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Furcation The Problem and Its Management
Furcation The Problem and Its Management
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.
Anatomical Considerations
Root trunk Furcation entrance Root surface anatomy Enamel projections Accessory canals
Root Trunk
Represents the undivided region of the root. The height of the root trunk is the distance between the CEJ and the separation line between two root cones
Furcation Entrance
Entrance: the transitional area between the undivided and the divided part of the root Fornix: the roof of the furcation
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
Root Concavities
Mandibular Molars 100% mesial roots 99% distal roots Maxillary Molars 94% mesiobuccal roots 31% distobuccal roots 17% palatal roots
13% of molars have CEPs These projections may favor the onset of periodontal lesions in the affected furcations
Enamel Pearls
Incidence: 1.1% - 9.7% Maxillary 2nd molar found near the CEJ extending into molar bifurcations
Classification
Glickman`s Classification(1953)
The level of bone loss allows for the insertion of the periodontal probe into the concavity of the root trunk
The level of bone loss allows for the insertion of a periodontal probe into the furcation area between the roots.
Class IV
As in Class III, but the gingival tissues recede apically so that furcation is clearly visible.
Furcation Probing
Furcation Probing
Mandibular Molars
Buccal Furcation Place the probe between the two buccal roots from the buccal aspect
Furcation Probing
Mandibular Molars
Lingual Furcation Place the probe between the two lingual roots from the lingual aspect
Furcation Radiography
Location of the interdental bone and bone level within the root complex should be examined
Differential Diagnosis
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
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 selfperformed plaque control.
Scaling & root planing Most effective in grade I and shallow grade II. Deeper sites respond less favorably
In most situations, it results in the resolution of the inflammatory lesion in the gingiva.
Antimicrobials
Adjunct to scaling and root planning Chlorhexidine Tetracycline fibers No clinically significant difference in clinical parameters after irrigation
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.
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
Root Resection
Contraindications Inadequate bone support Fused roots Inoperable endodontically Patient considerations
Endodontic treatment Provisional restoration RSR Periodontal surgery Final prosthetic restoration
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
Hemisection
Mandibular molars Grade III furcation Need widely separated roots Soft tissue positioned below level of pulp chamber
Hemisection
Root Separation
Root separation involves the sectioning of the root complex and the maintenance of all roots
Grade III furcation Permits plaque removal Root caries (4% stannous fluoride) 25% failure rate at 5 years Recurrent periodontitis
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
Furcation Defects
Most predictable Mandibular or Buccal Maxillary Class II Furcations Mesial or Distal Maxillary Class II Furcations
Osseous Grafting
Autogenous bone Allografts Freeze dried bone Demineralized Freeze dried bone
Alloplasts Hydroxyapatite
Non-porous Porous
Bioglass
Extraction
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
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