|Year : 2014 | Volume
| Issue : 1 | Page : 21-25
Effective management of mandibular Grade III furcation: A dicey issue
Rekha Rani Koduganti, Sarada Jandhyala, N Sandeep, P Veerendra Nath Reddy
Department of Periodontics, Panineeya Mahavidhyalaya Institute of Dental Sciences and Research Centre, Kamala Nagar, Dilsukh Nagar, Hyderabad, Andhra Pradesh, India
|Date of Web Publication||5-Sep-2014|
Department of Periodontics, Panineeya Mahavidhyalaya Institute of Dental Sciences and Research Centre, Road No. 5, Kamala Nagar, Dilsukh Nagar, Hyderabad - 500 060, Andhra Pradesh
Source of Support: None, Conflict of Interest: None
The changing perspectives in dentistry aim at retaining functionally active teeth with an adequate amount of healthy supporting tissues. One such treatment opportunity available is for the management of teeth with furcation involvement, which in earlier times was attributed with a guarded prognosis. Treatment of teeth with these lesions is an uphill task for the clinician and maintenance after treatment also poses a problem to the patient due to anatomical variations, which favor the growth of micro-organisms. Teeth with furcation involvement can be maintained in a state of function for a longer period of time if appropriately treated, and if the patient is motivated adequately. Bicuspidization is a procedure, which in a properly selected case can facilitate retention of the tooth in a functional state.
Keywords: Bicuspidization, endodontic treatment, furcation involvement, prosthesis
|How to cite this article:|
Koduganti RR, Jandhyala S, Sandeep N, Nath Reddy P V. Effective management of mandibular Grade III furcation: A dicey issue. J Oral Res Rev 2014;6:21-5
|How to cite this URL:|
Koduganti RR, Jandhyala S, Sandeep N, Nath Reddy P V. Effective management of mandibular Grade III furcation: A dicey issue. J Oral Res Rev [serial online] 2014 [cited 2019 May 19];6:21-5. Available from: http://www.jorr.org/text.asp?2014/6/1/21/140203
| Introduction|| |
Management of teeth with furcation involvement has always been a challenge. The term furcation involvement refers to the invasion of the bifurcation and trifurcation of multirooted teeth by periodontal disease.  If left untreated periodontal breakdown continues and may lead to total loss of tooth unless these defects are repaired and health of the tissues restored. Thus, tooth separation and resection procedures are done in advanced Grade II and Grade III furcation involvement with the prime objective to preserve as much tooth structure as possible rather than sacrificing the whole tooth.  Various resective procedures to treat furcation involvement include root amputation, hemisection, and bicuspidization. Bisection/bicuspidization is the separation of mesial and distal roots of mandibular molars along with its crown portion, where both segments are treated prosthetically and retained individually  thereby facilitating proper access for maintenance of the furcation area.  Persistent periodontal disease may clear up only after definitive periodontal therapy is coupled by successful endodontic treatment.  Treatment option should be considered after evaluation of root length, curvature, and divergence, angulation of root in the arch and finally the need and feasibility for endodontic treatment. In the present case, we attempted bicuspidization after considering all treatment options and we seemed to have achieved a good result, considering the fact that the patient is asymptomatic and has maintained good oral hygiene.
| Case Report|| |
A 52-year-old male patient attended Department of Periodontics of Panineeya Dental College, Hyderabad, India with a chief complaint (Symptom) of abscess in relation to right lower back tooth [Figure 1]. On examination, an abscess that was localized to 46 was noticed, with Grade I mobility of the same tooth. Pocket was elicited in the furcation, with a probing depth of 5 mm horizontally and vertically. Patient was not medically compromised. Subsequently, the abscess was drained and the patient was advised systemic antibiotics. Intra oral periapical radiograph showed periapical involvement. Patient was referred to the department of Conservative Dentistry regarding the pulpal assessment and management. They opted for root canal treatment in relation to 46. After the root canal, treatment was done; patient was scheduled for periodontal surgery. On the day of periodontal surgery, the patient complained of fracture of distolingual cusp of 46 and therefore, the patient was again referred back to the department of Conservative Dentistry. He was treated by placing a post in distal canal, over which a core was built up [Figure 2] and [Figure 3]. Following this, flap was reflected under adequate local anesthesia. With the help of a long shank straight fissure diamond bur a vertical cut was given through the bifurcation area corono-apically [Figure 4]. The furcation area was trimmed to ensure that no residual debris was present that could cause further periodontal irritation. Curettage of the furcation area was done, which became accessible on separation. The occlusal table was minimized to redirect the forces along the long axis of each root. Flaps were repositioned and sutured [Figure 5]. Postoperative instructions were given and prophylactic antibiotics were prescribed before disposal of the patient. Immediate postoperative checkup was satisfactory. One week later sutures were removed. Crowns were placed on individual tooth segments resembling two individual premolars [Figure 6], [Figure 7], [Figure 8]. Care was taken to direct forces along long axis of tooth to prevent further periodontal loss. Patient was motivated for further follow-up visits and adequate maintenance at home. One month and 3 months follow-ups were satisfactory with no complaints from the patient and site of surgery showed no further disturbances. At 9 months a follow-up radiograph was taken which showed resolution of periodontal widening which was evident in the preoperative radiograph [Figure 9] and [Figure 10]. One year follow-up showed that the patient was maintaining dentition well in function and was fully satisfied with no complaints.
