ATREVIEVY OF ROOTARESECTIVETHERAPY,ASA

TREATMENT OPTION FOR MAXILLARY MOLARS

TIMOTHY HEMPTON, D.D.S.; CATALDO LEONE,

DM.D.,

D.SC.

Restorative treatment planning is often confounded when periodontal attachment loss, caries or tooth fracture involves the furcation area of the tri-rooted maxillary molars. Although such involvement

invariably diminishes the long-term prognosis of the affected teeth, extraction is not always an option. Root resective
therapy, which removes the involved root plus its associated crown portion (trisection), is one of several treatment modalities that can be used in such cases. This article reviews the indications and contraindications for root resective therapy, describes the technique of surgical trisection and presents a case in which combined resective, endodontic and prosthetic management resulted in a successful
outcome.

ne of the most compelling challenges we face in dentistry today is treatment planning in the posterior maxilla. Multirooted teeth such as maxillary molars have root contours that greatly limit accessibility to cleaning during nonsurgical and surgical therapy.1'2 The maxillary molar usually has three roots. These roots may be divergent or fused, or they can be divergent coronally and fused apically (Figure 1). The locations of separation of the roots from the root trunk-the furcation areas-typically occur on the mesial, distal and buccal aspects of maxillary molars. Periodontal disease that extends into the furcation areas can pose significant difficulty during treatment, as can extensive caries or root fractures that involve the furcation areas. Treating any of

these problems is particularly difficult with regard to the interproximal furcation areas (mesial and distal), as the disease process and subsequent treatment could affect the periodontal attachment apparatus of the adjacent teeth. Root resective therapy can be used when attachment loss, caries or a fracture involves a furcation area of a maxillary molar. This article reviews root resective therapy and the concomitant endodontic and prosthetic management as a treatment option for maxillary molars. The indications and techniques of this treatment are presented as well as literature that reports success and failure of this treatment.
REVIEW OF RELEVANT LITERATURE

A significant number of papers have been published regarding the potential for success with root resective therapy.34 Endodontic therapy is typically performed either before or after root resection. Endodontic complications (root fractures) have been cited as a reason for eventual failure of teeth treated with root resective therapy.57 A root from a maxillary molar and the associated portion of the crown supported by that root can be removed, rather than amputating just the root as it emanates apically from the crown. Greenstein called this treatment of maxillary molars a trisection of the tooth.8 Keough reviewed the technique of removing a root and its accompanying crown portion while concurrently modifying the emergence profile of the tooth as it emanates from the osseous crest. He advocated recontouring adjacent osseous structures to reestablish

positive osseous architecture.9

JADA, Vol. 128, April 1997 449 Downloaded from jada.ada.org on September 25, 2010

~~C[INICAL PHACTIIE

LAL iLf13 L~
Figure 1. Maxillary molars can have divergent roots (A), fused roots (B) or roots that diverge coronally and fuse at the apex (C).

Modifying tooth structure in

this fashion eliminates undercuts and has been described as a "barreling in" of the root form.'0 Crown preparation of the altered tooth and prosthetic contours to allow increased access by the patient has been demonstrated by Kastenbaum."1 Carnevale and others"2 reported a success rate of 95 percent for root resective therapy using the surgical and prosthetic procedures similar to those advocated by Keough9 and Kastenbaum". Proper selection of teeth, conservative endodontic access and the design of the prosthetic treatment may have lead to the low failure rate. Determining whether the morphology of the tooth is amenable to root resective therapy is critical. An important factor is the length of the root trunk. This length can be defined as the distance between the cementoenamel junction and the opening of the furcation. A tooth with a long root trunk is less likely to have furcation involvement, as the junctional epithelium
must traverse a

longer

distance before the roots separate. Wrhen furcation involvement occurs on this tooth, however, successful resective therapy is not as predictable because the length of the remaining roots may not be long enough for support. In addition, removing one root followed by osseous resection to establish positive osseous contours would involve excessive osseous removal on the adjacent teeth. Teeth with short root trunks are more likely to have furcation involvement as the j'unctional

epithelium migrates apically.

