Vol. 2011 ISSUE : 18

Swami Devi Dyal Hospital & Dental College

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The Journal of the Indian Association of Public Health Dentistry(JIAPHD), Vol. 2011, Supplement III, Issue: 18

With Best Compliments from

Vol. 2011

SUPPLEMENT III

ISSUE : 18

JOURNAL OF THE INDIAN ASSOCIATION OF PUBLIC HEALTH DENTISTRY Vol:2011 ISSUE:18 SUPPL. III

Periodontal Treatment of Multi – Rooted Teeth Dr.D.Jayanthi1, Dr.M.B.Aswath Narayanan2, Dr.S.G.Ramesh Kumar3 ABSTRACT Multi – rooted teeth present unique challenge to the success of periodontal therapy because of furcation areas. Anatomical and morphological complicating factors dictate modification in treatment modalities and to emphasize that for a detailed clinical, radiographical and intraoperative diagnosis of the furcation invasion. The various approaches are available for the treatment of multi – rooted teeth. Furcation management is usually, based on the individual clinical situations morphological, functional variations and also general health status of the concerned individual status of the concerned individual. BACKGROUND

system (removed during root procedures). Smaller root surface.

Multirooted teeth present unique challenge to the success of periodontal therapy because of furcation areas. Anatomical and morphological complicating factors dictate modification in treatment modalities and to emphasize that for a detailed clinical, radiographical and intraoperative diagnosis of the furcation invasion :

resective

Maxillary molar3

1. Mesial root is oblong, has distal concavity (retension) mesial furcation about 2/3 the buccopalatal surface of the tooth to the palate. So palatal approach in indication when probing the mesial palatal furcation.

“Furcation” is defined as “the anatomic area of a multirooted tooth where the roots diverge. “Furcation invasion” means pathologic resorption of bone within a furcation

2. Distal, palatal furcation shorts, is in the middle portion of the tooth – it can be probed from either facial (or) palatal application. IMPACT OF ETIOLOGIC FACTORS IN TREATMENT3

DIFFERENCE BETWEEN MANDIBULAR AND MAXILLARY MOLAR1,2

1. Primary factors

Mandibular molar furcations opens from the buccal to lingual direction. It do not damage the interdental bone of the adjacent teeth. Rather in maxillary molar it opens in mesial and distal with loss of interdental bone on adjacent teeth.

(a) Plaque associated inflammation: Extension of inflammatory periodontal disease process into the furcation areas leads to interradicular bone resorption and formation of furcation defects. No unique histological features were found in the furcation areas suggesting that they were extension of existing periodontal pocket. (Glickman 1950).

Mandibular molar3

1. Mesial root is thin, biconcave disk, have two root canal, apical portion shows distal curvature. That is obstacle to extraction when the tooth is sectioned. (mesial root is to be removed).

(b) Trauma from occlusion :

2. Distal root is more oblong, flat mesial and distal structure. It has one root canal and is easier to manage prosthethics because it is more parallel to the post.

3. Candidate for a post and core build up due to its perimeter morphology and root canal 1, 3

Controversy still exists: Trauma from occlusion is suspected etiologic factor in isolated furcation defects (Glickman et al, 1961) reported. The periodontal fiber orientation in furcation areas facilitated a more rapid spread of inflammation and accounted for inflammation increased susceptibility to occlusal forces. Trauma from occlusion combined with deeper inflammation in furcation results in

Assistant Professor, 2Professor and Head, Dept. of Public Health Dentistry, Tamilnadu Govt. Dental College and Hospital, Chennai.

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(b) Root Trunk and root length4

more rapid loss of attachment than from inflammation alone (Lindhe and Svanberg 1974). If etiology is trauma from occlusion first correct the occlusal prematurities than procede further management.

(i) Short trunk and long root lengths

(c) Pulpal pathology: The high percentage of molar teeth patent Accessory canals opening into the furcation suggests that pulpal disease could be in etiological factors.

More easy to furcation invasion The amount of remaining periodontal tissue support is sufficient. (Suitable for resection / separation of roots). Prognosis is good

Pulpal lesions are pure endodontic–treated early by endodontic therapy. These furcation defects, resolve with regeneration of new interfurcal bone and attachment. Combined endodontic – periodontic defect – prognosis is poor.

(ii) Long root trunk and short root length

Furcation invasion is non vital tooth – first to initiate endodontic therapy and wait 3 and 4 weeks for endodontic lesion healed clinically and to perform extensive periodontal surgery

Furcation involvement occur later Periodontal support is insufficient (not suitable for root resection procedure) Prognosis is poor

Surgical treatment of furcation invasion should be delayed for at least 6 months to allow for healing of hard and soft tissue defects caused by the endodontic lesion

(d) Vertical root fracture: Rapid, localized, alveolar bone lose is often associated with vertical root fracture. Root fracture involves the trunk of a multi – rooted, tooth, furcation – a rapidly forming isolated furation defects can result. The prognosis is poor and usually results loss of the tooth. (Lommel et al 1978).

