HEMISECTION: A CONSERVATIVE APPROACH FOR FURCATION-INVOLVED MANDIBULAR MOLAR
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This document describes a case study of a hemisection procedure performed on a mandibular first molar. A 26 year old male patient presented with pain and caries in his left mandibular first molar. Radiographs and probing revealed furcation involvement and severe bone loss around the mesial root. It was decided to perform a hemisection to remove just the mesial root and crown portion while preserving the distal root. After endodontic treatment of the distal root, the mesial root and crown were surgically removed. The patient was followed up after restoration of the distal root with a full crown, and had good oral function and no further issues. The document discusses the indications, technique, and long
![*Corresponding Author Address: Dr.Abu-Hussein Muhamad,. Email: abuhusseinmuhamad@gmail.com
International Journal of Dental and Health Sciences
Volume 02, Issue 03Case Report
HEMISECTION: A CONSERVATIVE APPROACH FOR
FURCATION-INVOLVED MANDIBULAR MOLAR
Muhamad Abu-Hussein1
, Nezar Watted2
, Azzaldeen Abdulgani3
1
University of Naples Federic II, Naples, Italy, Department of Pediatric Dentistry, University
of Athens, Athens, Greece
2
Clinics and policlinics for Dental, Oral and Maxillofacial Diseases of the Bavarian Julius-
Maximilian-University Wuerzburg, Germany
3
Department of Conservative Dentistry, Al-Quds University, Jerusalem, Palestine
ABSTRACT:
Hemisection is a treatment procedure involving removal of the involved tooth root
and its associated crown portion, which is done with the purpose of preserving as much
tooth structure as possible rather than sacrificing the whole tooth. This treatment can
produce predictable results as long as proper diagnostic, endodontic, surgical, prosthetic
and maintenance procedures are performed.
Key words: Hemisection; root resection; furcation involvement; mandibular molar
INTRODUCTION:
In 1867, Magitot reported on the
complete removal (root resection or
amputation) of molar roots. However,
Farrar, in 1884 is often cited as the first
author and clinician to detail the resective
techniques for the radical removal by
amputation of any portions of the roots of
the teeth that can be of no further use.[1]
Through root resection therapy furcation
involved molars can be converted to non-
furcated single root teeth and provide a
favorable environment for oral hygiene
for patients and clinicians. In a recent
article, Minsk and Polson suggested that
root resection can be a valuable
procedure when the tooth in question has
a very high strategic value or when there
are specific problems that cannot be
solved by other therapeutic
procedures.[1,2,3]
Hemisection (removal of one root)
involves removing significantly
compromised root structure and the
associated coronal structure through
deliberate excision[4]. Appropriate
endodontic therapy must be performed
before these tooth modifications to avoid
intrapulpal dystrophic calcification and
postoperative tooth sensitivity. The
furcation region is carefully smoothed, to
allow proper cleansing and thus to
prevent accumulation of plaque.[5 ]Root
fracture is the main cause of failure after
hemisection, so occlusal modifications are
required to balance the occlusal forces on
the remaining root.[1,4,5] (Fig. 1).
Weine F [5]has listed the following
indications for tooth resection;
Periodontal Indications:](https://image.slidesharecdn.com/dm0923-150711115630-lva1-app6891/85/HEMISECTION-A-CONSERVATIVE-APPROACH-FOR-FURCATION-INVOLVED-MANDIBULAR-MOLAR-1-320.jpg)
![Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020
1013
1. Severe vertical bone loss involving only
one root of multi-rooted teeth.
2. Through and through furcation
destruction.
3. Unfavourable proximity of roots of
adjacent teeth, preventing adequate
hygiene maintenance in proximal areas.
4. Severe root exposure due to
dehiscence.
Endodontic and Restorative Indications :
1. Prosthetic failure of abutments within
a splint: If a single or multi-rooted tooth is
periodontally involved within a fixed
bridge, instead of removing the entire
bridge, if the remaining abutment support
is sufficient, the root of the involved tooth
is extracted.
2. Endodontic failure: Hemisection is
useful in cases in which there is
perforation through the floor of the pulp
chamber, or pulp canal of one of the roots
of an endodontically involved tooth which
cannot be instrumented.
3. Vertical fracture of one root: The
prognosis of vertical fracture is hopeless.
If vertical fracture traverses one root
while the other roots are unaffected, the
offending root may be amputed.
