|Year : 2014 | Volume
| Issue : 1 | Page : 41-45
Resective procedures in the management of mandibular molar furcation involvement: A report of three cases
Ashwath Balachandran1, Subramoniam Sundaram2
1 Department of Pediodontics, Madha Dental College and Hospital, Kundrathur, India
2 Priyadarsini Dental College, Thiruvallur, Chennai, Tamil Nadu, India
|Date of Web Publication||21-Jun-2014|
Department of Pediodontics, Madha Dental College and Hospital, Kundrathur
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The presence of attachment loss in the furcation is one of the most serious anatomical sequela of periodontitis. Furcations are not accessible for professional debridement, since their entrance is small compared with the size of periodontal instruments, and they present with ridges, convexities, and concavities that make it difficult for clinicians to debride effectively. In cases, where advanced defects are seen, treatment may involve combining, endodontics, periodontics, and prosthodontics so that the teeth are retained in whole or in part. Advances in dentistry have provided the opportunity for clinicians to provide patients with the option of retaining their teeth in the long-term. Such teeth can be useful as independent units of mastication or as abutments in simple fixed bridges. This article presents three cases of mandibular molar furcation involvement, which were treated by three different therapeutic modalities.
Clinical Relevance to Interdisciplinary Dentistry
- Management of a furcation involved tooth requires an inter-disciplinary approach to enhance the long-term prognosis.
- The success rate of resective procedures is high if the case selection, treatment plan, treatment sequence are well-executed.
- The importance of inter-disciplinary approach is highlighted by the success of these clinical scenarios.
Keywords: Furcation defects, molar, periodontitis, root resection
|How to cite this article:|
Balachandran A, Sundaram S. Resective procedures in the management of mandibular molar furcation involvement: A report of three cases. J Interdiscip Dentistry 2014;4:41-5
|How to cite this URL:|
Balachandran A, Sundaram S. Resective procedures in the management of mandibular molar furcation involvement: A report of three cases. J Interdiscip Dentistry [serial online] 2014 [cited 2019 Jun 20];4:41-5. Available from: http://www.jidonline.com/text.asp?2014/4/1/41/135010
| Introduction|| |
Furcation is the region that is present in multi-rooted teeth that represents an area of complex anatomy and morphology. Furcation involvement is defined as bone resorption and attachment loss in the inter-radicular space that results from plaque-associated periodontal disease.  The complexities involved in treating a tooth with advanced periodontal disease involving the furcation region include periodontal, endodontic, and prosthodontic considerations. Although such involvement invariably diminishes the long-term prognosis, tooth extraction is not mandatory.
Root resection is the process by which one or more of the roots of a tooth are removed at the level of the furcation, while leaving the crown and remaining roots in function.  Various resection procedures described are: hemisection, radisection bicuspidization and tunneling. Hemisection is defined as the removal of half of a tooth performed by sectioning the tooth and removing one root. It is frequently used with reference to lower molars.  Root separation is defined as the sectioning of the root complex and the maintenance of all roots.  Tunnel preparation is the intentional creation of a Class-III furcation with its entrance accessible for oral hygiene procedures.  The treatment modality that is chosen depends on the grade of furcation, amount of attachment loss present, remaining bone level in relation to the roots and the furcation region, morphology of the roots, and long-term prognosis of the involved tooth. This article presents three cases of mandibular molar furcation involvement treated by three different therapeutic modalities, namely hemisection, bicuspidization, and tunneling.
| CASE REPORTs|| |
All cases presented in this article were treated in a private dental clinic in Chennai. Informed consent was obtained from all patients prior to performance of the respective therapeutic modality. The patients were prescribed postoperative medications (Amoxycillin 500 mg T.D.S., Aceclofenac sodium 50 mg B.D), and were provided with routine postoperative instructions.