With less distance for the

junctional epithelium to traverse,

furcation involvement is more likely. But when these teeth are treated with root resection, the prognosis is greatly

improved. Radiographs

help determine the root trunk morphology.' 13 Majzoub and Kon'14 described tooth morphology after distobuccal root resection in maxillary
can

first molars. Root removal

accomplished by using the technique described by Keough. The root was sectioned through
was

the coronal aspect of the tooth. The distobuccal root and its accompanying

portion were removed simultaneously, resulting

crown

in an elimination of all undercuts (a trisection procedure). Figure 2 shows a maxillary first molar after a trisection procedure.

One of the parameters that the authors looked at was the distance between the distal aspect of the pulp chamber floor and the most coronal aspect of the root separation. They determined that the average value for this distance was 2.7 millimeters. But only 6 percent of the teeth consistently had a distance of 3 to 4 mm.'" It is necessary to consider the advantage of surgical access and trisection through the crown, which provides proper visualization of the location of the floor of the pulp chamber, and the most coronal aspect of root separation. This information enables the practitioner to determine the feasibility of retaining the remaining portion of the tooth and providing a cast restoration. Backman"1 described four cases in which incomplete root resections w'ere performed. Continued osseous loss was observed after root amputation. The author commented that the initial surgical access may have been inadequate. In addition, he recommended a postoperative radiograph to determine the accuracy of root removal." Newell'16 examined 70 root-resected teeth and described faulty root resections in 30 percent of the teeth examined. Practitioners using the root amputation technique had left subgingival,

residual roots, furcal tips and/or ledges (Figure 3)."

450 JADA, Vol. 128, April 1997 Downloaded from jada.ada.org on September 25, 2010

CLINICAL PRACTICE
Figure 2. In a maxillary first molar, th root was removed via a trisection ani quently prepared for full coverage. D distance between the floor of the pul the fomix of the furcation. A measure for D would allow for 1 mm of margin tooth structure and 2 mm for the sup tachment apparatus (biologic width).

These subgingival structures encourage future periodontal disease because they are potentially plaque-retentive. Current thinking is that a confluence of the root to prosthetic crown contours is more beneficial; axial contours of restored teeth must be physiologically developed and emerge from the root with a zero-degree emergence profile. Flat contours that follow the root morphology are less plaque-retentive than the contours of restored teeth with a cervical bulge at the apical portion of the crown.'1720
INDICATIONS AND

CONTRAINDICATIONS FOR
ROOT RESECTIVE THERAPY

Indications. Rosenberg and colleagues" listed the following indications for root resection: - a severe osseous defect around one root with adequate osseous support on the adjacent roots (the osseous defect can be a one-, twoor three-walled infrabony lesion); - grade II or

III horizontal furcation involvement with a negligible vertical component of osseous loss on the roots to be retained; - adverse root proximity to an adjacent tooth; e distobuccal - severe caries
d was subserepresents

the that extends lp chamber and into the root ement of 3 mm

placement on and/or the furracrestal at- cation area;

- an endodontic perforation such as perforation of the pulp chamber floor or a lateral perforation of a root canal; - a root fracture that involves only one root. Contraindications. In our experience, root resective therapy should not be considered in these situations: - used roots; - unfavorable root anatomy for the remaining roots (in general, maxillary molars with short root trunks and more divergent roots have a more favorable prognosis when root resective therapy is used; teeth with long root trunks and roots in close proximity are poor candidates for root resective therapy); - excessive mobility that did not improve after initial therapy (that is, nonsurgical therapy with possible concomitant chemotherapeutic agents);

- inadequate osseous support on the remaining roots leading to a poor crown-to-root ratio; - the teeth mesial and distal to the affected tooth have large restorations that warrant cast restorations; retaining the involved molar may not be necessary if a three-unit fixed bridge can be fabricated.
TECHNIQUE FOR ROOT RESECTION OF MAXILLARY
MOLARS

