Furcations: Oral and Dental Sciences PDF

Furcations Oral and Dental Sciences Miss Felix GDC Learning Outcomes 1.2.3/1.11.4/1.11.5/1.8.2 Aim of this lecture To recognise the clinical presentation of a furcation involved tooth, the impact of this on the patient and the subsequent treatment modalities available Learning Outcomes By the...

Furcations Oral and Dental Sciences Miss Felix GDC Learning Outcomes 1.2.3/1.11.4/1.11.5/1.8.2 Aim of this lecture To recognise the clinical presentation of a furcation involved tooth, the impact of this on the patient and the subsequent treatment modalities available Learning Outcomes By the end of the session student should be able to: Define the term furcation Identify the challenges for the for the patient and clinician in the management of furcation Consider the anatomical factors that impact assessment and treatment of furcation's Explain the assessment measures and classification for furcations Discuss potential treatment options for furcation involved teeth Interpret the role of the DH/DTH in the treatment of a furcation involved tooth What is a Furcation Furcation is the anatomical area where the roots divide. Therefore, a furcation defect (also called furcation involvement) refers to bone loss at the branching point of the roots. Furcation can only be present on multi-rooted teeth, not single-rooted teeth. Consider which teeth are multi rooted ? Tooth morphology lectures Key anatomical features of a tooth with furcation involvement Consider the different types of multi rooted teeth Consider and observe the different teeth and therefore difference in the furcation area. Review tooth morphology lectures Not all furcation's are the same Not all furcations are the same Look at the radiograph and spot the differences in the anatomy of the roots shown in the image Look at the image of the three lower molars spot the differences of the root pattern. Not all furcation’s are the same: variations with anatomical features Consider the furcation index grade given Root trunk length Root length Interradicular dimensions Cervical enamel projection and enamel pearls Grading according to the clinical presentation The amount of bone loss and gingival recession determines the severity of the furcation and therefore the numerical index grade. Allocating a grade assists in the recording and subsequent monitoring of such a clinical finding. Furcation index Glickman 1953 Glickman Classification – Grade I Class I: Curvature of the concavity between the roots can be detected with the probe tip but it cannot enter the space. Glickman Classification – Grade II Class II: Probe penetrates into the furcation but does not completely pass through to the other side. Glickman Classification – Grade III Class III: Probe passes completely through the furcation but is not clinically visible because the soft issue still fills the furcation defect. Glickman Classification – Grade IV Class IV: Probe passes completely through the furcation and the entrance to the furcation is clinically visible because of gingival recession. Furcation indices universally accepted Glickman 1953 Further details given in the lecture Hamp, Nyman & Lindhe 1975 Lindhe 1983 Tarnow & Fletcher 1984 Root trunk length : The distance from the cement enamel junction to the entrance of the furcation and root length Consider the impact of these particular morphological features Root length Consider the impact of these particular morphological features Interradicular dimensions Consider the degree of separation/ difference of number of roots diverging.  Cervical Enamel Projections/ Enamel Pearls Observe the EP = Extension of enamel beyond pearl like item in the furcation the CEJ in an apical direction towards furcation area Consider the impact What are the challenges for the patient / clinician when there is a tooth with a furcation? What is the impact on the patient when they have a tooth with a furcation? Unsightly for patients with a broad smile Food packing Difficult to clean Sensitivity with exposed dentine / possible root caries Impact on prognosis A furcation is identified during an examination, what next ? Gingival tissues Patient Probing concerns depth Assessmen t of Furcation Secondar Recessio y factors n Radiogra ph Assessment / Grading of the furcation Using the Nabers Probe https://www.iperiopal.com/nabers-probe-left Examination and recording of a furcation Gingival tissues Signs of inflammation Probing depths Recession Consider the clinical signs of gingival inflammation Radiographic view to identify bone loss in a furcation. Which is the preferred choice of image ? Introduction into Radiography lecture Secondary factors related to the tooth with a furcation Over hanging restoration Crown margin Possible accessory root canal Calculus deposit  Accessory/ root canal and its impact An accessory canal represents a junction of the main pulp canals or the pulp chamber, which communicates with the root surface. Frequently identified in the furcation area and then there is the SEM study of morphologyc need and for Root incidence Canal canals in the furcation region of permanent molars] - PubMed (nih.gov) of accessory Multiple challenges for the