CASE REPORT

Hemisection—Corrective Endodontic Surgery:

A Case Report
Shanmugapriya Kesavamoorthy1 , Vinay G Kumar 2, Vinoo S Ramachandran3, Sibi Swamy4, Surya S Sudhakar5,
Sneha S Kumar6, Vijay VK7
Received on: 19 July 2024; Accepted on: 21 August 2024; Published on: 27 September 2024

A b s t r ac t
T he removal or separation of a mandibular molar root along with a portion of the crown is called hemisection. This treatment option is
appropriate when there is irreparable decay, resorption, perforation, or periodontal damage limited to one root while the other root remains
healthy. Hemisection helps preserve the tooth attachment apparatus and surrounding bone, and may aid in the placement of a fixed prosthesis.
In this case report, hemisection was successfully done to save pressure-induced resorption of the distal root of the mandibular second molar.
The combination of hemisection and prosthetic rehabilitation resulted in a satisfactory outcome. Through careful planning and precise surgical
management, the negative consequences of tooth loss can be avoided.
Keywords: Case report, Distal root, Endodontic surgery, Hemisection, Mandibular molar, Pressure-induced external root resorption, Root resection.
Journal of Operative Dentistry and Endodontics (2023): 10.5005/jp-journals-10047-0136

Introduction 1
Department of Conservative Dentistry and Endodontics, RVS
Retaining the original tooth structure through surgical and non­ Dental College and Hospital, Dr. M.G.R Medical University, Chennai,
surgical procedures remains the best option, considering the high cost Tamil Nadu, India
and potential risks associated with replacing a tooth using a bridge 2
Department of Conservative Dentistry and Endodontics, KLE Society’s
or dental implant. Corrective endodontic procedures encompass Institute of Dental Sciences, Bengaluru, Karnataka, India
root resection (RR) and crown resection (CR). Root resection 3–6
Department of Conservative Dentistry and Endodontics, RVS Dental
comprises the removal of the root, while CR entails removing either College and Hospital, Coimbatore, Tamil Nadu, India
the portion of the crown that overlies the removed root or leaving 7
Department of Periodontics and Implantology, RVS Dental College
the crown intact. Root resection involves the removal of the root or and Hospital, Coimbatore, Tamil Nadu, India
any RR at the cementoenamel junction without extracting parts of Corresponding Author: Shanmugapriya Kesavamoorthy, Department
the crown. Crown resection deals with hemisection, trisection, and of Conservative Dentistry and Endodontics, RVS Dental College and
premolarization (bicuspidization). The involvement of class III furcation Hospital, Dr. M.G.R Medical University, Chennai, Tamil Nadu, India,
is a possible contributing factor to periodontal risk. Also, deep class Phone: +91 9176936752, e-mail: [email protected]
II furcation involvement or localized severe bone loss affecting a How to cite this article: Kesavamoorthy S, Kumar VG, Ramachandran
single root may play a role. Endodontic causes include vertical root VS, et al. Hemisection—Corrective Endodontic Surgery: A Case Report.
fractures, subgingival root caries, persisting periapical pathology, J Oper Dent Endod 2023;8(2):41–46.
root resorptions, iatrogenic root perforations, and irretrievable Source of support: Nil
periapical extrusion of materials. Also, teeth with significant strategic Conflict of interest: Dr Ramachandran is associated as the Editorial
importance or cases where anatomical structures prevent the Board member of this journal and this manuscript was subjected to this
placement of implants must be preserved. It’s advantageous that journal’s standard review procedures, with this peer review handled
resective therapies can potentially extend the lifespan of a patient’s independently of this editorial board member and his research group.
tooth, thereby delaying the need for implant placement until a later Patient consent statement: The author(s) have obtained written
time, thus offering a way to prolong the tooth’s life.1 informed consent from the patient for publication of the case report
Hemisection is defined as “The removal of half of a tooth details and related images.
performed by sectioning the tooth and removing one root”. It is
frequently used concerning mandibular molar teeth. Mandibular
molars are considered suitable candidates for hemisection, as long
as there is proper opposing occlusion and sufficient bone support C a s e P r e s e n tat i o n
for the remaining root. The remaining root and crown structure A 38-year-old healthy male patient from Coimbatore city reported
are then restored to function as a premolar. The retained root will to the Department of Conservative Dentistry and Endodontics, RVS
undergo endodontic therapy.2 The effectiveness of hemisection Dental College and Hospital, Coimbatore, with a chief complaint
greatly depends on the careful selection of cases and adherence of pain, discomfort, and food lodgment in his lower right back
to interdisciplinary approaches including endodontic, surgical, tooth region. Informed consent was obtained. In past dental
restorative, and prosthodontic protocols. Instead of extracting every history, 48 was extracted due to mesioangular impaction, which
molar, it has been suggested that hemisection should be considered also caused pressure-induced resorption of the distal root of 47.
as a viable option due to its proven long-term success.3 Clinically, tooth 47 had no signs of a carious lesion, bone loss,

