Furcations Flashcards
What is furcation involvement
Horizontal loss of bony support in areas where roots of multi rooted teeth converge.
It is always in the areas between the root cones (not trunk)
Where there is loss of attachment -furcation happens/bifurcation is exposed
Furcation indicates severe/advanced periodontal disease in that site-reduced prognosis
Aetiology of furcation involvement
It is the result of plaque-induced inflammation within the periodontal tissues which then move away from the furcation.
Prevalence and severity increases with age
Local plaque retentive factors may affect furcation development -cervical enamel projections, overhangs…
Which teeth and which sites are affected
Any multi-rooted tooth
Always check all molars and upper 4 s
Previous radiographs can be useful
Maxillary molars and furcation
3 roots so check mesio-palatally, buccaly and distally
Roots can be divergent or fused.
Maxillary premolars /first
Can have 2 roots which often bifurcate further apically /in mid-apical third (so distance from furcation and CEJ is great)-resection is not great
Mandibular molars
Check buccaly and lingually as two roots
6s have more furcation involvement as buccal bone- in that area is thinner compared to one next to 7s and 8s
Difference in maxillary and mandibular furcation involvement
In manidbular- even if attachement loss and bone loss is severe, only buccal and lingual plates are involved/affected. As long as there is no interproximal loss of bone, maintaining the tooth with furcation won’t have much negative effect on adjacent teeth
In maxillary- potential for severe damage to the mesial and distal bone areas which can affect adjacent teeth - for this reason, more aggressive treatment is needed in maxillary than mandibular teeth with furcation
How to diagnose furcation involvement
Diagnosis should be done clinically rather than radiographically
Radiographs can suggest furcation as some furcation are difficult to see if filled with soft tissues or due to superimposition.
Radiographs are useful once diagnosis is verified clinically - can help to show root apices and extent of the bone loss relative to the length of the root
Differential diagnosis
Occlusal trauma can present with widening of PDL and tunnelling bone loss with/out furcal bone loss
Articulating paper to be used in ICP and excursion.
Pulpal pathosis can cause inter-radicular lesions.
Sensibility tests- if non-vital: first do Endo, then perio.
If viral: treat as plaque-induced periodontal disease and review with further sensibility testing
Probing around full circumference of the root-if furcation present:
1. Determine the extent of the furcation defect
2. Position of the attachment level relative to the furcation
3. Configuration of the furcation involvement
4. Identify factors that may have contributed to the development of the furcation (morphology, tooth position, anatomy of alveolar bone, extent of restorations, presence of caries….)
5. Identify factors which may complicate the treatment of furcation defect
Why are the furcations hard to access
Majority have an entrance size of less than 1 mm.
Nabers probes are curved and shaped to access furcation more readily
Local anatomical factors
Root trunk length -if short- can expose furcation sooner but makes he furcation more accessible for treatment
Root length- if short- little is left in the bone so less support and can reduce the ability to deal with functional demands-leading to occlusal trauma
If long roots- have more anchorage
Root form- some are curved - due to shape it is difficult to clean or even access the surface
Inter-radicular dimension/ degree of separation of roots- teeth with widely separated roots are easier to treat as there is greater access for instruments
Anatomy of furcation- concavities, accessory canals, bifurcational ridges, perforations…
Cervical enamel projections- plaque retentive factors and can complicate the management of furcation involvements. They act as a tunnel for bacteria to enter the furcation as they prevent a connective tissue attachment to the tooth in this area
Enamel pearls-represent and area devoid of connective tissue attachment and lead to plaque accumulation.
Sequelae of furcation involvement
Caries can happen in furcation due to plaque stagnation and can go into pulp and cause pulpal necrosis
Furcal/accessory canals within the furcation can allow direct entry to RCS and pulpal death
*Good practice to often do sensibility tests on teeth with furcations and record it
Treatment options for furcation involvement -objectives
Treatment aims two objectives-
1.eliminate microbial plaque from the exposed root surface
2. To establish anatomy allowing effective plaque removal/control
Earlier furcation is identified/diagnosed-easier is to treat it
KEY- acheiving plaque free zone
Treatment option for Hump class I
OHI
Repeated scale and polishing, RSD
Non surgical mechanical debridement
Furcationplasty-it is a surgical resection treat to eliminate the interradicular defect. Mainly for buccal and lingual furcations. It is recontouring/smoothening the roof of the furcation to eliminate plaque traps and facilitate OH, usually by raising a flap to expose the area and remove granulation tissue
Pocket elimination surgery with or without osseous recontouring
Post treatment success defined as:
1. No entrance to the probe into furcation
2. Pocket of no more 3 mm or BOP
Treatment options for Hump class II
Options:
Furcationplasty
Tunnel preparation
Root resection
Guided tissue regeneration (GTR)- in mandibular molars- ideal treatment-to regenerate lost attachment (perio tissues), form new cementum, functionally orientated PDL, alveolar bone and gingivae. Most success in class II.
Enamel matrix derivative (EMD)-Emdogain -use enamel matrix proteins, it is surgery without bone recontouring. Flap is raised, exposed roots are treated with EDTA and then Emdogain is syringed into the defect and flap placed back on
XLA- final treatment. Can be indicated if the tooth with the furcation is unopposed and the last standing molar in the arch; if adjacent teeth have enough bone support and prosthesis or implant can be placed; if increasing mobility; if pt have poor OH/plaque control, high caries activity, if not commited to suitable maintenance program; complex medical history; even if class I furcation-tooth should be considered for XLA is bone loss is affecting adjacent teeth and cause periodontal involvement of those