3. Root Concavities1

(e) Teratogenic co-factors: Overhanging restoration lead to furcation invasion molar with crown (or) proximal restoration had a significantly high percentage of furcation involvement than non restored teeth (Wang et al, 1993). In these case first corrects the overhanging margin than proceds further management regarding furcation involvement.

Reducing efficacy of periodontal therapy

2. Contributing factors (a) Furcation Entrance width1

< 1 mm = 8.1% in maxillary molar = 63% < 0.75mm = 58% in mandibular molar = 53% (Baves et al, 1979) Considering that average width of a currette blade face ranges between. 0.75 to 1.10mm only for proper root preparation. 1165

Maxillary first molar. Concavities seen. Especially mesiobuccal roots (94%) Mandibular first molar, especially mesial root = 100%


These concavities exceed in 1mm depth and covered by a thicker layer of cementum than the adjacent root concavities which allow bacterial plaque, toxin calculus to penetrate further into the root surface and making their removal more difficult.

1. Intermediate ridges connect the mesial & distal root consists primarily cementum. 2. Buccal and lingual ridge primarily consists of dentin with thin lager of cementum. These ridges from root of the furcation locate more coronally than the entrance and provide yet another barriers to successful plaque control and root perforation.

4. Cervical enamel projections5 (CEPs)

The lack of connective tissue attachment on enamel surface. CEPs cause Because it is ectodermal origin derivative and is covered only by epithelium Incidence of CEPs – 28.6% (Mandibular molars), 17% (maxillary molars) CEPs make a molar more vulnerable to inflammatory disease. In 1964 Master’s and Hoskins classified CEPs into – 3 grades. Prevalence is higher in mandibular and second maxillary molar

These ridges in addition to root concavities, create small hard to reach inches and Cul-de-sacs for plaque control. 6. Enamel Pearls

Preventing connective attachment Prevalence of enamel – pearls in less thanCEPs Incidence 2.6% (Moskow and Canut 1990)7

7. Inter radicular dimension Grade I

Grade II

Distinct change in CEJ contour with enamel projecting toward the bifurcation ( 1/3).

1. Glickman (1953) 2. Goldman (1958) 3. Hamp et al (1975) 4. Ramford and Ash (1979)

Grade III

5. Ricchetti (1982)

CEP extending into the furcation proper

6. Tarnow & Fletcher (1984) IMPACT OF DIAGNOSIS8 (a) Radiograph:

Furcation arrow: Maxillary, small triangular, radiolucent shadow is seen over the mesial and distal root in the proximal furcation (deep grade II (or) grade III).

The extent of the enamel projection is directly proportional to the amount of furcation involvement. CEPs affects

1. Ross and Thompson 1980 of ported that radiograph was able to detect FI 22% of maxillary, 8% mandibular molar (discrepancy based on bone density) (Mesial FI – 19% degree I, 44% degree II, 55% degree 3 Furcation Distal FI - 12% degree I, 30% degree II, 52% degree III) (b) Clinical probing: Both horizontal / vertical measurement done for accuracy

1. Plaque removal and complicate sealing and root planning 2. Local factor for developing gingivitis and periodontic 5. Bifurcational ridges6

Types:

1. Intermediate (73%) 2. Buccal and lingual ridges (60%) 1166


1. Horizontal probing done with Nabers probe with calibrated in 1mm increments can be used to measure the horizontal break down

(c) Correlate with x – ray after clinical examination 2. Status of adjoining interporximal / buccal lingual gree

Mandibular molar probing:

3. Morbidity (grade III furcation involvement with mobility)

(a) Easily probed become of bucco lingual entrance (b) Furcation located midway mesiodistally in maxillary molar. Maxillary molar probing:

4. Root angulation 5. Health of neighboring tooth 6. Position of the tooth in the arch 7. Age and health of the patient 8. Foul tune of endodontic therapy TREATMENT OF MULTI-ROOTED TEETH3 Goals of treatment

1. Arresting the disease process 2. Maintaining the teeth in health and function with appropriate esthetics Varies treatment approaches

(a) Buccal furcas accessible midway mesiodistally (b) Distal furcation – midway bucolingually probed bucally (or) palatally. (c) Large buccolingual width of the mesio force root – mesial forces open 2/3 of the way towards the palate. So palatal aspect is easily probed. 2. Vertical probing: used to measure attachment loss with straight probe.

