J Interdiscip Dentistry
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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 3  |  Page : 141-144

Salvaging a tooth with radisection: A case report with 3-year long-term follow-up


1 Department of Conservative Dentistry and Endodontics, SRM Dental College, SRM Institute of Science and Technology, Bharathi Salai, Ramapuram, Chennai, Tamil Nadu, India
2 Private Practioner, Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belagavi, Karnataka, India
3 Maratha Mandal's Nathajirao G. Halgekar Institute of Dental Sciences and Research Centre, Belagavi, Karnataka, India

Date of Submission29-May-2020
Date of Acceptance19-Aug-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Monisha P Khatri
Department of Conservative Dentistry and Endodontics, SRM Dental College, Bharathi Salai, Ramapuram Campus, Chennai - 600 089, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jid.jid_45_20

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   Abstract 


The successful management of endodontically involved teeth depends on adequate
biomechanical preparation and obturation in adherence to a satisfactory coronal
seal. However, challenges such as extensive carious involvement, periodontal
attachment loss, and iatrogenic mishaps which include ledges, blocked canals, and
instrument separation compromise the salvation of the teeth. Treatment options
for such mishaps in multirooted teeth can range from endodontic treatment alone,
combined endodontic-periodontic treatment, or extraction in cases with poor
prognosis. One such treatment in case of file fracture or extensive periodontal
involvement in maxillary molars could be root resection, also known as radisection.
This procedure offers an economically viable treatment option for the patient to
preserve the natural tooth. This article highlights a case report of root resection
in maxillary molar with endodontic, periodontic, and prosthetic management with
resultant successful oral rehabilitation along with a follow-up of 3 years.

Keywords: Endodontic treatment, furcation involvement, root resection, radiasection


How to cite this article:
Khatri MP, Biradar A, Paradkar S, Shivanaikar S. Salvaging a tooth with radisection: A case report with 3-year long-term follow-up. J Interdiscip Dentistry 2020;10:141-4

How to cite this URL:
Khatri MP, Biradar A, Paradkar S, Shivanaikar S. Salvaging a tooth with radisection: A case report with 3-year long-term follow-up. J Interdiscip Dentistry [serial online] 2020 [cited 2021 Oct 17];10:141-4. Available from: https://www.jidonline.com/text.asp?2020/10/3/141/304155




   Clinical Relevance to Interdisciplinary Dentistry Top


This case report emphasizes on the fact that the key to success of radisection procedure does not only depend on thorough diagnosis, selection of patients with good oral hygiene, careful surgical and restorative management but also in evaluating the case with long term follow up.


   Introduction Top


The ultimate goal of endodontic restoration is to provide a dentition that will function in health and provide comfort for life. Procedural advancements such as root resection are helping the clinicians to achieve this goal. The American Academy of Periodontology defined root resection as a process by which one or more of the roots of a tooth are removed at the level of furcation while leaving the crown and remaining roots in function.[1] Root resection (also known as radisection or root amputation) can be distinguished from crown resection (CR) procedure, by the former being defined as a process including amputation at the level of the cementoenamel junction with intact coronal portion. On the other hand, “crown resection” includes hemisection, trisection, or bicuspidization of the crown in a multirooted tooth, which is traversed through the furcation in a way that both the root and the associated portion of the crown may be removed or retained.[2]

The indications of radisection broadly include teeth with periodontal problems, endodontic problems, root fractures, and prosthetic problems. In endodontic complications such as root fracture, file fracture, root perforation, deep subgingival caries, and radisection could be a boon if the teeth are of high strategic value or when all other approaches to save the tooth have failed.[3] During such complications, a choice between preservation and extraction followed by replacement of lost tooth structure has to be made. A study done by Fugazzotto showed a success rate of 96.8% for root resected molars and 97.0% for molar implants after an accumulative period of 15 years.[4] A systematic review and meta-analysis by Setzer et al.[2] reported five studies of root resection performed on the maxillary arch, in which data extraction regarding specific procedures showed an overall success rate of 97.8% in cases with a follow-up of more than 12 months.

Although radisection is a valid treatment option to salvage the tooth, long-term follow-ups of cases performed are very few in literature. Therefore, this report focuses on a case where the distal root of the maxillary molar was resected owing to its etiology with a long-term follow-up.


