Furcations PDF

Classification 28 October 2024 07:19 Most common classification is by Hamp et al 1975: Class 1 - Horizontal loss of periodontal tissue support of less than 3mm Class 2 - Horizontal loss of periodontal tissue support over 3mm but not a through and through defect Class 3 - A through and through...

Classification 28 October 2024 07:19 Most common classification is by Hamp et al 1975: Class 1 - Horizontal loss of periodontal tissue support of less than 3mm Class 2 - Horizontal loss of periodontal tissue support over 3mm but not a through and through defect Class 3 - A through and through defect This classification focuses more on the horizontal component of the furcation defect. Tarnow and Fletcher 1984 suggested an additional subclassification of furcation lesions which incorporated a vertical component based on the vertical invasion from the furcation fornix: A - Vertical probing depth of 1-3mm B - Vertical probing depth of 4-6mm C - Vertical probing depth >7mm When assessing the vertical component of a furcation defect, then this should be measured from the CEJ position to the base of the periodontal pocket or if there is no CEJ due to a restoration then it should be measured from the restoration margin to the base of the periodontal pocket. Radiographically, it is assessed from the CEJ or RM to the alveolar crest. The dimensions of horizontal bone loss can be assessed through directly probing the horizontal bone level. Tonetti et al. 2017 used a similar vertical subclassifcation where the area of remaining periodontal support is estimated using the root with the worst periodontal breakdown. The remaining periodontal support is measured to the coronal (subclass A), middle (subclass B), or apical (subclass C) third of the root length. Over a ten-year period, they examined 200 patients with Class II furcation involved molars. Of these, they found subclass C to have the lowest survival of 23% at ten years, compared to 91% and 67% for grades A and B, respectively. Vertical subclassification may therefore be an important predictor of to]['oth survival. Furcations Page 1 Clinical Assessment Friday, 8 September 2023 16:16 BPE The presence of FIs should be completed when undertaking a basic periodontal examination (BPE). A Nabers probe with a specific action should be used in all cases of probing depths over 4mm in order to clinically identify FI and to produce reproducible and valid information about furcation invasion. Why not a straight probe? Straight rigid probes are inappropriate for furcation assessment as they cannot be used to follow the curved course of the furcation and therefore are likely to underestimate the extent of the furcation Upper molars - In maxillary molars, owing to the anatomical position of the palatal and mesiobuccal root, the mesial furcation entrance is located closer to the palatal than the buccal root and as such, the mesial furcation should be probed from the palatal aspect of the tooth. The distal entrance, however, can be probed from either the buccal or palatal aspect, as it is commonly located half way between the buccal and palatal aspects of the tooth. Of the furcation entrances, the buccal entrance of the maxillary molars is comparatively more accessible than the mesial and distal furcation entrances particularly if it is a wide and broad contact point is present and the adjacent teeth are present. Lower molars - Both entrances of the lower molars are comparatively more accessible than upper molars and so in some cases, these can be reached with an explorer or small curette. Soft tissue preventing full probing? In Class III FI, where the bone is not attached to the dome of the furcation in the early stages, this may be fllled with soft tissue and clinicians may not be able to pass a periodontal probe completely through. Measurements of the horizontal buccal and lingual probing depths should be combined and if this is equal or greater than the dimension of the tooth, we should conclude a Class III furcation exists. Indices If there is bleeding or suppuration from the furcal area, then this should be noted, as should plaque and bleeding scores, which enable the patient and clinician to monitor and assess the patient’s ability to maintain oral hygiene in these areas. Recession should be recorded and mobility classified. Once all relevant assessments have been undertaken, a classification of the patient’s periodontal condition should be stated and the patient informed. Sensibility testing Periodontitis is not the only cause of a FI and clinicians should consider differentials in their diagnosis. Furcations Page 2 In a patient who has a low experience of periodontal disease, FI with an associated radiographic furcation radiolucency may be indicative of an endodontic issue. A periodontal-endodontic lesion with a furcal radiolucency secondary to endodontic pulpal necrosis and a lateral canal is a possibility as well as a crack/fracture line communicating with the periodontium through the furcation area. Another cause could be perforation of the pulpal floor during previous endodontic treatment leading to endodontic pathosis in the furcation