Classification of Furcation Involvement Question And Answers

Management Of Furcation Involvement Question And Answers

• The treatment of periodontally diseased multirooted teeth and the involvement of the furcation in these cases present a unique therapeutic problem.
• Access of instrumentation and complications in anatomy are the primary limitations to the management of furcation involvement. The evolution of new methods of instrumentation and regenerative techniques has mitigated this problem somewhat.
• But furcation involvement nevertheless remains one of the challenges to periodontal therapy.

Furnication Definition

Read And Learn More: Periodontology Important Question And Answers

Question 1. Define and classify furcation or Furcation In Dentistry
Answer:

Furnication Definition: Furcation is an area of complex anatomic morphology that may be difficult or impossible to debride by routine periodontal instrumentation.

Furcation Involvement Classification or Classification Of Furcation

Furcation Grade 1: It is the incipient or early stage of involvement of furcation. Radiographic changes of bone loss are not found usually.

Furcation Grade 2: It is a ‘cul-de-sac’ lesion. It affects one or more furcation of the same tooth which does not communicate with each other. There is a definite horizontal component with or without vertical bone loss. There is radiographic evidence of bone loss in most instances.

Furcation In Dentistry

Furcation Grade 3: It is a through-and-through involvement of the furcation where the bone is not attached to the dome of the furcation and it may be filled with soft tissue. The furcation involvement is not clinically visible.

Furcation Grade 4: It is clinically visible through-and-through furcation with a tunnel existing between the roots of the affected tooth. There is interdental bone loss and the soft tissues would have receded apically exposing the furcation.

Dental Furcation Treatment – Furcation Therapeutic Objectives: Management of furcation involvement is primarily aimed at achieving the following two treatment objectives:

1. Elimination of periodontal disease and etiologic factors from the furcation area and possible regeneration of lost tissue and structure.
2. Establishment of a furcation anatomy that is conducive to proper maintenance.

Based on Glickman’s classification the following recommendation for management can be made although they may not be universally applicable.

1. Grade 1: Furcation Involvement – Scaling root planing and furcation odontoplasty.
2. Grade 2: Furcation Involvement – Furcation odontoplasty, periodontal flp surgery, regenerative periodontal therapy.
3. Grade 3: Furcation Involvement –  Furcation odontoblasts, periodontal flap surgery, regenerative periodontal therapy/tunnel preparation/ root resection/tooth extraction.
4. Grade 4: Furcation Involvement – Periodontal flap surgery, regenerative periodontal therapy/coronally repositioned flap/tunnel preparation/root resection/tooth extraction.

Furcation In Dentistry

Question 2. Describe the Furcation Management Techniques.
Answer:

Furcation Odontoplasty

• This respective form of treatment is used to alter the shape of tooth substance and is usually performed at the level of the furcation entrance. It is usually feasible only in buccal and lingual furcations.
• It is useful to remove enamel pearls, projections, and other plaque retentive morphological problems at the furcation entrance. Additionally, it can also be used to widen the furcation entrance or eliminate /reduce the horizontal component of involvement.
• Furcation odontoplasty must be performed with caution as it increases the risk of tooth/root hypersensitivity and pulpal exposure.

Odontoplasty

Dental Furcation Treatment – Scaling And Root Planing

• Scaling and root planing of all root surfaces enclosing the furcation results in the elimination of etiological factors and cemental endotoxins. This in turn results in the resolution of soft tissue inflammation and good adaptation of the gingiva to the furcation walls.
• Access of hand instruments is frequently limited in furcation areas. Very few hand instruments are designed to enter the furcation area and be angled properly to debride root surfaces.
• Ultrasonic devices have helped to overcome this problem to some extent and specially designed slim instruments and diamond-coated ultrasonic curettes are quite effective in furcation areas.
• Ultrasonic scaling also offers the additional benefit of irrigation and the resultant beneficial effects of cavitation and debridement in an enclosed area.
• Some have attempted chemotherapeutic irrigation as well, although the evidence for use of these agents is as yet limited. The use of controlled drug delivery devices as an adjunct to scaling and root planing may however hold some promise for the future.

Furcation Involvement Classification

Dental Furcation Treatment – Tunnel Preparation

• Tunnel preparation of multi-rooted teeth is performed in grade 3 and grade 4 furcation involvement when alternative forms of periodontal therapy are not possible. The primary objective of this mode of treatment is to establish a self-cleansing furcation area which is also conducive to patient maintenance with interdental cleansing aids.
• The th procedure is frequently possible only in mandibular molars and may occasionally require apically repositioned periodontal flap surgery as well. There is a risk of root hypersensitivity and development of root caries in this procedure.
• Tunnel preparation is performed with the help of rotary instruments, and care must be exercised to avoid damage to the root surfaces as pulpal proximity may result in pulp exposure and pathoses.

Odontoplasty

Question 3. Describe Root Resection and Separation. Write a note on the factors governing this procedure.
Answer:

The resection of one or two roots of a multi-rooted tooth or separation of tooth/root structure has been a common procedure for the management of furcation involvement in the past.

• The evolution of periodontal regenerative therapy has diminished the use of these procedures to some extent and they are limited to some situations where alternative therapy is not possible.
• Several factors affect the consideration of root resection as a treatment modality.

Odontoplasty – Root Trunk Length

• The trunk of the root is that portion of the root length prior to root separation.
• Short root trunk length is not conducive to root resection.