   Case Report Top


A 47-year-old male reported to the department of conservative dentistry and endodontics with the chief complaint of pain in the upper left posterior tooth region for 10 days. Pain was intermittent in nature and aggravated on mastication and food impaction. The medical history of the patient was noncontributory. The patient had a history of incomplete root canal treatment done in the same region 5 months back. On clinical examination, there was a large open cavity with respect to the maxillary left upper first molar (26) and metal crown placed with respect to the maxillary left upper second molar (27). The maxillary left upper first molar was tender on percussion, periodontal pocket of 5 mm [Figure 1]a was present on the distobuccal side of the tooth, and Grade II furcation involvement of the same tooth was observed. Radiographically, there were multiple file separations associated with the distal root of 26. Based on the examination, a final diagnosis of symptomatic apical periodontitis with previously attempted root canal treatment and separated instrument was made with respect to 26. The treatment plan was formulated, and the postoperative restorative plan was discussed with the patient. An attempt of file retrieval was done, but since there were multiple file separations, a final treatment plan of completion of root canal treatment with mesial and palatal roots, followed by root resection of the distal root of 26 and crown placement was finalized, and the same was done as follows. The patient was thoroughly explained about the procedure and its complications, and the consent of the patient was taken.
Figure 1: (a) Preoperative radiograph, (b) working length determination, (c) postobturation radiograph, (d) postsurgical radiograph, and (e) 3-year follow-up radiograph

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Root canal treatment was completed [Figure 1]a, [Figure 1]b, [Figure 1]c, followed by Phase I periodontal therapy. Following premedication and disinfection protocol, root resection was carried out after a week's time. 2% lignocaine hydrochloride (Lignox 2%, Indoco Remedies Ltd., India) with 1:200,000 concentration of adrenaline was administered locally in the area of 26. The full-thickness envelope flap was reflected after giving a crevicular incision from the distal line angle of the first premolar to the distal line angle of the second molar [Figure 2]a, [Figure 2]b, [Figure 2]c. A small amount of bone was removed on the facial aspect in relation to 26 so as to aid in the root removal. With the high-speed tapered fissure carbide bur directed below the cementoenamel junction, resection of the distal root was carried out, and the resected portion was removed [Figure 2]d and [Figure 2]e. The sectioned area was evaluated, trimmed, and filled with mineral trioxide aggregate (Dentsply Proroot MTA). The extraction socket was debrided and irrigated with saline, and the tooth was checked for occlusion. Flap approximation was done secured with 3-0 Black Silk Suture (Sutures India Pvt. Ltd., India) [Figure 2]f. Surgical site was covered with periodontal dressing (COE-PAK, GC). Postoperative instructions and medications were prescribed. The patient was recalled after a week for suture removal and assessed for healing. A permanent coronal seal with composite was given, and crown was placed after a waiting period of 2 weeks [Figure 1]d. The patient was periodically followed up for a period of 3 years [Figure 1]e.
Figure 2: (a) Measuring the periodontal pocket, (b) elevation of full-thickness envelope flap, (c) exposed distal root along with separated file, (d) radisected tooth, (e) resected distal root and separated file, and (f) flap approximation and suture placement

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   Discussion Top


The late 1800s mark the introduction of root resection as a successful treatment option in dentistry.[5] In 1884, Farrar stated that root resection is an acceptable surgical treatment for selective furcated molar teeth. Dr. W J. Younger in 1894 had also addressed the gathering of the American Medical Association and explained his opinion of root amputation procedure in hopelessly involved roots of molar teeth that can be made comfortable and serviceable for years. Coolidge in 1930 and Sommer in 2002 emphasized the importance of eradication of microorganisms by proper preparation and sealing of the root canal before beginning the root resection. Contributions made by Hiat and Amen were highlighting the indications and procedures for root amputation in the 1960s,[6] which were put to practicality by Farshchian and Kaiser by implementing bicuspidization procedure in managing teeth with severe furcation involvement.[7]

According to Dalkýz et al., endodontic indication of root resection by several authors includes the inability to successfully treat and fill a canal, root fracture, root perforation, or root caries of the furcation area.[8] In the present case report, root resection of the distal root was carried out due to the inability to successfully treat the canal as it was associated with multiple file separations and the danger of perforation associated with an attempt of retrieval. This case was also selected based on the factors associated with selection criteria for root resection such as the presence of acceptable level of bone around the remaining roots, angulations, and position of the tooth in the arch, long, and straight roots, divergent roots, and feasibility of endodontic and restorative dentistry in the roots to be retained.[8],[9]

