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CASE REPORT
Year : 2020  |  Volume : 10  |  Issue : 1  |  Page : 61-64

Hemisection with platelet rich fibrin: A novel approach


Department of Conservative Dentistry and Endodontics, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission30-Jan-2019
Date of Decision15-Feb-2019
Date of Acceptance10-Mar-2019
Date of Web Publication27-Dec-2019

Correspondence Address:
Prof. Promila Verma
Department of Conservative Dentistry and Endodontics, King George's Medical University, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sej.sej_19_19

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  Abstract 

Since time immemorial, endodontics have proved to be an ultimate tooth savior. Hemisection is a conservative procedure where a part of hopeless multi-rooted teeth, with better retention, is preserved rather than saving the tooth as a whole. But with time, the extraction socket shows alveolar ridge resorption thus complicating the prosthetic procedure. Thus, a new technique of socket preservation evolved preventing such dimensional changes in postextraction socket. This case report shows grossly carious first and second mandibular left molar with furcation involvement in the second molar of a healthy 25-year-old male patient. Following endodontic treatment and hemisection, autologous platelet-rich fibrin was placed in the extraction socket, and the patient was followed at 1, 3, 6, and 12 months for hard- and soft-tissue evaluation, clinically and radiographically. The fixed prosthesis was placed at the end of 3rd month. Radiographs at 6th and 12th months showed little resorptive changes with better healing, occlusion, and function clinically.

Keywords: Alveolar ridge resorption, hemisection, platelet-rich fibrin, socket preservation


How to cite this article:
Gupta S, Tikku AP, Verma P, Bharti R. Hemisection with platelet rich fibrin: A novel approach. Saudi Endod J 2020;10:61-4

How to cite this URL:
Gupta S, Tikku AP, Verma P, Bharti R. Hemisection with platelet rich fibrin: A novel approach. Saudi Endod J [serial online] 2020 [cited 2020 Apr 9];10:61-4. Available from: http://www.saudiendodj.com/text.asp?2020/10/1/61/274186


  Introduction Top


The evolution of recent advancement and strategies has shown various ways to save a hopeless tooth. However, in the past, the only treatment option for such a tooth was extraction, but this radical treatment option has now been undertaken by more conservative options such as root amputation, hemisection, and bicuspidization in an attempt to rehabilitate functional occlusion rather than compromising it.[1] Although hemisection preserves a healthy part of a tooth over a compromised and diseased part, it also forms an extraction socket which conventionally is left to heal without any intervention, as a result, postextraction changes continues leading to the dimensional loss of horizontal and vertical height of residual alveolar ridge, thus complicating further treatment, for example, implant placement. Socket preservation with biomaterials prevents such kind of bone loss and helps in early and predictable healing.[2] In this context, the Choukroun's platelet-rich fibrin (PRF), a second-generation platelet-rich concentrate has proved to be a double-edged sword in the field of dentistry, majorly focusing on the improved and early bone regeneration and soft-tissue healing, due to the presence of various growth factors and cytokines.[3]


  Case Report Top


A 25-year-old male patient reported with a chief complaint of pain in the lower left back tooth region for 1 month. The pain was mild which aggravated on mastication. Intraoral examination revealed deep caries in relation to lower left first (#36) and second (#37) molar teeth with extensive decay of the mesial part of #37 [Figure 1]a. The teeth were tender on percussion and responded negatively to thermal tests and electric pulp tests. The radiographic examination revealed carious involvement of the furcation in respect to #37 [Figure 1]b. The patient was informed about the poor prognosis of #37 and hence, extraction followed by implant was suggested. Moreover, owing to the long time and higher treatment cost for implant, the patient opted for hemisection. Thus, root canal treatment was planned for #36 and #37 along with hemisection of mesial root of #37 with postextraction socket preservation with autologous PRF. The patient was advised for blood tests before extraction, including total leukocyte count, differential leukocyte count, computed tomography (CT), blood transfusion, Hepatitis B surface antigen, HIV, hemoglobin%, and blood sugar. The treatment was commenced as the values were in normal range and the patient was medically fit. A provisional diagnosis of pulpal necrosis with symptomatic apical periodontitis was made in relation to tooth #36 and #37.
Figure 1: (a) Preoperative intra-oral picture depicting extensively decayed mesial part of the second molar. (b) Preoperative radiograph showing furcation involvement of the second molar. (c) Hemisectioning of mandibular second molar. (d) Immediate postoperative radiograph. (e) Platelet-rich fibrin clot. (f) Placement of platelet-rich fibrin into the socket

