Archives of Medicine and Health Sciences

CASE REPORT
Year
: 2014  |  Volume : 2  |  Issue : 2  |  Page : 209--213

Root resection: Apropos of 6 cases


H Rajesh1, Anand Dharamsi2, KS Rajesh3, Shashikanth A Hegde4,  
1 Reader, Department of Periodontics, Yenepoya University, Mangalore, Karnataka, India
2 Reader, Sri Guru Gobind Singh College of Dental Sciences, Burhanpur, Madhya Pradesh, India
3 Senior Professor, Department of Periodontics, Yenepoya University, Mangalore, Karnataka, India
4 Senior Professor and Head, Department of Periodontics, Yenepoya University, Mangalore, Karnataka, India

Correspondence Address:
H Rajesh
Department of Periodontics, Yenepoya University, Mangalore - 575 018, Karnataka
India

Abstract

Root resection procedures are indicated in the treatment of advanced Grade II and Grade III furcation involvement. Their long-term prognosis is comparable to that of implants. The objective of this article is to present case reports of hemisection in mandibular first molar and root amputation in maxillary second molar, employed successfully as a part of the oral rehabilitation procedure.



How to cite this article:
Rajesh H, Dharamsi A, Rajesh K S, Hegde SA. Root resection: Apropos of 6 cases .Arch Med Health Sci 2014;2:209-213


How to cite this URL:
Rajesh H, Dharamsi A, Rajesh K S, Hegde SA. Root resection: Apropos of 6 cases . Arch Med Health Sci [serial online] 2014 [cited 2020 Apr 3 ];2:209-213
Available from: http://www.amhsjournal.org/text.asp?2014/2/2/209/144342


Full Text

 Introduction



The ultimate goal of periodontal therapy is to provide a dentition that will function in health and comfort for life. [1] The recent advances in dentistry are helping clinicians to inch closer towards this goal. The tooth can be retained in part or entirety to serve as strategic abutment tooth in fixed dentures or as a single unit fixed prosthesis improving the masticatory efficiency. Hence, root resective procedures can help in conserving the remaining natural tooth structure. [2]

Root resection is the process by which one or more roots of a tooth are removed at the level of the furcation and leaves the crown and remaining roots functional. [3] Farrar introduced the root resection procedure. [4] The term root amputation is defined as the removal of the root apical to the furcation, without removal of the crown portion of the tooth. Hemisection is defined as removal or separation of the tooth in half with its accompanying crown portion (applies to mandibular molars). The term resection may apply to the removal of a root or a hemisected half. Various other resective procedures applied are hemisection, bisection, trisection, and bicuspidization.

A well-designed treatment plan is crucial for a successful and long-term final outcome. The predictable results and high success rates are achieved if basic considerations are taken into account. Periodontal, prosthodontic, and endodontic assessment for proper case selection is important. [5]

 Case Reports



Case 1

A 50-year-old male patient reported with a chief complaint of bleeding while brushing and inability to chew food. Patient was systemically healthy and non-smoker. On clinical examination, a diagnosis of chronic generalized periodontitis was made. Occlusion was mutilated and patient required full mouth rehabilitation. Patient was advised full mouth extraction, and a provisional treatment plan of full mouth rehabilitation with implant-supported prosthesis was advised. However, the patient did not agree for full mouth extraction or for implant-supported prosthesis due to financial constraints. He agreed for extraction of teeth with bad prognosis.

On periodontal examination, distobuccal to 36, a 10-mm periodontal pocket was seen; grade III furcation involvement and grade I mobility was noted. Tooth was tender on vertical percussion and non-vital. Informed consent was obtained. Root canal treatment was completed and was followed by Phase I periodontal therapy. Hemisection was planned on 36 as a part of the comprehensive treatment plan after 6 months, as it allows for healing of periapical lesions due to pulpal origin.

