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 783

Root Resection and Hemisection Revisited. Part II:

A Retrospective Analysis of 195 Treated Patients with
Up to 40 Years of Follow-up

Jean-Marie Megarbane, DMD, CAGS, FAIDS, FICD1 Various treatment options with high
Abdel Rahman Kassir, DDS2 survival rates have been suggested
Nadim Mokbel, DDS, MSc, PhD, FICD3 throughout the years for different
Nada Naaman, DDS, PhD4 degrees of furcation involvement.1,2
In the advanced degree, resective
therapy—such as root resection/
Root resection and hemisection is a well-documented treatment option for amputation or hemisection—is a
extending the life span of furcated molars. The aim of the present study was to relatively common treatment.3,4
retrospectively evaluate the long-term results of root resection and hemisection Root amputation was originally in-
of 195 patients with up to 40 years of follow-up. Records of 195 patients who had
troduced more than 100 years ago
undergone root resection or hemisection were reviewed. A minimum follow-up of
5 years was needed. A molar was recorded as a survival if it was still present and as “radical and heroic,”5 and it con-
functional without any signs of discomfort, pain, or pathology from restorative, tinues to be an effective therapy for
endodontic, and periodontal points of view. Ninety-eight patients were excluded extending the functional life span of
for not accomplishing the minimum 5-year observation period. Of the 97 remaining treated teeth. It enhances profes-
patients, 5 teeth were lost during the first 5 years of treatment and 92 teeth sional and self-performed plaque
survived the follow-up period, ranging from 5 to 40 years. The overall survival rate
control by converting multi-rooted
was 94.8%. When up to 40 years of follow-up data were analyzed, it was found that
high survival rates can be obtained with root resection and hemisection. The results teeth into nonfurcated single-root
are satisfying when a proper case selection, endodontic treatment, restorative teeth. Thus, it delays the progres-
design, and good maintenance program are given. This treatment option sion of attachment loss around the
should always be considered before every extraction and implant placement. remaining roots.6
Int J Periodontics Restorative Dent 2018;38:783–789. doi: 10.11607/prd.3797 These days, when a deep fur-
cation involvement is diagnosed,
tooth extraction and replacement
by dental implant has unfortu-
nately become the treatment of
choice. However, the reported high
prevalence of peri-implant compli-
cations7–10 and the unpredictabil-
Professor in Periodontology, Private Practice, Masters Dental Clinic, Beirut, Lebanon.
1
ity of their treatment may lead to
Resident, Periodontology Department, Faculty of Dental Medicine, Saint-Joseph University
2

of Beirut, Beirut, Lebanon. renewed interest in periodontal re-

3Assistant Professor, Department of Periodontology, Faculty of Dental Medicine,
sective surgery.
Saint-Joseph University of Beirut, Beirut, Lebanon. Due to the literature’s wide
4Professor, Periodontology Department and Honorary Dean, Faculty of Dental Medicine,

Saint-Joseph University of Beirut, Beirut, Lebanon.

range of root resection and hemisec-
tion survival rates, and the presence
Correspondence to: Dr Jean-Marie Megarbane, Masters Dental Clinic, Al Tawfiq Building, of very few studies with adequate
Tabbara Street, P.O. Box 118285, Zarif, Beirut, Lebanon.
information on the procedure to as-
Fax: +9611737650. Email: jmmegarbane@gmail.com
sess its true reliability, a well-detailed
 ©2018 by Quintessence Publishing Co Inc. long-term study is essential.