region. Guttman 1976 reported that furcation accessory canals are present in 29% of mandibular molars and 27% in maxillary molars. Vertucci 1974 - reported between 45-60% of mandibular first molars can have lateral canals in the furcation area. Pulpal inflammation can communicate to the periodontium via these canals, and the result is furcation lesions in the absence of demonstrable periodontal disease. Likewise, the long-term presence of periodontal furcation lesions may influence the viability of the coronal or radicular pulp tissue when these aberrant channels are present Vitality (sensibility) of the affected tooth should be confirmed through two methods. If a tooth has had endodontic treatment in the past, it is advisable during the assessment process to refer back to any previous radiographs in order to assess for any changes in the radiographic appearance of the furcation or evidence of perforation of the pulp chamber floor. Occlusion Finally, the occlusion should be evaluated with a review of the static and dynamic contacts along with any working and non-working side interferences. This may highlight any occlusal issues or fremitus which may exacerbate any periodontal pathology. Furcations Page 3 Prognosis Friday, 8 September 2023 16:40 Nibali 2016 found that the presence of furcation involvement doubled (2x) the risk of tooth loss in molars maintained in supportive periodontal therapy over 10-15 years. They also found that the degree of FI (Hamp et al. 1975) was significantly associated with risk of tooth loss, increasing from furcation degree I to II to III. Nibali 2016 did note that despite an increased risk of tooth loss, over a 5-15 year follow-up period only 30% of molars even with grade III furcation involvement were lost and therefore these teeth can be maintained with reasonable outcomes with good quality periodontal treatment as well as supportive periodontal therapy. Tonetti et al. 2017 used a similar vertical subclassifcation where the area of remaining periodontal support is estimated using the root with the worst periodontal breakdown. The remaining periodontal support is measured to the coronal (subclass A), middle (subclass B), or apical (subclass C) third of the root length. Over a ten-year period, they examined 200 patients with Class II furcation involved molars. Of these, they found subclass C to have the lowest survival of 23% at ten years, compared to 91% and 67% for grades A and B, respectively. Vertical subclassification may therefore be an important predictor of tooth survival. BSP S3 Guidelines and Jepson systematic review study 2020 recommends that class II and class III molars with residual deep pockets should be treated with periodontal therapy and this treatment is more cost effective than extraction and replacement with implant supported prostheses. The Jepson study also found that furcation involved molar teeth had reasonable survival rates between 4-30.8 years and that survival was higher in class I and class II furcation involved molars compared to class III furcation lesions. Furcations Page 4 Treatment 28 October 2024 07:21 Options - 1) Monitor and review - high probability of tooth loss due to progression of bone loss and difficulty for patient to maintain plaque control in furcation region 2) Non-surgical instrumentation/PMPR - combination of micrograceys and ultrasonic instruments 3) OFD with an access flap +/- resection of pocket epithelium +/- furcationplasty 4) OFD + tunnelling (apically repositioned flap) to improve access for patient cleaning 5) Periodontal regeneration (EMD or bone graft +/- resorbable membrane) 6) Root resection or Root separation 7) Extraction and consideration to tooth replacement Grade I Furcation Involvement Non-surgical periodontal treatment has been shown to be effective for Grade I FI molars and when combined with effective supportive periodontal treatment, such treatment results in a good prognosis of such molars - Rasperini 2020. Furthermore, Huynh-Ba et al. 2009 (systematic review) found that the survival rate of grade I furcation involved molars treated non-surgically was over 90% after 5–9 years. If the site is accessible and the patient is able to maintain adequate oral hygiene, with no plaque or bleeding on probing (BOP) present, then this site can be maintained with professional mechanical plaque removal. This is most likely to be the case in Class A1 FI teeth (horizontal loss of periodontal support 4mm with BOP are detected and the site cannot be adequately accessed or maintained by the patient and the tooth anatomy is favourable, clinicians can then consider surgical treatment of the FI molar. Grade 1 FI which does not respond to NSPT or Grade II/III FI S3 guidelines: Plaque scores smaller than 20%–25% have been consistently associated with better surgical outcomes. Nyman 1977 - it is not recommended to undertake periodontal surgery on patients with inadequate plaque control, as a dose-dependent effect of plaque control on healing outcomes has shown poor plaque control can negatively affect outcomes. Only patients with optimal plaque control i.e. 2mm KT, or intra-crevicular access approach if