Root removal. There are two ways to remove the affected root: with or without the associated crown portion. Removal of a root only, without its accompanying portion of the crown, is referred to as a root amputation." This can be done with a long fissure bur or diamond, with copious irrigation, and by amputating the root at the CEJ. This leaves the crown portion intact except for the aperture associated with the entrance of the root canal of the involved root into the pulp chamber. This area can be widened, and a restorative material such as amalgam can be placed. The reflection of a gingival flap often enhances access in root amputation procedures. "Trisection" is the term applied specifically to surgical excision of a maxillary molar root and its accompanying crown portion; the same procedure is called a "hemisection" when performed on a mandibular molar.23'24 Similar to the root amputation procedure, elevation of buccal and palatal mucoperiosteal flaps enhances access to

the involved teeth as well as to the adjacent osseous structures. A long fissure bur on a highspeed handpiece is placed along the long axis of the tooth in the area of the buccal furcation and a cut is made. This cut is chanJADA, Vol. 128, April 1997 451
Wvw ! :!y WW W :: W! W!

Downloaded from jada.ada.org on September 25, 2010

CLINICAL P RACIICE
Figure 3. After a faulty root resection, a subgingival residual furcal tip is present on this maxillary
molar.

neled toward the center of the tooth and then directed toward the interproximal furcation opening of the affected root. The cuts are made essentially over the portion of the crown that is supported by the root to be removed. When viewed occlusally, a C-shape typically appears as the cut is made. The bur is moved from the interproximal opening toward the buccal area in a back-andforth motion, and concurrently moved apically toward the furcation area. Once the bur severs the floor of the pulp chamber, the root is separated from the remaining portion of the tooth. The bur must not be extended apically to the floor of the pulp chamber to resect the underlying osseous structures. These structures are recontoured as needed after the root is removed and direct visualization is possible. The severed portion of the root can be removed with a periosteal elevator and/or a small extraction forceps. The remaining

portion of the root is barreled in to remove any ledges or undercuts, as these structures are potentially detrimental to periodontal maintenance. Osseous recontouring. When odontoplasty is completed, osseous therapy can begin. The practitioner should establish adequate soft tissue width between the restorative margin and the osseous crest and create positive osseous architecture on the tooth undergoing root resection and on the adjacent teeth. Positive osseous architecture can be described as the topographic arrangement of hard tissues where the crest of the interdental tissue (interproximal bone) is coronal to the level of the radicular osseous tissue, facially or lingually. High-speed rotary instrumentation with copious amounts of water can eliminate any osseous defects while establishing moderate parabolic contours on the proximal surfaces and flat contours in the interproximal areas. When this has been completed, the osseous crest on the proximal surfaces will be apical to the osseous crest in the interproximal areas. There will be a minimum of 3 mm from the floor of the pulp chamber to the osseous crest. Two of those millimeters allow for establishment of the supracrestal attachment apparatus, the so-called biological width, and 1 mm for placement of the crown margin. If the remaining root trunk-the distance

from the floor of the pulp chamber to the fornix of the furcationis wide enough, additional tooth structure will be obtained through osseous resection to allow for more distance between the junctional epithelial attachment and the crown margin. A minimum of at least 0.5 mm is desirable. Clearly, reflection of flaps and surgical access provide not only for proper osseous recontouring and odontoplasty but also visualization of the distance between the floor of the pulp chamber and the separation of the two remaining roots. This also allows the dentist to eliminate undercuts. Repositioning of gingival flaps. The aforementioned measurements are of great concern if prosthetic treatment is to be done using the concept of the biological width.25 If this concept is used, a minimum distance of about 2 mm is needed between the osseous crest and the proposed restorative margin. One millimeter would account for the supracrestal fibrous insertion into the cementum and the second millimeter would account for attachment of the junctional epithelium according to the average measurements reported by Gargiulo and colleagues. 26 Even though these average measurements might allow establishment of the supracrestal attachment apparatus, the restorative margin would still be in close proximity

to the junctional epithelial attachment. In theory, however, this attachment would not be violated. Certainly, an increased tooth structure would be beneficial so the restorative margin could be placed coronally to the base of the sulcus-the most coronal aspect of the junctional

epithelium.
No definitive scientific study, however, has documented the need to establish these dimensions for periodontal health. Dello Russo, in a letter to the editor of The Journal of Periodontology,27 pointed out
452 JADA, Vol. 128, April 1997

