Periodon tics

The overall significance of regenerative procedures in the treatmentof furcations

Hans-Peter Müller*/Thomas Eger**

Abstract A retn>speetive sttidy examined the frequency of a feasible or retnotely pos.sibleindication for regenerative therapy of furcation involvement in a large group ofperiodontally diseased patients. The Judgment about the feasibility of tiie indicationwas mainly based on results of current randomised controlled chnicai triais withregard to tooth type and iocation of the Jurcation lesion. Data from .i.̂ S patientstreated by nvo periodonti.^ts, one experienced and one in training, were anaiyzed.Furcation involvement of at least one miiltirooted tooth was found in 40% and 63%ofthe two dentists' patients. In oniy 20% and 27% of tiieir patients was there apotetitiai indication for regenerative Jurcation treatment. Of I. ¡34 Jurcationlesions. ¡80 (15.9%) were conceivably suitable for this procedure. Only 17 siteswith aj'easible or remotely possible indication were treated in that wax: In tnostcases, conventional furcational treatment (flap surgery- with scaling and rootplaning) was performed. (Quintessence Int ¡997;28:32l-328.)

Clinical relevance

One major indication for guided tissue regenerationprocedures may be buecal and/or lingual furcationinvolvement of mandibular molars and buecal in-volvement of maxillary molars, but this type ofperiodontal lesion is rare, even in a selectedpopulation with periodontitis.

Introduction

Although it is generally accepted that the progressionof a periodontal lesion into the interradicular areaseriously affects the long-term prognosis of a multi-

' Depanment of Operalivc Dentistry and Periodonlotogy, tJniversity ofHeidelberg, Heidelberg, Germany,

** Department of Denlistri', German Armed t-orces Central Hospital.Koblenz, Germany.

• Reprint requests: Dr Hans-Peter Müller, Depanment of OperativeDemistry and Periodontology, tJniveriity of Heidelberg, Im Neiien-heimer Feld 400, D-69120 Heidelberg, Germany, e mail: hani-peler-imiellei@krzmait.krz.uni-heidetberg,de

The opinions e>,pressed in this anicte are Ihose ofthe autliorb and cannoibe conslrued as reileclmg the views of tlie German Armed Forées'Medical Serviee, the German Ariiied Forces at iarge, or ttie GermanMinistry of Defense,

rooted tooth,' '' there is surprisingly little informationwith regard to the overall prevalence of interradieularperiodontitis in a given population, and only a fewstudies have focused on that topic, ̂

Whether furcation involvement plays a significantrole in daily practice eleariy depends on the type ofclientele referred to and preferred by the dentist. Theperiodontist will treat more patients with furcationinvasions than will a dentist whose main emphasis ison restorative and prosthodontic treatment. A retro-spective analysis was made of treatment modalities ofall patients of one of the authors, an experiencedperiodontist. Of 309 patients treated during 1987through 1994, 193 (62,5%) presented with at least onefurcation invasion. The operator was confronted withsimilar numbers of ineipient, moderately advanced,and through-and-thro ugh furcation involvements,'' Incontrast, of 249 patients treated by the other authorduring his 3-year postgraduate training program, only100 (40.2'Ä) had at least one multirooted tooth withinterradieular periodontitis. The vast majority of thosefurcation invasions were diagnosed as being incipient.

When the data were analyzed in more detail, itbecame clear that the treatment pattern of bothoperators was quite similar; conventional measures, ie,scaling, root planing, and furcation plasty, predomi-

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Müller/Eger

nated by far, even in more advanced eases,^ Boththerapists extracted more than 40% of teeth with athrough-and-through furcation invasion. Regenerativemeasures, such as guided tissue regeneration' orcoronally repositioned and fixed mucoperiostealflaps,** were only rarely employed,''

A number of recent randomized and well-control ledstudies have convincingly indicated that guided tissueregeneration may provide considerable advantage overconventional treatment modalities. Especially in buccaland/or lingual class II itircation involvement of mandib-ular molars'''"' and buccal furcations of maxillarymolars, ' ' better results are to be expected. In contrast,through-and-through furcation involvements.'''-' fur-cation invasions of maxillary premolars,'"* and mesialor distal Ilircation invasions ofmaxiilary molars" '̂ areprobably not very suitable for these technically demand-ing procedures.