Root resection is a complex multidisciplinary procedure which requires the knowledge and skill of proper case selection. Cases with fused roots, unfavorable architecture, endodontically untreatable retained roots, severe root desorption, and poor oral hygiene are some of the contraindications for this procedure.[8] As stated by Newell, root resection is the retention of some or the entire tooth, but there are certain disadvantages associated with this procedure.[10] Being a surgical procedure, it may cause an increased level of anxiety and pain to the patient, susceptibility to caries is increased at the furcal area after resection, and there is a high chance of treatment failure due to the occurrence of dental caries posttreatment if the area is not maintained or there may be a failure of endodontic treatment in remaining roots. In addition to this, restoration of the remaining tooth structure to function independently or as an abutment for prosthesis contributes to periodontal destruction due to defective margins or undue forces on the improper occlusal contact area.[11] A 15-year follow-up study done by Fugazzotto[4] reported a success rate of 97.6% for root resected maxillary first molars when compared to Langer et al.[12] who reported 84% failure rate in molars after a period of 5 years. This discrepancy reported was due to random selection of cases in the latter study without proper follow-up, thereby failing to assess the quality of periodontal and endodontic therapy after root resection as well as ignoring the aspect of functional loading and unloading in such cases.[4] Hence, radisection is a technique-sensitive procedure and should be attempted only after contemplating the prognosis of the tooth to be operated with a thorough follow-up.


   Conclusion Top


In accordance with the current case report, radisection can be viewed as a valid treatment option to eliminate the diseased root so as to allow the remaining healthy tooth to survive. Appropriate case selection and interdisciplinary approach, which include endodontic, periodontic, and prosthodontic management, are key factors for the success of root resection procedures. Moreover, long-term follow-up of radisection cases is necessary so as to validate them as a successful treatment option.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
American Academy of Periodontology, editor. Glossary of Periodontal Terms. 4th Edition 737 North Michigan Avenue Chicago: American Academy of Periodontology; 2001.  Back to cited text no. 1
    
2.
Setzer FC, Shou H, Kulwattanaporn P, Kohli MR, Karabucak B. Outcome of crown and root resection: A systematic review and meta-analysis of the literature. J Endod 2019;45:6-19.  Back to cited text no. 2
    
3.
Park JB. Hemisection of teeth with questionable prognosis. Report of a case with seven-year results. J Int Acad Periodontol 2009;11:214-9.  Back to cited text no. 3
    
4.
Fugazzotto PA. A comparison of the success of root resected molars and molar position implants in function in a private practice: Results of up to 15-plus years. J Periodontol 2001;72:1113-23.  Back to cited text no. 4
    
5.
Nabhi K, Mehra P, Sharma B. Root resection of maxillary first molar: A case report. Journal of Dental and Medical Sciences 2017;16:103-7.  Back to cited text no. 5
    
6.
Mantri V, Maria R, Kamat S, Raut AW. Root amputation: Case reports and review. Endodontology 2013;25:89-95.  Back to cited text no. 6
    
7.
Sahoo S, Sethi K, Kumar P, Bansal A. Management of periodontal furcation defects employing molar bisection; a case report with review of the literature. Dent Hypotheses 2013;4:97.  Back to cited text no. 7
  [Full text]  
8.
Dalkýz M, Çilingir A, Beydemir B. Bicuspidization: A case report. Gülhane Týp Dergisi 2008;50:42-5.  Back to cited text no. 8
    
9.
Muzzi L, Nieri M, Cattabriga M, Rotundo R, Cairo F, Pini Prato GP. The potential prognostic value of some periodontal factors for tooth loss: A retrospective multilevel analysis on periodontal patients treated and maintained over 10 years. J Periodontol 2006;77:2084-9.  Back to cited text no. 9
    
10.
Newell DH. The role of the prosthodontist in restoring root-resected molars: A study of 70 molar root resections. J Prosthet Dent 1991;65:7-15.  Back to cited text no. 10
    
11.
Kinsel RP, Lamb RE, Ho D. The treatment dilemma of the furcated molar: Root resection versus single-tooth implant restoration. A literature review. Int J Oral Maxillofac Implants 1998;13:322-32.  Back to cited text no. 11
    
12.
Langer B, Stein SD, Wagenberg B. An evaluation of root resections. A ten-year study. J Periodontol 1981;52:719-22.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2]



 

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