Furcation involvement

furcation

1. Furcation involvement

2. CONTENTS - Introduction -Anatomical considerations -Classification -Epidemiology - Etiopathogenesis -Diagnosis -Management -Factors affecting clinical outcome -Conclusion -References

3. Introduction Furcation is an area of complex anatomic morphology, that once involved is difficult to debride by routine periodontal instrumentation.

4. Furcation – anatomic area of a multirooted tooth where the roots diverge. AAP 1992 Furcation invasion – pathologic resorption of bone within the furcation . AAP 1992 Furcation involvement – invasion of the bifurcations/ trifurcations of multirooted tooth by periodontal disease.

5. Anatomical considerations 81% of furcation have orifice of 1mm or less and 58% 0.75mm or less (Bowers 1979)

6. 81% orifice of 1mm or less and 58% 0.75mm or less (Bowers 1979)

7. Classification

8. Glickman 1953. Grade I – incipient stage, suprabony pocket, R/G change absent Grade II – cul-de-sac, horizontal component. R/G – may/ maynot be present. Grade III – bone not attached to dome of furca . Grade IV –soft tissue apically receded, tunnel. Classification

9. Classification

10. Title Goldman 1958 Grade I : incipient. Grade II : cul-de-sac. Grade III : through & through.

11. Hamp et al 1975. Degree I - < 3mm Degree II - > 3mm, not total width. Degree III – through & through. Ramford & Ash 1979. Class I : beginning involvement. Tissue destruction < 2mm Class II : cul-de-sac > 2mm but not through & through. Class III : through & through. Classification

12. Title Lindhe & Nyman 1983 Degree I : initial horizontal loss < 1/3 width of root. Degree II : partial horizontal loss > 1/3, but not through & through. Degree II : total through & through loss

13. Title Riochetti 1982 Class I : 1mm of horizontal measurement. Class I a : 1-2 mm of horizontal invasion, earliest damage. Class II : 2-4 mm Class II a : 4-6 mm Class III : > 6mm

14. Title Basaraba 1990 Class I : initial/incipient furcal invasion Class II : partial/ patent furcal invasion Class III : communicating furcal invasion.

15. Title Staffileno Based on surface location, no of bony walls, degree of furcal exposure. Class I Class II Class III

16. Title Hain & Canter 1968 Similar to Hamp et al. Sub classified furcation by no of walls remaining.

17. Title Fedi 1985 Combined Glickman & Hamp classification. Grade I to IV. Grade II furcations subdivided degree I (< 3mm) degree II (> 3mm)

18. Title Vertical component Tarnow & Fletcher 1984. Subclass A – denotes furcation involvements with vertical bone loss of 3mm or less. Subclass B – vertical bone loss of 4-6 mm Subclass C – bone loss from the fornix of 7mm or more

19. Title Eskow & Kapin 1984 Same classification as Tarnow & Fletcher, but thirds instead of 3mm units are used.

20. Title Easley & Drenman1969 Based on the ledges & morphology of remaining bone. Class I : fluting coronal to furcation affected. no definite horizontal component. Class II : Type I – essentially horizontal, no buccal /lingual ledge. Type II - buccal/lingual ledge, definite vertical component. Class III : through & through.

21. Epidemiology Incidence and Distribution Lorato (1981) found that: Average no. of furcation involvement increased with age. Furcation involvement most common in 1 st permanent molars In maxillary molars, buccal aspects more often invaded. Maxillary premolars-Lower incidence of furcation . 22

22. 23 Plaque associated Inflammation Trauma from Occlusion Contributing anatomical factors Etiopathogenesis

23. Plaque associated Inflammation Extension of inflammatory periodontal disease in furcation area leads to inter- radicular bone resorption —reduction of bone height and formation of furcation defect. Furcation involvement is a phase in root ward extension of periodontal pocket(Glickman, 1950) Cellular and fluid inflammatory exudation---epithelial proliferation 24

24. Trauma from Occlusion Suspected etiologic/contributing factor in isolated furcation defects—crater like or angular deformities in bone---bone destruction is localized to one of the roots--controversial Glickman(1950) Waerhaug (1980) inflammation + oedema =extrude tooth Traumatized and sensitive 25