4. Severe destructive process: This may
occur as a result of furcation or sub
gingival caries, traumatic injury, and large
root perforation during endodontic
therapy.
Hemisection represents a form of
conservative dentistry, aiming to retain as
much of the original tooth structure as
possible.[2] Hemisection (removal of one
root) involves removing significantly
compromised root structure and the
associated coronal structure through
deliberate excision[3]
Indications for Hemisection include :
1. The tooth is affected by caries, vertical
root fracture, periodontal disease or
iatrogenic root perforation where only
one root of a multirooted tooth is
affected.
2. The surviving root is accessible and
treatable endodontically.
3. The surviving root is structurally
capable of supporting a dowel and core
restoration.
4. The surviving root is aligned so as to
provide proper draw for the resulting
fixed prosthetic restoration.
The root morphology allows for surgical
access and proper periodontal
maintenance of the final restoration.[4-9]
Contrα indications of using a tooth root
as an abutment can include:
1. Poorly shaped roots or fused roots.
2. Poor endodontic candidates or
inoperable endodontic roots.
3. Patient unwilling to undergo surgical
and endodontic treatments and
undertake the care or the resulting
restoration.[6-8 ]](https://image.slidesharecdn.com/dm0923-150711115630-lva1-app6891/85/HEMISECTION-A-CONSERVATIVE-APPROACH-FOR-FURCATION-INVOLVED-MANDIBULAR-MOLAR-2-320.jpg)
![Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020
1015
partial dentures than an osseointegrated
counterpart[10].
Buhler compared survival rates of
hemisected teeth with those of single-
tooth alloplastic implants and found that
the failure rates of the two treatment
alternatives were not substantially
different[5]. It was suggested that
hemisection, being a relatively simple,
inexpensive treatment option with a good
chance of success (given appropriate case
selection), should always be considered as
an option before molar extraction[5,9].
According to Buhler, hemisection, being a
relatively simple, inexpensive treatment
option with a good chance of success
(given appropriate case selection), should
always be considered as an option before
molar extraction[5]. After accurate
evaluation and taking into account all the
positive considerations, the case was
selected for hemisection therapy[5].
In the present case the above mentioned
indication for case selection in performing
hemisection was optimum as the roots
were not closely approximated or fused.
The tooth had to be endodontically
treated before hemisection. In situations
when resection periodontal therapy is
decided, initiation of conventional
endodontic treatment before therapy
simplifies the surgical procedure. This is
because tooth preparation can invade the
pulp chamber and jeopardize control of
the coronal seal of the endodontic access
opening complicating the completion of
endodontic therapy.
Carnevale in his study on long term effects
of root resective therapy suggested that it
can be considered an effective measure to
resolve periodontal problems of furcation
defects.[11] The data indicate that
recurrent periodontal disease is not a
major cause of the failure of these teeth.
It was shown that such teeth can function
successfully for long periods .Therefore,
early and correct diagnosis is imperative,
as delay will result in rapid loss of
supporting bone and eventually tooth
loss.[11]
Βaston et al reviewed records of 100
patients who had undergone root
resection over a 10 years period. They
reported a failure rate of 38%, of which
15.8% occurred within the first 5 years
after surgery. Most failures involved
mandibular teeth and occurred for
reasons other than inflammatory
periodontal disease.[12]
Recently, Park et al. have suggested that
hemisection of molars with questionable
prognosis can maintain the teeth without
detectable bone loss for a long-term
period, provided that the patient has
optimal oral hygiene.[13,14]
Saad et al. have also concluded that
hemisection of a mandibular molar may
be a suitable treatment option when the
decay is restricted to one root and the
other root is healthy and remaining
portion of tooth can very well act as an
abutment. In the present case, the mesial
root was extremely resorbed while the
distal root could act as an abutment for
the future prosthesis.[10,14,15] As there
was a bone loss from the mesial surface of](https://image.slidesharecdn.com/dm0923-150711115630-lva1-app6891/85/HEMISECTION-A-CONSERVATIVE-APPROACH-FOR-FURCATION-INVOLVED-MANDIBULAR-MOLAR-4-320.jpg)
![Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020
1016
the distal root of 46 and adequate bone
support was present on the distal surface
of the distal root, in order to provide
better bone support and faster bone
healing, bone graft material was placed
inside the socket of the extracted mesial
root as well as on the mesial surface of
the distal root.[10]
Erpenstein reported the results of root
resection of 34 molars examined clinically
and radiographically over 4-7 years.
