Advances in Health Sciences Research, volume 33

Proceedings of the 4th International Conference on Sustainable Innovation 2020–Health

Science and Nursing (ICoSIHSN 2020)

Bicuspidization of Necrosis Mandibular Second Molar

With Grade II Furcation Involvement
A Case Report
Maharatih Tiwi Sandjoko1 Kurnia Fitriningtyas2 Margareta Rinastiti3,* Raphael Tri Endra
Untara4
1
Student at Conservative Dentistry Specialist Program, Faculty of Dentistry (Gadjah Mada University), Yogyakarta, Indonesia
2
Student at Conservative Dentistry Specialist Program, Faculty of Dentistry (Gadjah Mada University), Yogyakarta, Indonesia
3
Lecturer at Department of Conservative Dentistry, Faculty of Dentistry (Gadjah Mada Univerity), Yogyakarta, Indonesia
4
Lecturer at Department of Conservative Dentistry, Faculty of Dentistry (Gadjah Mada University), Yogyakarta, Indonesia
*Corresponding author. Email: rinastiti@ugm.ac.id

ABSTRACT
Innovations in dental science and the higher patient expectations that appear when the periodontal disease affects the furcation
area have led to a more conservative treatment approach to save teeth. Bicuspidization is a surgical procedure performed to
separate the mesial and distal roots of molars with its crown portion, where both segments are then retained individually. This
separation eliminates the existence of a furcation and facilitates an effective oral hygiene practice. This procedure will maintain
the dentition with a hopeless periodontal prognosis. The objective was to describe the conservative management of a grade II
furcation-involved molar, with good oral and general conditions, by bicuspidization procedure. The condition of the tooth and
its supporting tissue were in accordance with the success factors of bicuspidization. A 59-year old female patient complained
about her lower molar. The clinical examination showed the necrotic pulp in tooth 47. The radiographic view showed a
radiolucency on the occlusal of teeth, spreading to the furcation area. Bicuspidization was performed to maintain the molar. The
roots were separated mesial and distal. Prefabricated fiber post was used, and the crown was restored with porcelain fused to
metal (PFM) in two smaller crown portions. This bicuspidization produces a satisfying result, as inflammation was not found,
and both the occlusion and gingiva are in normal condition. Bicuspidization may be a suitable alternative to extraction and
implant, which should be discussed with patients during the consideration of treatment options. The prognosis of the tooth with
bicuspidization depends on the supporting bone, the restoration, and the patient's oral hygiene. This case report presents the
successful bicuspidization.

Keywords: bicuspidization, furcation involvement, endodontic surgery, oral surgical procedure, mandibula molar

1. INTRODUCTION
2. CASE REPORT
Patients in modern lives expect to maintain their functional
A 59 years old female patient referred to the conservative
dentition for a lifetime. Innovation and therapies performed to
dentistry clinic at RSGM UGM Prof. Soedomo that complained
ensure retention of teeth vary in complexity. Losing
of her lower molar. She had noticed that there was a big cavity
attachment and radiographic evidence of bone loss in the
for 3,5 years. Having an ameloblastoma history on her upper
bifurcation and trifurcation areas of multi-rooted teeth referred
teeth and operated about one year ago, she also wore a partial
to as a furcation involvement with a variety of defect, i.e subtle
denture on her upper teeth. A clinical examination showed the
loss of attachment furcation area, shallow to the advanced
big and deep cavity of #47. The tooth was not sensitive to
pocket with >10 mm depth, advanced bone loss to a clinical
percussion and palpation, and the mobility was normal. The
exposure of the furcation [1]. Root canal treatment should be
tooth did not respond to the vitality test that showed a necrotic
performed in necrose teeth with Grade II or Grade III furcation
pulp. Radiograph examination showed a radiolucency on the
following by bicuspidization to preserve the teeth and
occlusal of teeth and spread to the furcation area. There was
maintain the health of surrounding tissue. Here, it is bisected
evidence of bone loss involving the furcation area, reveals a
into two parts post root canal treatment, in which those parts
Grade II furcation involvement (fig. 1).
formed to two units of single bicuspid molars that enable the
patient to hygiene the area easily [2].

