|Year : 2012 | Volume
| Issue : 2 | Page : 141-143
An innovative approach for treating vertically fractured mandibular molar - hemisection with socket preservation
Vineet S Agrawal1, Sonali Kapoor1, Nimisha C Shah2
1 Department of Conservative and Endodontics, M.P. Dental College and Hospital, Piparia-Vadodara, India
2 Department of Conservative and Endodontics, K.M. Shah Dental College and Hospital, Piparia-Vadodara, India
|Date of Web Publication||4-Sep-2012|
Vineet S Agrawal
Department of Conservative and Endodontics, M.P. Dental College and Hospital, Piparia-Vadodara
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Vertical root fracture has been described as longitudinally oriented fracture of the root extending from the root canal to the periodontium. The most predictable treatment option for vertical root fractures would be extraction in case of anterior teeth, and hemisection or root amputation of the involved root in the multi-rooted teeth. Following extraction, socket preservation procedure helps to retain the available bone and soft tissue for better function and aesthetics. This case report describes the treatment of a vertically fractured mandibular molar by hemisection with socket preservation surgery followed by restoration with a fixed prosthesis.
Clinical Relevance to Interdisciplinary Dentistry
- Combined periodontics, endodontics, prosthetic and restorative innovative approach for management of vertically fractured teeth.
- Interdisciplinary approach combining surgical technique with endodontic and prosthetic rehabilitation.
Keywords: Dental prosthesis, dental restoration, tooth extraction, tooth fractures, tooth injuries, tooth socket
|How to cite this article:|
Agrawal VS, Kapoor S, Shah NC. An innovative approach for treating vertically fractured mandibular molar - hemisection with socket preservation. J Interdiscip Dentistry 2012;2:141-3
|How to cite this URL:|
Agrawal VS, Kapoor S, Shah NC. An innovative approach for treating vertically fractured mandibular molar - hemisection with socket preservation. J Interdiscip Dentistry [serial online] 2012 [cited 2019 Jul 16];2:141-3. Available from: http://www.jidonline.com/text.asp?2012/2/2/141/100611
| Introduction|| |
One of the most puzzling and frustrating diagnostic problems encountered by the dental practitioner is the vertical root fracture (VRF).  The prevalence of VRF in endodontically treated teeth is much higher, ,, than in nonendodontically treated, restored or intact teeth. , Hemisection therapy is a predictable treatment modality for vertical root fractures that enables clinicians to better access the remaining tooth structure for periodontal and subsequent prosthetic therapy.  Following hemisection, socket preservation procedure helps to retain the available bone and soft tissue for better function and aesthetics. 
| Case Report|| |
A 39-year-old female patient reported to the Department of Conservative and Endodontics, with the chief complaint of pain in lower left back tooth since 2 months. Patient gave history of root canal therapy about 2 years back in relation to 36. Both mobility and percussion tests were negative and periodontal probing revealed isolated 7-mm pocket in the distal root region of 36 [Figure 1]a. Radiographic examination, revealed radiolucency at the furcation and widening of the periodontal ligament space in relation to the mesial and distal root of 36. A fine radiolucent line was noted running from middle third to apical third of the distal root of 36 which was suggestive of VRF [Figure 1]b.
|Figure 1: (a) Preoperative view showing periodontal pocket in distal root region. (b) Preoperative radiograph. (c) Exploratory surgery revealing vertical root fracture and vertical cut made toward the bifurcation area for hemisection. (d) (1)Hemisected distal root (2) Vertically fractured fragment in hemisected root. (e) Socket after hemisection of distal root. (f) Following extraction of mesial root of 46, socket filled with a mixture of demineralized freeze-dried bone allograft (Dembone TM) and synthetic hydroxyapatite bone graft. (g) A horizontal cross mattress sutures placed using 3-0 black silk suturese graft (Eugraf TM). (h) Healing of surgical site after 4 weeks. (i) Postoperative radiograph. (j) Metal crown given over the mesial root of 36. (k) Postoperative radiograph after 2 years|
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| Treatment|| |
Exploratory surgery was performed by reflecting a flap [Figure 1]c and the affected area (distal root of 36) was thoroughly debrided. An incomplete vertical root fracture extending in the buccolingual direction, involving the distal root of 36 was detected with a V'-shaped osseous defect extending to the apex of the distal root of 36. Hemisection was planned to retain the mesial root as it had adequate alveolar bone support. A long shank tapered fissure carbide bur was used to make the vertical cut toward the bifurcation area [Figure 1]c. The distal root was extracted [Figure 1]d and the socket was irrigated adequately with sterile saline to remove bony chips [Figure 1]e. Socket preservation was done by grafting the extraction site with a mixture of demineralized freeze dried bone allograft (Dembone TM Flower ST, Los Angeles, USA) and synthetic hydroxyapatite bone graft (Eugraf TM Eucare pharmaceuticals Private limited, Chennai, India) in the ratio of 1:1 and covered with a bioresorbable collagen membrane (HealiguideTM Advanced Biotech Products (P) Ltd, Chennai, India) to prevent the collapse of the soft tissue in to the socket [Figure 1]f. Horizontal cross mattress sutures were placed using 3/0 black silk sutures (Mersilk - Ethicon, Division of Johnson & Johnson Ltd., Aurangabad, India) and the flap was approximated [Figure 1]g. The occlusal table was minimized to redirect the forces along the long axis of the mesial root. The surgical site was covered with a periodontal dressing (coe-packTM GC America INC.ALSIP, IL, USA). Four weeks following surgery, complete healing was observed at surgical site [Figure 1]h and on radiograph [Figure 1]i. At surgical site, extraction socket was covered completely by approximation of flaps, epithelial attachment has taken place and no more periodontal pocket was evident. A fixed metal bridge was given involving occlusal part of mandibular second molar for occlusal rest and retained mesial half of mandibular first molar [Figure 1]j. Two years later, intraoral periapical radiograph showed complete bone formation at the grafted site with minimal crestal bone loss in relation to mesial root of 36 [Figure 1]k.
