ROOT CONDITIONING
INTRODUCTION
• The removal of bacterial deposits, arrest of periodontal disease
and regeneration of periodontal tissues that are lost due to the
disease process constitute the ideal and main goal in
periodontal therapy.
• Thus, biocompatibility of root surface is of extreme
importance for achieving success of periodontal therapy.
Definition:
 Root biomodification is a periodontal regenerative procedure
which involves chemical modification of root surface.
Rationale:

Root debridement generates a smear layer which contains
micro-organisms & toxins, that interfere in periodontal healing.

Blood element adhesion to the demineralized roots and clot
stabilization by collagen fibers are important for the success of
therapy.

Thus, the use of an agent to remove this smear layer and to
expose the collagen fibers is an important factor to obtain
biologically acceptable tooth surfaces.
Various Chemical Agents Used For Root Biomodification:
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Citric acid
Tetracycline hydrochloride
Fibronectin
Laminin
EDTA
Sodium hypochlorite
Sodium deoxycholate
Stannous fluoride
Hydrochloric acid
CITRIC ACID
•
Accelerated healing & new cementum formation.
•
Removes the smear layer.
•
Exposes the dentinal tubules.
•
Makes the tubules appear wider with funnel shaped orifices.
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Eliminates endotoxins & bacteria.
•
Prevents apical migration of epithelium.
Technique of application:
• Raise a mucoperiosteal flap
• Thoroughly instrument the root surface removing calculus
and underlying cementum.
• Apply cotton pledgets soaked in a saturated solution of
citric acid (pH1) and leave it on for 2-4 minutes. The
appropriate concentration of citric acid necessary to
achieve a pH1 solution was determined to be 61 gms of
citric acid per 100 ml of distilled water.
• Remove pledgets, and irrigate root surface profusely with
water.
• Replace the flap and suture.
• The use of citric acid has also been recommended in
conjunction with coverage of denuded roots using free
gingival grafts.
TETRACYCLINE
• Are broad spectrum antibiotics with activity against both gram
positive and gram negative bacteria as well as mycoplasma,
rickettsial and chlamydial infections.
• Tetracycline, doxycycline and minocycline are commonly used
and all three have a similar spectrum of activity and resistance
to one may indicate resistance to all three.
• They are generally used as a 0.5% solution at a PH of 3.2 and
is applied for 5 minutes
• The solution is prepared by adding 1 standard ml of sterile
water to the contents of each capsule, then thoroughly mixing
the two. The material is applied with lateral pressure using a
sterile cotton pellet.
• It inhibits tissue collagenase production and bone resorption.
Another beneficial effect is that the drug is released in
biologically active concentration for 48 hours after application.
FIBRONECTIN
• Is a high molecular weight glycoprotein that is found in
the extracellular tissue and is the main component that
holds the clot together. It promotes cell adhesion to both
collagen and scaled root surfaces and has a chemotactic
effect on fibroblasts and mesenchymal cells.
• Fibronectin is a major participant in a variety of cellular
activities such as cell-cell and cell- substrate
adhesiveness.
EDTA
• It is a chelating agent and functions by forming a calcium
chelate solution with calcium ions.
• It is suggested that neutrally buffered EDTA will reduce the
probability of damage to the soft tissues of the periodontium
• This means that the cells found in the periodontal ligament and
in the vicinity of the alveolar bone will be available when
needed to proliferate on the previously diseased root surface,
thereby initiating regeneration.
• Remove any plaque and/or calculus as well as blood from the
root surfaces exposed during periodontal surgery
• Apply EDTA on root surfaces for 2 minutes. Active rubbing
(“burnishing”) is not recommended.
• Rinse thoroughly with sterile saline.
• Avoid recontamination of the conditioned root surfaces after
the final rinse.
ENAMEL MATRIX PROTEINS
• Enamel matrix proteins (EMP) mimics the events that take
place during development of periodontal tissues.
