prognosis for retained viable option compared to implants or implant root. supported fixed partial dentures.

4) Remaining root attachment- Cylindrical, 4. CONCLUSION ovoid, long roots serve well and are excellent abutments. A conservative approach has been the main stay of dentistry and medicine for the preservation Objectives: [7] of natural body structures. Hemisection is considered to be a viable and conservative 1) To facilitate maintenance. alternative to tooth extraction and implants. It 2) To prevent further attachment loss. conserves bone and also serves as a natural 3) To obliterate furcation defects as a abutment and prevents the necessity of periodontal maintenance problem. preparing and cutting adjacent teeth for use as abutments. However, proper case selection and During the vertical cut, care should be taken to preoperative evaluation are the cornerstones for avoid bur injury to adjacent bone. Thorough root a successful procedure. planning was performrd on the mesial side of retained distal root of tooth #47. Odontoplasty ETHICAL APPROVAL was to performed to remove the any sharp areas This case was done in the Department of and developmental ridges on the mesial aspect Conservative Dentistry and Endodontics, of distal root in order to to facilitate oral hygiene Himachal Dental College, Sundernagar, measures. Himachal Pradesh, India.

3.3 Prosthodontic Phase COMPETING INTERESTS

A hemisected tooth loses its full periodontal Authors have declared that no competing support after root amputation. The remaining root interests exist. has to function independently to serve as an abutment for fixed partial denture. REFERENCES

The point should be taken into consideration that 1. Weine FS. Endodontic Therapy. 5 th a faulty prosthesis will lead to further periodontal Edition; 1996. destruction. Schmitt and Brown [8] suggest that 2. Bühler H. Survival rates of hemisected the preparation of the crown must be ‘barreled in’ teeth: An attempt to compare them with to follow the profile of the root complex. This survival rates of alloplastic implants. Int J procedure should be performed in the presence Periodontics Restorative Dent. 1994;14: of root concavities or shallow class II furcations. 536-543. These require that the crown preparation of the 3. Hitesh U. Pawar, Leena Padhye, crown follows the root contour by eliminating the Narpatsingh Rajput. Tooth hemisection

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