Furcation defects have presented a major challenge to endodontists because of their unique anatomical characteristics and their variable response to treatment. (1) Losing posterior teeth leads to tooth migration, loss of masticatory function, and reduction in arch length. (2)Root resection is the process by which one of the roots of a tooth is removed at the level of the furcation, presenting with an opportunity to remove the infected part, and preserve the relatively healthy portion of the tooth, while maintaining its integrity within the socket .(3) Hemisection is a conservative treatment modality which integrates principles from prosthodontics, oral surgery, endodontics, periodontics, and restorative dentistry (4).

In hemisection a multi-rooted tooth undergoes surgery in which the healthy section of the crown and its associated root are left in place at the level of the furcation, retaining the tooth's integrity within the socket. One-half of the crown and the associated unrestorable root are also removed. The most important consideration

in such instances is that it needs a comprehensive pre-operative multi-disciplinary assessment during case selection ⁽⁵⁾.

According to Weine(6) Periodontal Indications for hemisection :

Severe vertical bone loss involving only one root of multi-rooted teeth.  through and through furcation involvement.

Unfavourable proximity of roots of adjacent teeth, preventing adequate hygiene maintenance.

Severe root exposure due to dehiscence.

Endodontic and Restorative Indications for hemisection:

1. Prosthetic failure of abutments within a splint: If a single or multiple-rooted tooth is periodontally affected within a fixed bridge, the root of the concerned tooth is excised in place of removing the complete bridge if the remaining abutment support is adequate.
2. Endodontic failure: Hemisection is helpful when a pulp chamber's floor or a root's pulp canal of a tooth with endodontic involvement has been perforated and cannot be instrumented.
3. Vertical fracture of a single root: Hemisection can be performed if a vertical fracture crosses one root but leaves the other root undamaged.
4. Extremely destructed tooth structure either due to endodontic therapy, trauma, significant root perforation, furcation, or subgingival

A 34-year-old woman reported to the Department of Endodontics with the chief complaint of food impaction in her lower right back tooth area for the past 1 months. The patient gives history of endodontic treatment done 7 years back with the same tooth and dislodged crown 1 month back. She had no significant medical or dental history.

On clinical examination a   periodontal pocket measuring 7-8mm was detected on the buccal and distal surfaces of the right mandibular second molar (47), along with grade-II furcation involvement, without mobility. The tooth had a positive response to horizontal percussion.

Radiographic examination revealed evidence of root caries extending sub gingivally at the distal root and a distinct radiolucency in the furcation region with vertical bone loss involving the distal root. The extent of decay rendered the tooth non-restorable on the distal aspect, leading to a diagnosis of previously endodontically treated tooth with root caries.

The patient was informed about the treatment plan, and her written informed consent was acquired. The treatment options discussed with the patient were

1. Extraction followed by implant
2. Extraction followed by bridge prosthesis
3. Hemisection followed by crown prosthesis.

Procedure: Before starting the surgical procedure, oral prophylaxis was carried out. A crevicular incision was made from the second premolar to the second molar, and a full-thickness flap was reflected under local anaesthesia. The crown was resected using the vertical cut technique. A carbide bur with a tapered shank was utilized to create a vertical cut in the direction of the bifurcation area. The distal hemisected portion of tooth number 47 was removed using mandibular molar forceps.

After the sectioning, clearance of the extraction socket was verified by using a periapical radiograph. The socket was irrigated adequately with sterile saline to remove bony chips and amalgam debris.  The furcation area was trimmed to ensure that no spicules were present to cause further periodontal irritation.   Platelet-rich fibrin (PRF) obtained from patient's blood was placed in the extracted root socket to facilitate better healing . Following this, suturing was done using a 3-0 Vicryl suture using a figure of 8 technique.

The patient was recalled after one week for follow-up. The patient was recalled again after three months for follow-up. During this visit, the healing of the extraction socket was analyzed.

The patient was then advised for prosthetic rehabilitation. At 6-month recall, adequate healing of the extraction socket associated with the distal root of 47 was observed in the radiograph. However, the periapical region associated with the mesial root of tooth number 47 displayed a healing lesion.

During the prosthetic phase of treatment occlusal contacts were reduced in size and repositioned more favourably A full metal bridge was.  Lateral forces were reduced by making cuspal inclines less steep and eliminating balancing incline contacts.

