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 ? Tooth morphology lectures  Key anatomical features of a tooth with furca&on involvement Only multi rooted teeth Level of bone loss and junctional epithelium attachment is exposing furcation area Inter-radicular bone loss - space between roots Divergence - space between apices of roots Consider the diHerent types of mul& rooted teeth Consider and observe the diNerent teeth and therefore diNerence in the furca8on area. 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 L - the roots shown in the image Root divergence - space between roots Left tooth - wider space Middle - smaller space Right tooth - even smaller space Look at the image of the three lower molars spot the diNerences of the root paRern. & Both LL6 and LL7 have radiographic furcations but present differently - LL6 more bone loss than LL7 Inter-radicular bone loss present 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 Grading according to the clinical presenta&on The more recession present and bone loss present - the more the furcation will be Grade 1 least severe - grade 4 most severe Helps monitor furcation area 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 Bnding. Furca&on index Glickman 1953 Glickman ClassiQca&on – Grade I 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 1 or more aspect of furcation but periodontal ligaments remain intact. Don’t always see this on radiograph because the bone hasn’t been lost enough to expose inter-radicular area. Glickman ClassiQca&on – Grade II Class II: Probe penetrates into the furca8on but does not completely pass through to the other side. Bone is destroyed in 1 or more aspects of furcation But not always see on radiograph but will be obvious than a grade I May start to see clinically and feel with probe Glickman ClassiQca&on – Grade III Class III: Probe passes completely through the furca8on but is not clinically visible because the soW issue s8ll Blls the furca8on defect. Probe is able to get into furcation ares but not completely through Visible clinically and able to identify radiographically - bone level below furcation area Glickman ClassiQca&on – Grade IV Class IV: Probe passes completely through the furca8on and the entrance to the furca8on is clinically visible because of gingival recession. Probe passes completely through furcation Most severe scoring Clinically visible due to gingival recession Some computer system don’t have grade IV Nabers probe is used for recording furcations 3mm, 6mm and 9mm black band markings Not ball ended Curved 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 Short truck - root split is closer to CEJ Long truck - root split is closer to apices of roots We may have horizontal bone loss and recession but no furcations present due to long truck compared to tooth with short truck. Consider the impact of these particular morphological features  Radiographs show root morphology Root length Consider impacts of different root lengths Consider the impact of these par&cular morphological features  Root divergence - degree of separation - space between roots Measured in mm (most appropriate) - can be measured on radiographs Interradicular dimensions Consider the degree of separa8on/ diNerence of number of roots diverging. Every tooth is diNerent  Cervical Enamel Projections/ Enamel Pearls At CEJ - projections - enamel pearls Extension of enamel - hard tissue - can be identified on radiographs Can be identified when probing and detecting Impacts - difficult access for patients cleaning - plaque retentive factor - secondary local factor Observe the EP = Extension of enamel beyond pearl like item in the furcation the CEJ in an apical direction towards furcation area Appear as radio opacities- important to identify correctly Just below clinical crown at furcation area 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 May affect work/aesthetics/communication Food packing Di_cult to clean Sensi8vity with exposed No enamel den8ne / possible root caries Impact on prognosis Limited prognosis but can be managed - every patient is different A furca&on is iden&Qed during an examina&on, what next ? Gingival &ssues Assess gingival tissues - how do they appear Probing depths - select the right probe Record recession Look at radiographs and cross check against previous Pa&ent Probing Assess for secondary local factors concerns depth Patients feelings and through Assessment of Furca&on Secondary Recession factors Radiograph Assessment / Grading of the furca&on Does not have ball end - do not need tactile feedback Using the Nabers Probe Curved, calibration probe - helps with access Marked every 3mm https://www.iperiopal.com/nabers-probe-left Examina&on and recording of a furca&on Gingival 8ssues Redness? Inflammation? Signs of inbamma8on Look back at previous records and make comparisons Probing depths Junctional epithelium to gingival margin Recession Supperation present? Clinical attachment loss? Consider the clinical signs of gingival inflammation Radiographic view to iden&fy bone loss in a furca&on. OPG doesn’t give as much detail but still helpful Which is the preferred choice of Easier to reproduce peri apical radiographs - can look back and see if it’s deteriorating or not over period of time. Peri apical radiograph more stabile for assessing furcations and bone (patterns, height, bone loss and inter-radicular bone loss) 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 Very large restoration LR6m with overhang extends to LR5 with distal restorations. Traps plaque/bacteria and allows for calculus build up on root surface. Medial root more affected than distal root LR6 with bone loss.  Possible need for root canal if accessory canal identified within furcation area. 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 a 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 Furca&on Treatment Objec&ves Must keep area clean and reinforce this to patients - do not want furcation to get worse Removal of bacterial plaque/ bioBlm as prognosis is already reduced. Remove overhangs, calculus, excess cement - anything that makes cleaning more difficult for patients. Removal of secondary local factors Prevent further aRachment loss Maintain func8on of tooth Pa8ent educa8on - OHI  Furcations aren’t just buccal on posterior teeth - Can have furcation palatally on maxillary molars And lingually on mandibular molars. Oral hygiene coaching for the pa&ent Need to identify what’s best for patients to access depending how it presents. Oral hygiene advice different for tooth with furcations. Waterflosser may be beneficial in some cases. What’s best for patient - manual dexterity, current Optimal plaque control oral hygiene. is essential in the long term Specific oral hygiene advice Into furcation with interspace brush and or interdental brush. Interdental brushes Depending on furcation severity - patient may be able to place interdental brush through furcation horizontally and possibly horizontally. Site specific for patient SpeciQc instruments for debridement use in furca&on Hand scalers (specific curettes) and power driven scalers (different working ends) Different working ends for better access into different furcations. Personal choice Some instruments speciBcally designed Power driven scaler assorted working ends Remember furac8ons are not all the same What are the ini&al treatment op&ons? Support and reinforce importance of looking after tooth with furcation to patient. Identify furcation correctly, record accurately to be able to look back, compare and monitor. Clinical photographs/radiographs can be used to monitor appearance and changes of Pa8ent educa8on and mo8va8on furcations over period of time. Impressions/digital scans can also be used for monitoring. Need to determine patients recalls - (may be weeks, months) Oral hygiene coaching support Non surgical periodontal therapy Careful and regular monitoring Restora&ve treatment op&ons Endodon8c therapy Periodontal surgery Possible restora8ve treatment  Further treatment op&ons Refer for surgery Beyond scope of therapist Guided Tissue Regeneration (GTR) Root Resection Not all surgeries will be suitable for the furcations Guided Bone Regeneration (GBR) Root Separation Furcation Plasty  Designed to make furcation easier to clean and more accessible. 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 Radiographs Intra oral images Grade and record furca8on Accurate clinical notes and charting Then repeating this at intervals to compare 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/ What may influence prognosis of furcation involved tooth? General periodontal status Age Consistent plaque control Smoking Bruxism What pressure does tooth recieve 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