© The Author(s). 2023 Open Access. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.
org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to
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 Hemisection—Corrective Endodontic Surgery

Figs 1A and B: Preoperative photographs–lateral and occlusal view

single cone compaction with bioceramic sealer for mesial canals

(Fig. 4). Whereas, the distal canal was only packed with calcium
hydroxide medicament (RC Cal). A composite resin postendodontic
restoration was placed.
After a week, the patient was symptom-free, prompting us to
start the surgical approach with local anesthesia administration
(lignocaine with 1:100000 epinephrine). Incisions were placed,
and a triangular flap was reflected with a periosteal elevator. Upon
reflection of the flap, the bony defect along the distal root became
quite evident. All chronic inflammatory tissue was removed with
curettes to expose the bone (Fig. 5). A horizontal indentation was
given in the central groove (buccolingually). A long shank tapered
fissure carbide bur was used to make a vertical cut toward the
bifurcation area (Fig. 6). The tooth was sectioned into two, and the
distal portion was extracted using elevators (Fig. 7). The margins of
the preserved mesial portion were trimmed and smoothed to ensure
that no sharp edges were present to cause further periodontal
Fig. 2: Preoperative radiograph
pathology (Fig. 8). A wet gauze was packed into the extraction socket
before any mesial root modifications, this is to prevent any lodgment
or mobility (Fig. 1). On further investigations, 47 were tender of trimmed enamel/dentin/restorative material into the socket. The
on percussion (positive), there was no response on the electric socket was sutured with 3-0 black silk. A week later, sutures were
pulp test, and there was no response to the cold test. Basic removed and copious betadine irrigation with saline was done. A
periodontal examination (BPE) showed a code 3 status for tooth 2-month follow-up was done (Fig. 9). Prosthodontic rehabilitation
47. Radiographically, an ill-defined radiolucency was seen in the was done with a PFM crown. And monthly follow-ups were done
distal portion near cementoenamel junction (CEJ) and the coronal accordingly (Fig. 10).
third of the distal root. An ill-defined radiolucency was seen in At 6-months follow-up, the patient was clinically asymptomatic
the periapical area of mesial roots with widening of PDL space in (no signs or symptoms), and radiographically, the extraction socket
47 suggestive of symptomatic apical periodontitis (Fig. 2). Thus, of the root was completely healed (Fig. 11).
we came to a provisional diagnosis of pressure-induced external
root resorption with symptomatic apical periodontitis in 47.
Oral prophylaxis, root canal treatment followed by hemisection Discussion
and prosthodontic management were planned accordingly. The The absence of posterior teeth can lead to various unfavorable
main challenge in this case was restricted mouth-opening due to consequences, including the shifting of adjacent teeth towards
extraction of impacted 48. the front, the supraeruption of opposing teeth, a reduction in the
Routine endodontic treatment was started with access length of the dental arch, and an impairment of chewing ability.
opening, working length determination done with the root ZX-J The clinician’s decision regarding the treatment option relies on the
Morita apex locator, and shaping and cleaning was done up to F3 patient’s age, medical history, ability to maintain oral hygiene, the
Protaper-Gold (Dentsply) (Fig. 3). Irrigation was performed with 2 cost of treatment, and the available clinical evidence of success for
mL/min of 3% NaOCl after the use of each file. The final irrigation various modalities.4 In this case, hemisection was planned rather
before root canal filling was performed with 2 mL/min 3% NaOCl, than extraction/implant placement.
2 mL/min 17% EDTA, and 2 mL/min 3% NaOCl, and root canals Hemisection is a valuable alternative to extraction in order
were dried by using paper points. Obturation was done with to preserve multirooted teeth through an endodontic approach.

42 Journal of Operative Dentistry and Endodontics, Volume 8 Issue 2 (July–December 2023)

 Hemisection—Corrective Endodontic Surgery

Figs 3A and B: Working length determination and master cone

Figs 4A and B: Obturation clinical picture and radiograph

Figs 5A and B: Flap elevation 1

This involves performing root canal treatment on the remaining reduce the chances of displacement. Finally, a fixed prosthodontic
roots and restoring them with appropriate restorative material. prosthesis is utilized to maintain the occlusal balance.5 The efficacy
Additionally, splinting the tooth with the adjacent tooth helps of RR procedures relies heavily on appropriate case selection.

