Management of periodontal furcation defects employing molar bisection; a case report with review of the literature

Sukant Sahoo; Karan Sethi; Prince Kumar; Aman Bansal

Official publication of the American Biodontics Society and the Center for Research and Education in Technology

CASE REPORT

Year : 2013 | Volume : 4 | Issue : 3 | Page : 97-101

Management of periodontal furcation defects employing molar bisection; a case report with review of the literature

Sukant Sahoo, Karan Sethi, Prince Kumar, Aman Bansal
Department of Prosthodontics, Shree Bankey Bihari Dental College and Research Centre, Ghaziabad, Uttar Pradesh, India

Date of Web Publication

8-Aug-2013

Correspondence Address:
Prince Kumar
Department of Prosthodontics, Shree Bankey Bihari Dental College and Research Centre, Masuri, Ghaziabad, Uttar Pradesh
India

Source of Support: None, Conflict of Interest: None

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Abstract

Introduction: The management and long-term retention of molars exhibiting furcation invasion have always been a challenge in dentistry. Latest innovations in dental sciences and higher patient's expectations have led to more conservative treatment approaches in saving the teeth with hopeless periodontal prognosis. When periodontal disease affects the furcation area of tooth, the chance of its exfoliation increase considerably. Here, authors have sought to discuss a comprehensive review of literature with case report for the management of decayed mandibular first molars (with furcation invasion) using bicuspidization procedure. Case Report: The furcation defect (in mandibular first molars) was clinically detected in a middle aged male, which was converted into two bicuspids by intentional bisection procedures. The definitive treatment included restoration with double crowns. Bicuspidization procedure with double metal crowns truly yielded a satisfactory result. Discussion: The treatment of furcations affected by periodontal disease is one of the most difficult problems for the general dentist and periodontist. An increase in the exposed root surface, anatomical peculiarities and irregularities of the furcation surface all favor the growth of bacteria. These problems make it harder for the patient to maintain hygiene, and impede adequate treatment. Bisection/bicuspidization of the decayed molars can be a practicable treatment option when there is vertical bone loss involving root/roots with furcation defect. In real terms, it is the separation of mesial and distal roots of mandibular molars along with its crown portion, where both segments are then retained individually.

Keywords: Bicuspid, bicuspidization, furcation defect

How to cite this article:
Sahoo S, Sethi K, Kumar P, Bansal A. Management of periodontal furcation defects employing molar bisection; a case report with review of the literature. Dent Hypotheses 2013;4:97-101

How to cite this URL:
Sahoo S, Sethi K, Kumar P, Bansal A. Management of periodontal furcation defects employing molar bisection; a case report with review of the literature. Dent Hypotheses [serial online] 2013 [cited 2023 Mar 22];4:97-101. Available from: http://www.dentalhypotheses.com/text.asp?2013/4/3/97/116341

Introduction

The dentistry being practiced in the present twenty first century has provided multiple prospects to the patients for preservation and maintenance of a functional dentition all over life. The mandibular molars are first teeth to erupt in oral cavity and therefore are having high caries susceptibility index, which actually necessitates cautious implementations of oral hygiene measures . Any deprivation in the maintenance may lead to serious problem like furcation involvement .The glossary of periodontal terms defines furcation as "the anatomic area of a multi-rooted tooth where the roots diverge" and furcation invasion refers to the "pathologic resorption of bone within a furcation." ^[1] Furcation invasion is the most commonly seen phenomenon in relation to mandibular molars. Maintaining the health of these teeth with an exposed bifurcation/trifurcation area can be a major problem . This is due to the difficulty of plaque control and the danger of root caries incident to inadequate oral hygiene procedures . An open furcation is subject to rapid plaque accumulation and calculus formation and is an ideal local environment for the multiplication of microorganisms . The patient, faced with a difficult problem in maintaining an open furcation, often fails in efforts to maintain adequate plaque control . One has to be extra careful while managing such clinical situations with restorative and periodontal therapy . Various treatment procedures have been discussed in the literature viz; root amputation, hemisection, radisection, and bisection . Root amputation denotes the removal of one or more roots of multi rooted tooth keeping other roots intaced . Term hemisection indicates the removal of root with its associated crown portion of mandibular molars. Nevertheless, radisection is a novel terminology for removal of roots of maxillary molars . Bisection/bicuspidization is the separation of mesial and distal roots of mandibular molars along with its crown portion, where both segments are then retained individually . ^[2] A multidisciplinary treatment procedure for such clinical situations that includes restorative dentistry, endodontics, periodontics, and prosthodontics is necessary to preserve the teeth in whole or in part . These teeth can act as independent single units of mastication or as abutments in simple fixed bridges. Hence, tooth resection measures are employed to preserve maximum tooth structure rather than sacrificing the whole tooth. This clinical report cum literature review has sought to systematically review with multidisciplinary treatment procedure for periodontically severed mandibular molar by bicuspidization and total rehabilitation using the double crowns technique. Bicuspidization of affected molars their consecutive prosthetic rehabilitation yielded a satisfactory result .

