Furcations PDF

Furca&ons 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 presenta8on of a furca8on involved tooth, the impact of this on the pa8ent and the subsequent treatment modali8es available Learning Outcomes By the end o...

Furca&ons 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 presenta8on of a furca8on involved tooth, the impact of this on the pa8ent and the subsequent treatment modali8es available Learning Outcomes By the end of the session student should be able to: DeBne the term furca8on Iden8fy the challenges for the for the pa8ent and clinician in the management of furca8on Consider the anatomical factors that impact assessment and treatment of furca8on's Explain the assessment measures and classiBca8on for furca8ons Discuss poten8al treatment op8ons for furca8on involved teeth Interpret the role of the DH/DTH in the treatment of a furca8on involved tooth What is a Furca&on Furca&on is the anatomical area where the roots divide. Therefore, a furca&on defect (also called furca&on involvement) refers to bone loss at the branching point of the roots. Furca&on can only be present on mul8-rooted teeth, not single-rooted teeth. Consider which teeth are mul& rooted ? premolars (molars Tooth morphology lectures Key anatomical features of a tooth with furca&on involvement Consider the diHerent types of mul& rooted teeth Consider and observe the diNerent teeth and therefore diNerence in the furca8on area. Molars mandible and maxilla Maxillary first pre molar Review tooth morphology lectures Not all furca&on's are the same Not all furca&ons are the same Look at the radiograph and spot the diNerences in the anatomy of the roots shown in the image Look at the image of the three lower molars spot the diNerences of the root paRern. & Inter-radicular bone loss Not all furca&on’s are the same: varia&ons with anatomical features Consider the furca8on index grade given Root trunk length Root length Interradicular dimensions Cervical enamel projec8on and enamel pearls Pearls Grading according to the clinical presenta&on The amount of bone loss and gingival recession determines the severity of the furca8on and therefore the numerical index grade. Alloca8ng a grade assists in the recording and subsequent monitoring of such a clinical 1 - 4 Bnding. Least most Severe. Furca&on index Glickman 1953 Glickman ClassiQca&on – Grade I sembal Charting - Class I: Curvature of the concavity between the roots can be detected with the probe 8p but it cannot enter the space. Bone is destroyed in one or more aspect of the furcation, but the periodontal ligaments remain intact don’t always see this on the radiograph because the bone level hasn’t reduced significantly enough to expose the interradicular area. Glickman ClassiQca&on – Grade II symbol. Charting - Class II: Probe penetrates into the furca8on but does not completely pass through to the other side. Bone is destroyed one or more aspects of the furcation and you may not always see this on the radiograph although may be a little bit more obvious then a grade one on the radio graph this is where you may start to see clinically as well. Also be able to feel it with the probe so when you stroke the probe just under the gingiva or along the surface of the root that’s why you may be able to see it. Glickman ClassiQca&on – Grade III symbol charting M Class III: Probe passes completely through the furca8on but is not clinically visible because the soW issue s8ll Blls the furca8on defect. prob is actually able to get into the furcation area but not completely through. this is visible clinically and you will be able to identify radiographically as well as you can see on the image that the bone level is below the furcation area. Glickman ClassiQca&on – Grade IV Charting symbol - Class IV: Probe passes completely through the furca8on and the entrance to the furca8on is clinically visible because of gingival recession. Most sever scoring grade for a furcation. Some Systems only record locations grade 12 and 3 they don’t go up to a grade 4 so you need to familiarise yourself with the particular computer system. neabers probe ,so this is a curved probe looks a little bit similar to your BPE probe but it’s slightly different and it has markings on it at 3 mm 6 mm and 9 mm It does not have a ball end. it’s to help you access the furcation and it’s also got the markings as black band to help you measure the furcation as well. Furca&on 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 junc&on to the entrance of the furca&on and root length Consider the impact of these particular morphological features Root length Consider the impact of these par&cular morphological features Interradicular dimensions Space between the roots , measured in mm using radiographs. Consider the degree of separa8on/ diNerence of number of roots diverging. Every tooth is diNerent  Cervical Enamel Projections/ Enamel Pearls Plaque retentive factor - difficult to clean and access to clean O Observe the EP = Extension of enamel beyond pearl like item in the furcation the CEJ in an apical direction towards furcation area O G O Consider the impact What are the challenges for the pa&ent / clinician when there is a tooth with a furca&on? What is the impact on the pa&ent when they have a tooth with a furca&on? Unsightly for pa8ents with a broad smile Food packing Di_cult to clean Sensi8vity with exposed den8ne / possible root caries Impact on prognosis A furca&on is iden&Qed during an examina&on, what next ? Gingival &ssues Pa&ent Probing concerns depth Assessment of Furca&on Secondary Recession factors Radiograph Assessment / Grading of the furca&on No ball end Using the Nabers Probe gam sma 3 um https://www.iperiopal.com/nabers-probe-left Examina&on and recording of a furca&on Gingival 8ssues Signs of inbamma8on Probing depths Recession Consider the clinical signs of