|Figure 10: Nine months postoperative radiograph depicting reparative response|
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| Discussion|| |
With increasing patient demand for retaining natural dentition, dental treatment should be oriented to fulfill this demand. Advances in various fields of dentistry facilitate to preserve a compromised tooth in healthy functional state with multidisciplinary involvement. However, the treatment plan is better assessed in years of healthy functioning dentition and not by mere retention of tooth. Reduction and elimination of etiologic and contributing factors in the periodontal treatment, a proper restoration, and reorientation of occlusal forces may result in good prognosis with well-functioning dentition.
The term furcation involvement refers to the invasion of the bifurcation and trifurcation of multirooted teeth by periodontal disease. It is synonymous with advanced periodontitis and the unique anatomical position of the furcation influences the treatment outcome, invariably tilting the prognosis towards guarded. 
According to the classification of intrabony pocket by Goldman and Cohen in 1958, the furcation defect is truly a no wall defect, for which the prognosis is poor due to lack of osteogenic cell proliferation into the area or more precisely, lack of sufficient bony walls providing the cells of the periodontal ligament which contribute most importantly to the regenerative process. 
According to Weine,  if a patient with open or closed furcation area displays the classic symptoms of pulpitis, despite the absence of decay or extensive restorations, an endodontic procedure must be considered until another logical alternative is discovered. Endodontic therapy may help in regression of periapical lesion, but not the periodontal aspect. This makes periodontal intervention imperative.  Gerstein 1977  suggested that endodontic care before root resectioning or sectioning (bisectioning) has remained today a necessity in treating mandibular molars. In the present case, a compliant, healthy patient with minimal local factors presented with abscess and furcation involvement. Further analysis revealed deep Grade II/Grade III furcation involvement, clinically (which on opening the flap was confirmed to be Grade III furcation involvement). Probing on adjacent roots revealed no pockets. No caries was elicited clinically. The lesion was suggestive of primary periodontal with secondary endodontic involvement as denoted by Rotstein and Simon in the year 2000.  Radiograph showed periapical lesion and radiolucency in furcation area. Roots were divergent with adequate separation, length and had good periodontal and moderate bone support. The various treatment options that could have been considered were regeneration, root resection, and tunneling. All of them have their own limitations. The regenerative therapies include techniques ranging from curettage or debridement approaches, bone grafts, epithelial excision procedures, root conditioning, coronally positioned flaps, guided tissue regeneration and various combinations of techniques.  Bower 1979, reported that when the furcation entrance diameter was smaller than the blade face width of commonly used periodontal curettes, efficient debridement may not be possible. Further he also noted that buccal furcation entrance diameter in the mandibular first molar teeth was smaller than the lingual. He reported that the furcation concavities are caused by more cementum than the adjacent convexities and this is clinically significant due to cementum's ability to absorb and/or adsorb toxic bacterial products such as endotoxins when altered by inflammatory process. Incomplete removal of this diseased thicker cementum would thus discourage ultimate union of healthy fibroblasts and epithelial cells after treatment, resulting in persistence of periodontal pockets. 
Bone replacement grafts carry limitations such as problems related to graft containment, epithelial exclusion, microbial contamination, and variable inductivity of the graft. Guided tissue regeneration procedures are successful in Grade II, but carry limited success rate in relation to Grade III furcations. , Tunnel technique is an indication in advanced Grade II or Grade III furcation involvement. , It is indicated for teeth with short root trunks, divergent roots and favorable crown root ratio. However, the technique is limited by gingival overgrowth into the tunnel (following inflammation), secondary caries and hyper sensitivity and few patients maintain adequate oral hygiene regime.  Owing to limited success rate with regenerative procedures and with tunnel technique, Grade III furcation involvement requires extensive procedures like resective procedures.