Local anesthesia was administered (Xylocaine 2% with 1:80,000 adrenaline). A full thickness flap was raised. The area was thoroughly debrided. Distal root was resected. OsteoGen HA; alloplast was placed in the socket to improve bone fill [Figure 1]. The flap was then repositioned and sutured with 3-0 black silk sutures. Amoxicillin 500 mg t.i.d for five days and Diclofenac sodium 50 mg for three days were prescribed. Chlorhexidine gluconate mouthwash 0.2% 10 ml b.d was prescribed for one month. The patient is awaiting further treatment.{Figure 1}

Case 2

A male patient aged 42 years came with a chief complaint of dull pain in relation to the lower left back tooth. Patient was systemically healthy, and this was the patient's first dental visit. On examination, a deep periodontal pocket was present distobuccal to 36. Advanced Grade II furcation was seen. Tooth was non-vital [Electric pulp tester, DIGITEST, PARKELL, USA]. A provisional diagnosis of chronic generalized periodontitis was made. Radiograph showed presence of deep angular defect distal to 36. A primary periodontal and secondary periodontal lesion was seen. Informed consent was taken. Root canal treatment was followed by Phase I therapy. Hemisection procedure was carried out in relation to 36 after 6 months, as it allows for healing of lesions due to pulpal pathology. The patient is awaiting crown placement [Figure 1].

Case 3

A male patient aged 52 years came with a chief complaint of dull pain in relation to the lower left back tooth. Patient was systemically healthy and this was patient's first dental visit. On examination, a 9-mm deep periodontal pocket was present distal to 46; advanced Grade IV furcation, generalized abrasion, and attrition was seen. Tooth was non-vital [Electric pulp tester, DIGITEST, PARKELL, USA]. A provisional diagnosis of chronic generalized periodontitis was made. Radiograph showed presence of deep angular defect distal to 46. A primary periodontal and secondary endodontic lesion was seen. Informed consent was taken. Root canal treatment was followed by Phase I therapy. Hemisection procedure was carried out in relation to 46 after 6 months, as it allows for healing of lesions due to pulpal pathology. After 15 days, temporization was done. The final prosthesis was placed 6 months after the surgical procedure. The width of the occlusal table was reduced buccolingually and mesiodistal width was maintained to redirect the forces along the long axis of the mesial root. The hemisected root was contoured as two premolars to facilitate contouring of sanitary pontic. This would facilitate good plaque control by the patient using interdental aids [Figure 1].

Case 4

A 30-year-old male patient reported to the department of Periodontics with a chief complaint of pain in relation to upper right back tooth. Medical history was non-contributory. On examination, 10-mm periodontal pocket was seen on distobuccal aspect. Tooth was non-vital [Electric pulp tester, DIGITEST, PARKELL, USA]. A diagnosis of primary periodontal and secondary endodontic lesion was made. Root canal treatment was followed by Phase 1 therapy. After re-evaluation, distobuccal root amputation was planned after 6 months as it allows for healing of lesions due to pulpal pathology.

A full thickness flap was raised (2% Lignocaine hydrochloride with 1:100000 adrenaline). Thorough debridement was done. Distobuccal root was resected. The flap was then repositioned and sutured with 3-0 black silk sutures. Sufficient care was taken to gain coaptation of the flap to achieve good soft tissue closure and to facilitate accessible maintenance of good oral hygiene. Amoxicillin 500 mg t.i.d for five days and Diclofenac sodium 50 mg for three days were prescribed. Chlorhexidine gluconate mouthwash 0.2% 10 ml b.d. was prescribed for one week. Patient is awaiting the placement of fixed prosthesis [Figure 2].{Figure 2}

Case 5

A 35 year male patient reported to the department of Periodontics with a chief complaint of pain in relation to upper right back tooth. Medical history was non contributory. On examination a 10-mm deep periodontal pocket in relation to distobuccal aspect of upper right first molar. Tooth was non-vital [Electric pulp tester, DIGITEST, PARKELL, USA]. A diagnosis of chronic generalized periodontitis was made. Primary periodontal and secondary endodontic lesion was seen in relation to 16. Informed consent was taken. Root canal treatment was followed by Phase 1 therapy. After re-evaluation distobuccal root amputation was carried out after 6 months, as it allows for healing of lesions due to pulpal pathology. Amoxycillin 500 mg t.i.d for five days and Diclofenac sodium 50 mg for three days were prescribed. Chlorhexidine gluconate mouthwash 0.2% 10 ml b.d was prescribed for one week. Temporization was done within one month. Nickel chromium crown was placed as per patient's request after 6 months [Figure 2].