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Treatment

Under local anesthesia and complete rubber dam isolation, endodontic access cavity was prepared in #36 and #37 with no #2 round diamond bur (Endo Access Bur, DENTSPLY Maillefer). The internal axial walls were refined with safe tip fissure carbide bur (Endo-Z Bur, DENTSPLY Maillefer), and canals were explored using 10 k-file (Mani, Inc., Tochigi, Japan). Patency was maintained and working length was established by radiographic method. Biomechanical preparation was done using crown-down technique with rotary ProTaper Next files till F2 (Dentsply Maillefer, Ballaigues, Switzerland). Copious irrigation with 3% sodium hypochlorite, 17% ethylenediaminetetraacetic acid for 1 min, and normal saline was done, and finally, canals were obturated with corresponding gutta–percha cones and AH-Plus sealer (Dentsply Maillefer, Ballaigues, Switzerland).

In next sitting under local anesthesia, crevicular incisions were given from second premolar (#35) to #37 followed by the reflection of a envelop flap to expose the area of hemisection. At slow speed, long shank-tapered fissure carbide bur was used to make vertical cut buccolingually up to the bifurcation area [Figure 1]c. Periodontal probe was used to confirm the complete separation. After this, the mesial part of tooth #37 was extracted as atraumatically as possible followed by an intraoral periapical radiograph [Figure 1]d.

Preparation of the platelet-rich fibrin

A volume of 10 mL of the patient's blood was collected by puncturing the antecubital vein. The blood sample obtained was transferred in a test tube and was centrifuged (REMI model R-8C with 12 mL × 15 mL swing out head) at 3000 revolutions per minute for 10 min. After centrifugation, three layers were naturally formed in the tube: platelet-poor plasma at the surface, PRF clot in the middle, and red blood cells at the bottom.[4] Sterile tweezers were used to gently grab and remove the fibrin clot out of the test tube. Using a pair of sterile scissors, the clot was cut to an appropriate size [Figure 1]e and placed into the extraction socket such that the cavity is completely filled with it [Figure 1]f.

The flap was repositioned and sutured [Figure 2]a. Postextraction instructions were given to the patient. Antibiotics and analgesics were prescribed for 1 week. Sutures were removed after 7 days. Two-unit fixed prosthesis was planned once complete healing of the extraction socket was evident and finally cemented [Figure 2]b. Clinical and radiographic follow-up was done at 1, 3, 6, and 12 months [Figure 2]c, [Figure 2]d, [Figure 2]e, [Figure 2]f for the evaluation of the occlusion and functionality.
Figure 2: (a) Suture placement. (b) Prosthesis after 3 months, (c) Follow-up radiographs at 1 month, (d) At 3 months. (e) At 6 months, (f) At 12 months radiopaque areas and arrows showing well-formed cortical plates with minimal resorption of hard and soft tissues, respectively

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Outcome and follow-up

Clinically at the 7th day, the patient reported with a well-approximated postextraction socket with no pain, swelling, and inflammation with normal oral function in the postextraction period. There was no halitosis and food lodgment due to the presence of biological barrier in the form of PRF in the socket. Radiographs were taken at the end of 1st and 3rd months, which showed similar bone level with minimum hard- and soft-tissue resorption. Thus, a 2-unit (porcelain fused to metal) bridge was planned in relation to tooth #36 and #37 as per Ante's Law (“the total pericemental area of the abutment teeth must be equal or exceed that of the teeth to be replaced”). At the end of 6th and 12th months, radiographs showed little resorptive changes with better occlusion and function clinically. The arrows in [Figure 2]c and [Figure 2]d show the soft-tissue contouring over the socket, while the bony height can be well appreciated by the radiopaque area of the socket.


