|Year : 2020 | Volume
| Issue : 5 | Page : 819-823
|Root resection - Exploring ways beyond extraction
Monika Pal, Santhosh Kumar, G Pratibha
Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka, India
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|Date of Submission||07-Feb-2018|
|Date of Decision||16-Aug-2019|
|Date of Acceptance||07-Oct-2020|
|Date of Web Publication||08-Jan-2021|
| Abstract|| |
One of the crucial challenges that any present-day general dentist confronts is the treatment determination between extracting a tooth and placement of a dental implant or by conserving the natural tooth with an interdisciplinary approach. The rising concern amongst the patients towards preserving their dentition has driven the clinicians towards providing treatment options that are more appropriate and conservative and at the same time does not hamper its functional needs. This report highlights one such way of preserving the periodontally compromised natural tooth with just resecting the diseased part of it and also conserving the proprioceptive capacity of the tooth. One-year of regular follow up and maintenance paving way to a healthy periodontium and complete resolution of mobility concerning the affected tooth is described. This report also provides information on root resection in a mandibular molar as a viable and a definitive treatment modality, providing better access to the remaining tooth structure and thereby enabling successive prosthetic rehabilitation.
Keywords: Endo-Perio lesions, furcation, mandibular molar, root resection
|How to cite this article:|
Pal M, Kumar S, Pratibha G. Root resection - Exploring ways beyond extraction. Indian J Dent Res 2020;31:819-23
| Introduction|| |
There are a plethora of options available to salvage a mandibular molar with suboptimal bone support. With increasing awareness amongst the patients, the desire to preserve the natural dentition has also increased. However, preserving of a critically diseased tooth and its supporting structures demands a detailed and well-phased treatment plan employing a multidisciplinary team.
The first permanent teeth to erupt in the oral cavity are the mandibular molar and they are susceptible to progressive overload and overuse. This makes them more vulnerable to develop an extensive carious lesion, vertical tooth fracture, advanced loss of clinical attachment or furcation invasions. These elaborate conditions notably complicate the therapy and the final prognosis. The extraction of these affected teeth is not axiomatically an alternative. In such cases, resection/root amputation type of surgical approach may be considered. This final treatment plan will provide better access to the residual structure of the tooth, thus validating subsequent prosthetic reintegration and also preserve the proprioceptive capacity of the tooth.
Root resection generally is defined as removal of a root without reference to how the crown is treated, while root amputation is the removal of the root at the furcation or apical to it, without removal of the crown, usually performed on maxillary molars.
Root resection is indicated in cases with severe vertical bone loss involving only single root of a multi-rooted tooth, furcation invasion due to any cause, iatrogenic mishaps such as perforation through the floor of pulp chamber or a vertical root fracture of one root.
This therapy has contraindications such as anatomical aberrations like fused roots where separation would be difficult and obviously case scenarios where the root to be conserved cannot be endodontically treated.
Endodontic treatment of the retained root is mostly performed before root resection however it could be done after root resection also, which would involve endodontic treatment within 1-week post resection. The motive of this therapeutic approach is to make furcation area accessible and self-cleansable. Any roughness on the unaffected root surface would also be eliminated during this procedure to prevent further plaque accumulation.
Occlusal stress subjected to the permanent mandibular molar is very high. The resected tooth loses its ability to bear such intense loads. Hence, it is obligatory to adequately restore such a tooth with an extra coronal restoration or any prosthesis with adjacent support.
A detailed systemic as well as dental history, thorough clinical and radiographic evaluations including periapical radiographs, diagnostic casts, and consultation with the restorative dentist should be carried out prior to the surgery. Treatment options must be described to the patient such as an alternative of a dental implant, and the potential complications or failures of a surgical procedure should also be discussed. The decision about the final treatment to be done should be made after evaluating the response of the cause-related therapy.
Usually, root resections are performed for maxillary molars and hemisection is instituted for mandibular molars as a furcation therapy. The literature is rare regarding root resection of the mandibular molars.
This clinical case report depicts a scenario where distal root resection, sparing the crown structure of the mandibular molar was considered as a treatment alternative along with platelet-rich fibrin to promote and accelerate the process of osseous healing followed by a minimally invasive prosthesis.
| Case Presentation|| |
A 36-year-old systemically healthy male patient presented to the Department of Periodontology complaining of slight pus discharge in the lower right back tooth and dull intermittent pain associated with it since five days for which he took no medications. He gave a history of food lodgement in the same region with no history of any external trauma.
