General Dentistry

QUINTESSENCE INTERNATIONAL GENERAL DENTISTRY Adrian Kasaj Root resective procedures vs implant therapy in the management of furcation-involved molars Adrian Kasaj, PD Dr med dent1 Therapeutic decision making and successful treatment of fur- ment, the clinician is increasingly confronted with the dilemma cation-involved molars has been a challenge for many clin- of whether to treat a furcated molar by traditional root resec- icians. Over recent decades, several techniques have been tive techniques or to extract the tooth and replace it with a advocated in the treatment of furcated molar teeth, including dental implant. This article reviews the outcomes of root resec- nonsurgical periodontal therapy, regenerative therapy, and tive therapy for the management of furcation-involved multi- resective surgical procedures. Today, root resection is consid- rooted teeth and discusses treatment alternatives including ered a relevant treatment modality in the management of fur- implant therapy. Treatment guidelines for root resective thera- cation-involved multirooted molars. However, root resective py, along with advantages and limitations, are presented to procedures are very technique-sensitive and require a high help the clinician in the decision-making process. level of periodontal, endodontic, and restorative expertise. (Quintessence Int 2014;45:521–529; doi: 10.3290/j.qi.a31806) Given the high documented success rates of implant treat- Key words: furcation involvement, furcations, molar, periodontal disease, root resection The management and long-term retention of furcated teeth without furcation involvement.3,4 Even with a molar teeth has always been a challenge for clinicians. surgical approach selected to improve access for root Furcation involvement is defined as interradicular bone surface debridement, complete calculus removal in the resorption and attachment loss in multirooted teeth furcation area is rare.5 The compromised results in fur- caused by periodontal disease. The interradicular space cation areas can be attributed to the limited accessibil- of the molar teeth is inaccessible for proper mainte- ity of the furcation entrances for complete debride- nance, and long-term stability of molars with furcation ment as well as the complex anatomy and morphology involvement is compromised. Thus, maxillary molars of molar teeth.6 Moreover, the morphology of the fur- are the most common teeth lost, followed closely by cation area provides an environment favorable to bac- mandibular molars.1,2 In addition, furcation-involved terial deposits, which hampers professional as well as multirooted teeth generally respond less favorably to self-performed plaque control.7 treatment compared with single-rooted teeth or molar Various therapeutic approaches have been introduced for several decades that aim to retain furcation- 1 Associate Professor, Department of Operative Dentistry and Periodontology, involved molars, including nonsurgical and surgical School of Dental Medicine, University of Mainz, Mainz, Germany. mechanical debridement, regenerative therapy, and Correspondence: Dr Adrian Kasaj, Department of Operative Dentistry resective surgical procedures. Root resection is one and Periodontology, University of Mainz, School of Dental Medicine, Augustusplatz 2, 55131 Mainz, Germany. Email: [email protected] treatment option for preserving molars with furcation VOLUME 45 • NUMBER 6 • JUNE 2014 521 QUINTESSENCE INTERNATIONAL Kasaj involvement. Through root resection therapy, furcation- Tarnow and Fletcher12 later on further described the involved molars can be converted to nonfurcated/sin- extent of furcation involvement with a subclassification gle root teeth and provide a favorable environment for evaluating the degree of vertical involvement: oral hygiene maintenance by eliminating plaque reten- • Subclass A, 1–3 mm tive morphology. The procedure of root resection has • Subclass B, 4–6 mm been used in the treatment of furcation-involved • Subclass C, ≥ 7 mm. molars for more than 100 years.8 However, the interest in root resective procedures has declined in recent Molar root anatomy years due to complications and failures and the fact that The practitioner must have a thorough understanding modern implant dentistry has modified the treatment of the complex furcation anatomy for accurate diagno- planning process. Indeed, it seems that today furcation- sis and selection of treatment modalities. Thus, several involved molars are extracted more frequently in favor problematic anatomical features exist in multirooted of implant placement. Thus, today the ethically oriented teeth such as furcation entrance width, presence of practitioner is challenged with the question whether to root concavities, bifurcation ridges, root trunk