Downloaded from jada.ada.org on September 25, 2010

CLINICAL PRACTICE
Figure 4. Tooth no. 14 has a fracture on the mesial aspect that extended into the furcation area. Teeth nos. 3 and 15 had no restorations. Figure 5. Surgical exposure of tooth no. 14. The mesiobuccal root has been removed and positive osseous contours established.

that the range of values for the epithelial attachment was 0.08 to 3.72 mm, and the range for the connective tissue attachment was 0.00 to 6.52 mm in Gargiulo and colleagues' 1961 paper. Dello Russo27 questioned the extrapolations made from that article which are utilized as guidelines for performing crown lengthening procedures. If the epithelial attachment and the connective tissue attachment measurements could be as low as 0.08 mm and 0.00 mm respectively, then it is possible that "an individual patient might have a perfectly healthy periodontium with very little biologic

width."
CASE REPORT

Figure 4 shows a case in which treatment planning could involve fixed prostheses over natural teeth, implant placement or root resective therapy. The patient, 44 years old and in good health, had a fracture on the mesial aspect of tooth no. 14. This fracture extended into the furcation area, separating the mesiobuccal root from the remaining portion of the tooth. Using fixed prostheses would have meant extracting tooth no. 14, followed by fabrication of a three-unit fixed bridge. The potential distal and mesial abutments, teeth nos. 13 and 15, were unrestored, caries-free teeth. The radiograph indicated that the mesiobuccal and palatal roots were divergent and of adequate length to allow for a reasonable crown-to-root ratio after resection of the mesiobuccal root. Root resection was deemed more favorable because of the observed positive morphological characteristics of the affected tooth weighed against the preparation of the adjacent teeth or placement of an implant into bone of potentially poor quality. Figure 5 is a surgical view of the maxillary molar shown in Figure 4 (preoperative view). The mesiobuccal root has been removed and osseous recontouring performed, establishing positive osseous architecture and an adequate

distance between the floor of the pulp chamber and the crest of bone. Odontoplasty has eliminated all undercuts. After surgery, the buccal and palatal flaps were sutured at the osseous
crest. When osseous resective therapy is used and after healing is complete, the gingival contours reflect the underlying surgically created osseous contours. The coronal development (the extent of height) of the interproximal gingival tissue on the mesial aspect of the maxillary molar was reduced because of the alteration of the emergence profile of the mesial aspect of the tooth. After surgery and an adequate time for proper healing (about eight weeks), we initiated final tooth preparation (Figure 6). The outline of the root was followed and the undercuts initiated during surgery were removed in the final preparation. Root resection and final preparation removed the mesiobuccal portion of the tooth, resulting in an L-shape, or pork-chop type of appearance, when the crown preparation is viewed from the occlusal aspect. The concavity on the mesial portion of the tooth represents that part of the crown that was supported by the resected mesiobuccal root. When prepared in this fashion, the outline of the prepared tooth represents the outline of the resected tooth at the level of the epithelial attachment. We recommend a light cham-

JADA, Vol. 128, April 1997 453 Downloaded from jada.ada.org on September 25, 2010

-CLINICAL PRACTICE

Figure

6. Final preparation of tooth no. 14 (Figures 4, 5) for a full-coverage cast restoration. The crown preparation follows the contours of the remaining root structure as it emanates from the periodontium.

