TREATMENT OF FURCATION INVOLVEMENT IN THE PERIODONTAL DISEASE. A CLINICAL REPORT

Transcription

1 Cercetãri Experimentale & Medico-Chirurgicale Anul XIV Nr.2-3/2007 Pag Cercetari ) experimentale & medico-chirurgicale TREATMENT OF FURCATION INVOLVEMENT IN THE PERIODONTAL DISEASE. A CLINICAL REPORT Boariu Marius, Laura Cârligeriu, Marinescu Adrian Efthimios Papakonstadinu 2 SUMMARY: The purpose of this paper is to demonstrate that regardless of the furcation grade defects some teeth can be salvaged and used in the rehabilitation of the arcade. The term furcation involvement refers to commonly occurring conditions in which the bifurcations and trifurcations of multirooted teeth are invaded by the desease process. The anatomical particularity of each tooth, bone and gingiva can make the treatment chalenging. The length of the root trunk influence the clinical management of furcation lesions. Different techniques can be used to achieve our aim and we present two clinical cases and the techniques used. Key Words: furcation, grade involvement, guided tissue regeneration, Bio-Oss, Emdogain, periodontal flap Received for publication: Revised: REZUMAT: Scopul acestui articol este demonstrarea faptului cã în ciuda afectãrii parodontale a unor dinþi datorate gradului de afectare a furcaþiei aceºtia pot fi menþinuþi pe arcadã ºi pot fi folosiþi în reabilitarea acesteia. Gradul de furcaþie se referã în general la stadiul de afectare parodontalã suferitã de bifurcaþia sau trifurcaþia dinþilor pluriradiculari. De multe ori lungimea rãdãcinii influenþeazã în mod direct gradul de afectare al furcaþiei. Se pot folosi diferite materiale ºi tehnici pentru menþinerea dintelui pe arcadã ºi regenerarea osoasã necesarã. Acest articol prezintã douã cazuri ºi tehnicile folosite. 1 - Department of Odontotherapy-Periodontology, Faculty of Dental Medicine Timisoara 2 - UMF Timisoara INTRODUCTION The term furcation involvement refers to commonly occurring conditions in which the bifurcations and trifurcation of multi rooted teeth are invaded by the disease. In spite of the added stability provided by extra root anchorage, furcated teeth and their surroundings exhibit several anatomic characteristics that can make therapy difficult and can influence the result of the treatment. Classification Glickman in 1953 have developed the following classification of furcation involvement: - Grade I involvement. Grade I is incipient or early lesion. The pocket is suprabony, involving the soft tissue; there is slight bone loss in the furcation area. The bone loss is minimal so sometimes is not shown on the radiologic image. - Grade II involvement. In grade II cases, bone destruction on one or more aspects of the furcation is present, but a portion of the alveolar bone and periodontal ligament remains intact, allowing only a partial penetration of the probe into the furcation. A special diagnosis problem appears when the maxillary molars are affected because the roots appears at facial view X-ray overlap each other. - Grade III Involvement. At this stage the interradicular bone is completely absent, ant the facial and/or the lingual orifices of the furcation are occluded by gingival tissue.that is why the furcation opening can be seen only radiographicaly. There may be a crater like lesion in the interradicular area, creating an apical or vertical component along with the horizontal Correspondence to: M. Boariu, Department of Odontotherapy-Periodontology,, Faculty of Dental Medicine Timisoara boarium@yahoo.com 110