During the followup period, 3 treated
molars were extracted: two of them due
to symptomatic apical periodontitis and
one due to periodontal pocketing and
excessive mobility. The treated teeth were
successfully used as abutments for small
bridges. There was no statistically
significant difference in probing depth
between rootresected and other surfaces
at final examination, and a
significantreduction in probing depth was
observed and maintained as a result of
treatment.[16]
Successful restoration of periodontally
weakened teeth is aided by creating an
occlusal scheme with canine guided
occlusion and flattened posterior cusps
with point contact thereby directing the
occlusal forces along long axis of the tooth
[8].Goals of prosthetic rehabilitation
prevent fracture ofthehemisectioned
tooth and root, preserve the healthof the
periodontal tissues, preserve the
proprioception, restores occlusion &
functions.[17]
Consideration when choosing to perform
a hemisection procedure should be given
to the morphology, clinical length and
shape of the roots of a multirooted tooth.
The divergence of the roots is indeed an
important indication. Those affected teeth
with roots spread apart facilitate the
clinician's ability to perform a root
resection, whereas teeth with closely
approximated or fused roots should not
receive hemisection therapy.[18]
The long-term success of root resection
varies from 27% to 100%. Most reported
failures were non-periodontal in nature,
with periodontal failures accounting for
only 0-10% of the total failures6. Buhler
conducted a meta-analysis attempting to
find the common denominators among
the different studies and demonstrated
that over a seven-year observation period,
the failure rate for teeth treated by root
resection was 11%9.[19,20]
CONCLUSION:
With recent refinements in endodontics,
periodontics and restorative dentistry,
hemisection has received acceptance as a
conservative and dependable dental
treatment and teeth so treated have
endured the demands of function.This
article presents a technique for the
dentist to offer patients to maintain tooth
structure where that structure
iscompromised.In conclusion, this
treatment modality has produced
predictable results in restoring occlusion
and achieving expected degree of
function. Proper diagnosis, perfect
endodontic treatment, and proper
surgical procedure are the prerequsites
for successful prosthodontic rehabilitation
in such cases.](https://image.slidesharecdn.com/dm0923-150711115630-lva1-app6891/85/HEMISECTION-A-CONSERVATIVE-APPROACH-FOR-FURCATION-INVOLVED-MANDIBULAR-MOLAR-5-320.jpg)
HEMISECTION: A CONSERVATIVE APPROACH FOR FURCATION-INVOLVED MANDIBULAR MOLAR
- 1. *Corresponding Author Address: Dr.Abu-Hussein Muhamad,. Email: abuhusseinmuhamad@gmail.com International Journal of Dental and Health Sciences Volume 02, Issue 03Case Report HEMISECTION: A CONSERVATIVE APPROACH FOR FURCATION-INVOLVED MANDIBULAR MOLAR Muhamad Abu-Hussein1 , Nezar Watted2 , Azzaldeen Abdulgani3 1 University of Naples Federic II, Naples, Italy, Department of Pediatric Dentistry, University of Athens, Athens, Greece 2 Clinics and policlinics for Dental, Oral and Maxillofacial Diseases of the Bavarian Julius- Maximilian-University Wuerzburg, Germany 3 Department of Conservative Dentistry, Al-Quds University, Jerusalem, Palestine ABSTRACT: Hemisection is a treatment procedure involving removal of the involved tooth root and its associated crown portion, which is done with the purpose of preserving as much tooth structure as possible rather than sacrificing the whole tooth. This treatment can produce predictable results as long as proper diagnostic, endodontic, surgical, prosthetic and maintenance procedures are performed. Key words: Hemisection; root resection; furcation involvement; mandibular molar INTRODUCTION: In 1867, Magitot reported on the complete removal (root resection or amputation) of molar roots. However, Farrar, in 1884 is often cited as the first author and clinician to detail the resective techniques for the radical removal by amputation of any portions of the roots of the teeth that can be of no further use.[1] Through root resection therapy furcation involved molars can be converted to non- furcated single root teeth and provide a favorable environment for oral hygiene for patients and clinicians. In a recent article, Minsk and Polson suggested that root resection can be a valuable procedure when the tooth in question has a very high strategic value or when there are specific problems that cannot be solved by other therapeutic procedures.[1,2,3] Hemisection (removal of one root) involves removing significantly compromised root structure and the associated coronal structure through deliberate excision[4]. Appropriate endodontic therapy must be performed before these tooth modifications to avoid intrapulpal dystrophic calcification and postoperative tooth sensitivity. The furcation region is carefully smoothed, to allow proper cleansing and thus to prevent accumulation of plaque.[5 ]Root fracture is the main cause of failure after hemisection, so occlusal modifications are required to balance the occlusal forces on the remaining root.[1,4,5] (Fig. 1). Weine F [5]has listed the following indications for tooth resection; Periodontal Indications:
