RestorativeDentistry

AR Vivekananda Pai
V Mohan Babu and Kundabala M

The Role of Hemisection in the

Prosthetic Management of a Distal
Extension Ridge A Case Report
Abstract: This case report illustrates the use of hemisection to minimize the distal extension span. The LR6 was the only molar next to a
distal extension of the lower Kennedys Class II ridge. Its unrestorable distal root was removed and its mesial portion was retained to serve
as an effective antagonist and abutment tooth and lessen the extent of right distal extension.
Clinical Relevance: Regarding the prosthetic rehabilitation of distal extensions, hemisection can be advantageous and offered as an
alternative to other treatment modalities.
Dent Update 2014; 41: 514516

A distal extension removable prosthesis

used for the rehabilitation of Kennedys
Class I and II ridges is associated with
unfavourable leverage forces. The longer
the edentulous span of distal extension,
the greater will be force transmitted to the
abutment teeth. Therefore, preservation of
strategic terminal abutment teeth may be
beneficial. In some situations, preserving a
part of such a tooth may lessen the extent
of distal extension span.
Hemisection is defined as the
division of a tooth in half and the removal
of the unwanted, diseased portion, together
with its root or roots. It can be considered as
a valid treatment since it follows the basic

AR Vivekananda Pai, MDS, Professor and

Head of the Department, V Mohan Babu,
BDS, Specialist Resident and
Kundabala M, MDS, Professor, Department
of Conservative Dentistry and Endodontics,
Manipal College of Dental Sciences
(Manipal University), Light House Hill Road,
Mangalore 575001, Karnataka, India

514 DentalUpdate

philosophy of conservative dentistry which

is to aim to retain as much of the natural
dentition as possible.1
Hemisection should be
considered when the furcation of the
molars is the result of either periodontal or
non-periodontal problems like vertical root
fracture. Further, it may be a valuable form
of treatment when there is an extensive
carious lesion extending subgingivally in
one area of the root, making it impossible
to place an adequate restoration in that
area and making that root unrestorable.2
Studies regarding the success of
hemisection have produced varying results.
However, considering various criteria for
failure, such as periodontal problems,
endodontic complications, prosthetic
problems, and caries, the average failure
rate over a 7-year period was found to be
13.1%. Furthermore, the average failure rate
was found to be 11%, when the number of
cases in each study was taken into account.3
Despite these figures, the comparative lack
of robust evidence means that hemisection
should always be considered a back to the
wall treatment modality which may provide

success in favourable conditions.

The removable prosthesis
used for the rehabilitation of Kennedys
Class I and Class II ridges, which have
bilateral and unilateral distal extensions,
respectively, with limited treatment
options, may be subjected to greater
stresses as it is supported by soft tissue
or a combination of tooth and soft tissue.
Also, the distal extension denture base of
the prosthesis can act as a lever arm and,
therefore, the longer the distal extension
span, the longer will be the denture
base and the greater may be the force
transmitted to the underlying ridge and
abutment tooth. Hence, an increase in
the extent of distal extension span should
preferably be avoided by retaining as
many teeth as possible. Moreover, from
the point of view of efficient mastication,
tooth retention rather than extraction
and replacement is desirable. However,
in certain situations, the retention of the
whole tooth may not be possible. In certain
circumstances, preserving a portion of
the tooth, particularly of a molar, may be
beneficial. For this purpose, given proper
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RestorativeDentistry

Figure 1. Pre-operative radiograph of LR6.

Figure 5. Radiograph following the hemisection

of LR6.

Figure 2. Radiograph following the obturation in LR6.

Figure 6. Hemisected LR6 with a metal crown

functioning as an additional antagonistic premolar.

Figure 3. Occlusal view following the sectioning

of LR6.
Figure 7. One year follow-up view of hemisected
LR6.

Figure 4. Distal view following hemisection and

extraction of distal root of LR6.

case selection and treatment planning,

hemisection can be a viable option.4,5
The literature on the sectioning
of a mandibular molar and the removal
July/August 2014

of its distal root is limited as this root is

more often retained than the mesial root
for anatomical reasons.2 Hemisection
requires a multidisciplinary approach
towards treatment, encompassing the
realms of endodontics, periodontics and
prosthodontics.6
This case report is about the
hemisection of a distal root to meet the
prosthetic treatment needs of the patient.

Case report
The patient, a 54-yearold woman, required the prosthetic

rehabilitation of her upper and lower

Kennedys Class II, modification 1 type ridges
(with unilateral distal extensions). It was
planned to deliver a transitional, removable
prosthesis to delay a tooth-tissue supported
type of prosthesis for financial reasons. The
patient was referred with severe pain in
LR6 for three days. Clinical and periapical
radiographic examinations of LR6 revealed
an occlusal amalgam restoration with deep,
subgingival distal proximal caries and 56
mm deep pocket on its disto-buccal aspect
(Figure 1). As the tooth gave an exaggerated
and prolonged response to the thermal and
electric pulp tests and showed tenderness
to percussion, along with apical widening of
periodontal ligament space, a diagnosis of
irreversible pulpitis with apical periodontitis
was made and root canal treatment was
suggested. Following treatment initiation
and deep caries excavation, LR6 was
deemed unrestorable at its distal aspect.
However, its extraction was considered. LR6
was the only effective antagonistic tooth
to UR5 and both were terminal abutments
in their quadrants. Extraction of LR6 would
have led to the loss of an antagonistic tooth
and an increase in the extent of lower right
distal extension. Therefore, it was decided
to hemisect LR6 and retain its mesial half.
Prior to hemisection, root canal therapy
was performed in LR6 (Figure 2) and access
opening was sealed using glass ionomer
cement (GC Gold Label 2, GC Corporation,
Japan).
Hemisection of LR6 was
performed under local anaesthesia, using
an envelope flap design by giving only
horizontal intrasulcular incision without
any vertical component. The sectioning
of the tooth was performed using a long
diamond bur in a withdrawing motion,
from the furcation to the crown, first midbuccally, then mid-lingually (Figure 3). After
confirming the complete separation, the
distal half of the tooth was extracted (Figure
4). Following radiographic confirmation
(Figure 5), the furcation side of the retained
mesial half was contoured.
Following clinical and
radiographic healing, the retained mesial
half was restored with an all-metal crown to
function like a premolar (Figure 6) and serve
as an antagonistic and abutment tooth to
engage the clasp extension of the tissue
borne, acrylic-based transitional, removable
prosthesis passively. At one year review,
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RestorativeDentistry