• This is based on the finding that the cells of the hertwigs
epithelial root sheath deposit enamel matrix proteins on the
root surface prior to the deposition of the cementum
GROWTH FACTORS
• Growth factors are polypeptide molecules released by cells in
the inflamed area that regulate events in wound healing. These
factors primarily secreted by macrophages, endothelial cells,
fibroblasts and platelets.
• Include platelet derived growth factor (PDGF), insulin like
growth factor (IGF), basic fibroblast growth factor (BFGF)
and transforming growth factor (TGF) α and these Growth
factors could be used to control events during periodontal
wound healing.
• These growth factors help promote migration and proliferation
of fibroblasts for the periodontal ligament formation or to
promote the differentiation of cells to become osteoblasts and
favoring bone formation.
• The addition of PDGF has been shown to enhance bone
formation in periodontal osseous defects.
ENZYMES
• Enzymes such as elastase & hyaluronidase have been found
effective in new connective tissue attachment after
instrumentation & demineralization.
MANAGEMENT OF FURCATION
INVOLVEMENT
INTRODUCTION
• The progress of inflammatory periodontal disease if left
unabated, ultimately results in attachment loss sufficient
enough to affect the bifurcation or trifurcation of multirooted
teeth.
• The furcation is an area of complex anatomic morphology that
may be difficult or impossible to debride by routine
periodontal instrumentation.
• The presence of furcation involvement is one clinical finding
that can lead to a diagnosis of advanced periodontitis and
potentially to a less favorable prognosis for the affected tooth
or teeth.
• Furcation involvement therefore presents both diagnostic and
therapeutic dilemmas.
Furcation can therefore be defined as the area
located between two root cones.
ETIOLOGY OF FURCATION
INVOLVEMENT
• Primary etiologic factor is bacterial plaque and the
inflammatory consequences that result from its long-term
presence.
• The extent of attachment loss required to produce a furcation
defect is variable and related to local anatomic factors such as
root trunk length, root morphology and local developmental
anomalies such as cervical enamel projections.
LOCAL ANATOMIC FACTORS IN
TREATMENT OF FURCATIONS
• Clinical examination of the patient should allow the therapist
to identify not only furcation defects but many of the local
anatomic factors that may affect the result of therapy
(prognosis).
•
Well-made dental radiographs, while not allowing a definitive
classification of furcation involvement, provide additional
information vital for treatment planning. Important local
factors are described in the following section.
THE TOOTH
• During treatment planning, the following anatomic features of
the affected teeth should be considered:
• Root trunk length
• Root length
• Root form
• Interradicular dimension
• Anatomy of furcation
Root trunk length:
• This is a key factor in both the development and treatment of
furcation involvement.
• The distance from the cementoenamel junction to the en trance
of the furcation can vary extensively.
• Teeth may have very short root trunks, moderate length trunks
or roots than may be fused to a point near the apex. The
combination of root trunk length with the number and
configuration of the roots affects both the ease and success of
therapy.
Root length:
•
Root length is directly related to the quantity of attachment
supporting the tooth.
•
Teeth with long roots trunks and short roots may have lost a
majority of their support by the time that the furcation
becomes affected.
•
Teeth with long roots and short to moderate root trunk length
are more readily treated as sufficient attachment remains to
meet functional demands.
Root form:
• The mesial root of most mandibular first and second molars
and the mesiofacial root of the maxillary first molar are
commonly curved to the distal in the apical third.
• In addition, the distal aspect of this root is usually heavily
fluted. The curvature and fluting may increase the potential for
root perforation during endodontics or complicate post
placement during restoration.
Interradicular dimension:
• The degree of separation of the roots is also an important
factor in treatment planning.
• Closely approximated or fused roots can preclude adequate
instrumentation during scaling, root planing, and surgery.
•
Teeth with widely separated roots present more treatment
options and are more readily treated.
Anatomy of the furcation
• The anatomy of the furcation is complex.
