FURCATION and its classification 1 .pptx

Furcation introduction , etiology of furcation problems , classification of furcation defects , diagnosis ,treatment

1. FURCATION: Involvement and its treatment plan Presented by: Dr Neelu Verma Asso . Professor Dept. of Periodontology 1

2. Introduction Terminology Etiology of Furcation Problems Classification of Furcation Defects Diagnosis Local Anatomic Factors in Treatment of Furcations Classification of Cervical Enamel Projections Differential Diagnosis Treatment of Furcation Defects Conclusion 2 CONTENTS

3. 3 INTRODUCTION The progress of inflammatory periodontal disease, if unabated, ultimately results in attachment loss sufficient enough to affect the bifurcation or tri furcation of multi-rooted teeth.

4. Furcation-- Bower described furcation is an area of complex anatomic morphology that may be difficult or impossible to debride by routine periodontal instrumentation. Furcation involvement--- The term furcation involvement refers to the invasion of the bifurcation and trifurcation of multirooted teeth by periodontal disease. 4 DEFINITIONs

5. ROOT COMPLEX a. Root Cone b. Root Trunk ROOT TRUNK: ROOT TRUNK: 5 TERMINOLOGies Fig: Root complex of maxillary molar

6. FURCATION ENTRANCE : The transitional area between the undivided and the divided part of the root. 6 Fig. Apical- occlusal view of a maxillary molar where the three root cones make up the furcated region and the three furcation entrances

7. FURCATION FORNIX : The roof of the furcation. 7 Fig. A buccal view of the furcation entrance and of its roof.

8. DEGREE OF SEPARATION : DIVERGENCE : 8 Fig. showing angle (degree) of separation and the divergence between the mesio-buccal and the palatal roots of a maxillary molar .

9. PLAQUE ASSOCIATED INFLAMMATION The primary etiologic factor is bacterial plaque and the inflammatory consequences that result from its long term presence. The extent of attachment loss is related to local anatomic factors (e.g., root trunk length, root morphology) and local developmental anomalies (e.g., cervical enamel projection). 9 ETIOLOGIC FACTORS

10. The local factor contributes to the development of periodontitis and attachment loss. Furcation morphology, including width, distance from cementoenamel junction (CEJ) and shape has been implicated as a predisposing factor for furcation invasion. 10

11. Trauma from occlusion is a suspect etiologic factor in furcation defects. Forces elicited by occlusal interferences, may cause inflammation and tissue destruction within the inter- radicular area of a multi-rooted tooth. In such a tooth radiolucency may be seen in the radiograph of the root complex. 11 TRAUMA FROM OCCLUSION –

12. Horizontal component of the Furcation involvement-- Glickman (1953) Vertical component of the Furcation involvement--- Tarnow and Fletcher (1984) Eskow and Kaplin (1984) Hau et al (1988) 12 CLASSIFICATION OF FURCATION DEFECTS

13. Glickman (1953) classified furcation involvement into four grades as follows: Grade I: It is incipient or the early stage of furcation involvement; the pocket is suprabony and primarily affects the soft tissue. 13 Horizontal component of the Furcation involvement- Fig. showing Glickman’s Grade I furcation involvement

14. Early bone loss may have occurred with an increase in probing depth, but radiographic changes are not usually found.  14

15. Grade II: It can affect one or more of the furcations of the same tooth. The furcation lesion is essentially a cul-de-sac with a definite horizontal component. 15 Fig. showing Glickman’s Grade II furcation involvement

16. If multiple defects are present, they do not communicate with each other because a portion of the alveolar bone remains attached to the tooth. The extent of the horizontal probing of the furcation determines whether the defect is early or advanced. Vertical bone loss may be present and represents a therapeutic complication. Radiographs may or may not depict the furcation involvement, particularly with maxillary molar because of the radiographic overlap of the roots. 16

17. Grade III: In Grade III furcation the bone is not attached to the dome of the furcation. In early Grade III involvement the opening may be filled with soft tissue and may not be visible. Fig. showing Glickman’s Grade III furcation involvement