length, treat furcation-involved molars by “traditional” root cervical enamel projections, and enamel pearls (Fig 1).14 resective techniques or to replace it with an implant. The diameter of the furcation entrance was evaluated This paper will review root resection procedures as by Bower,15 with the majority of entrances measuring well as the different therapeutic alternatives, especially < 0.75 mm. Considering that the blade width of com- implant therapy, for furcation-involved molars. Treat- monly used periodontal curettes ranges from 0.75 mm ment guidelines for root resective therapy, indications, to 1.10 mm, it is unlikely that proper debridement of and contraindications are presented to help the practi- the furcation area can be achieved with curettes alone tioner in the decision-making process with regards to (Fig 2). Moreover, efficacy of periodontal therapy in the furcation-involved molars. furcation area may be limited by the presence of root concavities and ridges in the interradicular root surface Furcation involvement classification area.15,16 The position of the furcation entrance, particu- The glossary of periodontal terms defines furcation as larly in maxillary molars, is also important with respect “the anatomic area of a multirooted tooth where the to accessibility. Thus, the mesiopalatal entrance of the roots diverge” and furcation invasion refers to the first maxillary molar is located approximately two thirds “pathologic resorption of bone within a furcation”.9 towards the palatal aspect of the tooth, while the disto- Several classification schemes have been introduced to palatal furcation is in the middle portion of the tooth. describe the degree of periodontal tissue destruction in Therefore, a buccal or palatal approach can be used the interradicular area. Most of them are based on the when probing the distopalatal furcation, whereas a extent of periodontal destruction in a horizontal and/or palatal approach is indicated when probing the mesio- vertical direction.10-12 A simple and commonly used palatal furcation. Another important factor that affects system is Hamp’s classification,13 defining periodontal the development of furcation involvement and the destruction in a horizontal direction. Three different mode of treatment is the length of the root trunk. This classes of severity were identified: length is defined as the distance between the cemento- • Class I, horizontal loss of periodontal tissue support enamel junction and the furcation. In a tooth with a < 3 mm short root trunk less attachment needs to be lost before • Class II, horizontal loss of support > 3 mm, without the furcation is involved. On the other hand, a tooth extending through the opposite side with a short root trunk is more amenable to root resec- • Class III, horizontal through-and-through destruc- tive procedures and is also more accessible to mainte- tion of periodontal tissue in the furcation. nance procedures compared to teeth with a longer 522 VOLUME 45 • NUMBER 6 • JUNE 2014 QUINTESSENCE INTERNATIONAL Kasaj a b c d e f Figs 1a to 1f Root anatomy of mandibular and maxillary molars. (a) A cross-sectioned mandibular molar with the mesial root char- acterized by root concavities on the mesial and distal surfaces, whereas the distal root is more robust and has only a minimal concav- ity on the mesial aspect of the root. (b) Third mandibular molar with pronounced curved roots and a short supernumerary root. (c) A maxillary molar with a narrow furcation entrance between the buccal roots and concave and convex areas in the interradicular root surface area. (d) Maxillary molar with fused roots and (e) roots that diverge coronally but fuse apically. (f) Enamel pearl in the furcation entrance area. Figs 2a and 2b (a) An extracted mandibular molar used to demonstrate that the entrance of the furcation is often nar- rower than the width of the curette blade. (b) Preference should be given to slim ultrasonic scaler tips to enable greater access and efficient periodontal debride- a b ment in the furcation area. root trunk. Alternatively, the furcation of a tooth with a with or without furcal involvement was 82.5% and long root trunk will be invaded at a later stage, but suc- 17.5%, respectively. Thus, cervical enamel projections cessful resective therapy is not as predictable because can be considered as an important predisposing factor the length of the remaining roots may not be sufficient in the initial furcation invasion due to the lack of fiber for support. Other important anatomical variations that attachment on the enamel extensions. However, the can be considered as local cofactors in causing furca- presence of cervical enamel projections is often difficult tion lesions include cervical enamel projections and to detect for the clinician,

Load more