This document discusses the diagnosis and classification of periodontal disease, as well as factors that affect treatment options. It describes Glickman's four-grade classification system for periodontal disease and details treatment approaches for each grade. Surgical procedures like root resection, hemisection, and extraction are discussed as options for managing multi-rooted teeth with furcation involvement, depending on factors like root morphology, bone loss pattern, and oral hygiene. Maintaining a clean, maintainable architecture and preventing further attachment loss are the goals of treating furcation defects.

1. Presented by
Dr. Sharashchandra, MDS
Prof and HOD

2. ETIOLOGY
-- Bacterial plaque
-- Root trunk length
-- Root morphology
-- Cervical enamel projections
Local factors affect the rate of plaque deposition
or complicate the performance of oral hygiene
procedures and contributing to the development
of periodontitis and attachment loss

3. DIAGNOSIS
-- Careful probing
-- Transgingival probing
factors that contribute :
Morphology of the affected tooth
Position of tooth relative to adjacent teeth
Local anatomy of the alveolar bone
Configuration of any bony defects
Caries and pulpal necrosis

4. CLASSIFICATION
GLICKMAN
FOUR CLASSES

5. GRADE I
Incipient or early stage
Supra bony pocket
Early bone loss
Radiographic changes are not found

6. GRADE II
Cul-de- sac
Vertical bone loss
Radiograph may not show the involvement

7. GRADE III
Facial and lingual bony plates are lost
Filled with soft tissue and not visible
Radiolucent in the furcation area

8. GRADE IV
Inter dental bone is destroyed
Soft tissue have receded apically
Furcation opening is clinically visible
Tunnel therefore exists between the roots

9. FACTORS AFFECTING TREATMENT
ROOT TRUNK LENGTH
ROOT LENGTH
ROOT FORM
INTER RADICULAR DIMENSION
ANATOMY OF FURCATION
CERVICAL ENAMEL PROJECTIONS

10. ROOT TRUNK LENGTH
Shorter the root trunk length – more accessible
to facilitate surgical procedures than the long
root trunks or fused roots

11. ROOT LENGTH
Teeth with long roots are more readily treated, as
sufficient attachment remains,to meet functional demands

12. ROOT FORM
Curvature – complicates

13. INTER RADICULAR DIMENSION
Teeth with widely separated roots present
adequate instrumentation during scaling,
root planning, and surgery than closely
approximated or fused
roots

14. ANATOMY OF THE FURCATION
Bifurcation ridges
Concavity in the dome
Accessory canals
Complicates scaling, root planing and
surgical therapy and maintenance

15. CERVICAL ENAMEL PROJECTIONS
Prevalence is highest for mandibular and
maxillary second molars
AFFECT : plaque removal
COMPLICATE : scaling and root planning
They are removed to facilitate maintenance

16. DIFFERENT ANATOMIC FEATURES OF ROOTS
WIDELY SEPERATED FUSED
SEPERATED BUT CLOSE ENAMEL PROJECTIONS

17. THE ANATOMY OF BONY LESIONS
PATTERN OF ATTACHMENT LOSS
Horizontal bone loss can expose the
furcation as thin facial/lingual plates of bone
The pattern of bone loss on other surfaces
of the affected tooth and adjacent teeth must
be considered during treatment planning
Molars with advanced attachment loss on only
one root may be treated by resective procedures

18. OTHER DENTAL FINDINGS
The combination of furcation involvement and
root approximation with an adjacent tooth may
dictate the removal of the most severely
affected tooth or the removal of a root

19. TREATMENT
OBJECTIVES
Facilitate maintenance
Prevent attachment loss
Obliterate the furcation defects

20. CLASS I
Odontoplasty
Re-contouring

21. CLASS II
Flap procedures -- osteoplasty / odontoplasty
This reduces the dome of the furcation
and alters gingival contours to facilitate the
patients plaque removal

22. CLASS III / IV
Periodontal surgery
Endodontics
Replacement of tooth

23. ROOT RESECTION – MANDIBULAR II MOLAR

24. SURGICAL THERAPY
ROOT RESECTION
INDICATED
Multi rooted teeth with grade II to IV furcation
Teeth serving as abutments of fixed or
removable restorations
Teeth that have sufficient attachment
remaining for function

25. Teeth with furcation defects that have been
treated successfully with endodontics but now
present with a vertical root fracture
Patients with good oral hygiene and low
activity for caries

26. CONTRA INDICATIONS
Patients unable or willing to perform
good oral hygiene and preventive measures
are not suitable candidates

27. WHICH ROOT TO REMOVE AND WHY ?
Remove the roots that will eliminate the
furcation and allow the production of a
maintainable architecture on the remaining roots
Remove the root with the greatest amount of
bone and attachment loss

28. Remove the root that best contributes to the
elimination of periodontal problems on
adjacent teeth
Remove the root with the greatest number
of anatomic problems such as severe curvature,
developmental grooves or accessory root canals

29. HEMISECTION
Splitting of two-rooted into two separate
portions
Also called as bicuspidization
INDICATED
Mandibular molars with buccal and lingual
class II or III furcations
CONTRAINDICATED
Molars with advanced bone loss in the
inter proximal and inter radicular zones

30. RESECTION / HEMISECTION PROCEDURE
Most commonly – disto-buccal root of the
maxillary first molar
Local anesthesia given
Full thickness flap is raised
Both facial and lingual / palatal flap raised
to provide better visibility and instrumentation

31. Debridement
A cut is then directed from just apical to
the contact point of the tooth through the
tooth to the facial and distal orifices of
the furcation
A high speed surgical length fissure or
cross-cut fissure carbine bur is used

32. For hemisection a vertically oriented cut is
made facio-lingually through the buccal and
lingual developmental grooves of the tooth
through the pulp chamber and through the
furcation
After sectioning the root is elevated from its
socket
Care should be taken not to traumatize bone
on the remaining roots or to damage an
adjacent tooth

33. Odontoplasty is performed to remove portions
of the developmental ridges and prepare a
furcation that is free of any deformity
Flaps are then approximated to cover any
grafted tissues or to slightly cover the bony
margins around the tooth
Sutures are then placed to maintain the
position of the flaps
The removal of a root alters the distribution
of occlusal forces on the remaining roots
Adjust the occlusion

34. RESECTION – MESIAL ROOT MOLAR II

35. HEMISECTION – II MOLAR

36. HEMISECTION – I MOLAR

37. REGENERATION
INDICATION
Furcation with deep two-walled defects

38. EXTRACTION
Extraction of teeth with through and through
furcation defects [class III and IV ] and advanced
attachment loss is most appropriate therapy
for some patients

39. PROGNOSIS
The keys of long-term success :
Thorough and careful diagnosis
Selection of patient with good oral hygiene
Careful surgical and restorative management