18. The clinicians may not even be able to pass a periodontal probe completely through the furcation because of interference with the bifurcational ridges or facial/ lingual bony margins. Properly exposed and angled radiographs of early grade III furactions display the defect as a radiolucent area in the crotch of the tooth. 18

19. Grade IV: In Grade IV furcation the interdental bone is destroyed, and the soft tissues have receded apically so that the furcation opening is clinically visible. A tunnel therefore exists between the roots of such an affected tooth. Thus the periodontal probe passes readily from one aspect of the tooth to another. 19 Fig. showing Glickman’s Grade IV furcation involvement

20. Tarnow and Fletcher (1984) classified vertical bone loss interradicular sites as: Subclass A – vertical bone loss of 3mm or less. Subclass B – vertical bone loss of 4-6mm. Subclass C – vertical bone loss of 7mm or more.  20 Vertical component of the Furcation involvement---  

21. Clinical examination of the patient should allow the therapist to identify not only furcation defects but many of the local anatomic factors that may affect the result of therapy (prognosis). The Important local factors are--- 21 LOCAL ANATOMIC FACTORS

22. Root trunk length Root length Root form Inter-radicular Dimension anatomy of furcation Cervical enamel projection 22

23. The distance from the cementoenamel junction to the entrance of the furcation can vary extensively. Teeth may have very short root trunks, moderate length trunks or roots than may be fused to a point near the apex The shorter the root trunk, the less attachment has to be lost before the furcation is involved. Once the furcation is exposed, teeth with short root trunks may be more accessible to maintenance procedures and the short root trunks may facilitate some surgical procedures 23 a)Root trunk length--

24. Fig. Different anatomic features that may be important in prognosis and treatment of furcation involvement. A, Widely separated roots. B, Roots are separated but close. C, Fused roots separated only in their apical portion. D, Presence of enamel projection that may be conducive to early furcation involvement 24

25. Alternatively teeth with unusually long root trunks or fused roots may not be appropriate candidates for treatment once the furcation has been affected. b) Root length-- Teeth with long roots trunks and short roots may have lost a majority of their support by the time that the furcation becomes affected. Teeth with long roots and short to moderate root trunk length are more readily treated as sufficient attachment remains to meet functional demands 25

26. 26 c) Root form : The mesial root of most mandibular first and second molars and the mesiobuccal root of the maxillary first molar are commonly curved to the distal in the apical third. The curvature may increase the potential for root perforation during endodontics , and may also result in an increased incidence of vertical root fracture.

27. 27 D) Interradicular dimension : Closely approximated or fused roots can preclude adequate instrumentation during scaling, root planing and surgery. Teeth with widely separated roots present more treatment options and are more readily treated.

28. 28 e) Anatomy of furcation : The anatomy of furcation is complex. The presence of bifurcational ridges, a concavity in the dome and possible accessory canals complicates not only scaling; root planing, and surgical therapy but also periodontal maintenance. Odontoplasty to reduce or eliminate these ridges may be required during surgical therapy for an optimal result.

29. 29 f) Cervical enamel projections (CEPs): They have been implicated as etiologic factors in furcation defects due to the lack of connective tissue attachment on enamel surfaces.

30. 30 CLASSIFICATION OF CERVICAL ENAMEL PROJECTIONS   (Masters and Hoskins, 1964) Grade I – The enamel projections 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.

31. 31 Grade III – The enamel projection extends horizontally into the furcation. CEPs should be eliminated to facilitate maintenance and they are reported to occur on 8.6% to 28.6% of molars.