  Discussion Top


Extraction of posterior teeth is associated with detrimental oral health including loss of arch length by shifting of teeth, collapse of the vertical dimension of occlusion, supraeruption of opposing teeth, loss of supporting hard/soft tissues, and a decrease in functionality. However, hemisection can be a hope for such grossly carious tooth by preserving the healthy part over the compromised part. In the present case, all the possible treatment options were explained to the patient with their pros and cons, but due to the financial status of the patient, he opted for hemisection over implant owing to its longer treatment time, higher cost, and a more extensive surgical procedure. Moreover, the patient was adamant to preserve his natural teeth. However, the patient was convinced that hemisection can be a provisional treatment option till a more definite implant treatment can be afforded in the near future.

Mokbel et al. systematically reviewed various root resection (RR) and hemisection studies and concluded that the survival rates in RR and hemisection cases were >90% with a follow-up of 5–23 years and emphasized that since RR and hemisection are associated with high survival rates and they should be considered as a viable treatment option for furcated and cariously involved teeth before extraction or implant placement.[5] Yuh et al. in their retrospective study reported a survival rate of 91.1% and failure of 8.9% over 1–3 years in RR cases. Failure occurred in higher age group patients (>74 years).[6] In a similar study, Park et al. reported that 70.2% survival and 29.8% failure over 10 years due to periodontal reasons.[7]

The higher success rates were attributed to better case selection criteria for hemisection including better periodontal support, no mobility, lesser age group, conservative approach to endodontic treatment, atraumatic surgical extraction, and better restorative and maintenance phase.[8] However, separate studies by Lee et al. and Langer et al. showed a failure of 59.7% and 38%, respectively, over a period of 10 years. The reasons being poor periodontal status and root fracture, respectively.[9],[10]

Furthermore, in the present case report, the efficiency of PRF in healing of the sockets cannot be overlooked. Avila-Ortiz et al. showed that alveolar ridge preservation with socket grafting significantly reduced the three-dimensional bone loss when compared to control.[11] Specifically in another similar study, PRF-filled sockets showed enhanced soft-tissue healing, increased rate with better quality of bone formation owing to its good osteogenic ability.[12]

Postextraction wound healing is a complex biological process that shows dimensional loss owing to the hard- and soft-tissue resorption which is highly marked in the first 3 months and decreases gradually thereafter.[5] Thus, in the presented case, the prosthesis was planned at the end of 3rd month.

Socket preservation with autologous PRF was chosen over other biomaterial as PRF contains a high concentration of nonactivated, functional, intact platelets enmeshed in a fibrin matrix, a key component affecting the initial phases of regeneration, especially during hemostasis and fibrin clot formation, it stimulates human osteoblastic proliferation and neoangiogenesis.[9] It releases a vast number of growth factors to the surrounding microenvironment favoring soft- and hard-tissue healing, including platelet-derived growth factors (PDGF-AA, PDGF-AB, and PDGF-BB), transforming growth factor-beta, vascular endothelial growth factor, and matrix glycoproteins (such as thrombospondin-1), having specific roles in tissue regeneration.[10] Hauser et al. showed that PRF-placed sockets showed 0.48% of alveolar ridge resorption as compared to 3.68% in the control group at 8 weeks. Moreover, the micro-CT showed the significantly better microarchitecture and higher bone fill.[13]

Jiing et al. showed that micro-CT of PRF-placed socket showed better and early healing.[14] Therefore, in the present case report, autologous PRF was considered over other bone grafts materials for the preservation of socket and early and enhanced healing of extraction defect.