the

Lang et al 1991 – pressure – controlled probes are used and a probing forces about 0.25N with probe diameter of 0.4 to 0.5 mm. (c) Bone sounding: Transgingival probing with local anaesthesia – more accurately determining the underlying bony contours. (Greenberg et al, 1976). A thorough understanding of molar root anatomy is essential for proper diagnostic and therapeutic decision. PROGNOSIS: Following factors to be considered in prognosis:

Factors to consider

1. Open and closed root preparation

1. Degree of Involvement

2. Odontoplasty

2. Crown / root ratio; length of roots

3. Opendebridement / pocket (apically positioned flap) elimination

3. Root anatomy / morphology

4. Tunneling procedures

4. degree of root separation

5. Root resection

5. strategic value of the tooth

(a) Root Amputation

6. Residual tooth mobility

(b) Hemisection

7. Need for endodontic treatment

6. Bicuspidization (root Separation)

8. Prosthetic requirements

7. Regenerative approaches (GTR, Bone Grafts, BMPs)

9. Periodontal condition of adjacent teeth

8. Extraction / Implant Placement

10. Ability of bone to place implants 11. Ability to maintain oral hygiene

1. Extent of involvement (a) Partial (or) total (b) Apical extent of bone loss

12. Financial consideration 13. Long – term prognosis

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TREATMENT APPROACHES BASED ON DEGREE OF INVOLVEMENT Class Class I

are narrower mesiodistally, wide post results in root perforation and fracture. Ideal root for placing posts are – maxillary palatal root, mandibular distal root. Placement of circular shaped posts with great diameter in mandibular mesial and maxillary mesiobuccal root canal results in root cracles perforation.

Treatment

• Scaling and root planning • Odontoplasty, gingivectomy

Class II

• Scaling and Root Planning

3. Crown margin should be supra gingival (0.5 to 1mm subgingival)

• Odontoplasy • Open debridement / Furcation Operation

4. Residual mandibular defect

• Apically positioned flap • GTR /

CONCLUSION

• Root resection

The various approaches are available for the treatment of multi – rooted teeth. An understanding of the special anatomical and morphological features of root furcations and the limitations those features present in essential for successful treatment outcome. Furcation management is usually, based on the individual clinical situations morphological, functional variations and also general health status of the concerned individual status of the concerned individual.

• Tunnel Preparation • Extraction / Implant Placement Class III

• Open Debridement / Furcation Operation • Apically positioned flaps • GTR (Questionable Success) • Root resection • Tunnel preparation • Extraction / Implant Placement

INDICATION AND CONTRAINDICATION OF ROOT RESECTION9

REFERENCES

Indication

Contraindication

1. Bower RC. Furcation morphology relative to periodontal treatment. Periodontal entrance architecture. J Periodontology 1979; 50;23

1. Class II (or) III Furcation involvement

1. Inadequate bone support on the remaining roots (or) unfavourable anatomical factors

2. Dunlap R and Gher ME. Root Surface measurement of the mandibular molars. J Periodontology 1985; 56; 234-238 3. Khala F, Al-Shammari, Christopher E-Kazar and Home KY Wans. Molar anatomy and management. J Clinical Periodontology 2001; 28 (8); 730-740

2. Significant discrepancies 2. Severe bone loss involving one (or) more roots. inadjacent interproximal bone height. 3. Root Fracture, perforation, resorption (or) deep root caries

4. Hermann DW, Gher ME, Dunlap R and Peller GB. The potential attachment areas of the maxillary first molar. J Periodontology 1983; 54; 431-434

3. Remaining roots cannot restored / endodondically treated.

5. Masters DH and Hoskin’s SW. Projection of enamel into molar. J Periodontology 1964; 35; 49-53

4. Root proximity with adjacent teeth

6. Everett FG, Jump EB, Holder TD and Williams GC. The intermediate bifurcational ridge. Journal of Dental Research 1958; 17-62

5. Failed endodontic treatment (or) inoperable / calcified canals

7. Moskow and Canut. Studies on root enamel pearls. J Clinical Periodontology. 1990; 17; 275-278

RESTORATIVE CONSIDERATION

8. Kalfwarf KL and Reinhardt RA.D. Diagnosis and treatment of furcation invasion. Dental Clinics of North America 1998; 32; 243-266

1. Posts and cores should be used when in absolute need.

9. G.Carnevele, R.Pontorioro and Gidi Febo. Long term effect of root – resective therapy in furcation involved molars. J Clinical Periodontology 1998; 25(3); 209-214

2. Using of thick, parallel post should be avoided in narrow, tapered once. Parallel posts will generate greater apical shift. In molar roots which

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