32. A blunt, sturdy, curved instrument such as Naber’s furcation probe should be used to explore and evaluate the extent and configuration of furcation defect and to identify factors that may have contributed to the development of the furcation defect or that could affect treatment outcome. Among these factors are--- the morphology of the affected tooth, the position of the tooth relative to adjacent teeth, the local anatomy of the alveolar bone, the configuration of any bony defects, and the presence and extent of other dental diseases such as caries and pulpal necrosis 32 DIAGNOSIS

33. - High resolution computed tomography, provides a more detailed 3-dimensional interpretation of bony lesions and teeth structure especially in the furcation areas seem possible. Evidence in healing furcation may be provided by computer assisted densitometric image analysis (CADIA), as well as qualitative and quantitative digital subtraction radiography. 33 Advanced diagnostic aids

34. However at present, these methods are mainly employed for scientific research purposes to examine the equivalence or superiority of new treatment modalities as compared to conventional measures. 34

35.   The objective of furcation therapy is to:- 1) Facilitate maintenance 2) Prevent further attachment loss; and 3) Obliterate the furcation defects as a periodontal maintenance problem (the establishment of an anatomy of the affected surfaces that facilitate proper self performed plaque control). 35 TREATMENT OF FURCATION DEFECTS

36. Class I (Early defects) – Incipient or early furcation defects are amenable to conservative periodontal therapy (Oral hygiene, Scaling and Root planing). Any thick overhanging margins of restorations, or cervical enamel projections should be eliminated by odontoplasty or recontouring or replacement 36 THERAPEUTIC CLASSES OF FURCATION DEFECTS

37. Class II – Once a horizontal component to the furcation has developed (class II) therapy becomes more complicated. Shallow horizontal involvement without significant vertical bone loss usually responds favourably to localized flap procedures with odontoplasty and osteoplasty . Isolated deep class II furcation may respond to flap procedures with osteoplasty and odontoplasty . 37

38. Class II to IV – Advanced defects- The development of a significant horizontal component to one or more furcation of a multirooted tooth (Late class II, Class III or IV) or the development of a deep vertical component to the furca poses additional problems. Periodontal surgery, endodontic therapy and restoration of the tooth may be required to retain the tooth. 38

39. THERAPY 39

40. It results in resolution of the inflammatory lesion in the gingiva, healing will re-establish a normal gingival anatomy with the soft tissue properly adapted to the hard tissue walls of the furcation entrance. 40 SCALING AND ROOT PLANING Non-Surgical Root Preparation

41. Fig. Resolution of inflammatory lesions in the gingiva achieved by scaling, root planing and the re-establishment of a correct tissue morphology in the inter-radicular area of degree I furcation-involved mandibular molars . 41 b) after therapy a) Before therapy

42. It is a resective treatment modality which should leads to the elimination of interradicular defect. Tooth substance is removed ( odontoplasty ) and the alveolar bone crest is remodeled ( osteoplasty ) at the level of the furcation entrance. 42 FURCATION PLASTY

43. This technique is used to treat deep degree II and degree III furcation defects in mandibular molars. The procedure involves the surgical exposure and management of the entire furcation area of the affected molar and can be offered at mandibular molars which have a short root trunk, a wide separation angle and long divergence between the mesial and distal root . 43 C) TUNNEL PREPARATION

44. 44 Tunnel preparation of a degree III-involved mandibular molar a) Radiograph b) photograph Fig Wide inter-radicular space where self-performed plaque control can be obtained by the use of an interproximal brush.

45. Root resection Root resection is the process by which one or more roots of a tooth are removed at the level of the furcation while leaving the crown and remaining roots in function. The objective of root resection is the obliteration of the furcation as a problem in periodontal maintenance. 45

46. Root resection may be indicated in multirooted teeth with grade II to IV furcation involvements. Root resection may be performed on vital tooth or endodontically treated tooth, however it is preferable to have endodontic therapy completed before resection of a root (Harrington, 1979 ). 46

47. Teeth that are of critical importance to the overall dental treatment plan Teeth that have sufficient attachment remaining for Function Teeth for which there is no more predictable or cost-effective method of therapy Teeth in patients with good oral hygiene and low activity for caries are suitable candidates. Patients unable or unwilling to perform good oral hygiene and preventive measures are not suitable candidates for root resection or hemisection 47 Indication and contraindication of root resection by BASARABA (1969)

48. Remove the root(s) that will eliminate the furcation and allow the production of a maintainable architecture on the remaining roots. Remove the root with the greatest amount of bone and attachment loss. sufficient periodontal attachment must remain after surgery for the tooth to withstand the functional demands placed on it. Teeth with uniform advanced horizontal bone loss are not candidates for root resection. 48 Which root to remove?