The presented case showed enhanced wound healing with lesser postextraction complication in early weeks. Thus keeping in mind, all the necessary requirements for hemisection, the predictability of the treatment can be increased.


  Conclusion Top


Regeneration, preservation, and prevention of hard- and soft-tissue atrophy due to extraction can help in supporting the prosthetic load or may be an implant in near future by utilizing the principles of osteogenesis, osteoinduction, and osteoconduction. Moreover, PRF is economical and shows no antigenicity with least chances of cross infection. Further, PRF can be combined with several other biomaterials, thereby further enhancing the clinical outcome in the long run.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Bhuyan D, Shah N, Mathew S, George JV, Parvekar P. Thinking beyond extraction: Hemisection with PRF as an alternative treatment option. Inst Integr Omics Appl Biotechnol J 2016;7:82-7.  Back to cited text no. 1
    
2.
Alzahrani AA, Murriky A, Shafik S. Influence of platelet rich fibrin on post-extraction socket healing: A clinical and radiographic study. Saudi Dent J 2017;29:149-55.  Back to cited text no. 2
    
3.
Dohan DM, Choukroun J, Diss A, Dohan SL, Dohan AJ, Mouhyi J, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part I: Technological concepts and evolution. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e37-44.  Back to cited text no. 3
    
4.
Sharma S, Mittal N. A comparative evaluation of natural and artificial scaffolds in regenerative endodontics: A clinical study. Saudi Endod J 2016;6:9-15.  Back to cited text no. 4
  [Full text]  
5.
Mokbel N, Kassir AR, Naaman N, Megarbane JM. Root resection and hemisection revisited. Part I: A systematic review. Int J Periodontics Restorative Dent 2019;39:e11-31.  Back to cited text no. 5
    
6.
Yuh DY, Cheng GL, Chien WC, Chung CH, Lin FG, Shieh YS, et al. Factors affecting treatment decisions and outcomes of root-resected molars: A nationwide study. J Periodontol 2013;84:1528-35.  Back to cited text no. 6
    
7.
Park SY, Shin SY, Yang SM, Kye SB. Factors influencing the outcome of root-resection therapy in molars: A 10-year retrospective study. J Periodontol 2009;80:32-40.  Back to cited text no. 7
    
8.
Green EN. Hemisection and root amputation. J Am Dent Assoc 1986;112:511-8.  Back to cited text no. 8
    
9.
Lee KL, Corbet EF, Leung WK. Survival of molar teeth after resective periodontal therapy – A retrospective study. J Clin Periodontol 2012;39:850-60.  Back to cited text no. 9
    
10.
Langer B, Stein SD, Wagenberg B. An evaluation of root resections. A ten-year study. J Periodontol 1981;52:719-22.  Back to cited text no. 10
    
11.
Avila-Ortiz G, Chambrone L, Vignoletti F. Effect of alveolar ridge preservation interventions following tooth extraction: A systematic review and meta-analysis. J Clin Periodontol 2019;9. doi:10.1111/jcpe.13057. [Epub ahead of print].  Back to cited text no. 11
    
12.
Zhang Y, Ruan Z, Shen M, Tan L, Huang W, Wang L, et al. Clinical effect of platelet-rich fibrin on the preservation of the alveolar ridge following tooth extraction. Exp Ther Med 2018;15:2277-86.  Back to cited text no. 12
    
13.
Hauser F, Gaydarov N, Badoud I, Vazquez L, Bernard JP, Ammann P, et al. Clinical and histological evaluation of postextraction platelet-rich fibrin socket filling: A prospective randomized controlled study. Implant Dent 2013;22:295-303.  Back to cited text no. 13
    
14.
Jiing HZ, Chung HT, Yu CC. Clinical and histologic evaluation of healing in an extraction socket filled with platelet-rich fibrin. J Dent Sci 2011;6:116-22.  Back to cited text no. 14
    


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