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31]
Hemisection: Tooth savior maneuver after
iatrogenic complication
Vineet Agrawal S, Isha Agrawal S1, Sonali Kapoor
Department of Conservative Dentistry and Endodontics and 1Periodontics and Implantology, M.P. Dental College and ORI, Vadodara,
Gujarat, India
ABSTRACT
Iatrogenic procedural accidents occurring during the root
canal procedure may lead to failure of the root canal
treatment and removal of the teeth. Advances in dentistry
as well as increased desire of patients to maintain their
dentition have led to the treatment of teeth that once
would have been removed. Hemisection maneuver has
given the dentist the choice to preserve the maximum
toot structure with good retention in future. This case
report describes the preservation of mandibular molar
through hemisection after iatrogenic furcal perforation
and ledge formation.
Key words: Furcal perforation, hemisection,
iatrogenic complication, ledge
INTRODUCTION
Failure of root canal treatment occurs when acceptable
standards are not achieved due to various procedural errors
that occur during treatment which prevents the control
and impedes the complete disinfection of the root canal.
Ledge formation, canal blockage, separated instruments,
perforations etc., are some of the iatrogenic procedural
accidents that can interrupt the sequence of steps during
root canal treatment.[1,2]
Address for correspondence: Dr. Vineet Agrawal S,
101, Vinay Complex, Near Dudhdhara Dairy,
Bholav‑Bharuch ‑ 392 002, Gujarat, India.
E‑mail: vineetdent@yahoo.co.in
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DOI:
10.4103/2278-344X.160897
© 2015 International Journal of Health & Allied Sciences | Published by Wolters Kluwer - Medknow
Case Report
A ledge is an iatrogenically created irregularity (platform)
in the root canal that impedes access of instruments (and
in some cases irrigants) to the apex, resulting in insufficient
instrumentation and incomplete obturation. Thus, ledges
frequently contribute to ongoing periapical pathosis after
root canal treatment. Ledging of curved canals is a common
instrumentation error that usually occurs on the outer side
of the curvature due to exaggerated cutting and careless
manipulation during root canal instrumentation.[3] Furcal
perforation occurs during the access opening or inadvertent
search for the canals, which leads to communication
with periodontal apparatus and jeopardize the root canal
treatment.[2]
Removal of the teeth with iatrogenic ledge formation and
furcal perforation remains the option for eliminating the
endodontic infection, but meticulous advances in dentistry
provided the patients with an opportunity to retain their
functional dentition. Also, today, the patient’s awareness and
desire to preserve their natural teeth made the dentist to think
an alternative to retain their teeth that once used to extract.
Hemisection denotes sectioning of mandibular molar into
two halves followed by removal or separation of diseased root
with its accompanying crown portion.[4] The procedure of
hemisection represents a form of conservative management
to retain maximum tooth structure as possible.[5,6]
This case report presents a case where distal half of the root
was preserved after iatrogenic ledge formation in mesial
root and furcal perforation of mandibular molar through
hemisection.
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How to cite this article: Agrawal VS, Agrawal IS, Kapoor S.
Hemisection: Tooth savior maneuver after iatrogenic complication. Int J
Health Allied Sci 2015;4:185-7.
185
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Agrawal, et al.: Hemisection after iatrogenic complication

