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CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 1  |  Page : 59-62

Hemisection with socket preservation using Platelet Rich Fibrin [PRF] - A case report with one year follow up


1 Department of Conservative Dentistry and Endodontics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
2 Department of Orthodontics and Dentofacial Orthopedics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh, India
3 Consultant Orthodontist, UAE

Date of Submission25-Aug-2020
Date of Decision10-Feb-2021
Date of Acceptance16-Mar-2021
Date of Web Publication19-May-2021

Correspondence Address:
Dr. Tammineedi Sravanthi
Department of Conservative dentistry and Endodontics, Sibar Institute of Dental Sciences, Guntur, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_115_20

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  Abstract 


With advances in dentistry as well as the increased patients' desire to retain their natural teeth, there is a paradigm shift from extraction to the preservation of teeth. Mandibular first molars are the primary occlusal load-bearing teeth, commonly extracted teeth due to dental caries and periodontal disease. Hemisection is a conservative alternative to retain a hopeless tooth. Following endodontic treatment and selective root removal, the remaining portion of the tooth is splinted to the adjacent teeth with a fixed partial denture prosthesis. The resorption of the alveolar ridge surrounding the extraction socket may complicate the subsequent prosthetic procedure. Hence, socket preservation technique evolved, which prevents such untoward changes in the extraction socket. This case report shows hemisection procedure in a grossly carious first mandibular right molar with furcation involvement of a healthy 40-year-old female patient followed by autologous platelet-rich fibrin placement in the extraction socket. One year follow-up showed little alveolar resorptive changes with better healing and function clinically.

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


How to cite this article:
Sravanthi T, Basam RC, Basam LC, Govula S. Hemisection with socket preservation using Platelet Rich Fibrin [PRF] - A case report with one year follow up. J NTR Univ Health Sci 2021;10:59-62

How to cite this URL:
Sravanthi T, Basam RC, Basam LC, Govula S. Hemisection with socket preservation using Platelet Rich Fibrin [PRF] - A case report with one year follow up. J NTR Univ Health Sci [serial online] 2021 [cited 2021 Jun 23];10:59-62. Available from: https://www.jdrntruhs.org/text.asp?2021/10/1/59/316309




  Introduction Top


Weine described root amputation as the removal of one or more roots of a multi-rooted tooth while other roots are retained.[1] In mandibular molars, the tooth is divided buccolingually through the furcation. The defective or periodontally involved root and its coronal crown are then removed, followed by a fixed prosthesis for the remaining tooth structure. Hemisection of a mandibular molar could be considered as a suitable treatment option when the caries is restricted to one root, and the other root is healthy and can act as an abutment (Saad et al.).[2]

As a part of the tooth is removed, an extraction socket is formed, which is usually left to heal. This may lead to loss of alveolar ridge height and width. Choukrons platelet-rich fibrin (PRF), a second-generation platelet-rich concentrate, helps in improved healing due to the presence of various cytokines and growth factors.[3] PRF helps in the continuous release of the crucial growth factors such as platelet-derived growth factor (PDGF), transforming growth factor-beta (TGF-β1), insulin-like growth factor (IGF) for up to 4 weeks and helps in stimulating the surrounding environment for a significant time during remodeling. PRF also inhibits osteoclastogenesis by stimulating the secretion of osteoprotegerin, thus, helping in maintaining alveolar ridge height following extraction. This case report aims to describe the hemisection procedure in a lower first molar, followed by socket preservation with PRF.


  Case Report Top


A 40-year-old female patient reported the chief complaint of a decayed tooth and food lodgment in the right lower back teeth region. History revealed severe pain 1 year back, which aggravated during the night and, while lying down, subsided after a few weeks upon using medication. On clinical examination, 46 revealed gross carious destruction of a tooth on the mesial side involving pulp [Figure 1]a, no tenderness to percussion and palpation, no mobility. The radiographic examination revealed caries involving pulp and furcation [Figure 1]b. The tooth also did not respond to vitality testing. Hence, a diagnosis of pulp necrosis was made irt 46. Treatment options included extraction followed by implant placement/FPD or root canal treatment (RCT) followed by hemisection and replacement. Because of the higher treatment cost for implants, she opted for RCT, followed by hemisection as an interim treatment option until she gets an implant placed. The patient consent was taken, and root canal treatment was initiated in relation to 36.
Figure 1: (a) Preoperative clinical image irt 46. (b) Radiographic picture irt 46. (c) Working length determination. (d) Master cone selection