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784
The aim of this retrospective
study was to evaluate and analyze
the long-term results of root resec-
tion and hemisection in 195 patients
with up to 40 years of follow-up.
Materials and Methods
Study Population
The data were reviewed of all pa-
tients within the last 40 years who
were treated with root resection
or hemisection and followed regu-
lar maintenance care at a private
clinic. All patients received initial
periodontal therapy, including mo-
tivation, oral hygiene instructions,
antibacterial mechanical decontami-
nation, and occlusal control if nec-
essary. Following repair evaluation,
the need and potential for receiving
a root resection/hemisection was
assessed. The record, including 195
patients (84 male and 111 female)
with a total of 176 root resections
and 19 hemisections, was reviewed.
Inclusion criteria were as follows:
(1) patients in good health with no
severe diseases that contraindicate
dental treatment; (2) a follow-up
period greater than 5 years; and
(3) radiographic residual bone level
> 50% of the length of the retained
root. A molar was recorded as a sur-
vival if it was still present and func-
tioning without any subjective signs
of discomfort, pain, or pathology
from restorative, endodontic, and
periodontal points of view.
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Endodontic Treatment
Root canal therapy was performed
by an endodontic specialist be-
fore surgery in all cases. During the
treatment, great care was taken to
preserve as much tooth structure
as possible and to avoid excessive
pressure, resulting from preparation
and obturation, on canal walls. The
root canals were sealed with gutta-
percha and cement, utilizing the lat-
eral or the vertical technique.
Surgical Technique
A full-thickness flap was raised, ac-
companied by a thorough debride-
ment. In order to not traumatize the
interradicular bony septum or the
adjacent roots, root resection or
hemisection was performed meticu-
lously with long, thin diamond burs.
To preserve the surroundings, the
damaged root was then removed us-
ing an ultrasonic device and very thin
elevators. The extraction socket was
then debrided and rinsed with saline.
The remaining root was then
checked to detect the presence
of ledges or irregular anatomy. If
present, they were corrected and
removed with diamond burs. Os-
teoplasty and/or osteotomy recon-
touring were achieved in order to
restore a favorable anatomy and/
or the 3 mm of necessary space for
the ferrule effect. The flap was then
apically positioned and sutured with
4/0 sutures. Patients were asked to
rinse with 0.12% chlorhexidine for 10
days. All surgeries were done by the
same skilled periodontist with ex-
tensive clinical experience (J.M.M.).
Restorative Phase
Various types of restorations were
performed according to each case
indication. Depending on the
amount of remaining tooth struc-
ture, a composite filling or inlay
core was used to provide adequate
build-up before placement of the
restoration. The posts were pre-
pared very conservatively in order
to avoid weakening the roots. No
threaded posts were used. Sixty-
five molars were self-sufficient and
27 molars served as abutments for
partial dentures. Knife-edge finish
lines were used in all cases, and the
teeth were restored with a ceramo-
metallic restoration. If the patient
had bruxism, a protective guard was
prescribed at the end of treatment.
Maintenance Phase
All patients were placed on a strict
4- to 6-month recall program. At
each visit, mechanical instrumen-
tation was performed and oral
hygiene was stressed. The occlu-
sion was checked and corrected if
needed in order to avoid excessive
trauma on the concerned teeth. Ad-
ditionally, the patients were asked
for updates regarding any present
health conditions.
Statistical Analyses
Statistical analyses of the data were
performed with Statistical Package
for Social Science software (SPSS
for Windows, version 22; IBM). The
risk error was set at P ≤ .05. The
 785

outcome variables of the study were

Table 1 Basic Clinical Characteristics of Patients Included in the Study
the survival rates after 40 years of
follow-up. In the initial stages, the Absent (n = 5) Present (n = 92) P
univariate analyses of categorical Age (y), mean ± SD 55.20 ± 6.611 50.60 ± 10.09 .317
and continuous variables were car- Gender
 Male 3 (7.1%) 39 (92.9%) .649
ried out using chi-square and Stu-  Female 2 (3.6%) 53 (96.4%)
dent t tests, respectively. Logistic Smokers
regression analysis was used with  Yes 4 (11.1%) 32 (88.9%) .042
 No 1 (1.6%) 60 (98.4%)
the survival rates as the dependent
Diabetes
variables. Variables that showed as-  Yes 4 (16.0%) 21 (84.0%) .015
sociations with P < .25 in univariate  No 1 (1.4%) 71 (98.6%)
analyses were candidates for the Bruxism
 Yes 4 (8.7%) 42 (91.3%) .187
multivariate model, according to the  No 1 (2.0%) 50 (98.0%)
Enter method. Logistic regression
SD = standard deviation.
analysis was performed, and the
independent variables included in
the model were diabetes, bruxism, Table 2 Survival of Resected Teeth According to Restoration Type
smokers, and type of root (mesial, (Self-Sufficient or Abutment) During a Follow-up Period
distal, or palatal). Ranging from 5 to 40 Years
Years No. of teeth (%) Self-sufficient (%) Abutment (%)
5–10 32 (35) 21 (32) 11 (40.7)
Results 10–15 21 (23) 18 (28) 3 (11.1)
15–20 11 (12) 10 (15) 1 (3.7)
In order for the root resections and 20–25 21 (23) 14 (22) 7 (26)
hemisections to be considered for 25–30 5 (5) 1 (1.5) 4 (14.8)
therapy assessment, the authors 30–35 1 (1) 1 (1.5) –
determined that patients needed 35–40 1 (1) – 1 (3.7)
a minimum follow-up of 5 years; 98 Total 92 (100) 65 (100) 27 (100)
patients treated with root resection
and hemisection were lost before
meeting this minimum. Therefore, according to their restoration type maxillary molars, distal roots were
the analysis was only done on the (self-sufficient or serving as an abut- resected more than mesial roots.
remaining 97 patients presenting 97 ment) in Table 2. For the whole sam- Though mesial and distal roots of
teeth, and the sample was divided ple, the survival rate was 94.8%. first mandibular molars had the
into two groups according to the Of the surviving molars, 80 same number of resections, mesial
presence or absence of teeth dur- were root resected (Table 3) and 12 roots were resected more than dis-
ing the follow-up period. Five teeth were hemisectioned (Table 4). All 5 tal ones in second mandibular mo-
were extracted within the first 5 failed molars were root resected. lars. Between failed and surviving
years, and 92 survived a follow-up However, no significant difference implants, no significant difference
period ranging from 5 to 40 years. between the treatment options was was found (P > .05) between the site
The rate of absent teeth was not sig- found (P > .05) (Table 5). of surgery (maxilla or mandible), nor
nificantly related to age, gender, or Maxillary and mandibular first the type of root (mesial, distal, or
bruxism (P > .05) (Table 1). molars were resected more often palatal), restoration (self-sufficient or
The numbers of survived molars than maxillary and mandibular sec- abutment), or molar (first or second)
per follow-up period are detailed ond molars. Of the root-resected (Table 5).