The intraoral examination revealed the presence of a periodontal abscess on the buccal aspect of the first molar. The periodontal probing depth was more than 10 mm disto-labially and 6 mm lingually [Figure 1], with grade-III furcation invasion (I Glickman 1953), also exhibiting grade I mobility (Miller's mobility index) and no sign of tenderness on percussion. There was food impaction on the distal surface of tooth #46 but there was no evidence of trauma from occlusion. Oral hygiene status was fair.
|Figure 1: Preoperative image – Pocket-probing depth of more than 10 mm with buccal aspect of #46 with pus discharge|
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The periodontal abscess in relation to the molar was drained through the sulcus using Gracey curette no. 13 and 14 (Hu-Friedy®, Chicago) with saline irrigation. Furcation debridement was done using Quentin furcation curette (SQBL26, Hu-Friedy®, Chicago). Oral prophylaxis included upper and lower supragingival scaling and subgingival scaling and root planing. The plunger cusp was eliminated in order to reduce the food impaction and oral hygiene instructions were given. 10 ml of 0.2% chlorhexidine mouthwash (Rexidine, Indoco Pharmaceuticals) at 1:1 dilution was prescribed to the patient to be gargled twice daily for 10 days.
On evaluation after 10 days of recall, there was persistent periodontal pocket probing depth of more than 10 mm on the distolabial and 8 mm on the lingual aspect of the first molar. Electric pulp testing showed non-vital tooth. The Intraoral Periapical radiograph showed advanced bone loss in relation to the complete distal root involving the furcation also [Figure 2]. The patient insisted on retaining the tooth and was not willing for any implant placement in his mouth. Endodontic treatment was thus initiated. After completion of endodontic treatment surgical resection was planned with respect to distal root.
|Figure 2: Preoperative Radiograph – Depicting complete alveolar bone loss with respect to distal root of #46|
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All procedures were performed under strict sterile conditions. Full-thickness mucoperiosteal flap by means of crevicular incisions was raised both on the buccal as well as lingual sides to expose the margins of the bone defect. The rotary motor utilizing straight end plain fissure carbide bur (no. 1158) with irrigation was used to resect the distal root, apical to CEJ. Access to the root was gained from the buccal side [Figure 3]. After curetting and elimination of the granulation tissue from the socket and removal of the tissue tags from the flap; thorough root planing of the mesial root was performed. After complete debridement, the open distal root orifice was sealed using biodentin (Septodont, Maharashtra, India). The sandwich technique was used for grafting the socket with platelet-rich fibrin along with osseous graft (Sybograft). The flap was sutured using 3-0 braided black silk sutures (Ethicon US, LLC, U.S.). Amoxicillin was prescribed for 5 days (Amox 500 mg/tid) (Sandoz Pharmaceuticals Inc.) and was asked to continue with 0.2% chlorhexidine rinse.
|Figure 3: Intraoperative image – buccal view of #46 after distal root resection|
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The sutures were well irrigated with saline and removed after 15 days. The surgical site exhibited good healing. No postoperative complications were noticed. There was no swelling or any exaggerated pain or discomfort as reported by the patient. The soft tissue had collapsed in the distal aspect leaving a space of more than 6 mm apical to the crown, making it self-cleansable. Oral hygiene instructions and touch to teach brushing technique was advised. The patient was advised to use a curaprox interproximal brush to keep it clean. Radiographically some evidence of bone formation was noticed distal to mesial root [Figure 4]. A rigid splint made of a single 19 gauge orthodontic wire was used to immobilize the resected tooth. The splint was secured using light cure composite [Figure 5].
|Figure 5: Post-operative Radiograph – Depicting some evidence of bone formation distal to the mesial root of #46|
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The patient was again evaluated after three months. The surgical site showed no sign of inflammation and the splint was then removed. The resected tooth exhibited absolutely no mobility and was thus ready for fixed crown prosthesis [Figure 6].
|Figure 6: Post Operative image – depicting adequate gingival healing after 3 months|
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Surveying of the teeth to be prepared was done using a dental surveyor to determine the path of insertion. Preparation of the lingual surface of the second premolar and second molar teeth was done for receiving a lingual wing of the Maryland bridge. The first molar was prepared to receive a metal-ceramic crown [Figure 7]. A Maryland bridge with lingual metal wings was then cemented using dual cured resin cement [Figure 8]. The crown contacts was in eccentric position.