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Endodontic phase

Under aseptic conditions, 1 mL of 2% lidocaine with epinephrine 1:1,00,000 was administered using inferior alveolar nerve block. After rubber dam application, access cavity preparation was prepared with no. 2 round bur (Endo Access Bur, Dentsply), and a working length of 18 mm was determined using an Apex Locator (Propex II, Dentsply) and radiographically confirmed [Figure 1]c. Pulp extirpation was done in all the canals. Biomechanical preparation was done in the distal canals starting with hand filing followed by Rotary NeoEndo till 25 4% files. Copious irrigation was done with 5.25% sodium hypochlorite and recapitulation with a 10 k file. The master cones were verified [Figure 1]d followed by obturation with Guttapercha and AH Plus sealer [Figure 2]a.
Figure 2: (a) Postobturation radiograph. (b) PRF obtained from patients' blood. (c) Vertical cut in relation to 46. (d) Atraumatic extraction of the mesial root. (e) Radiograph after root resection

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Preparation of the platelet-rich fibrin

In the next appointment, 10 mL of the patient's venous blood was collected, transferred to a test tube, and centrifuged at 3,000 revolutions per min for 10 min. After centrifugation, the blood is separated into three different layers, i.e., platelet-poor plasma at the surface, PRF clot in the middle, and RBC at the bottom.[4] The PRF is separated from the remaining portion [Figure 2]b.

Periodontal phase

Under local anesthesia, a flap was elevated in relation to 46. The vertical cut was placed buccolingually to separate mesial and distal halves [Figure 2]c. The mesial root was removed atraumatically [Figure 2]d, and the mesial side of the distal root was reshaped to remove any sharp irregularities. Occlusal reduction was done on the remaining root. The extraction socket was irrigated with sterile saline to remove any debris. Intraoperative radiograph was taken to verify the same [Figure 2]e. The PRF was placed into the extraction socket, and the flap was sutured. Antibiotics and analgesics were prescribed for 1 week, and postoperative instructions were given.

Prosthetic phase

The operative site healed after 1 month [Figure 3]a. Permanent restoration, tooth preparation was done, and metal-ceramic crowns were given irt 45,46. Occlusion was checked with articulating paper, and the prosthesis was cemented [Figure 3]b, [Figure 3]c. On 1 year follow-up the patient was asymptomatic, occlusion was stable, and radiograph [Figure 3d] did not reveal any signs of pathology.
Figure 3: (a) Healed site after 1 month. (b) Clinical image showing FPD i.r.t 45,46. (c) 1 month follow-up radiograph. (d) 1 year follow-up radiograph

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  Discussion Top


Extraction was widely practiced as a treatment option for the grossly decayed tooth. With the increasing preference of the patients to retain their natural teeth, hemisection is considered one of the last resorts to retain the tooth. But there is a constant dilemma among dentists about the prognosis of root resected teeth. Mokbel et al. in a systematic review concluded that the survival rate in hemisection cases was >90% in a follow-up period of 5–23 years.[5] Similar survival rate of 91.1% was observed in a retrospective study by Yuh et al.[6]

Fugazzotto et al., in a retrospective study, compared the survival rate of 701 resected molars to that of 1472 implants in molar areas after more than 15 years of function.[7] No significant difference was found between the cumulative success rate of the root resection therapy (= 96.8% ) and implants (= 97%). The resected molars or implants that were lone standing (terminal abutments) are more prone to failure.

Blomlof et al., reported a survival rate of 83% at 5 years, which decreased to 68% at 10 year follow-up. The authors concluded that although the resection may remove the diseased root, it may also create a new nidus for new aggravating factors such as overhanging restorations.[8] On the other hand, Carnevale et al. reported a survival rate of about 93% over a 10 year follow-up.[9] These variations in the reported survival rates were attributed to the technique, proper case selection, patient compliance with oral hygiene instructions, and adequate post-treatment restorative treatment.

