Furcation case

• 1. Case discussions

2. A 28-year-old male patient reported to the Department of Periodontology with chief complaint of a dull pain in right lower back teeth for past 10 days. Pain dull gnawing persistent pain aggravates with mastication. 3. Clinical examination Extraorally no abnormality of lymph nodes and TMJ detected Intraorally Oral hygiene was fair No soft tissue abnormality 4. Region of complaint- 46: Bluish red localized inflammation of the gingiva with exudate. Probing depth of 5mm buccally, 6mm interdentally on mesial and 6mm on distal aspect. Premature contacts were present wrt to 16 leading to trauma from occlusion Nabers probe was used to check for furcation involvement. There was partial penetration of probe, did not pass through and through. 5. Radiograph - radiolucency involving the furcation wrt 46. Loss of mild crestal interdental bone mesially and distally. Widening of PDL space in the inter-radicular region wrt 46. Loss of lamina dura evident in the roof of furcation furcation arrow.Grade II furcation involvement 6. DIAGNOSISChronic localized periodontitis irt 46Grade II furcation involvement 7. Treatment plan Non surgical therapy ( scaling and root planing) was doneand patient was kept on maintenance for 1 month. Occlusal correction done to correct trauma fromocclusion. Patient recalled after I month for evaluation and treatmentof furcation 8. Treatment for furcation involvement 9. Osseous defect debridedBone graftPRF placement 10. Post op healing after 15 daysAfter 6 monthsRadiographic picture after 6 months 11. 50 year old female patient had reported to the department of periodontology with the chief complaint of deposits on teeth . Patient was hypertensive , on medication. Health check up was done one month back and BP was 140/80. Dental history- lower anterior teeth had been extracted uneventfully 2 years back as they were mobile and grossly decayed C a s e II 12. On clinical examination Extraorally no abnormality of TMJ, lymph nodes detected Intraorallypoor oral hygeine Generalized probing depth of more than 5mm Grade I mobility in 36 associated with probing depth of buccally 7mm, interdentally 9 mm on distal and 7mm on mesial aspect. Proximal caries on the mesial aspect. 13. 36- Furcation involvement with nabers probe through and through involvement, not visible clinically. Radiographically- loss of interdental bone upto apical third wrt to distal root involving the furcation. On endodontic evaluation- Tooth was non vital 14. Chronic generalized periodontitisDiagnosis Furcation Grade III for 36??? 15. Treatment plan Non surgical periodontal therapy( scaling and root planing) Root canal treatment for 36 Periodontal treatment for 36Regenerative procedures? Hemisection ? Tunelling? 16. Raising mucoperiosteal flapNaber s probe grade III 17. hemisectionPlacement of bone graft and PRFsuturing 18. After 1 monthProsthodontic 3 unit bridge 19. Furca meansDivision Bydefinition A furcation is defined as the anatomic area of a multirooted tooth where the roots diverge. Furcation invasion refers to pathologic resorption of bone within a furcation. ( American Academy of Periodontology, 2001) 20. CLASSIFICATION OF FURCATION INVOLVEMENTGLICKMAN(1953)HAMP , NYMAN & LINDHE(1975)TARNOW & FLETCHER(1984) 21. GLICKMANS CLASSIFICATION 1953 Grade-I: Incipient or early stage Soft-tissue lesion or pocket extendinginto flute of furcation Suprabony pocket Inter-radicular bone intact or slightbone loss Radiographic evidence of bone lossusually not there 22. GRADE II Pocket formation & loss of inter-radicular bone of varying depths into the furcation but not through and through Portion of PDL and bone remainintact Cul de sac with a horizontalcomponent Partial penetration of probe ; Radiographs may or may not depict involvement esp. in maxillary molars. 23. Grade-III: Complete loss of inter-radicular bone Radiographic evidence--small triangular radiolucency Pocket formation --completely probable to the opposite side of the tooth Furcation not visibleclinically occluded by gingival tissue 24. Grade-lV: Same as Grade III except that loss of periodontal attachment &gingival recession -- furcation clearly visible to a clinical examination. 25. CLINICAL AND RADIOGRAPHIC CO RELATION OF GRADE 2, 3 AND 4. 26. Tarnow & Fletcher (1984)Takes into account vertical bone loss from roof of furcation apically Subclass A: Vertical destruction to one third of the total inter radicular height (3 mm or less).Subclass B: Vertical destruction reaching two thirds of the inter radicular height (4 to 6 mm).Subclass C: Inter radicular osseous destruction into or beyond the apical third (> 7 mm). 27. Etiology of furcation invasions PLAQUE ASSOCIATED OCCLUSAL ORIGIN ENDODONTIC ORIGIN COMBINED ORIGIN IATROGENIC FACTORS ROOT FRACTURES INVOLVING FURCATIONS 28. DIAGNOSIS2 Basic traditional methods are: CLINICAL PROBING RADIOGRAPHIC ASSESSMENT 29. Clinical probing The buccal furcation entrance of maxillary molars and buccal and lingual furcation entrances of the mandibular molars are normally accessible for examination using either of the following: a) A curved graduated periodontal probe b) An explorer c) A small curette 30. Probing of maxillary premolars often difficult due to limited access Flap explorative (surgical) procedure in the area Maxillary molars Distal furcation - located midway bucco-lingually -probing from both sides Mesial furcations- located 2/3rd towards palate -probed from palatal aspect 31. RADIOGRAPHS IN FURCATION DIAGNOSIS Should include both paralleing periapical and vertical bite wing Slight radiographic change in the furcation area should be investigated clinically, esp if there is bone loss on adjacent roots Diminished radiodensity in furcation area in which outlines of bony trabeculae are visible suggests furcation involvement Whenever there is marked bone loss in relation to a single molar root, it may be assumed that the furcation is also involved 32. Three broad strategies of furcation therapy (Kalkwarf & Reinhardt R.A 1988) I. Maintenance of the existing FurcationScaling and root planing Obstruction of Furcation II. Increasing access to the Furcation Gingivectomy/Apical positioned flap Odontoplasty Furcationplasty Osteoplasty /ostectomy III. Elimination of the Furcation Root amputation/ resection Bicuspidization 33. Recommended methods of therapy Degree I SRP Furcation plasty Degree II Furcation plasty GTR at mandibular molars Tunnel preparation Root resection Degree III Tunnel preparation Root resection Tooth Extraction 34. Indications of surgical procedures A significant amount of horizontal involvementof one or more furcations of multirooted teeth Inability to adequately instrument the furcation by scaling and root planingSevere bone loss accompanying the furcation which may require regenerative techniqiuesCarried out mostly in advanced grade II and grade III and grade IV furcations 35. 1.Cul de sac involvement of furcation according to Glickmans classification of furcation is: a. Grade I b. Grade II c. Grade III d. Grade IV 2.The classification of furcation involvement based on vertical component was given by: a. Glickman b. Hamp and Co-workers c. Tarnow and Fletcher d. Miller 3.Which of following tooth furcation involvement has a better prognosis? a. Mandibular molar b. Maxillary 1st premolar c. Maxillary molar d. None of the above 36. 4. The clinical probing of a furcation is done with the help of: a. Williams graduated probe b. UNC 15 probe c. Nabers probe d. All of the above 5.The root most commonly removed in root resection procedure in maxillary 1st molar is : a. Mesiobuccal b. Palatal c. Distobuccal d. Any of the above 6.Probing of mesial furcation of maxillary molars is done from: a. Buccal aspect b. Distal aspect c. Palatal aspect d. Mesial aspect