Review of Literature

A literature review was conducted using Medline, Google search engines, and manual library search. It evidenced various successful management techniques for mandibular molars with advanced furcation invasions. Hirschfeld and Wasserman was the first to report affirmative effect of repeated subgingival scaling, root planning and gingival curettage in the long-lasting retention of mandibular molars with Class III cases. ^[3] Later on Bower postulated that furcal openings of mandibular molars frequently are narrower than the blade of frequently used curettes. ^[4] However, taking into account the anatomical complexities of the surrounding furcal region in mandibular furcation, curettes used alone may not be sufficient for root preparation still narrow diameter ultrasonic debridement tips may use to have superior results.

Saxe and Carman stated tooth extraction as the last resort for advanced furcation involvements. ^[5] They put forwarded certain clinical guidelines for extraction in such conditions viz; unopposed molar representing the terminal tooth of the arch, a single mobile distal abutment, etc. their postulations later have been supported by Hamp et al., who also avowed extraction as an indication when the affected tooth would not improve the overall treatment plan, or when treatment of the furcation would result in an area that the patient could not clean readily. ^[6] Apart from the bicuspidization procedure, literature also supports few less intensive treatment options for Class III mandibular furcation involvement that is root resection. According to Bassaraba, root resection is indicated in teeth those are of critical importance extraction of which might have resulted in annihilation of the over all dental rehabilitation planning, e.g., teeth serving as abutments for fixed and removable partial dentures; teeth that have sufficient attachment remaining for function; teeth for which a more predictable or cost-effective method of therapy is not available and teeth in patients with good oral hygiene and low activity for caries. ^[7]

Farshchian and Kaiser was the first to depict the successful implementation of bicuspidization or molar bisection procedures in the management of severe furcation involvements. ^[8] In literal meaning, bicuspidization or molar bisection is splitting of the mandibular molar vertically through the furcation without removing both half and leaving two separate roots that are then treated as bicuspids. ^[9] They further affirmed factors related to the success of bicuspidization procedures : s0 tability of, and adequate bone support for the individual tooth sections; absence of severe root fluting of the distal aspect of the mesial root or mesial aspect of the distal root; adequate separation of the mesial and distal roots that could enable the creation of an sufficient embrasure for efficient oral hygiene. Soon after, Newell endorsed the bisection procedures; however, the remaining roots has to be endodontically treated with acceptable restorative management and prosthetic crowns. ^[10]

Nyman et al., in 1982 given the principle of guided tissue regeneration (GTR) for the treatment of osseous defects in periodontitis. ^[11] According to the American Academy of Periodontology in its glossary of periodontal terms, is the "regeneration of periodontal attachment through differential tissue responses." A variety of barrier materials for GTR have been reported to be used for the successful management of Class III furcation involvements FIs of mandibular molars. They are primarily polytetra fluoro ethylene, polyglactin, poly lactic acid, calcium sulfate, and collagen. Pontoriero et al, stated that vertical bone loss of more than 3 mm will limit the success of any attempt of GTR at mandibular molars with Class III FIs that is why any Class III mandibular furcation with a vertical bone loss of more than 3 mm would not be indicated for a GTR procedure. ^[12] Cohen have afterward coined the term "Tunneling," which is a periodontal surgical procedure that creates suitable access point for patient cleaning and maintenance within the furcal area of a molar tooth. ^[13],[14]

Case Report

A 39- year-old male reported to the dental office with chief complaint of pain in the right and left back region of his mouth since 3 weeks. History of present illness confirmed incessant and throbbing pain in said region that occasionally got worsened during mastication and sleep. On clinical examination both mandibular first molars was grossly carious, highly sensitive to percussion and showed Grade I mobility. Probing confirmed 8 mm deep periodontal pocket in root furcation area with a Class II furcation involvement; however, vitality testing of 36 and 46 yielded no response [Figure 1]. In radiographic examination, intraoral peri apical radiographs confirmed Class II furcation involvement with the evident vertical bone loss surrounding the roots [Figure 2]. Based on the clinical assessment and investigations, a systematic treatment planning was framed to achieve total rehabilitation step-by-step. At foremost, periodontal prophylactic therapy was carried out with scaling. Intentional endodontic treatment of involved molars was carried out and bicuspidization procedure performed under local anesthesia to separate the crown by vertical cut method using along shank tapered fissure carbide bur [Figure 3]. Patient responded well to the treatment. Soon after satisfactory tissue healing, restoration of molar bicuspids and definitive Prosthodontic treatment were started. Different treatment modalities for restoring the tooth were thought including temporary acrylic crowns, all metal crowns, porcelain fused to metal crown, and all ceramic crowns. Porcelain fused to metal crown and all ceramic crowns were ruled out because of economic factors. The patient desired a fixed prosthesis therefore all metal double crowns were finalized considering overall patient's needs. Tooth preparation was completed and a supra gingival chamfer finish line was placed to assist in oral hygiene procedures. Final impressions were made in custom acrylic (Rapid Repair Self Cure Resin, GN Sethi, New Delhi, India) tray using the heavy and low viscosity elastomeric impression materials (Addition Silicon, Reprosil, Dentsply India). Acrylic temporary crown was cemented using the zinc oxide non-eugenol temporary cement (RelyX Temp NE, 3M ESPE, United States) and the whole procedure was repeated on right mandibular first molar roots. Through assessment of all metal full veneer double crowns were carried out (occlusal interference corrected if any) on master cast and in patient's mouth. Double crowns were permanently cemented using luting Glass inomer cements (GC Gold Label 1, GC India) [Figure 4].

