Management of Furcation Defects- Martinez

Question 1

What teeth are multirooted?

Answer 1

• Maxillary 1st premolar
• Maxillary &mandibular molars

Question 2

Furcation Involvement Classification:

Answer 2

Question 3

Nabers Probe markings

Answer 3

• 3mm increments
  
  • 3, 6, 9, 12

Question 4

Furcation involvement: Diagnostic Challenges

Answer 4

• Initial furcation involvement
  
  • undetected in radiographs
  • detected by periodontal probing
    
    • might not be accessible to probing (max distal)-→under diagnosis

Question 5

Furcation Involvement: Etiology

Answer 5

• attachment and bone loss progress apically in inflammatory perio disease→can involve furcations
• cofactors:
  
  • local anatomic factors
  • Trauma from occlusion
  • Endodontic-periodontal disease
  • Fractures extending into furcations
  • Iatrogenic cofactors

Question 6

Furcation involvement: Local Anatomic factors

Answer 6

• enamel pearls
• cervical enamel projections (CEPs)
• root concavities

Question 7

Furcation Involvement: Endodontic- Periodontal disease

Answer 7

• patent accessory and lateral canals
  
  • open from the pulp into PDL space
  • cause infection & inflammation of pulp origin in periodontist

Question 8

Furcation involvement: Fractures extending into furcations

Answer 8

• causes rapid localized alveolar bone loss in furcations

Question 9

Furcation involvement: Iatrogenic cofactors

Answer 9

• endodontic perforations
• overhang restorations
• violation of biologic width

Question 10

Treatment of furcation involvement

Answer 10

Depend on these factors:

• Root diverence
• Root Trunk Length
• Root length & amount of remaining bone support
• Root proximity to adjacent teeth
• Bone loss pattern

Question 11

Tx: Root Divergence

Answer 11

• Close roots or fused root prevent instrumentatoin
• far apart roots
  
  • more treatment options
  • easier to treat

Question 12

Tx: Root Trunk Length

Answer 12

• Short root trunks
  
  • easier to access for maintenance procedures

Question 13

Tx: Root length and amount of remaining bone support

Answer 13

• long root trunks + short roots
  
  • lose most of their bone support
  • poor prognosis for any treatment

Question 14

Tx: Root proximity to adjacent teeth

Answer 14

• prevent adequate instrumentation
  
  • Same as inadequate root divergence

Question 15

What are all the possible treatment options for furcation involvement?

Answer 15

• Resective therapy
  
  • root amputation
  • hemisection
  • bicuspidization
  • tunnelization
• non regenerative therapy
  
  • open flap debridement
  • osseous surgery
• Regenerative therapy
  
  • GTR
  • osseous graft
  • biologics
• Laser Therapy
• Photodynamic therapy
• Endoscope
• Local delivery of antibiotics
• Statins
• Extraction and implants

Question 16

Resective Therapy

Answer 16

• Types:
  
  • root amputation
  • hemisection
  • bicuspidization
  • tunnelization
• Use when you cant extract or implant
• Retention of molars after respective therapy:
  
  • median survival=20 years
  • cumulative survival rate: 90% at 10 years, decreased after
• Complications that led to extraction:
  
  • perio 50%
  • Endo 25%
  • Caries: 15%

Question 17

Regenerative Therapy:

Answer 17

• Types:
  
  • GTR
  • osseous/bone graft
  • biologics (ex: EMD)
• GTR
  
  • Long term survival rate: 83-100% after 5-12 yrs
  • better than: OFD, tunneling, root amputation, hemisection
• GTR & Bone graft=best treatment for class 2 furcation involvement
• EMD (biologic)
  
  • better reduction in the # of proximal class 2 FI after 24 months vs OFD

Question 18

Laser Therapy

Answer 18

• only 1 study shows furcation regeneration
• more research is necessary

Question 19

Furcation Involvement: Therapeutic Challenges

Answer 19

• Majority walls are nonosseous
  
  • root surface
  • furcation dome
• Covered by:
  
  • cementum
  • dentin or enamel (sometimes)
    
    • enamel pearl
• Reduced area vascularity and limited source of bone precursor cells
  
  • challenge for regeneration
• Cervical Enamel Projections
  
  • complex= pouch-like opening that house oral biofilm that resist most extreme oral hygiene measures
  • help progression of furcation
• Narrow Furcation fornix
  
  • impossible for patient to maintain oral hygiene
  • hard to perform debridement