There is, at present, no information with regard tothe relative importance of regenerative procedures indaily periodontal practiee, Tlie aim of the presentstudy, therefore, was to detennine the prevalence ofapossible indication, as suggested by the results ofrandomized controlled trials, for a regenerative pro-cedure in the treatment of furcally involved multiroot-ed teeth. The analysis was based on charts of a largenumber of patients treated for periodontal disease bytwo operators mainly engaged in periodontics,^

Method and materialsPatients

The present study was based on retrospectively sampleddata of al! 309 patients treated by one ofthe authors(operator A), an experienced periodontist, during1987 through 1994, and 249 patients treated by theother author (operator B) during his 3-year post-graduate training program. Patients were between 16and 72 years of age and presented with moderatelyadvanced or advanced periodontitis.

Therapy

Patients entered an individual oral hygiene programconsisting of detailed education about the significanceof dental plaque for the development of periodontaldisease and instruction in proper oral hygiene mea-sures, Supragingival and, as far as possible, subgingivalbacterial deposits were earefully removed in a series ofweekly sessions. At multirooted teeth, the degree ofilircation itivolvement was estimated"' with a curved

Nabers' probe (PQ2N, Hu Friedy), Periodontal de-struction of about one third ofthe crown width in theinterradicular region was eonsidered a degree I in-volvement. If more than one third of, but not the entire,interradicular periodontium was destroyed, a degree IIfurcation was diagnosed. If the curved probe could bepassed through and through the furcation entrances,the tooth was eonsidered to have degree III involve-ment,

Periodontal surgery was performed at sites withpersisting periodontal probing depths of 5 mm or moreand bleeding on probing, Fureational lesions weretreated with one ofthe following therapies:

1, Conventional, ie, scahng and root planing and, ifindicated, furcation plasty. employing eurettes,periodontal files, and rotating fine diamonds

2, Resective measures, such as hemisection or rootresection

3, Tunnel preparation4, Regenerative procedures, either guided tissue re-

generation with expanded polytetrafluoroethylene(e-PTEE) membranes^ or coronally repositionedand fixed flaps'

5, Tooth extraction

In general, the actual degree of furcation involve-ment was reevaluated intraoperatively. The presentanalysis was based on ihis second estimate. Supportivecare was scheduled individually, depending on local,tooth-related, and general risk factors," Most patientswere recalled in 2- to 3-month intervals for subgingivalscaling at sites with a periodontal probing depth of5 mm or more and bleeding on probing.

Reasonable indications for regenerative procedures

In the retrospective analysis of the patient data, apossible indication for a regenerative procedure at afureational lesion was assumed in the followingsituations;

1, Buccal and/or lingual degree II ilircation involve-ment of first and second mandibular molars^'*

2. Buccal degree II furcation involvement of first andsecond maxiiiary molars"

The following was considered a remotely possibleindication;

1, Mesiopalatal degree II furcation involvement ofmaxillary molars

The following were considered to have no indica-tion for. or even a contraindication to. regenerativemeasures;

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MtJller/Eger

L Degree I furcation involvement2. Degree III irivolvement'-"3. Distopalatal degree II involvement of maxillary

molars"'^4. Buecal and/or mesiopalatal degree II furcation

involvement in the presence of degree II involve-ment ofthe distopalatal furcation or a through-and-through involvement between two furcation en-trances

5. Etircation involvement of third molars6. Furcation involvement of maxillary premolars'**

A number of teeth had been extracted in spite ofapossible indication for regenerative treatment. Be-cause, in most ofthese cases, the reason for extractioncould not be determined, a definite contraindicationwas supposed.