• The presence of bifurcation ridges, a concavity in the dome,
and possible accessory canals complicates not only scaling,
root planing, and surgical therapy, but also periodontal
maintenance.
•
Odontoplasty to reduce or eliminate these ridges may be
acquired during surgical therapy for an optimum rest.
Different anatomic features that may be important in prognosis
and treatment of furcation involvement:
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Widely separated roots.
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Roots are separated but close.
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Fused roots separated only in their apical portion.
•
Presence of enamel projection that may be conducive to early
furcation involvement.
CLASSIFICATION OF
FURCATION INVOLVEMENT
Glickman classification (1958)
GRADE I :
– incipient or early stage of furcation involvement.
– the pocket is suprabony and primarily affects the soft
tissues.
– early bone loss may have occurred with an increase in
probing depth.
– radiographic changes are not usually found.
GRADE II :
–
can affect one or more of the furcation of the same tooth.
–
it is a cul-de-ac lesion with a definite horizontal component.
–
if multiple defects are present, they do not communicate with
each other, since a portion of the alveolar bone remains
attached to the tooth.
–
vertical bone loss may be present.
–
radiographs may or may not depict the furcation involvement
(especially the maxillary molars).
GRADE III
• the bone is not attached to the dome of the
furcation.
• in early involvement, the opening may be filled
with soft tissue and may not be visible.
• radiographs display the defect as a radiolucent
area in the crotch of the tooth.
GRADE IV
• The interdental bone is destroyed.
• Soft tissue have receded apically so that the furcation opening
is clinically visible.
• Tunnel exists between the roots of such an affected tooth.
• Periodontal probe passes readily from one aspect of the tooth
to the other.
DIAGNOSIS OF FURCATION INVOLVEMENT
• Careful probing is required to determine the presence and extent of
furcation involvement, the position of the attachment relative to the furca
and the extent and configuration of the furcation defect.
Radiogrphic diagnosis:
• It should include tooth parallel intra oral periapical and vertical bitewing
radiographs.
• Inter dental bone as well as that within the root complex should be
examined.
THE OBJECTIVES OF FURCATION THERAPY
Are to :1) Facilitate maintenance,
2) Prevent further attachment loss, and
3) Obliterate the furcation defects as a periodontal maintenance
problem.
The selection of therapeutic mode varies with
• A- The class of furcation involvement,
• B- The extent and configuration of bone loss,
• C- Other anatomic factors.
Therapy for Early Furcation Defects: Class I
• As the pocket is suprabony and has not entered the furcation,
oral hygiene, scaling, and root planing are effective.
• Any thick overhanging margins of restorations, facial
grooves, or cervical enamel projections should be eliminated
by odontoplasty, recontouring, or replacement.
• The resolution of inflammation and subsequent repair of the
periodontal ligament and bone is usually sufficient to restore
periodontal health.
Therapy for Furcation Involvement: Class II
• Once a horizontal component to the furcation has developed
(class II), therapy becomes more complicated.
•
Shallow horizontal involvement without significant vertical
bone loss usually responds favorably to localized flap
operation with odontoplasty and osteoplasty.
• Isolated deep class II furcations may respond to flap
procedures with osteoplasty and odontoplasty
This reduces the dome of the furcation and alters gingival
contours to facilitate the patient's plaque removal.
Therapy for Advanced Furcation Defects:
Class II-IV
• Nonsurgical treatment is commonly ineffective as the ability to
instrument the tooth surfaces adequately is compromised .
• Periodontal surgery, endodontics, and restoration of the
tooth may be required to retain the tooth.
SURGICAL THERAPY FOR FURCATION
INVOLVEMENT
1- ROOT RESECTION
2- HEMISECTION
3- REGENERATION
4- EXTRACTION
CONCLUSION
• The ideal management of the furcation, or for that matter
any periodontal disease, would be preventive & this consists
of controlling plaque and occlusal forces so that the
resistance and reparative capacity of the periodontium is not
exceeded.