| Discussion|| |
Diagnosis of VRF was made by the presence of isolated periodontal pocket in the distal root region of 36, radiographic evidence of diffuse radiolucency in relation to distal root of 46 and a fine radiolucent line running from middle-apical third of the distal root, and confirmed by means of exploratory surgery. To ascertain a diagnosis of VRF the clinician should take at least two angulations with periapical radiographs to detect either a fracture line or typical periradicular radiolucency, and elevate an exploratory flap that usually helps to visualize the pattern of bone loss and fracture. 
The current prosthetic guidelines for rehabilitation, following resection therapy include a confluence of the root and the prosthetic crown contours. In addition, the axial tooth contours of the restored resected teeth should have a physiological contour, which implies that the restoration emerges from the root with a zero degree emergence profile.  Socket preservation with bone graft and membrane are reasonable choice to preserve sufficient volume and contour to permit subsequent implant placement or prosthetic restoration.  The approach is innovative because here the socket preservation was done after the hemisection using composite graft technique. Studies have shown that demineralized freeze-dried bone allograft (DFDBA) alone have little or no osteoinductive potential and resorbs sporadically. Combining DFDBA with synthetic hydroxyapatite, reduce the rapid resorption of both material and also hydroxyapatite have osteoconductive potential and DFDBA has osteoinductive property (thus, act as a scaffold). As there was a vertical bone loss present in relation to distal root, complete bone fill was not seen even after 2 years, as there was no wall left for new bone formation, but the socket preservation helped to maintain the remaining alveolar bone height and prevented further bone resorption.
| Conclusions|| |
Socket preservation following hemisection helps to maintain the remaining alveolar bone height, prevent further resorption of bony plates, minimize surgical procedures like ridge augmentation and improves aesthetics to achieve optimum treatment results.
| References|| |
|1.||Schetritt A, Steffensen B. Diagnosis and management of vertical root fractures. J Can Dent Assoc 1995; 61:607-13. |
|2.||Testori T, Badino M, Cartagnola M. Vertical root fractures in endodontically treated teeth -A clinical survey of 36 cases. J Endod 1993;19:87-91. |
|3.||Lommel TJ, Meister F Jr, Gerstin H. Diagnosis of possible causes of vertical root fractures. Oral Surg Oral Med Oral Pathol1980;49243-53. |
|4.||Dang DA, Walton RE. Vertical root fracture and root distortion effects of spreader. J Endod 1989;15:294-301. |
|5.||Yang SF, Revera EM, Walton RE. Vertical root fracture in non-endodontically treated teeth. J Endod 1995;21:337-9. |
|6.||Yeh CJ. Fatigue root fractures and spontaneous root fractures in non endodontically treated teeth. Br Dent J 1997;182:261-6. |
|7.||Moule AJ, Kahler B. Diagnosis and management of teeth with vertical fractures. Aust Dent J 1999;44:75-87. |
|8.||Darby I, Chen S, De poi R. Ridge preservation: What is it and when should it be considered. Aust Den J 2008;53:11-21. |
|9.||Tamse A. Vertical root fractures in endodontically treated teeth: Diagnostic signs and Clinical Management. Endod Top 2006;13:84-94. |
|10.||Kurtzman GM, Silverstein LH, Shatz PC. Hemisection as an alternative treatment for vertically fractured mandibular molars. Compend Contin Educ Dent 2006;27:126-9. |