25. Contributing anatomical factors Cervical Enamel Projections Root trunk length Root length Root form Interradicular dimension Anatomy of furcation 26

26. 27 CERVICAL ENAMEL PROJECTIONS 8.6%-28.6% of molars(highest—maxillary and mandibular 2 nd molar) Grade I: extension from CEJ of the tooth to furcation entrance Grade II: approaches entrance but doesnot enter the furcation (no horizontal component) Grade III Extends horizontally into furcation Masters and Hoskins(1964) --Clinical significance

27. 2. Root Trunk length: Teeth with shorter trunks are more prone for development of furcation defects compared to ones with longer root trunk length. 3. Root length Determines the amount of attachment or support that a tooth will have. Teeth with long root trunks and short roots would have lost significant amount of support by the time the furcation is affected.

28. 3. Root form: Flutings on the root surface coupled with developmental grooves and concavities-- plaque retentive areas hastening the process of periodontal breakdown leading to early furcation involvement. 4. Anatomy of the furcation Bifurcational ridges, concavity in the root and accessory canals may jeopardize plaque control as well as treatment outcome.

29. Interradicular dimension: Degree of separation

30. Enamel Pearls Incidence: 1.1% - 9.7% ( moskow & canut et al(1990) In ,Maxillary 2 nd molar -found near the CEJ extending into molar bifurcations Prevent connective tissue attachment.

31. Diagnosis PROBING Mealy and Beybayer (1994) have investigated the role of transgingival probing in defining the anatomy of the furcation defect. They found it to be importance in determination of factors such as Morphology of the tooth The position in relation to adjacent teeth. Local anatomy of the alveolar bone. Configuration of bone defects. Presence and extent of other diseases such as caries and pulpal necrosis.  

32. Diagnosis Probing of the furcation . Instruments. : Nabers probe. Buccal and lingual furcation can be easily probed. Proximal furcations are difficult for probing particularly when broad contacts are present n adjacent teeth. In maxillary molars mesial furcation is located more palatally than to the buccal tooth surface. It should therefore be probed from the palatal aspect.

33. Diagnosis In contrast the distal furcation is located midway bucco-lingually and can therefore be probed either from the buccal or palatal aspect Furcation probing in maxillary premolar is very difficult due to the presence of anatomic variations such as longitudinal furrows, invaginations opening at varying distances from the CEJ.

34. Diagnosis Radiographs It should include intra oral periapical and vertical bitewing radiographs. Inter dental bone as well as that within the root complex should be examined. Inconsistency in clinical and radiographic findings may occur.

35. Differential Diagnosis 1. Endo- Perio lesions A pulpal pathology may involve the furcations via accessory canals.

36. Differential Diagnosis 2. Trauma from occlusion Increase occlusal forces may cause tissue destruction or adaptation within the inter radicular area of multirooted tooth. In such cases a radiolucency may be evident in the root complex and tooth may exhibit increase mobility. Probing however fails to detect any furcations involvement. In such situations occlusal adjustment should precede periodontal therapy. If the defect is of occlusal origin the tooth becomes stabilized and the defect disappears within weeks following occlusal correction.

37. Management Objectives of furcation therapy To facilitate maintenance. To prevent further attachment loss. Obliterate furcation defects as a periodontal maintenance problem.

38. Factors to be considered when deciding for mode of therapy Degree of involvement Crown-root ratio Length of root Degree of root separation Strategic value of tooth Root anatomy Residual tooth mobility Ability to eliminate the defect Endodontic therapy & complications Prosthetic requirements Periodontal condition of adjacent teeth.

39. Can be broadly classified as put forth by Kalkwarf and Reinhardt as follows. (1988) Maintain the furcation Increase the access to furcation Removal of furcation Closure of furcation with new attachment.

40. Maintain the furcation Hirschfeld and Wasserman evaluated 600 patients who had been treated for periodontal disease and followed with maintenance appointments every 4-6 months for at least 15 years. Many furcations were primarily treated by sub gingival scaling. During the 22 year span of the study of the 1464 molars involved 460 were lost

41. Maintain the furcation Waerhaug has noted a close association of 0.91 mm between the sub gingival plaque front and attachment fibers in areas of attachment loss in furcations . Some amount of plaque was always left behind when it was present in the central area prior to treatment. He concluded that subgingival plaque removal in the furcation was invariably incomplete.