- 2. Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020 1013 1. Severe vertical bone loss involving only one root of multi-rooted teeth. 2. Through and through furcation destruction. 3. Unfavourable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance in proximal areas. 4. Severe root exposure due to dehiscence. Endodontic and Restorative Indications : 1. Prosthetic failure of abutments within a splint: If a single or multi-rooted tooth is periodontally involved within a fixed bridge, instead of removing the entire bridge, if the remaining abutment support is sufficient, the root of the involved tooth is extracted. 2. Endodontic failure: Hemisection is useful in cases in which there is perforation through the floor of the pulp chamber, or pulp canal of one of the roots of an endodontically involved tooth which cannot be instrumented. 3. Vertical fracture of one root: The prognosis of vertical fracture is hopeless. If vertical fracture traverses one root while the other roots are unaffected, the offending root may be amputed. 4. Severe destructive process: This may occur as a result of furcation or sub gingival caries, traumatic injury, and large root perforation during endodontic therapy. Hemisection represents a form of conservative dentistry, aiming to retain as much of the original tooth structure as possible.[2] Hemisection (removal of one root) involves removing significantly compromised root structure and the associated coronal structure through deliberate excision[3] Indications for Hemisection include : 1. The tooth is affected by caries, vertical root fracture, periodontal disease or iatrogenic root perforation where only one root of a multirooted tooth is affected. 2. The surviving root is accessible and treatable endodontically. 3. The surviving root is structurally capable of supporting a dowel and core restoration. 4. The surviving root is aligned so as to provide proper draw for the resulting fixed prosthetic restoration. The root morphology allows for surgical access and proper periodontal maintenance of the final restoration.[4-9] Contrα indications of using a tooth root as an abutment can include: 1. Poorly shaped roots or fused roots. 2. Poor endodontic candidates or inoperable endodontic roots. 3. Patient unwilling to undergo surgical and endodontic treatments and undertake the care or the resulting restoration.[6-8 ]
- 3. Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020 1014 This article describes a procedure of hemisection in mandibular molar and its subsequent restoration. The key to long term success appear to be thorough diagnosis, selection of patients with good oral hygiene and careful surgical and restorative management. CASE DETAIL: A 26 years old male patient reported to my private dental clinic with the complaint of pain in left mandibular first molar. On examination, the tooth was tender to percussion and was grossly carious. On probing the area, there was a deep periodontal pocket around the mesial root of the tooth. On radiographic examination, furcation involvement was evident. The bony support of distal root was completely intact (Fig. 2). It was decided that the mesial root should be hemisected after completion of endodontic therapy of the tooth. The working length was determined and the canals were biomechanically prepared using crown-down technique using protaper rotary instuments as per manufacturer instructions. Mesiobuccal and mesiolingual canals were prepared upto F3. The canals were obturated with lateral condensation method and the chamber was filled with amalgam to maintain a good seal and allow interproximal area to be properly contoured during surgical separation. Hemisection of the mesial root and crown was done with a vertical cut method. After vertical incision and sulcular incision, a mucoperiosteal flap was reflected. The crown was cut with a long shank, tapered fissure carbide bur till the furcation is reached(Figure 3,4). Once the separation was complete, the mesial half was extracted. The empty socket was thoroughly irrigated and the flap was sutured back into its position. All chronic inflammatory tissue was removed with currettes to expose the bone. The vertical cut method was used to resect the crown. A long shank tapered fissure carbide bur was used to make vertical cut toward the bifurcation area. The flap was then repositioned and sutured with 3/0 black silk sutures. After the complete healing of the extraction socket , the crown of the remaing thooth was restored with FPD on 45,46 so as to distribute the occlusal stresses(Figure 5). The occlusal table was minimized to redirect the forces along the long axis of the mesial root. Hemisected molar was restored with full coverage cast restoration. Patient had been followed up since with regular recall visits and oral prophylaxis. He had good masticatory efficiency with the restoration was very happy with the treatment outcome. DISCUSSION: Implant therapy is considered to be a predictable option with good functional outcome. However, in this case, because of financial constraints and the patient’s willingness to maintain the original portion of involved tooth structure, hemisection therapy was considered. Hemisection allows for physiologic tooth mobility of the remaining root, which is thus a more suitable abutment for fixed