Various resective procedures include root amputation, hemisection and bicuspidization. As the clinical and radiographic parameters were satisfactory (wide roots with adequate separation and periodontal support and moderate bone support around individual roots), bicuspidization was planned for the patient. Postoperative healing response was good. Farshchian and Kaiser et al. 1988  suggested that the success of bicuspidization depends on three factors (which seemed to have been satisfied in the present case). They are:
- Stability and adequate bone support.
- Absence of severe root fluting.
- Adequate separation of the mesial and distal roots such that adequate embrasure can be created.
Another treatment option for furcation involvement is root resection. Ten years retrospective study reported that success rate of root resection is dependent on the amount of bone support. To achieve a good result the remaining root should have >50% bone support.  In the present case, since both mesial and distal roots of the tooth appeared to have equal amount of bone loss, it was decided to go ahead with bicuspidization procedure. Basten et al in1996 have reported that furcation involved tooth can be maintained for a prolonged time with appropriate treatment and adequate oral hygiene regimes. A number of studies confirmed that teeth treated for furcation involvement can be maintained stable for 3-7 years. 
To conclude, a compromised tooth with furcation involvement can be effectively maintained and restored to function, with proper treatment planning in a patient who is compliant. However, the success rate is also affected by an effective endodontic treatment, and good prosthetic rehabilitation which redirect the occlusal forces in a manner that is not detrimental to the tooth. The future of effective dental treatment lies therefore in a multidisciplinary approach, and we should not hesitate to make use of the same approach, when a case warrants it.
| Acknowledgment|| |
We acknowledge the help extended by Dr. B. Chaitanya, Sr. Lecturer, Department of Conservative Dentistry.
| References|| |
|1.||Newman MG, Takei HH, Carranza FA, Klokkevold PR. Bone Loss and Patterns of Bone Destruction. Carranza's Clinical Periodontology, 10 th ed. Philadelphia: Saunders Elsevier; 2006:462-3. |
|2.||Vandersall DC, Detamore RJ. The mandibular molar class III furcation invasion: A review of treatment options and a case report of tunneling. J Am Dent Assoc 2002; 133:55-60. |
|3.||Dalkiz M, Cilingir A, Beydemir B. Bicuspidization: A case report. Gulhane Tip Derq 2008;50:42-5. |
|4.||Weine FS. Endodontic Therapy. 4 th ed. St. Louis: The CV Mosby Co.; 1989. |
|5.||Sunitha VR, Emmadi P, Namasivayam A, Thyegarajan R, Rajaraman V. The periodontal - endodontic continuum: A review. J Conserv Dent 2008;11:54-62. |
|6.||McClain PK, Scallhorn RG. Focus on furcating defects-guided tissue regeneration in combination with bone grafts. Periodontol 2000 2000:21;192-212. |
|7.||Goldman HM, Cohen DW. The infrabony pocket. Classification and treatment. J Periodontol 1958;29:272-91. |
|8.||Newman MG, Takei HH, Carranza FA, Klokkevold PR. The Periodontic-Endodontic Continuum Carranza's Clinical Periodontology, 10 th ed. Philadelphia: Saunders Elsevier; 2006: p.878. |
|9.||Gerstein KA. The role of vital root resection in periodontics. J Periodontol 1977;48:478-83. |
|10.||Rotstein I, Simon JH. The endo-perio lesion: A critical appraisal of the disease condition. Endodontic Topics 2006;13:34-56. |
|11.||Bower RC. Furcation morphology relative to periodontal treatment. Furcation entrance architecture. J Periodontol 1979;50:23-7. |
|12.||Ashita uppoor, Dilip G Nayak, Mahesh CP. Text Book of Periodontology & Oral Implantology 1st Edition Elsevier India; 2010. |
|13.||Sanz M, Giovannoli JL. Focus on furcation defects: Guided tissue regeneration. Periodontol 2000 2000;22:169-89. |
|14.||Cattabriga M, Pedrazzoli V, Wilson TG Jr. The conservative approach in the treatment of furcation lesions. Periodontol 2000 2000;22: 133-53. |
|15.||Rüdiger SG. Mandibular and maxillary furcation tunnel preparations Literature review and a case report. J Clin Periodontol 2001;28:1-8. |
|16.||Farshchian F, Kaiser DA. Restoration of the split molar: Bicuspidization. Am J Dent 1988;1:21-2. |
|17.||Sánchez-Pérez A, Moya-Villaescusa MJ. Periodontal disease affecting tooth furcations. A review of the treatments available. Med Oral Patol Oral Cir Bucal 2009;14:e554-7. |
|18.||Basten CH-J, Ammons WF, Persson R. Long-term evaluation of root-resected molars: A retrospective study. Int J Periodontics Restorative Dent 1996:16:207-219. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]