49. Remove the root with the greatest number of anatomic problems, such as severe curvature, developmental grooves, accessory and multiple root canals. Remove the root that least complicates future periodontal maintenance . 49

50. 50 (a) After root separation (b) 3 months after completion of orthodontic therapy Fig. Increasing inter-radicular distance with orthodontic root movement

51.   A) ENDODONTIC TREATMENT RSR starts with endodontic therapy if the tooth to be resected is vital or if an improper root canal filling was placed in a non-vital tooth. Direct filling with amalgam or chemically cured composite of the endodontically treated should be performed before RSR. 51 SEQUENCE OF TREATMENT AT Root Seperation and resection (RSR)

52. B) PROVISIONAL RESTORATION Alginate impression of the area to be treated are taken and sent to the laboratory together with a wax record of the intercuspal position and a proximal restoration is prepared. 52

53. The most common root resection involves the disto buccal root of the maxillary first molar. After appropriate local anaesthesia, a full thickness mucoperiosteal flap is elevated. After debridement, resection of the root begins with the exposure of the furcation on the root to be removed. The removal of a small amount of facial or palatal bone may be required to provide access for elevation and facilitate root removal. 53 ROOT SEPARATION AND RESECTION (RSR)

54. A cut is then dissected from just apical to the contact point of the tooth, through the tooth and to the facial and distal orifices of the furcation. This cut is made with a high speed, surgical-length fissure or cross-cut fissure carbide bur. For hemi section, a vertically oriented cut is made faciolingually through the buccal and lingual developmental grooves of the tooth, through the pulp chamber and through the furcation. 54

55. If the sectioning cut passes through a metallic restoration, the metallic portion of the cut should be made before flap elevation, this prevents contamination of the surgical field with metallic particles. If a vital tooth resection is to be performed, a more horizontal cut through the root is given; since an oblique cut exposes a large surface area of the radicular pulp and /or dental pulp chamber which can lead to post-operative pain and can complicate endodontic therapy. 55

56. This root stump can be removed by odontoplasty after the completion of endodontic therapy or at the time of tooth preparation After sectioning, the root is elevated from its socket. Removal of the root provides visibility to the furcation aspects of the remaining roots and simplifies the debridement of the furcation with hand, rotary or ultrasonic instruments. 56

57. If necessary, odontoplasty is performed to remove portions of the developmental ridges and prepare a furcation that is free of any deformity that would enhance plaque retention or adversely affect plaque removal . 57

58. 58 Hemisection is the splitting of two rooted tooth into two separate portions. This process has been called bicuspidization or separation because it changes the molar in to two separate roots. It is most likely to be performed on mandibular molars with buccal or lingual class II or III furcation involvements. Hemisection

59. As with root resection, molars with advanced bone loss in the interproximal and interradicular zones are not good candidates for hemisection . The anatomy of the mesial roots of mandibular molars often leads to their extraction and the retention of the distal root to facilitate both endodontics and restorative dentistry The interradicular dimension between the two roots of a tooth to be hemisected is also important. Narrow interradicular zones can complicate the surgical procedure. 59

60. variety of grafting materials have been tested on teeth with different classes of furcation involvement. Furcation defects with deep two-walled or significant three-walled components may however be candidates for regeneration procedures 60 RECONSTRUCTION

61. The extraction of a furcation-involved tooth must be considered when the attachment loss is so extensive that no root can be maintained or when the treatment will not result in a tooth/gingival anatomy which allow proper self-performed plaque control measures. This is particularly true for individuals who cannot or will not perform adequate plaque control, have a high level of caries activity, will not commit to a suitable maintenance programme or have socioeconomic factors that may preclude more complex therapies. 61 EXTRACTION

62. THANK- YOU 62