Case 6

A 45-year-old male patient reported to the department of Periodontics with a chief complaint of pain in relation to upper right back tooth. Medical history was non-contributory. On examination, patient had a 9-mm periodontal pocket in relation to distobuccal aspect of 16. Tooth was non-vital [Electric pulp tester, DIGITEST, PARKELL, USA]. A diagnosis of chronic generalized periodontitis was made. Radiograph showed radiolucency in the apical aspect of distobuccal and palatal root. Informed consent was taken. Combined lesion was seen in relation to 16. After careful consideration regarding strategic importance of the tooth, extraction was advised. Patient did not agree for the extraction. Informed consent was taken. Root canal treatment was followed by Phase I therapy. Patient was put under maintenance phase. Surgical intervention was planned 6 months after root canal treatment as it allows for healing of lesions due to pulpal pathology. After careful evaluation and in consultation with a prosthodontist, palatal root was resected. Amoxicillin 500 mg t.i.d for five days and Diclofenac sodium 50 mg for three days were prescribed. Chlorhexidine gluconate mouthwash 0.2% 10 ml b.d was prescribed for one week. Temporization was done within one month. After 6 months, a nickel chromium bridge with acrylic facing was given [Figure 3]. He was fully apprised of the consequences of the not-so-ideal treatment. He is currently under maintenance phase.{Figure 3}

 Discussion



The efficacy of root resection therapy remains controversial. Successful root-resection therapy requires a careful multidisciplinary approach including periodontal surgery, endodontic treatment, prosthetic reconstruction, and oral hygiene maintenance. It is important to consider the following factors before deciding to undertake any of the resection procedures: Selection of the roots to be amputated, and occlusal and endodontic considerations [Table 1]. The disadvantages associated with this procedure are pain and anxiety of a surgical procedure and susceptibility of the root surface area to caries. Failure of endodontic therapy due to any reason will cause failure of the procedure; progressive periodontal destruction and improper prosthesis design can lead to trauma from occlusion.{Table 1}

Although extraction and tooth replacement with implant was another treatment option, it was deferred because of the patient's financial constraints. Besides, Buhler suggested that hemisection should be considered before molar extraction as this procedure is cost saving with good long-term success. [9] In addition, it has been reported that the failure rates of single-tooth alloplastic (titanium) implants and hemisection are not substantially different. We preferred root resection after endodontic treatment. The distal root was resected because of poor bone support. The literature on distal root resection is limited; more often, this root is retained and the mesial root removed. However, the distal root is broader and straighter, making it more suitable as an abutment.

The mesial root contains a longitudinal groove, which decreases its surface area and contraindicates the use of posts. In this case, post was not considered to be necessary as sufficient tooth structure was present to use the mesial half as an abutment in the simple FPD prosthesis. Hemisection allows for physiologic tooth mobility of the remaining root, which is a more suitable abutment for fixed partial dentures than an osseointegrated counterpart is, as in cases 1-3. The smaller size of the occlusal tables, under-contouring of the embrasure spaces, and ensuring that the crown margin encompasses the furcation are all factors in the high success rates observed with hemisection therapy and root resection, as in cases 4-5. [10] Palatal root resection is rarely attempted. However, we went ahead with palatal root resection as per the patient's demand and in consultation with the prosthodontist. A fixed bridge with additional support from the first premolar was given so that future extraction of the resected root, a possibility, does not affect the prognosis of the long span bridge.

[INLINE:1]

 Conclusion



Root resection is one of the treatment options for preserving molars with furcation involvement. It involves a multidisciplinary approach. Careful case selection and appropriate treatment planing is quintessential for the success of this procedure. Success of this procedure is comparable to implant therapy. It can be an economically viable treatment option for the patients who refuse implant therapy due to financial constraints. Controversy existed between vital and non vital resection. Consensus opinion is to do root canal treatment prior to root resection. We preferred doing the endodontic treatment prior to root resection. The case reports mentioned in this article included hemisection of mandibular molar and distobuccal root resection.

 Acknowledgement



We would like to acknowledge the guidance and support provided by Dr. Ravi Varma M.D.S former Professor and Head, Department of Conservative Dentistry and Endodontics, Yenepoya Dental College, Mangalore. We would also like to acknowledge the guidance and support provided by Dr. Kamalakanth Shenoy M.D.S Senior Professor and Head, Department of Prosthodontics, Yenepoya Dental College, Mangalore.

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