Odontoplasty – Root Divergence

• The fire of divergence between roots of multi-rooted teeth is an important factor in the availability of space for root resection.
• In the case of root fusion, root proximity, etc. root resection may be impossible.

Dental Furcation Treatment – Remnant Tooth and Bone Structure

• It is important to consider the length of the root left behind after 1 or 2 roots have been resected as the tooth depends on the remnant root structure for periodontal stability.
• The amount of bone around remnant roots will also have to be carefully assessed.
• In the case of diminished remnant root length or when periodontal support around the remnant root is unfavorable, root resection may have to be rejected as a treatment option.

Furcation Involvement Classification

Accessibility for Oral Hygiene: Remnant tooth structure or the final prosthesis that follows root resection will have to be conducive to patient maintenance failing which recurrence of periodontal disease in the furcation will occur.

Furcation In Dentistry

Root Resection

• It is usually carried out in cases where the extent of disease and bone loss is confined to one root of a multi-rooted tooth. It is performed with the help of rotary instruments.
• The procedure involves raising a periodontal flap to assess the root to be resected. Resection of the root is usually carried out at the level of the point of separation.
• An oblique cut is made to resect the root completely and separate it from the remnant tooth structure. Elevators may then be used to carefully extract the amputated root. This is usually easy because of the amount of bone loss confined to the amputated root.
• A rotary instrument is then used to burn the tooth at the point of amputation. Reduction of the occlusal table of the tooth may also be considered to decrease the effect on the diminished remnant periodontium.
• A dressing may be placed on the pulpal floor if vital root resection has been attempted. However endodontic treatment of the tooth is recommended before root resection if such therapy is indicated.

Root Separation Or Bicuspidization

• It is a procedure that is performed in a situation where the extent of periodontal disease is confined to the furcation with sufficient bone support for individual roots to exist separately.
• A common example is a mandibular molar where the separation of two roots along with the coronal structure above them can result in two premolars or bicuspids. This procedure is usually performed when the furcation area is inaccessible and therefore not amenable to other forms of treatment.
• In the case of root proximity, orthodontic separation of the two resultant halves of the tooth may also be considered. Endodontic treatment of the tooth must essentially be performed before attempting root separation.
• Prosthetic restoration of the resultant separated portions will also have to be considered.

Hemisection

• It is a procedure that is commonly carried out in mandibular molars when the extent of periodontal disease or bone loss is confined to one root. The procedure is similar to root separation, but differs from it in that one-half of the tooth is constituted by the affected root, and its coronal structure is extracted.
• The remnant root and coronal structure are commonly restored prosthodontic allies as a fixed partial prosthesis where the prosthetic portion constitutes the hemisected part of the crown. It is important to compensate for the thickness of the rotary instrument used while performing a hemisection.

Question 4. What are the indications and contraindications for root resection or hemisection?
Answer:

Root Resection Or Hemisection Indications

1. Grade 3 and grade 4 furcation involvement
2. Advanced caries in one portion of the tooth
3. Severe soft tissue recession on a single root
4. Root caries
5. Endodontic failure or endodontic contraindication
6. Root resorption or iatrogenic perforation
7. Extensive bone loss confined to one root
8. Tooth fracture.

Furcation Involvement Classification

Root Resection Or Hemisection Contraindications

1. Poor crown root ratio
2. Unfavorable root trunk length
3. Poor remnant root—tooth periodontal support
4. Root fusion
5. Postresection prosthodontic contraindication
6. Endodontic contraindication
7. Poor access.

Furcation In Dentistry

Question 5. Describe the regenerative procedures attempted to manage furcation.
Answer:

• The topography of the furcation area is highly plaque-retentive and is thus a contributing factor to periodontal disease. However, the same topography is also conducive to the retention of bone grafts and the placement of barrier membranes in guided tissue regeneration.
• This has resulted in the extensive use of regenerative techniques in grade 2 and 3 furcation defects with much success.
• Consequently, the role of resective procedures in the management of furcation involvement has grossly diminished. The placement of osteoinductive bone grafts such as decalcified freeze-dried bone allograft (DFDBA) and alloplastics such as hydroxyapatite and bio-active grafts has yielded considerable success.
• The use of resorbable and non-resorbable membranes with or without bone grafts has also given good results. The topography of furcation defects often precludes the use of a bone graft in guided tissue regeneration techniques as space-making and retention are not a problem, as in the case of interproximal bone loss.
• The tooth also offers an excellent means of anchorage for membranes placed over a furcation defect. The use of regenerative periodontal therapy in the treatment of furcation defects is therefore on the rise, and grade II furcation defects in particular, represent one of the best prognostic outcomes in such therapy.

Coronally Positioned Flap

• Soft tissue recession concerning grade 4 furcation defects may sometimes require the use of a coronal repositioned flap concerning the affected tooth.
• This procedure is outlined in greater detail in the chapter on mucogingival surgery and the procedure may be used alone or in conjunction with periodontal regenerative therapy.

Furcation Involvement In Periodontal-Endodontic Therapy

• Involvement of the furcation is often seen in periodontal-endodontic lesions. Careful diagnosis needs to be made of whether the lesion is primarily periodontal or primarily endodontic, in which case exclusive periodontal or endodontic treatment can be instituted. In the case of the classic combined lesion, however, furcation involvement may see the use of one or more techniques described in this chapter.
• Careful diagnosis and management of furcation involvement can result in successful treatment outcomes despite anatomic limitations to treatment. The experienced clinician will also emphasize patient maintenance to prevent a recurrence.