the prosthesis is well fitting and stable

and the hemisected tooth is found to be
asymptomatic and functional without any
significant radiographic changes (Figure 7).

Discussion
Hemisection of LR6, in this
patient, was beneficial as the extraction of
LR6 could have led to the loss of a natural
antagonistic tooth and an increase in the
extent of the lower right distal extension,
leading to reduced masticatory efficiency
and the generation of greater stresses by
the prosthesis, respectively. Furthermore,
hemisection was suitable in this patient
as only the distal portion of the LR6 was
unrestorable and the mesial portion was
intact.
Endodontic therapy was
carried out prior to hemisection.7 The
access opening was sealed with GIC, as
materials such as amalgam are shown to
affect the healing if lodged in the socket
during hemisection.8 Since the periodontal
defect was restricted to the disto-buccal
portion of the root to be hemisected and
flap displacement was not anticipated,
an envelope flap design without vertical
incisions was used. This flap ensures
better adaptation and faster recovery
with less post-operative complication.9
Tooth recontouring was required to
ensure a smooth hemisected surface and
eliminate residual furcal lips, which may
go undetected and lead to periodontal
problems.8,10
Although post placement is not
routinely suggested in the retained root
owing to certain inherent risks involved,
a full crown is the preferred restoration
as it prevents the fracture of the retained
portion.7 The cuspal inclines of the crown
should be minimized to control excessive
lateral forces that could result in periodontal
damage and occlusion should be carefully
checked to balance the occlusal forces on
the remaining root.5,6,10
For this patient, aesthetics
was not of importance, so an all-metal
crown was fabricated as a post endodontic
restoration. Also, the metal crown would
provide a better surface to engage and
withstand the frictional forces generated
during functioning of the prosthesis.
Many causes, like faulty
resections, root fractures or endodontic

516 DentalUpdate

complications, have been attributed to

the failure of a hemisected tooth. The use
of such a tooth as an abutment for multiunit prosthetic reconstruction is another.11
Although presently, in this patient, the
hemisected and crowned LR6 is passively
engaging a tissue-supported transitional
removable prosthesis, it may still be utilized
as an abutment tooth for any future
requirement of a tooth-tissue supported
type of distal extension prosthesis, provided
that the prosthesis can be designed to
minimize undue stresses.

Conclusion
The removable prosthesis used
for the rehabilitation of Kennedys Class
I and Class II type ridges leads to greater
stress generation as the span of their distal
extension increases. This can be minimized
by retaining the tooth lying adjacent to the
distal extension. However, when retention
of the tooth is desirable, especially a
multi-rooted molar, preserving a portion
of it would be beneficial. Therefore, from a
prosthetic treatment point of view, given
a proper case selection and treatment
planning, hemisection can be useful for
preserving a portion of a tooth, particularly
one acting as a natural antagonistic tooth,
and it can be offered to the patient as an
alternative to other treatment modalities.

Dent Assoc 2009; 75(5): 387390.

6. Kryshtalskyj E. Root amputation and
hemisection. Indications, technique
and restoration. J Can Dent Assoc 1986;
52(4): 307308.
7. Green EN. Hemisection and root
amputation. J Am Dent Assoc 1986; 112:
511518.
8. Kost WJ, Stakiw JE. Root amputation
and hemisection. J Can Dent Assoc
1991; 57(1): 4245.
9. Takei HH, Carranza FA. The
periodontal flap. In: Carranzas Clinical
Periodontology 10th edn. Newman
MG, Takei HH, Klokkvold PR, Carranza
FA, eds. Missouri: Saunders, 2007:
pp926936.
10. Newell DH. The role of the
prosthodontist in restoring rootresected molars: a study of 70 molar
root resections. J Prosthet Dent 1991;
65(1): 715.
11. Prabhu NT, Munshi AK. Hemisection of
a permanent mandibular first molar:
a treatment option for a vertically
impacted second premolar. J Clin
Pediatr Dent 1996; 20(3): 233235.

ERRATUM
CPD ANSWERS
May 2014

References

1. A, B, C

6. B, C, D

1. Burke FJT. Hemisection: A treatment

option for the vertically split tooth.
Dent Update 1992; 19: 812.
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Clinical Removable Partial Prosthodontics
2nd edn. St Louis, Tokyo: Ishiyaku
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5. Saad MN, Moreno J, Crawford C.
Hemisection as an alternative
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2. A, B, C,

7. B, D

3. C

8. A, B, C

4. A, B, D

9. A, B

5. C

10. C, D

CPD ANSWERS
June 2014

1. D

6. A, B, D

2. A, B, C,

7. A, C, D

3. A, D

8. D

4. A

9. A, B, C

5. C

10. A, B, D
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