clinicians treating patients who have teeth with furcation involvement Complex treatment considerations May need specialist intervention Variance in presentation and treatment needs Challenging access , hard to reach for clinician and patient Less favourable prognosis Treatment options for a tooth with a furcation Furcation Treatment Objectives Removal of bacterial plaque/ biofilm Removal of secondary local factors Prevent further attachment loss Maintain function of tooth Patient education - OHI Oral hygiene coaching for the patient Optimal plaque control is essential in the long term Specific oral hygiene advice Into furcation with interspace brush and or interdental brush. Specific instruments for debridement use in furcation Personal choice Some instruments specifically designed Power driven scaler assorted working ends Remember furactions are not all the same What are the initial treatment options? Patient education and motivation Oral hygiene coaching support Non surgical periodontal therapy Careful and regular Restorative treatment options Endodontic therapy Periodontal surgery Possible restorative treatment Further treatment options Refer for surgery Guided Tissue Regeneration (GTR) Root Resection Guided Bone Regeneration (GBR) Root Separation Furcation Plasty Furcation Plasty Odontoplasty - Tooth substance is removed Osteoplasty – alveolar bone is remodelled at furcation entrance Tooth substance is removed (odontoplasty) and the alveolar bone crest is remodelled (osteoplasty)at the level of the furcation entrance Guided Tissue Regeneration Surgery / Guided Bone Regeneration Surgery Guided bone regeneration ( GBR) and guided tissue regeneration (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival tissue. More about that in Root separation surgery Separation – sectioning of root complex and maintenance of all roots Success depends on : Length and shape of roots Divergence/ stability of the root Successful RCT Good plaque control by Root resection surgery Resection – sectioning & removal of one or more roots Success depends on Length and shape and stability of remaining root Amount of support on remaining root Successful RCT Good plaque control by Conclusion : A tooth with furcation involvement The importance of monitoring a tooth with a furcation Grade and record furcation Repeat at appropriate recall interval Reinforce OHI Interesting additional reading article Management of Furcation-Involved Molars: Recommendation for Treatment and Regeneration - PubMed (nih.gov) https://pubmed.ncbi.nlm.nih.gov/32559031/  General periodontal status Age Consistent plaque control Smoking Bruxism Review periodontal aetiology lecture Furcation Lecture : Summary slide Consider the specifics of a careful examination of furcation areas when completing periodontal examination Inform / educate / advise the patient Consider the relevant treatment modality for the furcation Maintain and monitor If furcation progression occurs consider periodontal specialist referral. Image references https://www.jaypeedigital.com/book/9789386261731/chapter/ch54 https://www.semanticscholar.org/paper/Prevalence-and-microscopic-features-of-enamel-from-Kaminagakura-Salmon/ 5831b8c973d33078d36ddc98da13e1c600db3be9/figure/0 https://pocketdentistry.com/13-radiographic-assessment-and-interpretation/ https://pocketdentistry.com/62-furcation-involvement-and-treatment/https://www.spiedigitallibrary.org/conference-proceedings-of-spie/ 8925/89250J/Reliability-of-CBCT-as-an-assessment-tool-for-mandibular-molars/10.1117/12.2045782.short?SSO=1 https://www.yumpu.com/en/document/view/41216763/classifications-of-furcation-involvement https://www.yumpu.com/en/document/view/41216763/classifications-of-furcation-involvement https://www.yumpu.com/en/document/view/41216763/classifications-of-furcation-involvement https://www.yumpu.com/en/document/view/41216763/classifications-of-furcation-involvementhttps://ct-dent.co.uk/opg-xray-panoramic- orthopantomogram/ https://semmelweis.hu/parodontologia/files/2018/12/parA3osz2018-PZS-furcation.pdf https://ct-dent.co.uk/opg-xray-panoramic-orthopantomogram/ https://www.sciencedirect.com/science/article/pii/S1013905219305048 https://www.mdpi.com/2304-6767/6/3/34/htm https://www.slideshare.net/FarzanaNafi/furcation-involvement-and-its-management-108793588 https://aap.onlinelibrary.wiley.com/doi/10.1902/cap.2017.170007 https://oakhillsperiodontics.com/wp-content/uploads/2016/09/service_periodontal_tissueregen1 https://www.slideshare.net/FarzanaNafi/furcation-involvement-and-its-management-108793588 https://www.quora.com/Which-procedure-removes-a-root-from-a-multi-rooted-tooth http://www.jnda.com.np/article/2ygmcpkyve2.pdf https://www.researchgate.net/figure/Profile-and-overhead-view-of-the-singl-tufted-brush_fig1_51542663 https://www.slideshare.net/seyedehmarziehhashem/treatment-of-furcation-involved-teeth-endodontics-and-periodontics https://www.hu-friedy.com/products/periodontal/curettes/furcationhttps://www.jaypeedigital.com/book/9789386261731/chapter/ch54 Https://www.jaypeedigital.com/book/9789350250372/chapter/ch44 https://pocketdentistry.com/short-root-anomaly-in-an-orthodontic-patient-2/ https://www.medicinenet.com/root_canal/article.htm