|Year : 2015 | Volume
| Issue : 3 | Page : 185-187
Hemisection: Tooth savior maneuver after iatrogenic complication
Vineet S Agrawal1, Isha S Agrawal2, Sonali Kapoor1
1 Department of Conservative Dentistry and Endodontics, M.P. Dental College and ORI, Vadodara, Gujarat, India
2 Department of Periodontics and Implantology, M.P. Dental College and ORI, Vadodara, Gujarat, India
|Date of Web Publication||16-Jul-2015|
Vineet S Agrawal
101, Vinay Complex, Near Dudhdhara Dairy, Bholav Bharuch - 392 002, Gujarat
Source of Support: None, Conflict of Interest: None
Iatrogenic procedural accidents occurring during the root canal procedure may lead to failure of the root canal treatment and removal of the teeth. Advances in dentistry as well as increased desire of patients to maintain their dentition have led to the treatment of teeth that once would have been removed. Hemisection maneuver has given the dentist the choice to preserve the maximum toot structure with good retention in future. This case report describes the preservation of mandibular molar through hemisection after iatrogenic furcal perforation and ledge formation.
Keywords: Furcal perforation, hemisection, iatrogenic complication, ledge
|How to cite this article:|
Agrawal VS, Agrawal IS, Kapoor S. Hemisection: Tooth savior maneuver after iatrogenic complication. Int J Health Allied Sci 2015;4:185-7
|How to cite this URL:|
Agrawal VS, Agrawal IS, Kapoor S. Hemisection: Tooth savior maneuver after iatrogenic complication. Int J Health Allied Sci [serial online] 2015 [cited 2022 Aug 11];4:185-7. Available from: https://www.ijhas.in/text.asp?2015/4/3/185/160897
| Introduction|| |
Failure of root canal treatment occurs when acceptable standards are not achieved due to various procedural errors that occur during treatment which prevents the control and impedes the complete disinfection of the root canal. Ledge formation, canal blockage, separated instruments, perforations etc., are some of the iatrogenic procedural accidents that can interrupt the sequence of steps during root canal treatment. ,
A ledge is an iatrogenically created irregularity (platform) in the root canal that impedes access of instruments (and in some cases irrigants) to the apex, resulting in insufficient instrumentation and incomplete obturation. Thus, ledges frequently contribute to ongoing periapical pathosis after root canal treatment. Ledging of curved canals is a common instrumentation error that usually occurs on the outer side of the curvature due to exaggerated cutting and careless manipulation during root canal instrumentation.  Furcal perforation occurs during the access opening or inadvertent search for the canals, which leads to communication with periodontal apparatus and jeopardize the root canal treatment. 
Removal of the teeth with iatrogenic ledge formation and furcal perforation remains the option for eliminating the endodontic infection, but meticulous advances in dentistry provided the patients with an opportunity to retain their functional dentition. Also, today, the patient's awareness and desire to preserve their natural teeth made the dentist to think an alternative to retain their teeth that once used to extract. Hemisection denotes sectioning of mandibular molar into two halves followed by removal or separation of diseased root with its accompanying crown portion.  The procedure of hemisection represents a form of conservative management to retain maximum tooth structure as possible. ,
This case report presents a case where distal half of the root was preserved after iatrogenic ledge formation in mesial root and furcal perforation of mandibular molar through hemisection.
| Case report|| |
A 35-year-old female patient was referred by some general dentist after initiation of a root canal treatment in lower left posterior tooth. Tooth 36 was associated with a localized swelling on the lingual side and was tender on percussion. A diagnostic radiograph [Figure 1]a revealed that access opening was done in 36 with coronal temporary restoration placed, and severe curvature is present in the mesial root.
|Figure 1: (a) Diagnostic radiograph (b) canal negotiation radiograph showing ledge formation in mesial canals (c) postendodontic treatment radiograph (d) resected mesial root (e) postresection radiograph (f) intraoral healing after 1-month (g) porcelain fused metal bridge cementation (h) radiograph after bridge cementation (i) follow-up radiograph after 1-year|
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After removal of the temporary restoration, furcal perforation was seen on the pulpal floor. Canals were negotiated, but the mesial canals were unable to be negotiated till the apex due to the ledge formed by the general dentist [Figure 1]b. Attempts were made to negotiate the ledge by precurving file, using smaller files with chelating agents etc., but all were in vain. Hence, to preserve the maximum tooth structure possible, it was decided to hemisect the mesial root and remove it since both the furcal perforation and ledge will impede the further root canal treatment outcome.
Endodontic treatment was performed under rubber dam isolation, only for distal root canal and coronal access was sealed with permanent restorative material [Figure 1]c. Hemisection was carried out in relation to 36 with the vertical cut method as suggested by Weine  under local anesthesia. A fine probe was passed through the cut to ensure separation. After separation, the severed portion of the mesial root was removed with extraction forceps [Figure 1]d and e. The socket was irrigated with sterile saline to remove bony chips and debris. The remaining portion of the distal tooth was trimmed to remove any ledges or sharp spicules, as these structures are potentially detrimental for periodontal maintenance.
The patient returned after 1-month of postsurgical healing [Figure 1]f. Crown preparation was completed on 36 distal root and 35 and fixed porcelain fused to metal bridge was fabricated [Figure 1]g and h. The patient regular follow-up was taken and radiograph [Figure 1]i shows the complete healing after 1-year of the treatment.
| Discussion|| |
Hemisection should be considered as another weapon in the arsenal of the dental surgeon, determined to retain and not remove natural teeth. With recent refinements in endodontics, periodontics and restorative dentistry, hemisection has received acceptance as conservative and dependable dental treatment and teeth so treated have endured the demands of function.  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. 
In the present case, because of severe ledge formation in the mesial root along with the furcal perforation, the prognosis for root canal therapy was questionable. Buhler stated that hemisection should be considered before every molar extraction, because it provides good, absolute and biological cost saving alternative with good long-term success.  Park et al.  have suggested that hemisection of molars with questionable prognosis can maintain the teeth without detectable bone loss for long-term period, provided that the patient has optimal oral hygiene. Hence, it was decided to remove the mesial root through hemisection procedure and preserve the distal root that will act as an abutment later.
The tooth should be treated endodontically first for relieving the patient from pain and swelling.  The access cavity is sealed with the permanent restorative material because tooth preparation can invade pulp chamber and jeopardize control of coronal seal of the endodontic access opening and cause contamination of obturated tooth during the procedure of hemisection.
When choosing to perform a hemisection procedure, consideration should be given to morphology, clinical length and shape of roots of the multirooted tooth. In the present case, the above-mentioned indication for case selection in performing hemisection was optimum as roots were not closely approximated or fused. Also, in the present case, there was severe curvature present in mesial root that has to be carefully extracted without damaging the distal half of teeth that make this case difficult compare to other published case reports.
When the tooth has lost part of its root support, it will require a restoration to permit it to function independently or to serve as an abutment for a splint or bridge. According to Park et al.,  resected molars used as intermediate abutments of a fixed bridge, had a higher survival rate. Various aspects of the occlusal function such as location, size of contacts and steepness of cuspal inclines plays a significant role in restorative design. In the present case, three-unit bridge was provided to restore occlusal function that involved adjacent second premolar and retained distal root of mandibular first molar.
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