2 loss of bone. This type of lesion can be found on both III grade and IV grade lesions. - Grade IV involvement. The interradicular bone is completely destroyed as in the III grade lesions but this time the gingival tissue is also recessed apically so that the furcation opening is clinically visible. The anatomical particularity of each tooth, bone and gingiva can make the treatment challenging. The length of the root trunk influence the clinical management of furcation lesions. When the root trunk is short the furcation will appear in early stages of the disease development. In opposition if the root trunk is long then it will be involved in the latest stages of the disease development but it will be harder to instrumentate because of the difficulty of access. Treatment The treatment of the furcation involvement is different varying from one grade to another. In grade I involvement the treatment is simple because this kind of furcation usually exhibits suprabony pockets. So this grade is treated by scaling and curettage or by gingivectomy, depending on pocket depth and the fibrosity of pocket walls. Because the destructive process is in its early stages it is not necessary to enter the furcation during the treatment. However on other grades of furcation involvement the clinical management became more complex. In grade II involvement the technique involves the creation of a flap and then the area is debrided of granulation tissue, and the root surfaces are carefully scaled and planed with curettes and ultrasonic scalers. After that the graft material is placed, filling in the furcation area, particularly the crater area. Good results have been encountered using guided tissue regeneration methods in correlation with Emdogain, bone grafts or hydroxyapatite. In grade III and IV involvement the interradicular tissue destruction permits a probe to pass freely through the furcation. The gingiva is resected on the coronal level so we can have better visibility and access from all the directions so that the involved root surfaces may be thoroughly planed and smoothed without disturbing the bone. After that the graft material is placed, filling in the furcation area. When infrabony pockets and osseous defects are part of the clinical picture of furcation involvement, the treatment of choice is the flap operation and the use of GTR materials. CASE STUDIES Next we will present some cases of furcation treated in our clinic with different techniques. First case is B..M. Patient is 38 years old and is diagnose with rapidly progressive periodontitis. Because of that he has many molars with different grades of furcation involvement. As the X-ray from figure 1 shows the 2.8 molar have furcation grade III. It is vital we keep this tooth because of his prosthetics importance. After the anesthesia a Figure 1 111

3 Figure 2 Figure 3 Figure 4 mucoperiostal flap using modified Widman-Ramfjord was removed using sharp curette. Then we proceed to was created (figure 2). smooth and plan the area involved with manual and After the flap was created and the access have been rotative instruments (figure 3). made available all the tissue tags and granulation tissue Figure 5 112

4 Figure 6 After the removal of the granulation tissue and the necessary scaling-root planing completed we placed Bio-Oss and then we suture the flap (Fig.4). In the second case as displayed in the X-ray from Fig.5 the 4,7 molar have a grade IV involvement furcation. Like in the first case the tooth is essential in the prosthetics plan of treatment so his extraction is out of the question. Because of the big bone destruction we used hemisection, removing the distal root and keeping only the mesial ones for the prosthetics reconstruction. Once again a flap was created using the modified Widman-Ramfjord technique (Fig.6). The tooth is halved using diamoned and carbide burs. Then the distal root is removed. After that the scaling and root planing required was complete. The bone defect was filled with Emdogain Ts which is an enamel matrix derivated. The following X-ray has been made 3 years after the surgical intervention (Fig.7). The bone loss has diminished significantly. A gain of 5-6 mm of bone is revealed. Also the remaining roots on 4.7 is used in the prosthetics plan of treatment with success. Figure 7. REFERENCES 1. Armitage GC. Clinical peridontal examination. Contemporary periodontics. Genco-Goldman-Cohen, The C.V. Mosby Co. St. Louis 1990, Armitage GC. Development of a clasification system for periodontal deseases and conditions, Ann. Periodontol. 1989,4:16 113

5 REFERENCES (continued) 3. Brunsvold M.A., Melloning J.T. Bone grafts and perioodontal regeneration. Periodontology 2000, 993;1: Camargo P.M., Lekowich D., a.all. A comparison between enamel matrix proteins (EMP) used alone or in combination with BPBM (bovine propous bone minerals) in the treatment of infrabony periodontal deffects in humans. J. Periodontol; 2000;71: Carranza F.A.Jr. - Glickmans Periodontology, Saunders comp., Cortellini P., Pini-Prato G., Tonetti Periodontal regeneration of human infrabony deffects, J.Clin.Periodontol; 1994, 21: Fleszar T.J., a.all. Tooth mobility and periodontal therapy, J.Clin.Periodontol; 1980,7: Garret S., Polson A.M., Stoller N., Greenstein G. GTR in human furcation deffects after using a biodegradable barrier J.Dent.Res 73,285; Lekovic V., Kenney E.B., Carranza F.A., Danilovic V. Treatment of class II furcation deffects using porous hydroxyapatite in conjunction with PTFE membrane, J. Periodontol 1990,61: Lindhe J., Nyman S. Scaling and granulation tissue removal in periodontal therapy, J. Clin. Periodontol 1985,12: