BDS11005 furcation management.pdf

The furcation Defined as: • ‘‘the anatomic area of a multi-rooted tooth where the roots diverge’’ • furcation invasion: refers to the pathologic resorption of bone within a furcation (Periodontology, 2011). Anatomy of the furcation area • Root trunk: the area just coronal to the separation of...

The furcation Defined as: • ‘‘the anatomic area of a multi-rooted tooth where the roots diverge’’ • furcation invasion: refers to the pathologic resorption of bone within a furcation (Periodontology, 2011). Anatomy of the furcation area • Root trunk: the area just coronal to the separation of roots. • The height of the furcation trunk: is the distance between the CEJ and the line of root separation. • The furcation fornix: is the roof of the furcation. • The furcation entrances: are the earliest areas of furcation involvement. Diagnosis of furcation defects By: • Clinical examination (Careful probing) ①Nabors probe ②Transgingival sounding • Radiographic examination Aim of proper diagnosis of furcation defects: • To determine the extent and configuration of the furcation defect and classify it • To determine the position of the attachment level relative to the furcation • To identify factors that contributed in the furcation involvement or might affect the treatment outcome Nabors probe Transgingival sounding • tip of the probe makes direct contact with the bone • forced under LA through the gingiva. Goal: to determine • Tooth morphology • Bone morphology • Configuration of bone defects • Other dental diseases (caries, pulp involvement) Vertical depth Horizontal depth Radiographic examination of furcation defects Periapical & bitewing radiographs Superimposition of palatal root Classification of furcation involvement 1) Based on horizontal attachment loss • Glickman’s classification (1953) • Hamp’s classification (1975) 2) Based on horizontal and vertical attachment loss • Tarnow and Fletcher’s classification (1984) • Easley and Drennan’s classification (1969) Glickman’s classification is the most commonly used Glickman classification (1958) (horizontal CAL) Grade I: • Incipient/ early stage • Early bone loss / increase probing depth • No radiographic changes Glickman classification (1958) (horizontal CAL) Grade II: • Can affect one or more furcations of the molar • Not communicated with each other • Remaining alveolar bone attached to tooth (cul-de-sac) • May be early or advanced (according to extent of horizontal probing) • With or without vertical bone loss • RG: may or may not not be evident (superimposed buccal or lingual bone) and (superimposed roots) Glickman classification (1958) (horizontal CAL) Grade III: • Loss of bone at the dome of furcations • Through & through • RG : RL at furcation area • Clinically : covered by soft tissue Grade IV: • Interdental bone destroyed • Through & through • Soft tissue recession apically • Furcation opening is clinically visible • A tunnel exists between roots Dimension of the furcation entrance is variable 81%..................... Orifice is 1mm or less Problem !!! 58%....................... orifice is 0.75 mm or less Problem in diagnosis Problem in instrumentation Etiology of furcation involvement • The development of furcation defects is related to the extension of the inflammatory reaction and loss of attachment into the interradicular area. • The accumulation of plaque biofilm is the main factor leading to CAL in the furcation area. • The extent of attachment loss in the furcation is related to presence of local anatomic factors of the affected multirooted tooth local factors contribute to progression of CAL in furcation area: Local factors affect: • Rate of plaque deposition • Complicate the performance of oral hygiene procedures Not only affect the progression of the disease but also affect the treatment outcome (prognosis) Local anatomical factors • Root length • Root form • Interradicular dimension • Anatomy of the furcation • Cervical enamel projections Local anatomical factors Root length • Root length is directly proportional to the amount of attachment • Long roots………….more attachment • Short roots …………less attachment long root trunk and short roots Bad prognosis Majority of support is lost when furcation is affected Long roots & Short / moderate root trunks Better prognosis Sufficient attachment remains Local anatomical factors Root form • Mesial root of mandibular 1st & 2nd molars • Mesio-buccal root of maxillary first molar Curved to distal side at apical third + heavily fluted Curvature & fluting • Perforation during endo therapy • Hard to place a post • Vertical root fracture Local anatomical factors interradicular dimension Divergence • Degree of separation is a key factor in treatment planning Degree of separation Close or fused roots Difficult instrumentation Difficult surgical procedures Local anatomical factors Anatomy of the furcation • Bifurcation ridges • Concavity in the dome • Possible accessory canals complicates: • scaling & root planning • surgical therapy • periodontal maintenance Odontoplasty For the ridges during surgery Local anatomical factors cervical enamel projections (CEPs) • More common in maxillary & mandibular second molars Complicates: • plaque removal • local factor in the development of gingivitis and periodontitis. Management CEPs should be removed to facilitate maintenance. Local anatomical factors cervical enamel projections (CEPs) Classification (Masters & Hoskins 1964) Grade I: The enamel projection extends from the CEJ of the tooth toward the furcation entrance. Grade II: The enamel projection approaches the entrance to the furcation. It does not enter the furcation, and therefore no horizontal component is present. Grade III: The enamel projection horizontally into the furcation. extends Summary Diagnosis of furcation • Probing • X-rays Etiology of furcation involvement Local anatomical factors • Root length • Root form • Interradicular dimension • Anatomy of the furcation • Cervical enamel projections Classification of furcation involvement Glickman’s classification Objectives of treatment of furcation lesions • Elimination of plaque biofilm from exposed surfaces of the root complex. • Establishment of an anatomy of the affected surfaces that facilitates self-performed plaque control (facilitate maintenance) • Prevent further attachment loss Treatment options for furcation problems Maintain the furcation • Non-surgical mechanical debridement (Scaling/ root planning) Increase the access to the furcation Furcationplasty (odontoplasty/ osteoplasty) Gingivectomy Apical repositioned flap APF Open flap debridement OFD Tunnel preparation Remove the furcation Class I Class II early Class II advanced Root resection/ Root amputation/ Hemisectioning/ bicuspidization Class IV Closure of the furcation with new attachment GTR Nonsurgical therapy oral hygiene procedures Requires: • First: awareness of the furcation by the patient • Second: Choosing the correct oral hygiene tool that facilitates access such as: Tooth brush Rubber tips Interdental brush Nonsurgical therapy scaling & root planning DeMarco Curettes Problem with accessibility • Curettes • DeMarco curettes • diamond files • Quetin furcation curettes • mini Five Gracey Curettes. • Suitable for treating grade I & Grade II (early lesions) Quetin furcation curettes Hoes Fit in roof of furcation Diamond-coated sonic scaler insert Treatment options for furcation problems furcationplasty • mucoperiosteal flap for access • Scaling & root planning • Odontoplasty (crown/ root) To reduce the horizontal component of the defect and to widen the furcation entrance • Osteoplasty: Recontouring the alveolar bone crest to reduce the buccal–lingual dimension of a bone defect at the furcation area • suturing Treatment options for furcation problems furcationplasty • For treating early grade II furcation involvement Side effects Hypersensitivity and root caries Treatment options for furcation problems Tunnel preparation Indications: • Advanced grade II and grade III furcation involvement. • mandibular molars with short root trunk, wide separation angle, and long divergence between mesial and distal roots. • Objective: removal of bone from the furcation to produce an open tunnel allow cleaning the area by interdental toothbrush. Tunnel preparation Surgical procedures: • Flap is raised • Scaling & root planning • Bone recontouring to widen the furcation • Flap is apically positioned Side effects: Root sensitivity Root caries it is recommended that the exposed root surfaces are treated with chlorhexidine digluconate and fluoride varnish during maintenance. Treatment options for furcation problems Root resection • The root with worst prognosis • used to treat Class II and III furcation-involved molar. Indications: • Advanced grade II/ grade III • Root with vertical bone loss/ recession / caries/ fracture/ perforation • Tooth of High strategic value Treatment options for furcation problems Root resection Which root to remove????? Remove the root that will: • eliminate the furcation • greatest amount of bone and attachment loss. • eliminate periodontal problems on adjacent teeth. • anatomic problems: curvature, grooves, root flutings, or accessory and multiple root canals. • Facilitates future periodontal maintenance. Distobuccal root maxillary first molar of the Mesiobuccal or palatal root???? Treatment options for furcation problems Hemisection • The splitting of a two-rooted tooth into two separate portions. • Also called bicuspidization (molar changed into 2 bicuspids) • Common with mandibular molars with buccal and lingual Class II or III furcation involvements • After sectioning of the teeth, one or both roots can be retained. Treatment options for furcation problems Hemisection Which root to remove???? Better to remove the mesial root Contains 2 narrow root canals Difficulty in post & core construction Root Hemisection Distal root amputation Bicuspidization Treatment options for furcation problems Regeneration Aim: complete elimination of the defect within the inter‐radicular space facilitate optimal self‐performed plaque‐control measures. Treatment options for furcation problems Regeneration Good prognosis • Grade II furcation involvement in mandibular molars Poor prognosis • Grade II furcation involvement maxillary molars • Grade III furcation involvement maxillary & mandibular molars Bone grafts guided tissue regeneration (GTR) coronally positioned flap combination of different procedures Vertical bone defects have better prognosis than horizontal defects Treatment options for furcation problems Regeneration (bone graft + GTR) Grade II furcation involvement Mandibular first molar Fixation of the membrane Flap is coronally placed Full coverage prevent membrane exposure Re-entry after 6 months Treatment options for furcation problems Regeneration (bone graft + GTR) Extraction of furcation involved teeth Indications: • Attachment loss is so extensive (grade III /IV ) • Patient is not expected to stick to proper self‐performed plaque‐control measures. • when the maintenance of the affected tooth will not improve the overall treatment plan • The tooth represents a risk factor for the long‐term prognosis due to caries or endo-lesion Extraction and implant placement • anatomic limitations for implants in the maxillary and mandibular molar regions. • only if implant therapy will improve the prognosis of the overall treatment • Careful evaluation of the long-term periodontal, endodontic, and restorative prognosis must be considered before invasive surgical therapy is undertaken to save a tooth with an advanced furcated lesion https://www.semanticscholar.org/paper/Immediate-Placement-of-Ultrawide-Diameter-ImplantsHattingh-Bruyn/56247fdd41cf0a7f8f60300754f169d22a1c3d89 summary Treatment option Grade of furcation SRP Garde I furcationplasty Grade I/ early grade II Tunnel preparation Advanced grade II/ grade III mandibular molars (both roots have enough periodontal support) Root resection / root hemisection Advanced Grade II/ grade III (only 1 root is affected) Bicuspidization grade II/ grade III Mandibular molars (periodontal problem only limited to area of bifurcation) Regeneration Grade II mandibular molars Extraction Grade III/ IV + hopeless tooth Summary Diagnosis of furcation • Probing • X-rays Classification of furcation involvement Glickman’s classification Etiology of furcation involvement Local anatomical factors • Root length • Root form • Interradicular dimension • Anatomy of the furcation • Cervical enamel projections Treatment of furcation problems: Non-surgical • oral hygiene instructions • scaling and root planning Surgical: • Furcationplasty • Tunnel preparation • Osseous resection and root separation • Regeneration • Extraction and implants Reading material: • Carranza`s clinical periodontology, Newman, Takei, Klokkevold, Carranza (Chapter 62) • Clinical periodontology and implant dentistry, Jan Lindhe and Niklaus P. Lang, volume 2 (chapter 40) • Periodontology by Herbert F. Wolf and Thomas M. Hassell (page 303308)