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irrigated adequately with sterile saline. The single molar was

now separated into two cuspids (fig. 4).

Figure 1. (a) clinical view of 47, a necrotic pulp with a small

remaining crown; (b) radiograph shows a furcation
involvement.
As the opening access completed and working length was
determined. We performed biomechanical preparation in the
mesial and distal root with the crown down method and
irrigated with NaOCl 2,5% and normal saline. It is filled with
Ca(OH)2 for two weeks. On the next visit, we cleaned the
canal, and we master cone fitting was confirmed with a
radiograph. The canal was obtruded with a single cone Figure 4. (a) an incision made; (b) an envelope flap was
method, and we took the radiograph to make sure that the canal performed start form 46 to distal of 47; (c)vertical cut was
was filled with hermetic form (fig. 2). A week later, post length made with a long shank fissure diamond bur; (d) the separated
was determined, then a prefabricated fiber post was inserted, teeth was observed with a probe.
and it built a core (fig. 3).
After the tooth was successfully separated, the Flap was
repositioned and sutured. The periodontal pack was used to
protect the operation wound. A dose of antibiotic, analgesic
and anti-inflammation were given, then some post operated
instructions were explained (fig. 5)

Figure 2. (a) Master cone fitting was confirmed with

radiograph; (b) The canal filled with a hermetic result.

Figure 5. (a) the tooth has separated into two smaller parts,
mesial and distal; (b) periodontal pack was used to cover the
wound.
Figure 3. (a) insertion of the prefabricated post; (b) radiograph
A week later, the patient came to have the follow-up of her
of the post fit inserted into the canal.
tooth. All conditions were good, and the patient had no
The following week, we planned a surgical procedure with complaints. Then two weeks after surgery, the dissected
bicuspidization technique. Under local anesthesia, the full- portions were prepared for porcelain fuse to metal crown
thickness flap was reflected with an envelope flap formed from restorations, and a temporary crown crowned each part of the
the first premolar to the second molar. A vertical cut method tooth. After a week, the temporary crowns were removed, then
was used to separate the crown of 47. A long shank straight two premolars porcelain fused to the metal crown were
fissure diamond bur was used to make a vertical cut towards cemented. The patient had been followed a week later (fig. 6).
the bifurcation area. Curettage was performed to remove
chronic inflammatory tissues, and the working area was

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probe penetrates three millimeters or more from the entrance