42. Maintain the furcation Obliteration of the furcation : Baer et al (1983) proposed the elimination of anatomic niches by filling advanced furcation defects with biocompatible material. Furcation areas of 50 maxillary teeth and 20 mandibular molars were surgically exposed and 2 weeks later packed with Intermediate Restorative Material (IRM). Clinical success was reported for up to 5 years. They concluded that IRM was physiologically acceptable to gingival tissues, prevented caries and simplified plaque control. They also advised IRM placement in advancement furcations during flap reflection.

43. Increasing access to the furcation Gingivectomy / Apically positioned flap. Increases access for plaque control and allows resolution of periodontal inflammation.

44. Odontoplasty It is the reshaping of the tooth coronal to the furcation to improve access for plaque control. It increases entrance to the furca and reduces its horizontal depth. Mainly advised for Grade I and Grade II furcation defects. Caution should be exercised with regard to Hypersensitivity Pulpal irritation leading to permanent damage Pulp exposure Increase risk of root caries.

45. b . Osteoplasty and Ostectomy : Osteoplasty : Reshaping surfaces of bone without removing tooth supporting bone Ostectomy : Reshaping and removal of tooth supporting bone. Improved plaque control through osteoplasty is reported to be accomplished by-- --Creating bony ramps into the furcation area allowing the gingival to tuck into tooth concavities --Removing lip of the bony defect to decrease horizontal depth of the involvement --Reducing pocket depth by allowing apical adaptation of the flap. -- furcationplasty

46. Recommended for Grade I and II furcation involvements. In advanced cases of Grade II and Grade III furcations ostectomy may be extended into create a tunnel to expose the entire furcation area.

47. Tunnel preperation Grade III furcation Permits plaque removal Root caries Recurrent periodontitis

48. Such treatment should be restricted to Cases where other surgical procedures are contra indicated. Roots are divergent to allow adequate postoperative plaque control with inter proximal brushes Patient has demonstrated a high level of plaque control in the past. Hamp et al 1975—5 year clinical trial(7 teeth)—4/7 caries Helden et al 1989– 149 teeth(mean of 37.5 months)---75% functional

49. Grant and Stern advocate that such procedures often result in a reverse architerature , which may encourage further plaque accumulation. The main advantage of this technique -- avoidance of prosthetic reconstruction and endodontic therapy Anatomical consideration--maxillary

50. III. Elimination of the furcation : Terminology Tooth sectioning Root resection Hemisection /Root separation/ bicuspidization Root amputation

51. III. Elimination of the furcation : Root resection / Hemisection Objectives To resect the open root furcation area and make possible debridement of the residual root. To eliminate the periodontal pocket by removal of the furcation . To improve the furcation form for dental hygiene. To preserve maximum periodontal tissue to the residual root. To control inter dental sparse (embrasure) in the area adjacent to the root. To treat teeth with severe caries.

52. Indications for root resection and hemisection . --Advanced furcation involvement Grade II and Grade III is an absolute indication for root resection or hemisection .

53. Contra indications Insufficient periodontal support to save the roots Fused roots Extremely long root trunks. In conditions where endodontic treatment of the resected root is impossible. In patients who are unable to establish appropriate hygiene or where the strategic value of maintaining dental arch continuity is lacking.

54. From a prognostic point of view the following factors should be considered. Periodontal considerations. A long and wide root with a large crown is the ideal form After root resection / hemisection the crater like osseous defect around the residual root is removed by osseous resection and the periodontal pocket eliminated. A form that facilitates plaque control must be achieved. Patient must be capable of following through oral hygiene and keeping up the professional schedule.

55. Distobuccal root amputation of a maxillary first molar.

56. Bicuspidisation

57. 85- 100% predictable results if proper case selection,treatment and restoration done

58. Guided tissue regeneration

59. Guided tissue regeneration in the treatment of degree III furcation defects in maxillary molars Pontoriero R, Lindhe T, JCP, 1995; 22:810-812. 11 subjects with generalized periodontitis and advanced lesions in the maxillary molar regions, bilateral mesial distal, but not buccal degree III furcation defects in 1st and 2 nd molars --some reduction in PD and some gain in CAL had occurred at both test and control sites -- none of the furcation defects had closed, but retained the characteristics of degree III furcation defects.