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786

The logistic regression model

Table 3 Number and Type of Root-Resected Molars in Function
of the systemic condition of failed
Years in function teeth showed that diabetes was
Molar teeth 5–10 10–15 15–20 20–25 25–30 30–35 35–40 Total significantly associated with survival
Maxillary first molars 13 4 1 12 2 1 1 34 rates (P = .049). Diabetic subjects
Maxillary second molars 3 5 2 2 2 0 0 14 were 9.9 times more likely to present
Mandibular first molars 9 7 1 4 1 0 0 22 failure than nondiabetic subjects.
Mandibular second 3 2 3 2 0 0 0 10 However, the authors did not find a
molars
significant association between sur-
vival rates and bruxism (P = .337),
Table 4 Number and Type of Hemisectioned Molars in Function smoking (P = .265), or type of root
Years in function (P = .465) (Table 6).
Pre- and postoperative and fol-
Molar teeth 5–10 10–15 15–20 20–25 25–30 30–35 35–40 Total
low-up clinical cases are shown from
Mandibular first molars 3 3 3 1 0 0 0 10
Mandibular second 1 0 1 0 0 0 0 2
clinical and radiographic stand-
molars points in Figs 1 to 5.

Table 5 Statistical Comparisons Between Both Groups

Discussion
Regarding Tooth Site and Type of Treatment, Root,
Restoration, and Molar
The results of this retrospective
Absent (n = 5) Present (n = 92) P
study on 97 root-resected and
Site
 Maxilla 3 (5.9%) 48 (94.1%) 1.000 hemisectioned molars demonstrate
 Mandible 2 (4.3%) 44 (95.7%) an overall survival rate of 94.8% dur-
Treatment ing a follow-up period ranging from
 Resection 5 (5.9%) 80 (94.1%) 1.000
 Hemisection 0 (0%) 12 (100.0%) 5 to 40 years.
Root The high survival rate obtained
 Mesial 1 (2.8%) 35 (97.2%) .238 in this study and by many other au-
 Distal 3 (7.3%) 38 (92.7%)
 Palatal 1 (12.5%) 7 (87.5%) thors3,11–19 proves the efficacy and
Restoration the high level of success that could
 Abutment 0 (0%) 27 (100.0%) .556 be obtained with root resection and
 Self-sufficient 3 (4.4%) 65 (95.6%)
hemisection. Some may speculate
Molar
 First 4 (5.7%) 66 (94.3%) 1.000 that unknown failures may have oc-
 Second 1 (3.7%) 26 (96.3%) curred within the large number of
excluded patients (50.5%), which
may yield a lower success rate than
Table 6 Binary Logistic Regression for Factors Associated with the
Survival Rates reported. However, including pa-
tients who have less than 5 years of
95% CI of OR
follow-up in the statistical analysis
B SE df P OR Lower Upper may introduce some inherent bias.
Bruxism 1.143 1.191 1 .337 3.135 0.304 32.367 Moreover, the minimum 5-year fol-
Diabetes 2.292 1.168 1 .049 9.896 1.003 97.610 low-up period in this study should
Smokers 1.319 1.184 1 .265 3.739 0.368 38.044
be considered beneficial, as studies
Root –0.586 0.803 1 .465 0.557 0.115 2.684
reporting a treatment efficacy with
B = beta; SE = standard error of the mean; df = degrees of freedom; OR = odds ratio; 95%
CI = 95% confidence interval. less than 5 years of follow-up should

