furcation the problem and its management
TRANSCRIPT
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Furcation: The Problem and Its Management
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Definition
It can be defined as: an area of complex anatomic morphology that may be difficult or impossible to be debrided by routine periodontal instrumentation.
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Anatomical Considerations
Root trunk Furcation entrance Root surface anatomy Enamel projections Accessory canals
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Root TrunkRoot TrunkRoot TrunkRoot TrunkRepresents the undivided Represents the undivided
region of the root.region of the root.
The height of the root The height of the root
trunk is the distance trunk is the distance
between the CEJ and the between the CEJ and the
separation line between separation line between
two root conestwo root cones
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Furcation Entrance
Entrance:Entrance: the the transitional area transitional area between the between the undivided and the undivided and the divided divided part of part of the rootthe root
Fornix:Fornix: the roof of the roof of the furcationthe furcation
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Furcation Entrance Diameter
How does the furcation entrance diameter relate to the blade width of a new curette?– Blade width of new
Gracey curette = 0.75mm– 60% of molar furcation
entrances < 0.75 mm– Mandibular molars:
buccal wider than lingual maxillary molars:
mesial > distal > buccal
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Root Concavities
Mandibular Molars– 100% mesial roots– 99% distal roots
Maxillary Molars– 94% mesiobuccal
roots– 31% distobuccal
roots– 17% palatal roots
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Cervical Enamel Projections
13% of molars have CEPs
These projections may favor the onset of periodontal lesions in the affected furcations
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Enamel Pearls
Incidence: 1.1% - 9.7%
– Maxillary 2nd molar found near the CEJ extending into molar bifurcations
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Glickman`s Classification(1953)
Classification
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Class I Incipient FurcationThis is an early lesion. The pocket is suprabony, involving the soft tissue. There is slight bone loss in the furcation area. Radiographic change is not usual since bone loss is minimal. A periodontal probe will detect root outline or may sink into a shallow V-shaped notch into the crestal area
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Class I Incipient Furcation
The level of bone loss allows for the insertion of the periodontal probe into the concavity of the root trunk
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Class II Patent FurcationIn this, bone is destroyed in one or more aspects of the furcation, but a portion of the alveolar bone and periodontal ligament remain intact, permitting only partial penetration of the probe into the furca. Radiographs may or may not reveal this type of furcation.
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Class II Patent Furcation
The level of bone loss allows for the insertion of a periodontal probe into the furcation area between the roots.
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Class III Communicating or Through and Through Furcation
This type of probe penetrates completely from one side to the other side characterized by severe bone destruction in the furcation area. It is clearly shown in the radiographs as a radiolucent area in between the roots, especially in the lower molars.
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Class IV
As in Class III, but the gingival tissues recede apically so that furcation is clearly visible.
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Hamp, Nyman & Lindhe`s Classification (1975)
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Tarnow & Fletcher`s Classification (1984)
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Vertical bone loss is measured in mm from the roof of the furcation
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Furcation Probing
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Furcation Probing
Mandibular MolarsBuccal Furcation
Place the probe between the two buccal roots from the buccal aspect
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Furcation Probing
Mandibular MolarsLingual Furcation
Place the probe between the two lingual roots from the lingual aspect
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Furcation Radiography
Should include both
periapical and bitewing
Location of the
interdental bone and
bone level within the
root complex should be
examined
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Pulpal pathosis may some times cause a lesion
in the periodontal tissues of the furcation
Trauma from occlusion may cause
inflammation and tissue destruction within the
interradicular area of a multirooted tooth
Differential Diagnosis
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Objective of Treatment
The elimination of the microbial plaque from
the exposed surfaces of the root complex.
The establishment of an anatomy of the
affected surfaces that facilitates proper self-
performed plaque control.
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Non-Surgical Root Preparation
Scaling & root planing– Most effective in grade I and shallow grade II.– Deeper sites respond less favorably
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In most situations, it results
in the resolution of the
inflammatory lesion in the
gingiva.
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Antimicrobials
Adjunct to scaling and root planning
– Chlorhexidine
– Tetracycline fibers
No clinically significant difference in clinical parameters after irrigation
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Open Debridement
Greater calculus removal than closed Ultrasonic
– Narrow furcations– Dome of furcation
Surgical access and increased operator experience significantly enhance calculus removal in molar furcation.
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Osseous Surgery
Most effective in grade II furcation
Osteoplasty and ostectomy techniques
– Remove the lip of defect to reduce horizontal depth
– Bone ramps into the furcation to enhance plaque control
– Reduce probing depths
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Root Resection
Grade II or grade III Contraindications
– Inadequate bone support
– Fused roots
– Inoperable endodontically
– Patient considerations
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Sequence of treatment at RSR
Endodontic treatment
Provisional restoration
RSR
Periodontal surgery
Final prosthetic restoration
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Factors to be Considered
The length of the root trunk The divergence between the root
cones The length and the shape of the
root cones Fusion between root cones Amount of remaining support
around individual roots Stability of individual roots Access for oral hygiene devices
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Hemisection Mandibular molars
– Grade III furcation– Need widely separated roots– Soft tissue positioned below level of pulp
chamber
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Hemisection
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Root Separation
Root separation involves the sectioning of the root complex and the maintenance of all roots
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Grade III furcation
– Permits plaque removal
– Root caries (4% stannous fluoride)
– 25% failure rate at 5 years
– Recurrent periodontitis
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Regeneration of Furcation Defects
Guided tissue regeneration Predictable outcome of GTR
therapy was demonstrated only in degree II furcation involved mandibular molars
less favorable results have been reported in other types of furcation defects
GTR could be considered in areas with isolated degree II furcation defects
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Furcation DefectsMost predictable Mandibular or
Buccal Maxillary Class II Furcations
Mesial or Distal Maxillary Class II Furcations
Class III Furcations
Least predictable
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Osseous Grafting
Autogenous bone Allografts
– Freeze dried bone– Demineralized Freeze dried bone
Alloplasts– Hydroxyapatite
Non-porous Porous
– Bioglass
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Extraction
Attachment loss is so extensive that no root can
be maintained
If tooth/gingival anatomy will not allow proper
plaque control
For endodontic or restorative reason
Osseointegrated implant substitute
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Prognosis
Hirshfeld and Wasserman. “A long term survey of tooth loss in 600 treated periodontal patients.” J Perio 1978
– 600 patients followed an average of 22 years with recall every 4-6 months
– 1464 molars initially diagnosed with furcation invasion
– 70% survival of furcated molars
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Patients Factors
Determine patient`s goals and expectations Screen for local, behavioral and systemic factors;
– Oral hygiene
– Compliance
– Stress
– Intraoral Accessibility
– Uncontrolled Diabetes
– Smoking
– Healing response to Previous Therapy
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Successful Patient Outcomes
Function Ease of Care Esthetics Confort Health Value