- 4. Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020 1015 partial dentures than an osseointegrated counterpart[10]. Buhler compared survival rates of hemisected teeth with those of single- tooth alloplastic implants and found that the failure rates of the two treatment alternatives were not substantially different[5]. It was suggested that hemisection, being a relatively simple, inexpensive treatment option with a good chance of success (given appropriate case selection), should always be considered as an option before molar extraction[5,9]. According to Buhler, hemisection, being a relatively simple, inexpensive treatment option with a good chance of success (given appropriate case selection), should always be considered as an option before molar extraction[5]. After accurate evaluation and taking into account all the positive considerations, the case was selected for hemisection therapy[5]. In the present case the above mentioned indication for case selection in performing hemisection was optimum as the roots were not closely approximated or fused. The tooth had to be endodontically treated before hemisection. In situations when resection periodontal therapy is decided, initiation of conventional endodontic treatment before therapy simplifies the surgical procedure. This is because tooth preparation can invade the pulp chamber and jeopardize control of the coronal seal of the endodontic access opening complicating the completion of endodontic therapy. Carnevale in his study on long term effects of root resective therapy suggested that it can be considered an effective measure to resolve periodontal problems of furcation defects.[11] The data indicate that recurrent periodontal disease is not a major cause of the failure of these teeth. It was shown that such teeth can function successfully for long periods .Therefore, early and correct diagnosis is imperative, as delay will result in rapid loss of supporting bone and eventually tooth loss.[11] Βaston et al reviewed records of 100 patients who had undergone root resection over a 10 years period. They reported a failure rate of 38%, of which 15.8% occurred within the first 5 years after surgery. Most failures involved mandibular teeth and occurred for reasons other than inflammatory periodontal disease.[12] Recently, Park et al. have suggested that hemisection of molars with questionable prognosis can maintain the teeth without detectable bone loss for a long-term period, provided that the patient has optimal oral hygiene.[13,14] Saad et al. have also concluded that hemisection of a mandibular molar may be a suitable treatment option when the decay is restricted to one root and the other root is healthy and remaining portion of tooth can very well act as an abutment. In the present case, the mesial root was extremely resorbed while the distal root could act as an abutment for the future prosthesis.[10,14,15] As there was a bone loss from the mesial surface of
- 5. Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020 1016 the distal root of 46 and adequate bone support was present on the distal surface of the distal root, in order to provide better bone support and faster bone healing, bone graft material was placed inside the socket of the extracted mesial root as well as on the mesial surface of the distal root.[10] Erpenstein reported the results of root resection of 34 molars examined clinically and radiographically over 4-7 years. During the followup period, 3 treated molars were extracted: two of them due to symptomatic apical periodontitis and one due to periodontal pocketing and excessive mobility. The treated teeth were successfully used as abutments for small bridges. There was no statistically significant difference in probing depth between rootresected and other surfaces at final examination, and a significantreduction in probing depth was observed and maintained as a result of treatment.[16] Successful restoration of periodontally weakened teeth is aided by creating an occlusal scheme with canine guided occlusion and flattened posterior cusps with point contact thereby directing the occlusal forces along long axis of the tooth [8].Goals of prosthetic rehabilitation prevent fracture ofthehemisectioned tooth and root, preserve the healthof the periodontal tissues, preserve the proprioception, restores occlusion & functions.[17] Consideration when choosing to perform a hemisection procedure should be given to the morphology, clinical length and shape of the roots of a multirooted tooth. The divergence of the roots is indeed an important indication. Those affected teeth with roots spread apart facilitate the clinician's ability to perform a root resection, whereas teeth with closely approximated or fused roots should not receive hemisection therapy.[18] The long-term success of root resection varies from 27% to 100%. Most reported failures were non-periodontal in nature, with periodontal failures accounting for only 0-10% of the total failures6. Buhler conducted a meta-analysis attempting to find the common denominators among the different studies and demonstrated that over a seven-year observation period, the failure rate for teeth treated by root resection was 11%9.[19,20] CONCLUSION: With recent refinements in endodontics, periodontics and restorative dentistry, hemisection has received acceptance as a conservative and dependable dental treatment and teeth so treated have endured the demands of function.This article presents a technique for the dentist to offer patients to maintain tooth structure where that structure iscompromised.In conclusion, this treatment modality has produced predictable results in restoring occlusion and achieving expected degree of function. Proper diagnosis, perfect endodontic treatment, and proper surgical procedure are the prerequsites for successful prosthodontic rehabilitation in such cases.