A patient aged 23 years reported complaining of severe pain and swelling in the left lower posterior region for 3 days. Clinical examination revealed an abscess in the lingual region of the left mandibular first molar which was tender on percussion. A probing pocket depth of 7 mm was observed in the mid lingual aspect of the tooth [Figure 1]a. Radiographic examination revealed a perforation in the furcal region involving the distal root of left mandibular first molar, which had contributed to the symptoms [Figure 1]b. Since, the perforation could not be closed completely and considering the age of the patient, a treatment plan was designed to perform a hemisection involving the distal aspect of the tooth. This would eliminate the perforation and enable adequate restoration of the region.
|Figure 1: (a) Preoperative probing depth of 7 mm in lingual aspect of 36, (b) intra-oral periapical radiograph revealing perforation in the distal root of 36 extending up to the furcation, (c) hemisection of the distal half done and the section removed, (d) socket filled with bone graft particles, (e) 6 months postoperative radiograph, (f) 6 months postoperative view of the surgical site|
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Under local anesthesia, full-thickness mucoperiosteal flap was reflected after giving a crevicular incision from first premolar to second molar. Following debridement, the crown was resected using the vertical cut method. A safe-sided diamond disc was used to make the vertical cut along the furcation. Care was taken to preserve as much tooth structure as possible. The distal segment was extracted and the socket was irrigated adequately with sterile saline to remove bony chips and amalgam debris [Figure 1]c. The furcation area was smoothened to ensure that no tooth or bony spicules were remaining. Scaling and root planning of the root surfaces, which became accessible on removal of distal root was done. The site was irrigated using sterile saline and particulate bone graft was placed into the site [Figure 1]d. The flaps were then repositioned and sutured with 3-0 black silk sutures. A postoperative radiograph taken at 3 months revealed bone fill in the extraction region [Figure 1]e. Postoperative probing depth was found to be 3 mm.
A patient aged 42 years reported to with a complaint of pain in her left lower posterior region. The pain was a dull throbbing type of pain with no associated relieving or aggravating factors. Clinical examination revealed the presence of Grade-3 furcation involvement in 36 with a pocket probing depth of 8 mm [Figure 2]a. Radiographic examination revealed bone loss in the furcation region with minimal inter-proximal bone loss [Figure 2]b. A treatment plan was formulated to perform endodontic treatment followed by bicuspidization and placement of individual crowns as there was sufficient inter-proximal bone to support both segments without adversely affecting periodontal support in the long-term. The crown: Root ratio and the length of the mesial and distal roots were also adequate to perform resective periodontal therapy.
Following access opening, the working length was determined and the canals were biomechanically prepared using step-back technique. The canals were obturated with lateral condensation method and the chamber was filled with amalgam to maintain a good seal and allow inter-proximal area to be properly contoured during surgical separation. Postoperative radiograph revealed correct obturation.
Under local anesthesia, full-thickness flap was reflected after giving a crevicular incision from first premolar to second molar. Bone was exposed following curettage and root planning [Figure 2]c. The molar was then divided into two separate segments using a safe-sided disc to ensure as minimal tooth structure removal as possible [Figure 2]d. The furcation area was trimmed to ensure that no spicules were present to cause further irritation in the surgical area. The flaps were then repositioned and sutured with 3/0 black silk sutures. Suture removal was done 1 week following the surgical procedure. Healing was uneventful. Postoperative probing depth was found to be 2 mm for both segments. 2 months following the surgery, the patient was taken up for prosthetic rehabilitation [Figure 2]e. The two segments were prepared as individual units to receive metal crowns each [Figure 2]f.
|Figure 2: (a) Preoperative probing of the furcation region showing Grade - 3 involvement, (b) preoperative intra-oral periapical radiograph revealing through and through bone loss in the furcation region, (c) full-thickness mucoperiosteal flap reflected revealing furcation involvement, (d) bicuspidization procedure performed, (e) 3 months postoperative view, (f) rehabilitated tooth with prosthetic crowns|
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A patient aged 52 years reported to a private dental practice with a chief complaint of food lodgment in the right lower posterior region. Clinical examination revealed Class - III gingival recession in tooth number 46 with through and through Grade - 3 furcation involvement with a pocket depth of 7 mm [Figure 3]a. Radiograph revealed bone loss in the furcation region up to the middle-third of the roots. The radiograph also revealed satisfactory inter-radicular space with adequate root separation [Figure 3]b. There was also adequate inter-proximal bone present, which is essential to prevent posttreatment mobility following bone removal during resective procedures. Therefore, a treatment plan was formulated to perform a tunneling procedure where inter-radicular bone would be removed and flaps to be apically positioned in order to create sufficient space for the patient to perform plaque control.