of the furcation, but there is no total attachment loss with a
through and through the opening of the furcation. Class III is
total horizontal attachment loss with a through and through
opening the furcation. The inter-radicular bone is completely
absent [6]. In this case report, furcation involvement in
necrosis tooth 47 and partial loss of horizontal support in the
furcation area confirmed the classification of Grade II
furcation involvement.
Bicuspidization was usually performed in Grade II and III
furcation involvement of mandibular molar, with the purposes
to remove the irritants under the fornix and to get two single-
rooted teeth crowned as premolar [7]. In literal meaning,
bicuspidization or a molar bisection is splitting the mandibular
molar vertically through the furcation without removing both
halves and leaving two separate roots, where both segments
are then retained individually and treated as bicuspids [5]. It
differs from hemisection, where separation is made between
two roots, then a root and the associated portion of the crown
Figure 6. (a) separated tooth was confirmed with are removed. The treatment was preserved to maintain a
radiograph; (b) the clinical view of the mesial and distal parts; portion of a diseased or injured molar by removing one or
(c) two premolar crowns were well cemented; (d) radiograph more of its roots [8][14]. If dental caries are limited to one root,
confirmed the crowns. a hemisection procedure can be performed. Yet, in the present
case, the roots have inaccessibility to maintain the procedure
3. DISCUSSION [9], as in this case, the mesial and distal roots are
endodontically treatable [10]. Hence, the bicuspidization
Clinical examination found that the patient had a pulp method seemed to be the most applicable option [1].
necrose on her 47 teeth, which was initiated by the large cavity Molar with periodontally compromised and furcation
proximal area there. The growth conditions need to be optimal involvement comprises a more inferior survival rate compared
in order to develop a cariogenic biofilm below the to single-rooted one. That condition required higher effort and
interproximal contact point, i.e., from enamel extent to dentin. more complex treatment [11]. Various respective procedures
This ends at the pulpal inducing pulp necrosis following the include root amputation, hemisection, and bicuspidization. As
loss of circulation, and then the infecting organisms would the clinical and radiographic parameters were satisfactory
occupy the whole pulp space [3]. When the microorganism (wide roots with adequate separation and periodontal support
extends to the supporting tissue, it reduces the healing ability and moderate bone support around individual roots),
to deal with the inflammation. Meanwhile, pulp infection can bicuspidization was planned for the patient [12]. Endodontic
spread through the lateral and accessory canals of apical surgery was performed, started with an envelope flap to open
foramina. This may cause a furcation breakdown and the buccal area. It is the technique for separating the crown of
infrabony pocket, which conditions require combined therapy the tooth in bicuspidization because of some advantages such
for healing [4]. This article describes the procedure for as less scary, easy, and fast with low morbidity [13] [14].
bicuspidization at the mandibular molar under conditions that
support the success factors of bicuspidization [1]. Farshchian and Kaiser (1998) revealed that where adequate
bone support around furcation involved molars, the success
That loss of attachment on horizontal probing and bone rate chances would be higher. The success of bicuspidization
loss in the furcation area result in furcation involvement, depends on three factors. First, the stability and adequate bone
which would prevent individual access to maintain hygiene in support for the individual tooth sections. Second, the absence
the molar area and facilitate professional debridement of roots. of severe root fluting of furcation and septum area. Finally,
Furcation invasion is the most commonly seen phenomenon in adequate separation of mesial and distal roots creates an
relation to mandibular molars. Access to the molars furcation acceptable embrasure for effective oral hygiene. Various
areas is difficult for the patient and clinician because of the studies suggested that this condition can be kept in a healthy
posterior location of molars, the dimension and portion of state for up to 3-7 years [1][2]. Those conditions are suitable
furcation entrances, and the internal furcation surface that are to the present case as there is no root fluting and has stable
frequently concave or irregularly contoured [5]. Furcation adequate bone support. Newell (1991) suggested that the
involvements are divided into three disparate groups as advantage of bicuspidization is tooth retention. Meanwhile,
follows. Class I: incipient lesion. There is a slightly horizontal the disadvantage appears to be the need for root canal
attachment loss in the furcation area. The examiner probe treatment prior to the procedure. Failure in a root canal
penetrates two millimeters or fewer from the entrance of the procedure can also lead to an entire procedure failure [2].
furcation. Class II: partial horizontal bone loss. The examiner

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bicuspidization depends on the supporting bone, the

restoration, and the oral hygiene of the patient. This case report
presents the successful bicuspidization.

AUTHORS’ CONTRIBUTIONS
MTS wrote the paper, TK performed the treatment, and the
details of the case, MR and TER supervised, drafted, and did
the critical revision of the article. All authors read and
approved the final manuscript.

ACKNOWLEDGMENTS
Foremost, we would like to express our gratitude to the
Conservative Dentistry Department of Gadjah Mada
Figure 7. a week after the cementation as an initial assessment University to provide our general support to write this case
of early healing, good gingiva and good occlusion shown up, report. Our sincere gratitude also goes to Muhammadiyah
and the crowns have an excellent marginal adaptation University for the proceeding. The authors also thank the
patient for giving permission for publishing this report.
There are several other disadvantages associated with
bicuspidization, i.e., pain, anxiety, and resistance from lateral
excursive forces. To avoid periodontal destruction, a proper
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