- 6. Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020 1017 REFERENCES: 1. Prinz H. Dental chronology. Philadelphia Lea & Febiger,1945;119 2. Farrar JN. Radical and heroic treatment of alveolar abscess by amputation of roots of teeth. Dent Cosmos 1884;26:79-81. 3. Kost WJ, Stakiw JE. Root amputation and hemisection. J Can Dent Assoc 1991; 57(1):42–5. 4. Bühler H. Survival rates of hemisected teeth: an attempt to compare them with survival rates of alloplastic implants. Int J Periodontics Restorative Dent1994; 14(6):536–543. 5. Weine FS. Endodontic Therapy, Mosby, St Louis, Mosby, USA, 5th edition, 154-168 6. Rapoport RH, Deep P. Traumatic hemisection and restoration of a maxillary first premolar: a case report. Gen Dent 2003; 51(4):340- 342. 7. Kryshtalskyj E. Root amputation and hemisection. Indication, technique and restoration. J Can Dent Assoc 1986; 52(4):307–8. 8. Abrams LL. Hemisection- Technique and Restoration. Dental Clinics of North America. 1974;18(2):15- 44. 9. Green EN. Hemisection and Root Amputation. J Am Dent Assoc 1986;112(4):511-518. 10. Kurtzman GM, Silverstein LH, Shatz PC. Hemisection as an alternative treatment for vertically fractured mandibular molars. Compend Contin Educ Dent 2006; 27(2):126–9. 11. 10.Saad MN, Moreno J, Crawford C. Hemisection as an alternative treatment for decayed multirooted terminal abutment: A case report. J Can Dent Assoc 2009; 75 (5):387- 390. 12. Carnevale G, Pontoricro R, Di febo G. Long term effect of root resective therapy in furcation involved molars.-A 10 year longitudinal study J Clin. Periodontol 1998;25:209- 14. 13. Baston CH, Ammons WF, Persson R: Long term evaluation of root resected molars: A retrospective study:Int J Periodont Restor Dent 1996;16(3):207. 14. Carnevale G, Difebo G, Toyelli MP: A retrospective analysis of the periodontal- Prosthetic treatment of molars with interradicular lesions; Int J Periodont Restor Dent1991; 11:189-205. 15. Park JB. Hemisection of teeth with questionable prognosis.Report of a case with seven-year results; J Int Acad Periodontol.2009; 11(3):214- 9. 16. Haueisen H, Heidemann D. Hemisection for treatment of an advanced endodontic-periodontal lesion: a case report. Int Endod J, 35, 557-572, 2002. 17. Erpenstein H. A 3-year study of hemisectioned molars. J Clin Periodontol 1983:10:1-10. 18. H. T. Shillingburg, Jacobi R, Dilts W E. Preparingseverely damaged teeth. J Calif Dent Assoc 1983; 11:85 – 91. 19. Parmar G, Vashi P. Hemisection: a case-report and review. Endodontology. 2003;15:26-9. 20. Jain A, Bahuguna R, Agarwal V. Hemisection as an Alternative Treatment for Resorbed Multirooted Tooth-A Case Report. Asian Journal of Oral Health & Allied Sciences. 2011;1(1):44-6. 21. Kim S, Kratchman S. Modern endodontic surgery concepts and practice: a review. J Endod. 2006 Jul;32(7):601-23.
- 7. Muhamad A. et al., Int J Dent Health Sci 2014; 2(3):1012-1020 1018 FIGURES: Figure 1. Schematic of class III fracture: incomplete vertical fracture involving the attachment apparatus. Figure 2. Pretreatment radiograph of mandibular first molar demonstrating a class III fracture Figure 3. The separation was complete, the mesial half was extracted Figure 4. The mesial root has been amputated and the fracture is observed Figure 5. . A 8-year recall of hemisection and restoration