Outcome and Follow-up:The patient was followed up at 1 and 2 years. Radiographs showed healing of the periapical area and stable bone around the retained root. The patient reported normal function and no symptoms.

Molars demonstrate the highest rate of periodontal destruction in untreated disease and suffer the highest frequency of loss for periodontal reasons ^(7). Several lines of evidence indicate that teeth with furcation involvements are at higher risk for periodontal disease progression and tooth loss during periodontal recal^(8). Root amputation, hemi-section, radisection and bisection/ bicuspidization are various resection procedures for treatment of furcation defects which cannot be retained by regenerative procedures. ^(9,10)

The long-term viability of a resected molar depends on a variety of related factors, including the surgical process, the periodontal health of the tooth, anatomy of the root, maintenance therapy, endodontic and restorative treatment^{. [,11,12]} Before deciding to undertake any of the resection procedures the following factors should be considered:

1. Advanced bone loss around one root with acceptable level of bone around the remaining roots.
2. Angulation and position of the tooth in the arch. A molar that is buccally, lingually, mesially or distally titled, cannot be respected.
3. Divergence of the roots -teeth with divergent roots are easier to resect. Closely approximated or fused roots are poor candidates.
4. Length and curvature of roots -long and straight roots are more favourable for resection than short, conical roots.
5. Feasibility of endodontics and restorative dentistry in the root/roots to be retained.

If all of these requirements are met, hemisection is a feasible treatment option compared to extraction and replacement of tooth. ⁽¹³⁾ Several factors, include an unsatisfactory restoration with poor margins, an improperly established occlusal contact points that could transform favourable stresses into detrimental stresses ^(14,15,16). According to a study by Carnevale et al. found the overall survival rate of cases where hemisection was performed for the management of molars with furcation involvement was roughly 93% after a 10 year follow-up ^{.( 17)}

To minimize the occlusal forces on resected tooth, the occlusal table is reduced. Since, the hygienic pontic is the ideal design for posterior area a three unit fixed partial denture (FPD) covering the sectioned molar and second was given as the final prosthetic replacement. ⁽¹⁸⁾ Basten et al found that 92% of all hemisected molars sustained over a period of 12 years, with failures attributed to recurrence of caries, endodontic and strategic issues. ⁽¹⁹⁾

When compared to the success rate of the surgical endodontics in endodontic– periodontal combined lesions the success rate is very low.⁽²⁰⁾ Failure rate ranges from 25% to 38%. Failure rates of root-resected molars range from 25% ^(20,21) to 38%⁽²²⁾ .However, use of PRF in resected areas has better prognosis of the tooth.

Platelets being trapped in fibrin network keep the growth factors contained within this three-dimensional PRF mesh followed by the slow and gradual release of growth factors over time. Thus PRF contributes to enhanced healing provided by various growth factors which successively reduces alveolar bone loss after extraction and suppresses periodontal problems. Hence making PRF a ‘wonder material’ in advanced surgical dentistry.

The various growth factors released from PRF includes transforming growth factor beta-1 (TGF-β1), Platelet derived growth factor (PDGF), vascular endothelial growth factor (VEGF), epidermal growth factor (EGF), and insulin- like growth factor (IGF). TGF and VEGF plays major role in wound healing and neogenesis.

TGF is also crucial during bone formation contributing to osteoblast precursors in chemotaxis and stimulates osteoblast deposition of mineralized tissue on the bone collagen matrix. PDGF helps in cell production and collagen formation. EGF regulates epithelial cell growth and angiogenesis, whereas IGF regulates cell growth. ^(23).

The current case report demonstrates the use of a multidisciplinary treatment approach for the management of partially destructed molars. Factors such as the health of the periodontium, restorative treatment strategy, prosthetic considerations, and patient compliance to maintain oral hygiene play a key role in determining the success of hemisection procedures. The prognosis for root resection is the same as for routine endodontic procedures provided that case selection, the endodontic therapy  has been performed adequately and the restoration is of an acceptable design relative to the occlusal and periodontal needs of the patient. Placement of PRF post operatively gives a better prognosis for the affected tooth. If appropriate case selection is put into consideration, the success rates of hemisection are high and outcomes are predictable in compromised molars

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