|Figure 3: (a) Preoperative view of 46 showing Grade - 3 furcation involvement, (b) preoperative intra-oral periapical radiograph revealing through and through bone loss in the furcation region, (c) full-thickness mucoperiosteal flaps reflected and furcation region exposed, (d) 3 months postoperative view showing the tunnel interdentally, (e) interdental brush being passed through the tunnel created surgically|
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Following administration of local anesthetic agent, full-thickness mucoperiosteal flaps were reflected in relation to 45, 46, and 47 regions. Thorough debridement and root planning was performed and the inter-root distance was clinically measured. Inter-radicular bone was removed using tapered fissure carbide burs under copious irrigation. Bone removal corresponded to the space required to pass an interdental brush through and through the furcation region [Figure 3]c. Care was taken to avoid any sharp bony margins or ledges and the entire region was irrigated thoroughly. The flaps were then apically positioned and sutured using 3-0 black silk. Suture removal was done after 1 week. Follow-up visits were scheduled and there was excellent healing by the 1 st month. Postoperative probing depth had reduced to 3 mm at 2 months. The furcation region was wide enough to allow passage of an interdental brush to enable plaque control by the patient [Figure 3]d and e.
| Discussion|| |
Furcation defects represent a formidable problem in the treatment of periodontal disease, principally related to the complex and irregular anatomy of furcations. The anatomical characteristics of the areas involved, particularly the size of the furcation entrance, the presence of root concavities and the uneven surface of the roof of the furcation, make adequate instrumentation of the inter-radicular area extremely difficult.  Success of root resection procedures depends on proper case selection. All cases presented were carefully evaluated and all treatment options were examined before deciding on the resective form of therapy.
The morphology of the portion of the tooth remaining after root separation and resection therapy is of primary importance for the subsequent maintenance of the tooth. Case-2 had sufficient crown: Root ratio, sufficient root length, and thickness to undergo bicuspidization. This would allow the separated segments to bear the occlusal load adequately in the long-term. Molars that underwent resective procedures due to periodontal reasons had a higher success rate than those due to endodontic causes.  These procedures were able to remove periodonthopathic microorganisms, calculus, unfavorable anatomic contours, hemiseptal defects, and deep intra-bony defects.  In Case-3, the inter-radicular separation was wide enough to perform tunneling procedure, which will enable the patient to adequately clean the furcal region using oral hygiene aids. Furthermore, there was sufficient inter-proximal bone present, which enables the removal of bone in the furcal region without adversely affecting the support and thereby long-term prognosis for the tooth.
Clinical prediction of the long-term prognosis is crucial in order to ensure the sequence of therapy and avoiding additional expenditure for the patient. This requires proper diagnosis, treatment planning, and execution by all the clinicians involved in the inter-disciplinary approach. All the cases presented were able to retain form and function 3 years following resective procedures.
Adequate knowledge of the anatomy of the furcation region is crucial in both planning and execution of the treatment procedure. The degree of success in managing furcation involvement is inversely related to the horizontal probing depth.  As the furcation invasion progresses, the choice of therapy and the role of inter-disciplinary dentistry becomes more important.
However, there are some complications that can occur following resective therapy. The common cause of failure of resective procedures in mandibular molars is root fracture due to uneven distribution of occlusal forces with the resected portion receiving larger load than it can withstand.  One commonly reported drawback associated with the tunneling procedure is the development of root caries. 
Another important factor which should be given special consideration is the initial bone level.  It has been showed that molars with bone support more than 50% of the remaining roots at the time of the surgical procedure had a better survival rate if the etiology was due to periodontal disease.  All cases presented had sufficient remaining bone to undergo resective periodontal therapy and maintain form and function in the long-term.
An important patient-related factor in resective periodontal procedures is the maintenance of high levels of oral hygiene by the patient. In the cases shown, the patients were able to ensure adequate plaque removal. A meta-analysis by Huynh-Ba et al.  observed good long-term survival rates of multi-rooted teeth with furcation involvement with vertical root fractures and endodontic failures being the most frequent complications.
| Conclusion|| |
The three years success of the various procedures shown is the validity of resective procedures to treat advanced periodontal disease. The results support the fact that proper treatment planning, meticulous supportive periodontal care, and excellent home care can provide long-term solutions to such challenging clinical situations.
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[Figure 1], [Figure 2], [Figure 3]