60. Guided Tissue Regeneration in the treatment of degree II furcations in maxillary molars Pontoriero R, Lindhe J JCP 1995; 22:756-763 . 18 inter proximal (10M, 8 D) and 10 buccal pairs Re-entry after 6 months. The addition of GTR enhanced the result by promoting probing attachment and bone gain and decreases soft tissue recession on buccal furcation only None seen on mesial / distal furcation .

61. GTR in degree II furcation involved mandibular molars. Pontoriero R, Lindhe J JCP 1988: 15:247-254. 21 subjects --more than 90% of the sites treated with GTR complete resolution of the defect occurred. --Conventional therapy attained the same result in < 20% cases.

62. EXTRACTION OF FURCATION INVOLVED TEETH when attachment loss is so extensive that no root can be maintained or when treatment would result in a tooth form where plaque control by the patient is difficult to achieve. when no improvement of the overall treatment plan is expected or carious lesions or endodontic problems may cause the preserved tooth to be a future risk with regard to long-term prognosis.

63. I. Patient factors Adequate plaque control is a must for successful outcome. Cigarette smoking Rosenberg (1994), Tonetti et al (1995) showed less attachment gains in intra bony defects following GTR in smokers than non smokers. FACTORS AFFECTING CLINICAL OUTCOME

64. II. Defect factors Degree 1 and 2 buccal and lingual furcations of 1 st and 2 nd mandibular molars respond well to GTR therapy. However in maxillary molars location of the defect plays a critical role as no improvement beyond that of debridement as obtained in interproximal degree II defects compared to buccal defect ( Ponteriero et al 1995)

65. Direct correlation between initial depth of the defect and gain in attachment of GTR is observed. Based on present evidence successful outcome of GTR treatment can be expected only in mandibular and maxillary buccal degree II furcations .

66. III. Technical factors A flap management technique that places wound margins away from the entrance to the healing defects is essential for + ve outcome of regenerative therapy of furcation defects. Sander and Karring (1995) studied significance of bacterial contamination in monkeys. The findings of this study showed that new attachments and bone formation was favored considerably if bacterial contamination of the membrane was prevented during wound healing.

67. IV. Antibiotic therapy. Nyland & Egelberg (1990) studied effect of tetracycline irrigation of the site as compared to saline One-year evaluation of attachmentlevels and pocket depths showed similar clinically negligible (<1 mm) variation

68. Prognosis In a 5-year study of Hamp et al (1975) 175 teeth with various degree of furcation involvement in 100 patients were noted. Of the 175 teeth. 32 (18%) - SRP 49 (28%) - SRP + Furcationplasty 87 (50%) - Root resection. 7 (4%) – Tunnel preparation. Patients were enrolled in a maintenance program of periodic recall of 3-6 months. Plaque and gingivitis scores measured ensured that oral hygiene maintenance was of the highest quality. None of the teeth were lost during 5 years of the study.

69. Prognosis Key to long term success --thorough diagnosis --selection of patients with good oral hygiene --careful surgical and restorative management

70. Conclusion The presence of furcation involvement is one clinical finding that can lead to a diagnosis of advanced periodontitis and potentially to a less favorable prognosis for the affected tooth or teeth. Furcation involvement therefore presents both diagnostic and therapeutic dilemmas.

71. References Carranza’s clinical periodontology . 10 th edition. Clinical periodontology and implant dentistry. Jan Lindhe . 5 th edition. Diagnosis and epidemiology of periodontal osseous lesions. Periodontology 2000, vol 22, 2000. The conservative approach in the treatment of furcation lesions Periodontology 2000, vol 22, 2000.

72. References Management of furcation involvement Periodontology 2000, vol. 9, 1995, 69-89 Current status for furcation involvements – dcna 35, no 3, 1991. Molar root anatomy & management of furcation defects – jcp 2001; 28;730. Atlas ofcosmetic and reconstructive periodontal surgery 3 rd edition, Edward Cohen

73. Thank you!!!