Journal of Operative Dentistry and Endodontics, Volume 8 Issue 2 (July–December 2023) 43

 Hemisection—Corrective Endodontic Surgery

Figs 6A to C: Root separation—groove placement and sectioning

Fig. 7: Extracted distal crown and root

Fig. 9: 2 months follow-up radiograph

Additionally, the length and curvature of roots also impact the

resection process. Long and straight roots are more favorable
for resection compared to short, conical roots.
• It is essential to assess the feasibility of performing endodontic
and restorative procedures on the root or roots that are to be
retained.
In this case, we have prepared a triangular flap for better reflection,
visibility, and accessibility to the distal portion of the tooth. Also,
this flap design aids with the ease of operating in limited mouth
opening of the patient. There are two methods: the vertical cut and
the precontouring method for resecting the portion to be removed.
In this case, we have followed the vertical cut technique which
involves making indentation and grooves in the occlusal table and
followed by a vertical cut towards the furcation area.
The long-term success of hemisection relies on several
Fig. 8: Immediate postoperative radiograph
interconnected factors, including the tooth’s periodontal
condition, root anatomy, maintenance therapy, endodontic
Before opting for any of the resection procedures, it is crucial to
and restorative therapy, and surgical procedures.6 In terms of
consider the following factors.
periodontal considerations, the level of bone support and extent
• Significant bone loss is present around one root, while the of furcation involvement play crucial roles in determining case
remaining roots have an adequate level of bone support. selection and prognosis. Research indicates that molars with
• The angulation and position of the tooth within the arch are grade III furcation involvement have a significantly worse long-
crucial factors to consider. A molar that is tilted buccal, lingual, term prognosis compared to molars with lower levels of furcation
mesially, or distally cannot be surgically resected. involvement.7 From an endodontic perspective, various factors like
• Teeth with divergent roots are more suitable candidates, inoperable canals, the weakening of lateral walls in the remaining
whereas closely approximated or fused roots are not ideal. roots during endodontic instrumentation or postpreparation,

44 Journal of Operative Dentistry and Endodontics, Volume 8 Issue 2 (July–December 2023)

 Hemisection—Corrective Endodontic Surgery

Figs 10A and B: Crown placement

molars and 97.0% for molar implants, indicating that both

procedures showed a high level of success in function when
appropriately restored. However, Buhler noted that the failure
rates between the two treatment options were not significantly
different, with an average failure rate of 13.1% among hemisected
teeth. On the other hand, Zafiropoulos et al. found that hemisected
mandibular molars in periodontitis patients were more susceptible
to complications compared to dental implants. While both
procedures can yield high or low success rates based on the
treatment plan and the presence of harmful factors, they are not
interchangeable in clinical scenarios. Recently, an outcome study
stated the overall success rates for RR and CR were about 85.6%.
They also gave individual data of weighted mean survival rates of
81.9% for CR and 87.2% for RR.1
Therefore, the conservative treatment of a severely decayed
molar in young patients can not only save the tooth but also
alleviate financial costs, emotional distress, and issues with biting
Fig. 11: 6 months follow-up
and occlusal dysfunctions.

and poor post design are the causes for failure of RR. According
to Langer et al., over 10 years, 36% of root-resected mandibular C o n c lu s i o n
molars experienced failure, with the most common causes being The success rates of various studies range from 62 to 100% over
endodontic or restorative issues such as root fracture, recurrent follow-up periods of 1– 23 years. When considering the combined
untreatable periapical lesions, and caries, rather than periodontal data from these studies, an overall success rate of around 88% is
disease. Therefore, it is crucial for an endodontist to prioritize the anticipated for this procedure. The long-term outlook for teeth
preservation of as much tooth structure as possible.8 with hemisection will be influenced by factors such as the quality
Regrettably, there is a lack of consistent data in the literature of root canal therapy in the remaining roots or root, the contouring
concerning the long-term prognosis of RR or hemisection. Basten and quality of the final restoration, and the ability to maintain the
et al. found that 92% of resected molars survived for an average of health of the supporting periodontal soft and hard tissues. It is
12 years, with failures attributed to recurrent caries or endodontic important to note that any of these factors could potentially impact
and strategic reasons. This high success rate was also supported by the prognosis of the retained portion of the tooth.
Hamp et al. On the other hand, Erpenstein reported unfavorable
outcomes for hemisected molars, with an overall failure rate of Orcid
20.6% primarily due to pathologic apical factors. Bühler and Langer
et al. reached a similar conclusion in their studies, indicating that Shanmugapriya Kesavamoorthy https://orcid.org/0009-0005-
while the initial outcomes of resected molar teeth are positive, the 7255-8788
long-term results are less favorable.
Numerous studies have assessed the prognosis and success References
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