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 787

be considered with caution when

discussing long-term results.
In this study, maxillary first mo-
lars underwent root resection more
than maxillary second molars. This is
in agreement with Klavan’s finding.12
Some authors20,21 found that a b c
the distobuccal root of first maxil-
lary molars was the most affected.
In fact, its limited accessibility dur-
ing oral hygiene care and its thin,
vulnerable interdental bony sep-
tum being in close proximity to the
d e
mesiobuccal root of the second
maxillary molar make it more eas- Fig 1  Resection of a mesiobuccal root of a maxillary right first molar. Radiographic
examination (a) preoperatively, (b) after prosthesis delivery, and (c) after 40 years. Intraoral
ily compromised.1 The authors also view at (d) prosthesis delivery and (e) the last follow-up examination.
found that more distal roots were re-
moved from maxillary first and sec-
ond molars than mesial roots.
While some authors reported
much lower success rates and a
higher incidence of fracture with dis-
tal root resection in mandibular mo-
a b c
lars,19,20 this study did not correlate
with that finding. However, the resec- Fig 2  Resection of distobuccal root of a maxillary left first molar. Radiographic examination
(a) preoperatively and (b) after 26 years. (c) Intraoral view at the last follow-up examination.
tion of the mesial root should always
be selected when both distal and
mesial roots are equally affected.
The resection of palatal roots of
maxillary molars is possible but less
common than the mesial and distal
root resections. In fact, the pala-
tal root may also be suitable as an
abutment for fixed partial dentures a b c
if the edentulous area next to the
abutment tooth is sufficient for an
acceptable prosthetic reconstruc-
tion.13,22 In the present study, six
palatal roots were resected from
maxillary first molars, five are still
surviving, and only one failed.
The question whether or not
d e
to splint resected maxillary molars
Fig 3  Resection of the palatal root of a maxillary right first molar. Radiographic
was clarified long ago in the litera-
examination (a) preoperatively, (b) after prosthesis delivery, and (c) after 32 years. Intraoral
ture.12 Splinting teeth following root view (d) after prosthesis delivery and (e) at the last follow-up examination.

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788

a b

d
Fig 4 (above)  Resection of the mesial roots of mandibular left
first and second molars for endodontic reasons (perforation).
Radiographic examination (a) preoperatively and (b) after 33
years. Intraoral view (c) after prosthesis delivery and (d) at the last
follow-up examination.

Fig 5 (right)  Hemisection of a mandibular right first molar.

Radiographic examination (a) preoperatively, (b) after 4 years,
and (c) after 25 years. c

amputation is not always necessary.
However, concerning mandibular
molars, it is still not well-defined in
the literature whether to use the re-
sected teeth as abutments for par-
tial dentures (to protect them from
occlusion) or to utilize their remain-
ing capacity to withstand forces and
leave them as self-sufficient.20 In the
present study, only two mandibular
second molars with a resected dis-
tal root were restored as premolars
and kept self-sufficient; both had a
follow-up period of 10 to 15 years
and are surviving. Considering the
low number of nonsplinted man-
dibular roots, no reliable conclusion
can be made on this subject. Each
case is different, and depending on
the ampunt of periodontal residual
structure and type of occlusion, it
is up to the clinician to decide how
to proceed: The tooth can be incor-
porated into a fixed prosthesis with
intact adjacent teeth; otherwise, the
tooth can be restored as a premolar
and left nonsplinted with a reduced
occlusal table.
The utilization of mandibular re-
sected molars as terminal abutments
for fixed partial dentures is still con-
troversial in the literature. While
some recommend their routine use
as abutments for fixed partial den-
tures,23 others do not agree.24
The empty alveolus socket of
the extracted root can be filled with
biomaterials25 in order to limit bone
resorption distal or mesial to the re-
maining root while also preserving
bone for a possible future implant
placement in that site. In fact, dental
implants were first utilized solely to
replace missing or hopeless teeth;
now, teeth that are endodontically,
periodontally, and restoratively
compromised are being removed
when they can be treated safely and

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successfully with resective or restor-
ative procedures. Moreover, im-
plants are not free of complications.
A recent consensus conference–
based systematic review revealed an
overall 5-year single implant survival
rate of 96.9%, technical complica-
tions of 11.8%, and biologic compli-
cations of 6.4%.26 In comparison, the
present study had a similar overall
survival rate (94.8%) in a follow-up
ranging from 5 to 40 years. As this
comparison refers to two separate
articles with different designs, time
lapses, and survival criteria, it was
only mentioned as a mere indica-
tive comment. If the five phases of
the root resection and hemisection
procedure (presented in a previous
article)27 are conducted properly, a
high, long-lasting survival rate can
be obtained.
Conclusions
Root resection and hemisection is
a reliable procedure and should al-
ways be considered before every
extraction. High survival rates with
very few complications can be ob-
tained over a long period of time if
proper case selection, endodontic
treatment, restorative design, and
good maintenance program are
achieved.
Acknowledgments
The authors want to express their gratitude
to Mrs Zeina Totaro for her clerical assistance
and Dr Nada El-Osta for the statistical analy-
sis. The authors reported no conflicts of in-
terest related to this study.
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