Results

A total of 558 patients had been treated by the twooperators. A periodontitis-affected llircation was pres-ent in 62.5% of paiients treated by operator A, but only40,2% of patients treated by operator B, Table 1presents an overview ofthe distribution ofthe 1,134ftircation lesions treated by the two operators. About62.5% ofthe furcation lesions were found at maxillaryteeth. Operator A was confronted with considerablymore furcation invasions al maxillary premolars,whereas operator B had to treat more maxillary thirdmolars,

Eor operators A and B, the absolute frequencies ofinterradicular lesions at teeth probably suitable forregenerative procedures, ie, first and second molars,are shown in Table 2, Eor operator A. of 181 treatedfurcations at second maxillary molars, a possible orremotely possible indication for a regenerative pro-cedure was identified in only 22 cases (12.2%). Nosuch operation was performed, however. Of 179involved furcations at first maxillary molars, a possibleor remotely possible indication was present in 29 cases( 16,2/ii), but the procedure was only performed twice.In mandibular molars, regenerative measures wereindicated for 35,5% of second molars and 34,3% offu-st molars. The procedures were performed in ninecases.

Of 139 furcation involvements at maxillary secondmolars treated by operator B, nine (6,5%) exhibited apossible or remotely possible indication for a regenera-tive procedure. This operation was, however, not per-formed. The respective figures were 10,3% for maxil-

lary first molars and 35.1% and 19,4% for mandibularsecond and first molars, respectively.

Of 309 periodontally diseased patients treated byoperator A, only 84 (27,2%) had furcation lesionsprobably suitable for regenerative procedures. Therespective figure for operator B was 49 of 249 patients(19,7%), Ofa total of 1,134 furcation lesions treated,only 180 {15.9%) presented with a possible ( 140) orremotely possible (40) indication for regeneration.Table 3 shows the treatment modalities employed forfurcations with a possible or remotely possible indica-tion for regenerative procedures, Resective measuresand tunnel preparations were rarely performed. Con-ventional treatment ofthe furcations (scaling and rootplaning, Utrcation plasty) was carried out in the vastmajority of cases,

A regenerative procedure was performed in 17 in-dicated cases. When the study criteria are strictly con-sidered, in 15 cases a regenerative procedure was per-formed when it was not indicated, mostly for through-and-through furcations in the mandible (Table 4),

Discus.sion

In spite ofthe enormous growth within the past 30years ofthe knowledge ofthe etiology of inflammatoryperiodontal diseases, which has direct impact ondiagnosis and treatment of destructive periodontitis,the appropriate management of interradicular lesionsat multirooted teeth continues to be a major and, byand large, unsolved problem. This is especially true inlight of the rapid development of novel tools formechanical instrumentation ofthe complex root sur-face colonized by microorganisms as well as newperspectives for the regeneration of lost periodontaltissues. As in other areas of modern dentistry, inperiodontics the practitioner is faced with a be-wildering multitude of new methods and techniques.

On the other hand, when newly developed treat-ment modalities are recommended, in recetit years anevidence-based approach is strongly demanded notonly from the public but also from clinicians andscientists both in general medicine and dentistry,'̂ '-"^Different treatment modes for furcation-involved teethand their respective indications have been described inseveral recent publications and modern textbooks onperiodontology,-""-•' Although recommendations seemto depend mostly on the degree of involvement andtooth type, in practice, the decision for one or the othermodality, conventional, resective, or regenerative,seems to be guided by a number of other factors, eg, the

Quintessence International Volume 2B, Number 5/1997 323

Müller/Eger

Table I Distribution of 1.134 furcational lesions in 558 patients treated by two operators

Degree ofinvolvement

Operator A1IIIII

Total

Operator BIUIII

Total

18/28

148

¡3

2014

1

35

17/27

754957

¡81

864211

139

565172

179

7832

7

111

Tooth*

14/24

126

20

38

700

7

38/48

17169

42

29172

49

37/47

364727

HO

4330

4

77

36/46

303636

¡02

22113

Others

320

JÎ

401

5

Total

230211229

670

28914629

464

• FDt looth-numbering syslem.