CASE REPORT cut to ensure separation. After separation, the severed

A 35‑year‑old female patient was referred by some general
dentist after initiation of a root canal treatment in lower left
posterior tooth. Tooth 36 was associated with a localized
swelling on the lingual side and was tender on percussion.
A diagnostic radiograph [Figure 1a] revealed that access
opening was done in 36 with coronal temporary restoration
placed, and severe curvature is present in the mesial root.
After removal of the temporary restoration, furcal perforation
was seen on the pulpal floor. Canals were negotiated, but the
mesial canals were unable to be negotiated till the apex due to
the ledge formed by the general dentist [Figure 1b]. Attempts
were made to negotiate the ledge by precurving file, using
smaller files with chelating agents etc., but all were in vain.
Hence, to preserve the maximum tooth structure possible, it
was decided to hemisect the mesial root and remove it since
both the furcal perforation and ledge will impede the further
root canal treatment outcome.
Endodontic treatment was performed under rubber dam
isolation, only for distal root canal and coronal access was
sealed with permanent restorative material [Figure 1c].
Hemisection was carried out in relation to 36 with the
vertical cut method as suggested by Weine [7] under
local anesthesia. A fine probe was passed through the
portion of the mesial root was removed with extraction
forceps [Figure 1d and e]. The socket was irrigated
with sterile saline to remove bony chips and debris. The
remaining portion of the distal tooth was trimmed to
remove any ledges or sharp spicules, as these structures
are potentially detrimental for periodontal maintenance.
The patient returned after 1‑month of postsurgical
healing [Figure 1f]. Crown preparation was completed on
36 distal root and 35 and fixed porcelain fused to metal
bridge was fabricated [Figure 1g and h]. The patient regular
follow‑up was taken and radiograph [Figure 1i] shows the
complete healing after 1‑year of the treatment.
DISCUSSION
Hemisection should be considered as another weapon in
the arsenal of the dental surgeon, determined to retain
and not remove natural teeth. With recent refinements
in endodontics, periodontics and restorative dentistry,
hemisection has received acceptance as conservative and
dependable dental treatment and teeth so treated have
endured the demands of function.[4] The loss of posterior
teeth can result in several undesirable sequelae, hence a
guiding principle should be followed to try and maintain
what is present.[2]

a b c

d e f

g h i
Figure 1: (a) Diagnostic radiograph (b) canal negotiation radiograph showing ledge formation in mesial canals (c) postendodontic
treatment radiograph (d) resected mesial root (e) postresection radiograph (f) intraoral healing after 1-month (g) porcelain
fused metal bridge cementation (h) radiograph after bridge cementation (i) follow-up radiograph after 1-year

186 International Journal of Health & Allied Sciences • Vol. 4 • Issue 3 • Jul-Sep 2015
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Agrawal, et al.: Hemisection after iatrogenic complication
In the present case, because of severe ledge formation in the
mesial root along with the furcal perforation, the prognosis
for root canal therapy was questionable. Buhler stated
that hemisection should be considered before every molar
extraction, because it provides good, absolute and biological
cost saving alternative with good long‑term success.[8] Park
et al.[9] have suggested that hemisection of molars with
questionable prognosis can maintain the teeth without
detectable bone loss for long‑term period, provided that the
patient has optimal oral hygiene. Hence, it was decided to
remove the mesial root through hemisection procedure and
preserve the distal root that will act as an abutment later.
The tooth should be treated endodontically first for relieving
the patient from pain and swelling.[10] The access cavity is
sealed with the permanent restorative material because
tooth preparation can invade pulp chamber and jeopardize
control of coronal seal of the endodontic access opening
and cause contamination of obturated tooth during the
procedure of hemisection.
When choosing to perform a hemisection procedure,
consideration should be given to morphology, clinical length
and shape of roots of the multirooted tooth. In the present
case, the above‑mentioned indication for case selection in
performing hemisection was optimum as roots were not
closely approximated or fused. Also, in the present case,
there was severe curvature present in mesial root that has
to be carefully extracted without damaging the distal half
of teeth that make this case difficult compare to other
published case reports.
When the tooth has lost part of its root support, it will
require a restoration to permit it to function independently
or to serve as an abutment for a splint or bridge. According
to Park et al.,[11] resected molars used as intermediate
International Journal of Health & Allied Sciences • Vol. 4 • Issue 3 • Jul-Sep 2015
abutments of a fixed bridge, had a higher survival rate.
Various aspects of the occlusal function such as location,
size of contacts and steepness of cuspal inclines plays a
significant role in restorative design. In the present case,
three‑unit bridge was provided to restore occlusal function
that involved adjacent second premolar and retained distal
root of mandibular first molar.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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