Apart from a proper root canal treatment, a successful root resection therapy requires a comprehensive evaluation of restorative components too.[10] A root fracture is a significant cause of failure in resected teeth. Therefore, the use of a post should be generally avoided in such cases. It is shown that the placement of a post decreases the fracture resistance of a tooth.[11] Factors such as occlusal forces, tooth restorability, and the value of the remaining roots must be examined before treatment.[12]

The success of the hemisection procedure depends on the proper case selection and thorough clinical and radiographic examination of the offending tooth. After selecting the case, a dilemma exists whether to perform vital or nonvital resections. According to Francis et al., the prognosis for a vital root resection is poor, and endodontic therapy should be done before or as soon after vital root resection as possible.[13] Hence, rootcanal treatment is usually carried out before performing hemisection. Care should be taken not to over enlarge the canals while biomechanical preparation. The use of chelating agents should be kept minimal. According to weine, if root is to be amputated at the same appointment after canal filling, the chamber should be sealed with Zinc Oxide Eugeno (ZOE) accelerated with zinc acetate crystals. If amputation is performed at a later date, amalgam or ZOE can be used.

Postextraction wound healing occurs through a series of complex biological processes. It takes at least 3 months to have an evident radiographic bone display. It is often associated with alveolar ridge height reduction. Hence, socket preservation with various biomaterials was proposed to minimize ridge resorption and enhance new bone formation. Enhanced softtissue healing, with a better quality of bone formation, was observed in PRFfilled sockets (Zhang et al.).[14] A microCT study by Jiing et al. showed that of PRFplaced socket showed better and early healing by virtue of the high concentration of functional, intact platelets enmeshed in a fibrin matrix.[15] Few case reports showed that the use of PRF following hemisection helped in faster bone healing.[16],[17] Therefore, in the present case report, autologous PRF was considered as a graft material for the preservation of the socket.

Prognosis

The prognosis of a hemisection is the same as for routine endodontic procedures; if it meets the following criteria:

  1. The case selection has been correct,
  2. Precise endodontic treatment, and
  3. The restoration has met the periodontal as well as occlusal requirements of the patient.



  Conclusion Top


Hemisection is a conservative and dependable treatment procedure that helps retain the teeth which endure the demands of function. Socket preservation with PRF encourages early healing and helps in the maintenance of alveolar ridge height. Hence, this treatment procedure can be considered as an interim treatment option until the implant placement.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Weine FS. Endodontic Therapy. 6th ed. Mosby Publishers; Missourie, 2004. p. 423.  Back to cited text no. 1
    
2.
Saad MN, Moreno J, Crawford C. Hemisection as an alternative treatment for decayed multirooted terminal abutment: A case report. J Can Dent Assoc 2009;75:387-90.  Back to cited text no. 2
    
3.
Choukroun J, Diss A, Simonpieri A, Girard MO, Schoeffler C, Dohan SL, et al. Platelet-rich fibrin (PRF): A second-generation platelet concentrate. Part IV: Clinical effects on tissue healing. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:e56-60.  Back to cited text no. 3
    
4.
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. 4
    
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.
Fugazzotto PA. A comparison of the success of root resected molars and molar position implants in function in a private practice: Results of up to 15-plus years. J Periodontol 2001;72:1113-23.  Back to cited text no. 7
    
8.
Blomlof L, Jansson L, Appelgren R, Ehnevid H, Lindskog S. Prognosis and mortality of root-resected molars. Int J Periodontics Restorative Dent 1997;17:190-201.  Back to cited text no. 8
    
9.
Carnevale G, Pontoriero R, di Febo G. Long-term effects of root-resective therapy in furcation-involved molars. A10-year longitudinal study. J Clin Periodontol 1998;25:209-14.  Back to cited text no. 9
    
10.
Vivekananda Pai AR, Khosla M. Root resection under the surgical field employed for extraction of impacted tooth and management of external resorption. J Conserv Dent 2012;15:298-302.  Back to cited text no. 10
  [Full text]  
11.
Guzy GE, Nichols JI. In vitro comparison of intact endodontically treated teeth with and without endo-post reinforcement. J Prosthet Dent 1979;42:39-42.  Back to cited text no. 11
    
12.
Green EN. Hemisection and root amputation. J Am Dent Assoc 1986;112:511-8.  Back to cited text no. 12
    
13.
Filipowicz F, Umstott P, England M. Vital root resection in maxillary molar teeth: A longitudinal study. J Endod 1984;10:264-8.  Back to cited text no. 13
    
14.
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. 14
    
15.
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. 15
    
16.
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. 16
    
17.
Gupta S, Tikku AP, Verma P, Bharti R. Hemisection with platelet rich fibrin: A novel approach. Saudi Endod J 2020;10:61-4.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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