Table J Frequency of periodontally diseased furcations at first and second molars and indications for regenerativeprocedures

Tooth*

Operator ATotal number of furcation involvementsEeasible indication for regenerative procedureRemotely possible indication for regenerative procedureIndicated regenerative procedure performed

Operator BTotal number of furcation involvementsEeasible indication for regenerative procedureRemotely possible indication for regenerative procedureIndicated regenerative procedure performed

* FDI tooih-numbering system.

Mill

18112100

139360

16/26

1791217

2

117391

37/47

11039

04

1111

04

36/46

10235

05

36701

Tota

572982711

36940156

techtiical skill of the operator, the strategic importanceofthe particular tooth, and the patient's preference andcompliance.

In randomized controlled clinical trials,"*—^ onlylimited and transient effects could be ascertained afterconventional treatment of furcational lesions, ie.mechanical debridement of interradicular concavities.In contrast to single-rooted teeth and flat surfaces ofmolars, no long-lasting attachment gain should beexpected in the furcation area of molars following

[ionsui;gical periodontal therapy.-^ Tbis outcome hasbeen directly related to the considerable amounts ofbacterial deposits unintentionally left in the bizarreniches of the interradicular space-' as well as rapidrecolonization with periodontal pathogens.-^

An important indication for strongly propagatedguided tissue regeneration is a moderately advancedfurcation involvement (degree II) at mandibular mo-lars. A number of short-term, randomized controlledclinical trials unequivocally have demonstrated a

324 Quintessence Intemational Volume 28, Number 5/ig97

M ü 11 er/E ge r

Table 3 Treatment of periodontitis-affected furcations with a feasible or remotely possible indication forregenerative procedures

Tooth*

Operator ATotal number of furcation involvementsScaling/root planing/flircation plastyHemisection/root resectionTunnel preparationRegenerative procedure

Operator BTotal number of ftircation involvementsScaling/root planing/flircation plastyHemisection/root resectionTunnel preparationRegenerative procedure

* FDl toottintimbering system.

17/27

2222

000

99000

16/26

2925

202

1292Ü

4

37/47

3933

!14

2723

004

36/46

3526

135

76001

Tota

1258644

11

5547

206

Table 4 Distribution of nonindicated regenerativeprocedures performed by two operators

involvement

Operator AIIII

Operator BI111

Total

17/27

00

10

/

Tooth*

37/47

13

00

4

36/46

19

00

10

Total

212

10

¡5

' FDT tooth numbering system.

distinct short- and probably long-term-" advantage ofregenerative procedures over conventional therapy.'̂ "'*'On the other hand, at maxillary molars, a morebeneficial effect is obtained only at buccal, but notmesial or distal, degree II furcations."'^ Also, nodiscernable advantage is apparent in infrabony pocketsaround maxillary premolars.''' Thus, in the presentstudy, the most feasible indications for regenerativeftircation therapy were considered to be degree IIinvolvement of mandibular molars and buccal degreeII involvement of maxillary first and second molars.

A remotely possible indication was a mesiopalataldegree II furcation involvement in maxillary molars.This, however, could not entirely be substantiated fromthe current literature. In a limited number of randomizedcontrolled clinical trials dealing with the regenerativetreatment of maxiilary molar flircations, no advantageor no clinically relevant advantage over conventionalmeasures was ascertained."'^ This (remotely possible)indication was therefore based on the impression ofthe authors that a mesiopalatal, in sharp contrast to thedistopalatal, Ilircation may allow effective instrumenta-tion of root concavities. It should be noted, however,that no such procedure was actually performed by theauthors.