The patient reported after 6 months and the resected tooth exhibited no sign of gingival inflammation with excellent healing and a well-maintained self-cleansable area apical to the crown. The intraoral periapical radiograph depicted clear picture of regenerated bone in relation to the mesial root [Figure 9]. The patient was unable to report after one year but was very pleased with the overall treatment up to one year.
|Figure 9: Intraoral periapical radiograph – arrow depicting bone formation|
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| Discussion|| |
The root resection therapy is technique-sensitive and is predictable with good regeneration occurring in relation to the retained root. It involves multiple phases with equidistant time gaps. According to the reports in different studies, most of the failures were caused by reasons excluding periodontal destruction such as the improper selection of an adequate treatment strategy. The forethought given to each phase of treatment might become a solution and thereby minimise the post-treatment problem.,,
Thorough non-surgical periodontal therapy, to eliminate plaque and its retentive sources with adequate oral hygiene instructions helped in achieving optimal maintenance protocol. Then an endodontic treatment with minimal access cavity preparation was performed to gain enough access to the root canals and thus conserving maximum possible crown structure. Occlusal table of the affected molar was reduced to render it out of occlusion thus preventing abrupt masticatory load on it, which could further provide rapid healing of the periodontal ligament and ensure better stability of the residual root.
The main difference between resection in general and the present case is preservation of entire crown structure. Following hemisection of mandibular molar, two premolars shaped small and joint abutments are given which, (1) do not mimic the exact mandibular morphology and; (2) have to necessarily involve the adjacent teeth for support. However, in this present case, it could be possible because the lesion was primarily of periodontal origin.
Several materials have been utilised to fasten the process of bone healing post extraction of tooth. Platelet-rich fibrin being one such autologous material has been employed as a scaffold for promotion of bone growth and maturation. It also has shown excellent wound healing and haemostatic properties. These properties together influenced the selection of Platelet-rich fibrin as a favourable adjunct in this case.
The mesial root of mandibular molar has more surface area in comparison to the distal root that makes it more periodontally sound. However, the resection of a root changes the distribution of forces exerted on the tooth. It is thus suggested to evaluate the occlusion of the resected tooth and if required, occlusion should be then adjusted. While maintaining the centric holds, eccentric forces must be abolished from the area over the root that was resected. It is also wise to temporary stabilise the resected tooth in patients with advanced attachment loss to prevent tooth movement. Therefore, a rigid splint made of orthodontic wire was used in this case to stabilize and immobilize the tooth. This splint acted as a bridged support for the resected tooth for three months.
The temporary crown prosthesis was provided for a period of one month to visualise the consequences of the therapy. Treatment was well spaced to appreciate the timely improvement in the health of the tooth.
In general, any root resected or hemisected molar is followed by full coverage crowns forming three-unit bridge with treated tooth being in the centre.,, Maryland Bridge with lingual extension allowed minimum invasion of adjacent sound teeth to get extended support and also preservation of the adjacent dentition by preventing extensive tooth preparation.
Amid various treatment options for a periodontally compromised tooth, one is implant placement post extraction. Implant requires adequate bone support for its primary as well as long-term stability. Availability of an optimum bone level always is not feasible. However, such ridge deficiencies could be prepared for receiving implant with ridge preservation or augmentation procedures. Furthermore, such procedures are not only invasive but tremendously increase the expense of the treatment. Recent literature provides an insight to the fact that maintenance of furcation involved molars is less expensive than their substitute with dental implants and the subsequent therapies they might require in future, notwithstanding with the risk profile of the patient. When there is any consequence such as peri-implantitis, its initial and follow-up treatment further generates high cost. Therefore, a dentist must reassess the advantages regarding effortless dental extractions and implant prosthesis and procedures in order to conserve the natural dentition.
Predictability of this treatment is described in a 30-year retrospective evaluation of resected teeth and suggested this therapy to be a predictable treatment option when care is provided to each phase of treatment.
| Conclusion|| |
Case selection was the key to success of this treatment. The single-sided vertical osseous defect to the root, use of autologous platelet-rich fibrin with osseous graft, utilizing rigid splint, and minimally invasive prosthesis altogether determined the positive outcome. Regular clinical evaluation and intraoral radiographs helped us to depict pronounced difference in pre and post-therapeutic results.
The present case study suggests this distinct approach of root resection to be a successful treatment alternative for a mandibular molar with severely compromised periodontal support.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Monika Pal
Department of Periodontology, Manipal College of Dental Sciences, Manipal Academy of Higher Education, Manipal, Karnataka
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]
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