gingival inflammation Radiographic view to iden&fy bone loss in a furca&on. Which is the preferred choice of image ? Introduction into Radiography lecture Secondary factors related to the tooth with a furca&on Over hanging restora8on Crown margin Possible accessory root canal Calculus deposit  Accessory/ root canal and its impact An accessory canal represents a junc8on of the main pulp canals or the pulp chamber, which communicates with the root surface. Frequently iden8Bed in the furca8on area and then there is the need for Root Canal Therapy (RCT) Relevant study below SEM study of morphologyc and incidence of accessory canals in the furcation region of permanent molars] - PubMed (nih.gov) Mul&ple challenges for the clinicians trea&ng pa&ents who have teeth with furca&on involvement Complex treatment considera8ons May need specialist interven8on Variance in presenta8on and treatment needs Challenging access , hard to reach for clinician and pa8ent Less favourable prognosis www.xinweidds.com/Professionals/Immediate+Implant/1+Category,+table/2+Lower/4+Molars/ 1st+Molars/30-Class-IV-Furca-Ni-FB/Spongy-Layer-of+Bone/02+IMG_2417_lingual.jpg Treatment op&ons for a tooth with a furca&on 00 Furca&on Treatment Objec&ves. important Removal of bacterial plaque/ bioBlm -very. If present Removal of secondary local factors eg calculus , overhangs. excess cement Prevent further aRachment loss Maintain func8on of tooth Pa8ent educa8on - OHI Oral hygiene coaching for the pa&ent Optimal plaque control is essential in the long term Specific oral hygiene advice Into furcation with interspace brush and or interdental brush. SpeciQc instruments for debridement use in furca&on Personal choice Some instruments speciBcally designed Power driven scaler assorted working ends Remember furac8ons are not all the same n What are the ini&al treatment op&ons? Pa8ent educa8on and mo8va8on Oral hygiene coaching support Non surgical periodontal therapy Careful and regular monitoring Photos for monitoring Restora&ve treatment op&ons Endodon8c therapy Periodontal surgery Possible restora8ve treatment Further treatment op&ons Refer for surgery Guided Tissue Regeneration (GTR) Root Resection Guided Bone Regeneration (GBR) Root Separation Furcation Plasty Furca&on Plasty Odontoplasty - Tooth substance is removed Osteoplasty – alveolar bone is remodelled at furca8on entrance Tooth substance is removed (odontoplasty) and the alveolar bone crest is remodelled (osteoplasty)at the level of the furca8on entrance Guided Tissue Regenera&on Surgery / Guided Bone Regenera&on Surgery Guided bone regenera8on ( GBR) and guided 8ssue regenera8on (GTR) are dental surgical procedures that use barrier membranes to direct the growth of new bone and gingival 8ssue. More about that in periodontal surgery lectures Root separa&on surgery Separa&on – sec8oning 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 pa8ent Root resec&on surgery Resec8on – sec8oning & 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 pa8ent Conclusion : A tooth with furca&on involvement The importance of monitoring a tooth with a furca&on Grade and record furca8on Repeat at appropriate recall interval Reinforce OHI Interes8ng addi8onal reading ar8cle Management of Furca8on-Involved Molars: Recommenda8on for Treatment and Regenera8on - PubMed (nih.gov) hRps://pubmed.ncbi.nlm.nih.gov/32559031/  General periodontal status Age Consistent plaque control Smoking Bruxism Review periodontal aetiology lecture Furca&on Lecture : Summary slide Consider the speciBcs of a careful examina8on of furca8on areas when comple8ng periodontal examina8on Inform / educate / advise the pa8ent Consider the relevant treatment modality for the furca8on Maintain and monitor If furca8on progression occurs consider periodontal specialist referral. Image references hRps://www.jaypeedigital.com/book/9789386261731/chapter/ch54 hRps://www.seman8cscholar.org/paper/Prevalence-and-microscopic-features-of-enamel-from-Kaminagakura-Salmon/5831b8c973d33078d36ddc98da13e1c600db3be9/Bgure/0 hRps://pocketden8stry.com/13-radiographic-assessment-and-interpreta8on/ hRps://pocketden8stry.com/62-furca8on-involvement-and-treatment/hRps://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 hRps://www.yumpu.com/en/document/view/41216763/classiBca8ons-of-furca8on-involvement hRps://www.yumpu.com/en/document/view/41216763/classiBca8ons-of-furca8on-involvement hRps://www.yumpu.com/en/document/view/41216763/classiBca8ons-of-furca8on- involvementhRps://ct-dent.co.uk/opg-xray-panoramic-orthopantomogram/ hRps://semmelweis.hu/parodontologia/Bles/2018/12/parA3osz2018-PZS-furca8on.pdf hRps://ct-dent.co.uk/opg-xray-panoramic-orthopantomogram/ hRps://www.sciencedirect.com/science/ar8cle/pii/S1013905219305048 hRps://www.mdpi.com/2304-6767/6/3/34/htm hRps://www.slideshare.net/FarzanaNaB/furca8on-involvement-and-its-management-108793588 hRps://aap.onlinelibrary.wiley.com/doi/10.1902/cap.2017.170007 hRps://oakhillsperiodon8cs.com/wp-content/uploads/2016/09/service_periodontal_8ssueregen1 hRps://www.slideshare.net/FarzanaNaB/furca8on-involvement-and-its-management-108793588 hRps://www.quora.com/Which-procedure-removes-a-root-from-a-mul8-rooted-tooth hRp://www.jnda.com.np/ar8cle/2ygmcpkyve2.pdf hRps://www.researchgate.net/Bgure/ProBle-and-overhead-view-of-the-singl-tuWed-brush_Bg1_51542663 hRps://www.slideshare.net/seyedehmarziehhashem/treatment-of-furca8on-involved-teeth-endodon8cs-and-periodon8cs hRps://www.hu-friedy.com/products/periodontal/cureRes/furca8onhRps://www.jaypeedigital.com/book/9789386261731/chapter/ch54 HRps://www.jaypeedigital.com/book/9789350250372/chapter/ch44 hRps://pocketden8stry.com/short-root-anomaly-in-an-orthodon8c-pa8ent-2/ hRps://www.medicinenet.com/root_canal/ar8cle.htm hRps://www.researchgate.net/Bgure/Representa8ve-pa8ent-A-Preopera8ve-view-of-mandibular-right-molar-with-class-3_Bg2_338045943