Furcation involvement of third molars and maxillarypremolars were generally disregarded as indicationsfor regenerative therapy. Nevertheless, there might becircumstances where regenerative procedures shouldbe kept in mind for an attempt to improve long-termprognosis of a particular tooth of strategic importance.

In recent years, a number of attempts have beenmade to stabilize the wound area and allow periodon-tal regeneration, even in mandibular degree III furca-tions,'- "'" sometimes by employing citric acid condi-tioning and/or decalcified freeze-dried bone allograftsin combination with e-PTFE membranes or coronallyrepositioned fiaps.-"''- From the results of thesestudies it may be concluded that, in certain cases,especially with a small area ofthe furcation entrance,'^

Quintessence International Volume 28, Number 5/1997X

325

Müller/Eger

Fig 1a (¡eft) A highly standardized ver-tical bite-wing radiograph with occlusalimpressions reveals a through-and-through furcation involvement at tooth46. Atter thorough rootdebridement, thefiap was coronaiiy repositioned, andsutures were fixed at the crown of thetooth with resin

Fig 1b (righiJAverticalbite-wingradio-graph taken after 6 months revealscompiete closure. Ciinicaiiy, no furca-tion invoivement couid be probed.

Fig 2a (left) A vertical bite-wing radio-graph reveáis a furcation lesion at toofh36. Clinically, a buecal degree li furca-tion was present. Foilowing debride-ment, an e-PTFE membrane was piaced

Fig 2b frighfj A vertical bite-wing radio-graph taken alter 7 months revealsalmost compiete ciosure Clinically, thelesion was converted to a class I in-voivement.

some degree of closure of mandibular degree IIIftircations might occur. However, at present, thereseems to be no procedure that provides any predictableresult. In the present study, regenerative procedures atdegree III furcations were performed in 12 easestreated by operator A before 1990 (sec Tahle 4),

Figures la and lb demonstrate a case in which theprocedure (coronally repositioned and fixed flap)

resulted in closure ofthe degree III furcation of toolh30 (46), A buecal degree II furcation at tooth 19 {36}in the same patient was treated with an e-PTFEmembrane and displayed partial closure after 7 months(Figs 2a and 2b),

The present study, based on data aequired in morethan 550 periodontitis parients, should reveal howoften a reasonable indication for regenerative furcation

326 Quintessence International Volume 28, Number 5/1997

fvl ulier/Eg er

treatment aetually occurred. This seemed to be the casein only 20% and 27% ofthe two clinicians" patients. Ofmore than 1,100 periodontally involved furcations, anindication for a regenerative procedure was found in15.9%, When other major limitations with regard toindication are considered, such as questionable stra-tegic importance of the particular tooth.*" insufficientcompliance ofthe patient, or excessive smoking'-̂ -"^ aswell as local factors such as the location ofthe gingivalmargin in relation to the llireation entrance, themorphology of the defect.'' the interproximal boneheight, or the height and concavity ofthe root trunk,this figure would have been llirther decreased. Theoperators performed an indicated regenerative pro-eedure in only 17 cases total ( 9,4% of all 180 furcationswith a feasible or remotely possible indication). Basedon the rather strong criteria inferred from the currentliterature, another 15 regenerative operations were notindicated.

The present results showed that regenerative treat-ment of periodontally involved furcations is indicatedin relatively rare instances, even in a mainly periodontitis-afFected patient population. Considering the numer-ous open questions regarding, eg, the superiority ofnewly developed, biodegradable barriers.^^"'^ alter-native regenerative procedures,̂ ^•'"* long-term progno-5J5̂ 29,.í3,4i g|._ Qj- utmost importance, the quality andfimctional capacity of the regenerated tissue.''-''^regenerative procedures should not be regarded asroutine operations for use in daily periodontal prac-tiee. Further studies should determine the overallelinieal relevance of other potential indications forregenerative procedures, such as inirabony pocketsand gingival recession.

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