Figure 1: Pre-operative view showing furcation defect using Naber's probe

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Figure 2: (a and b) Intraoral periapical radiographs confi rming the Class II furcation defect

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Figure 3: Tooth preparation and fi nish line placement after bisection procedure

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Figure 4: Occlusal view illustrating double metal crowns on both mandibular first molar

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Discussion

Periodontitis is considered as subgingival inflammation caused by bacterial infection. It affects the periodontal supporting tissues including periodontal ligament, cementum, and alveolar bone. Periodontitis affects the junction of multi-rooted tooth, initially with tissue destructions then gradually with further bone loss and eventually end up with furcation involvement. The treatment of furcation defects is a complex and relatively difficult job that may compromise the success of periodontal therapy. Estimation of the prognosis of molars with furcation invasion is often an annoying and disappointing experience to the dental professional and patient. Undoubtedly, the bifurcations constitute one of the zones in the oral cavity where plaque is most difficult to remove. Thorough knowledge of the root morphology and of the surrounding topography of the pocket is crucial if access to difficult areas is to be gained. Though multiple treatment modalities have been attempted to preserve teeth with moderate to severe furcation involvement, clinical success has not been accurately predictable. Bicuspidization is a valuable treatment option to save multi-rooted teeth having the hopeless prognosis in periodontal context. Proper case selection and meticulous investigation is very important prior to these procedures. In addition, patient's oral hygiene status and attitude, caries susceptibility index and medical and drug history should be taken into account. Nevertheless, to accurately typify a furcation case, the following factors (many of which are anatomical and biomechanical in nature) should be taken into considerations. ^{[15],[16],[17],[18]}

Root divergence
Root fusion
Root concavity
The size of the furcation
The length of the root trunk
Separation of the roots
The ease with which hygiene of the affected furcation can be maintained
The capacity of the patient to maintain optimum hygiene
The remaining bone (crown/root ratio)
Mobility
Occlusion (prematurity and interferences)
Adherence of the gum.

Despite of the various advantages, the remaining root or roots must undergo intentional endodontic therapy and the crown has to be prosthetically managed. In dentistry, endodontic care prior to bicuspidization procedure has a long history and it has remained today as a necessity in treating furcally involved mandibular molars. ^{[19],[20],[21]} In case when the tooth has lost part of its root support, it will require a restoration to allow it to function autonomously or to serve as an abutment for a splint or crown or bridge. Disappointingly, a restoration may lead to periodontal destruction, if the margins are defective or if non-occlusal surfaces do not have anatomic and physiologic form. This confirms the significance of accurate marginal adaptation of the final restoration. ^{[22],[23],[24],[25],[26]} At the metal trial stage, the occlusal contacts were reduced in size and repositioned more favorably. In addition, lateral excursive forces were reduced by making cuspal inclines less steep and eliminating balancing cuspal inclinations. Hence, the above observations have implications for clinical practice in the treatment planning and prognosis determination of furcation involvements in patients with periodontal disease.

Conclusion

The management of furcation involvement presents one of the greatest challenges in periodontal therapy. Furcation-involved molar teeth respond less favorably to conventional periodontal therapy, and molars are lost more often than any other tooth type. Although the use of embryonic stem cells have been shown in recent literature, bicuspidization procedures with double crowns may be considered as a suitable alternative to extraction in multi-rooted teeth with hopeless prognosis. ^[21] The clinical outcome and long-term performance of bicuspidization and double crowns are predictable with high success rates. Bicuspidization with definitive prosthetic rehabilitation have received acceptance as a traditional and reliable dental treatment. These cost-effective, minimally invasive restorations not only improve masticatory function, but enhance esthetics and self-confidence, allowing patients to develop socially. However, patient motivation, faithfulness in adhering to frequent maintenance appointments, various physical handicaps, and poor manual dexterity are limiting factors in keeping these areas in a state of health.

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