Ashman Department of Periodontology and Implant Dentistry, New York University College of Dentistry, New York, NY, USA
Periodontitis is a chronic inflammatory condition that results in the loss of the periodontal attachment apparatus, namely, alveolar bone, cementum, and periodontal ligament. Traditional treatment modalities to manage this condition include, but are not limited to, non‐surgical periodontal debridement, various pharmacotherapeutic agents, and resective and regenerative surgical procedures. It may also involve dentoalveolar extractions, with or without alveolar ridge preservation, in preparation for a subsequent implant‐restoration.
Multirooted teeth often present with complex anatomical features that not only contribute to the initiation and progression of periodontal disease, but also complicate periodontal treatment and inhibit adequate patient homecare (DeSanctis and Murphy 2000; Al‐Shammari et al. 2001). In their long term tooth retention study, Hirschfeld and Wasserman (1978) reported that the maxillary first and second molars are the teeth most frequently lost in the mouth. It is not a coincidence that once a tooth becomes furcally involved, the treatment becomes more complex, and the prognosis decreases. However, this is in contrast to the study by Ross and Thompson (1980), which concluded many molars with furcation involvement functioned well from 5 to 24 years and suggested that their prognosis and treatment be reconsidered. They emphasized that treatment did not include any root amputation, hemisection, osseous surgery, odontoplasty, osteoplasty, or ostectomy (Figure 10.1).
Treatment of furcation involved teeth is often dictated by the degree of furcation involvement. Root amputation was first introduced by Farrar (1884) as a “radical and heroic” treatment alternative for classes II and III furcation involved molars. Over the next century, root resection has developed into a fundamental part of the periodontal armamentarium for the treatment of furcally involved multi‐rooted teeth. However, with the advent and high success rates of dental implants, the trend in treatment selection for multi‐rooted teeth with severe furcation involvement has shifted away from one of tooth preservation towards that of extraction with subsequent implant placement and restoration. Nevertheless, the periodontist, whose primary goal is to diagnose and treat periodontal disease and maintain teeth in form and function when possible, should not disregard root resection as a viable treatment alternative when indicated (Figures 10.1 and 10.2).
Inconsistent usage of the terms root resection, root amputation, hemisection, and root separation can be found throughout the literature. Nevertheless, Shillingburg et al. (1997) has adopted the following terminology:
- Root amputation is defined as the surgical removal of one or more root(s) of a multi‐rooted tooth, at the level of the cementoenamel junction, without the removal of the overhanging portion of the crown.
- Root resection is defined as the complete or partial surgical removal of a tooth root. Root resection is distinguished from root amputation in that the former provides no information regarding the crown of the root.
- Hemisection is defined as the surgical separation of a multi‐rooted tooth (generally a mandibular molar), through the furcation thus permitting the subsequent removal of both the crown and root of the sectioned tooth as one entity.
- Root separation is defined as the surgical separation through a crown and root of a multi‐rooted tooth without the subsequent removal of either half.
Indications and Contraindications
The indications and contraindications for root resection were first outlined by Basaraba (1969). Later, Minsk and Polson (2006) proposed inclusion of teeth with high strategic value as an additional indication. This is of particular importance when related to sites that are unable to receive implants (Figure 10.3).
- Isolated areas of severe bone loss involving an individual root
- Fractured root
- Failure of endodontic therapy or inoperable/calcified canals
- Bone resorption involving the furcation of multi‐rooted teeth
- Close interdental root proximity making plaque control impossible
- Extensive root exposure contraindicating new attachment procedures
- Root or furcation perforation
- Root resorption (internal and/or external)
- Extensive caries in the furcation/roots
- Advanced bone loss and secondary occlusal trauma
- Individual roots fused or in close proximity
- Remaining root cannot be restored and/or endodontically treated
- Poor root form or length of retained roots
- Apical location of furcation area resulting in severely compromised bone support of remaining root(s)
- Inability to create a good post‐surgical mucogingival environment with an adequate zone of attached gingiva and vestibular depth
- Evidence of poor oral hygiene
- When interdisciplinary therapy (endodontics, periodontics, restorative) is not possible due to patient’s finances or medical history (Figure 10.4).
Advantages and Disadvantages
As clinicians, it’s important to highlight the advantages and disadvantages for our patients so that they may make the best informed decision, based on our understanding of the evidence‐based literature. Some advantages of root resective procedures may include, but are not limited to, (i) preservation of the alveolar ridge by retaining the tooth in the alveolus, (ii) financial and psychological aspects of maintaining a natural tooth, (iii) when teeth are in proximity of anatomic landmarks which prevent more invasive surgical therapies, and (iv) avoiding extensive rehabilitative and reconstructive procedures (i.e. Caldwell‐Luc sinus augmentation, ridge augmentation, etc.).
One must also consider the various disadvantages, including but are not limited to (i) technique sensitive procedure which requires extensive surgical experience and skill, (ii) financial: price of endodontic, periodontic, and prosthetic treatment versus extraction and implant, and (iii) risk that procedure may ultimately fail and result in extraction.
- • Basic periodontal surgical kit:
- ○ Mirrors
- ○ Periodontal probe
- ○ Nabers probe
- ○ College pliers
- ○ Scalpel handles
- ○ Orban 1/2 knife
- ○ Chisels (i.e. Rhodes back‐action, TGO)
- ○ Aspirating syringe
- ○ Iris scissors
- ○ Elevators (i.e. Buser, Prichard)
- ○ Curettes (i.e. Gracey, Prichard 1/2, Lucas 87 DE)
- ○ Files (i.e. Sugarman, Hirschfeld)
- ○ Stainless steel bowl
- ○ Sterile saline
- ○ Tissue forceps
- ○ Curved hemostat
- ○ Needle holder
- • Rotary instrumentation:
- ○ High speed handpiece
- ○ Surgical length fissure cut carbide burs (for root resection)
- ○ Diamond rotary burs (for root resection and/or recontouring)