fer for the finish line for this preparation. This is particularly important in the area of the resection. At this location, a satisfactory amount of available tooth structure for a shoulder preparation is not always available. In addition, the tooth has now been lengthened, which causes a similar problem around the rest of the tooth outline. This light chamfer can be represented in the final cast restoration by 2 to 3 mm of metal (a metal collar). This allows us to place the porcelain at a more coronal portion where more support on the metal understructure is available. Usually, aesthetics are not a major concern in the area of the maxillary molars. Another option is an all-gold crown. The final restoration is also barreled in at the area of the root resection. The crown emerges from the gingiva for the first 2 mm at a zero-emergence profile. This eliminates the plaque-retentive contours of a crown that bulges directly into the gingival tissues as it emanates from the crown margin. The contours of this crown result in large embrasure areas; however, these areas can be cleaned easily. End-tufted brushes or proxy-brushes can be
Figure 7. A cast restoration has been placed on tooth no. 14. A large gingival embrasure area is evident on

the mesial aspect of this tooth because a cervical bulge has not been created to replace the portion of the crown that would have emanated directly from the mesiobuccal root. The crown emerges from the

used for main- periodontium with a zero-degree emergence profile, tenance. Figure following the morphology of the root structure as it
emanates from the soft tissue.

7 shows a palatal view of the final crown placed on the maxillary first molar, which was treated with a root resection. The first 2 to 3 mm of the crown are metal. A large embrasure area is present between teeth nos. 13 and 14. This embrasure area represents the emergence profile of the tooth, which gradually extends mesially to form a contact with the premolar. This restoration has functioned for about four years.
DISCUSSION

Because two of the three furcation areas associated with maxillary molars are located in interproximal areas, clinicians should recognize

that these interproximal areas can be particularly susceptible to plaque-induced inflammation. One reason for this increased risk is that patients may be less inclined to use dental floss, a highly effective technique for maintenance of this area. In addition, the gingival col apical to the contact areas has histologic characteristics that allow easier penetration of plaque components.28 The subsequent inflammatory response may initiate osseous loss, which can result in an infrabony defect. The extent of the defect may be influenced by the buccolingual dimensions of the

alveolar bone, the vascularity of the osseous tissue and the morphology of the adjacent roots. This last parameter also has significant impact on the treatment success. Concavities of adjacent roots can reduce or limit access for adequate detoxification. Once furcation involvement occurs on the mesial or distal aspects of a maxillary molar, our concern focuses not only on the involved tooth but also on the potential for periodontal deterioration on the proximal premolar or molar. Treatment options for furcation involvement include: scaling and root planing, tetracycline-impregnated fibers, open-flap clean-out, guided tissue regeneration or resective therapy. The first four options are limited by the extent of the furcation involvement, the contours of the involved roots and the morphology of the osseous de454 JADA, Vol. 128, April 1997

Downloaded from jada.ada.org on September 25, 2010

CLINICAL PRACTICE
fect. Guided-tissue regeneration has proved more predictable in the treatment of furcation areas associated with mandibular molars than with maxillary molars.25 Interproximal access may be a critical factor. Resective therapy provides improved access during both surgery and postoperative maintenance. Resective therapy includes osseous recontouring, odontoplasty, root resection and extraction. Extraction is, of

course, the ultimate resective therapy. Extracted maxillary molars can be replaced with conventional fixed bridges or implants. If the proposed abutments are unrestored, cariesfree teeth, we may use implant therapy. One variable to consider is the osseous quality of the posterior maxilla. Significant implant failure has been noted as the ratio of cancellous to cortical bone increases.30 Root resection and subsequent endodontic and prosthetic management, if carefully chosen, may be a more viable option than implant therapy or fixed prostheses utilizing unrestored, caries-free teeth as abutments. Recognizing that this treatment has a place in conventional dental therapy has been the aim of this paper.
SUMMAVflRY

Extensive periodontal, endodontic or caries involvement of maxillary molars makes the treatment decision-making process difficult because the resulting furcation exposures are difficult to manage. The technique of trisection described here illustrates one way to facilitate treatment planning of maxillary molars that have exposed furcation areas. This technique is particularly useful when the involved tooth has divergent roots, a short root trunk and an adequate distance between the separation point of the remaining roots (fornix) and the floor of the pulp chamber. Conversely,

this therapy is of little value in teeth with fused roots, long root trunks or unfavorable anatomy of the remaining roots. Proper case selection enhances therapeutic success. o