Classification and treatment of interradicular lesions

Classification and treatment of interradicular lesions

1. Introduction :

The diagnosis, prognosis, and treatment of teeth with furcation involvement are governed by the same general principles that can be applied to a single-rooted tooth.

However, despite the additional stability provided by the supplemental root anchorage, multirooted teeth and their surroundings have certain anatomical features that make treatment difficult and its results unpredictable.

2. Definition :

2-1-The furcation zone:

Classification and treatment of interradicular lesions

2-3-The interradicular lesion: 

It is a loss of periodontal tissues with bone lysis in the corono-apical direction and in the vestibulo-lingual direction of the interradicular septum.

3. Anatomical considerations:
   1. The tooth:

• The location of the furcation relative to the enamel-cementum junction.
• The concavity of the internal surface of the bare roots.
• The degree of separation of the roots.

2. The alveolar bone:

The shape of the bone in the exposed furcation may be horizontal or there may be varying degrees of vertical bone loss close to the roots or to the furcation side of the buccal or lingual bone.

In addition, a thick lingual or buccal bone rim, at the level of the teeth adjacent to an external oblique ridge, can promote the formation of vertical depression-like lesions at the furcation area. On the other hand, a thin radicular bone, will cause total loss of bone and no vertical lesions will form. 

3. The gum: 

The presence of sufficient attached keratinized gingival tissue and adequate vestibular depth will facilitate treatment of the gingiva at the furcation area.

4. Etiologies: 

Represented by the triad of Weski 1936, which include: local factors; general factors; constitutional factors.

5. The diagnostic approach:
   1. Clinical examination:

2. the radiological examination.
3. classification of interradicular lesions:

a-Horizontal classification of furcation lesions According to the Lindhe and Nyman scale:

Classification and treatment of interradicular lesions

b-Vertical classification of furcation lesions class 3 according to TARNOW and FLETCHER:

Classification and treatment of interradicular lesions

7. the purposes of the processing:

The treatment of interradicular lesions involves surgical techniques, which will have the following objectives:

• intervention under visual control and access to the root surfaces in order to be able to carry out correct debridement;
• elimination of bags;
• establishment, at the level of the dento-gingival region, of a morphology which facilitates the correct performance of hygiene care by the patient. 

1. Class I:

• scaling and root planing.
• Odontoplasty.
• Gingivectomy/gingivoplasty.
• Flap surgeries.

2. Class II:

• Scaling and root planing.
• Odontoplasty.
• Shreds.
• Root resection.
• Additive bone surgery (graft / RTG)
• Extraction.

3. class III: 

• scaling and root planing.
• Odontoplasty.
• Root resection (root amputation)
• Tunneling.
• RTG.
• Extraction.

8. the selection criteria:

• according to class (universal classification) 
• survey of pockets of the sector concerned
• character of lysis at the proximal level;
• character of lysis at the interradicular level;
• root anatomy: height of the root trunk width of the interradicular space root proximities of adjacent teeth;
• a priori therapeutic projects: preservation of natural teeth or fixed prosthesis.

9. Treatment of interradicular lesions:
   1. Conservative treatment:
      1. Descaling-surfacing :

Scaling is a procedure that involves removing plaque and tartar from the surface of the teeth.

Depending on the location of the deposits, scaling will be supra- or subgingival.

Root planing involves the removal of the “softened” cementum, leaving the root surface hard and smooth. 

2. Periodontal curettage:

Periodontal curettage is defined as the removal of the inner surface of the soft tissue wall of the pocket using a curette (Lindhe 1986).

The purpose of blind periodontal curettage is:

• To check and perfect under anesthesia:
• removal of soft and calcified deposits from the tooth surface;
• removal of infiltrated cementum;
• root polishing (smooth, clean surface allowing reattachment of soft tissues).
• To eliminate:

• the pathological epithelial tissue lining the base of the pocket;
• the infiltrated connective tissue of the attachment.

2. Resective techniques:
   1. Odontoplasty- Gingivoplasty:  

This term means “tooth remodeling” with respect to furcation involvement. It means widening the furcation diameter in the bucco-lingual or mesio-distal direction as well as the corono-apical direction. This is done using a high-speed diamond bur. 

         Gingivoplasty: 

The gingival surface is regularized using a COSTAVEJO chisel and rounding the angle formed by the incision. This plasty can be performed by rotating instruments. And this to perfect the gingival contour in relation to the furcation. 

2. gingivectomy:

For Lindhe: “Gingivectomy is a surgical technique that aims to eliminate the soft tissues of the pocket, it is therefore a gingival excision by incision followed by excision (plasty), and depending on the type of incision we speak of GBI or GBE.”

3. tunneling:

• It aims to create an interradicular space allowing the passage of a brush for perfect cleaning of this area.
• The indications are limited:

• class 02 and 03 injuries;
• horizontal or angular infra-osseous interradicular alveolysis;
• upper molar after amputation of one of the 03 roots; 
• low root trunk height;
• large interradicular space.

4. odontoplasty-osteoplasty:

If the furcation tunnel diameter is narrow or access to the furcation is restricted, osteoplasty. Odontoplasty may be necessary. The tooth and alveolar bone in the furcation area are then reshaped.
This technique is usually used as part of a complete periodontal surgery procedure and is not often used alone.

5. WIDMAN and modified WIDMAN flap: it is a muco-periosteal flap.

  According to Widman the advantages over gingivectomy:

• healing by first intention therefore better comfort for the patient
• ability to restore proper bone contour at sites with angular bone defects.

The indications: 

• survey revealing pockets of 07 to 08 mm
• all classes;
• lysis with moderate to medium angular defects.        
• a long root trunk.
• Modified Widman: it has the same indications as the original, but it is intended for molars with a short root trunk.

6. apically displaced flap:

It is a technique used to eliminate the periodontal pocket

The incision is internally beveled, it is moved apically relative to its initial position

The location of the displaced flap depends on:

• thickness of the marginal edge in the sector to be treated 
• height of attached gum
• the length of the clinical crown required for a prosthetic abutment 

Indication: 

• Reduce the periodontal pocket
• Increase the height of the attached gingiva 
• Lengthen the clinical crown
• interradicular lesion.

7. hemisection and root amputation:

• Hemisection: 

In hemisection, the tooth is cut in half. The technique is used exclusively on mandibular molars to treat Class II or III interradicular lesions. 

Unlike root amputations, extraction of the fragment is not mandatory. 

• Root amputation:

Root resections (amputations) are used when the interradicular lesion is too advanced to be corrected by the techniques described above. Access to the furcation can be gained by removing one or more of the affected roots. 

3. Additive techniques:

Note: Due to the anatomical complexity of the upper molars, the use of additive techniques would be limited to the treatment of the lower molars (class 02).

• Bone grafting.
• Combined technique: bone graft and RTG membrane. (see the course of treatment of periodontal bone defects)

4. Endo-periodontal treatment  : for true endo-periodontal lesions.
5. Prosthetic treatment: occlusal adjustment.
6. Conclusion: In general, we can say that:

Existing therapeutic possibilities allow successful treatment of teeth with interradicular lesions;

The conditions related to the success of a therapy are as follows:

• observe contraindications (anatomical, endodontic, hygiene); 
• regular check-ups with the periodontologist.
• Classification and treatment of interradicular lesions

  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

Classification and treatment of interradicular lesions