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Tunneling: A treatment modality for furcation involved teeth –A case report

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Abstract

Treating molar teeth with furcation involvement presents a difficult challenge to the clinician though a number of differing treatment options are available. Of these the tunneling procedure has been studied least often. The tunneling procedure is designed to create access for cleansibility and maintenance within the furcal area of a molar tooth which has incurred severe attachment and bone loss due to periodontal disease. If perfect compliance with plaque control is maintained, it can prove as a less invasive, cost effective treatment modality.
Case Report
Tunneling: A treatment modality for furcation involved
teeth A case report
Sonika Shakya 1, Shaili Pradhan2
1Resident, 2Professor and Head, Department of Periodontology and Oral Implantology
National Academy of Medical Sciences, Bir Hospital, Kathmandu, Nepal
ABSTRACT
Treating molar teeth with furcation involvement presents a difficult challenge to the clinician though a
number of differing treatment options are available. Of these the tunneling procedure has been studied
least often. The tunneling procedure is designed to create access for cleansibility and maintenance
within the furcal area of a molar tooth which has incurred severe attachment and bone loss due to
periodontal disease. If perfect compliance with plaque control is maintained, it can prove as a less
invasive, cost effective treatment modality.
Key words: grade ii, grade iii furcation involvement, tunneling procedure
INTRODUCTION
Furcation areas present some of the greatest
challenges to the success of periodontal therapy.
Higher mortality and compromised prognoses
for molars with furcal involvement have been
reported in several retrospective studies of
tooth loss. Additionally, reduced efficacy of
periodontal therapy has been consistently found
in multirooted teeth with furcal involvement,
regardless of the treatment modality employed.
A furcation is defined as ‘‘the anatomic area of a
multirooted tooth where the roots diverge’’, and
furcation invasion refers to the ‘‘pathologic
resorption of bone within a furcation’’. 1
Prevalence of furcation involved molars is higher
in maxilla than in mandible. From age of 30
years, 50% of 1st and 2nd molars in maxilla
showed at least 1 furcation site with deep
involvement. In mandible similar prevalence
observed first after age of 40 years. Highest
frequency is found at distal site of maxillary 1st
molar (53%), whereas mesial aspects of maxillary
2nd molar showed lowest frequency (20%).2
The examination of teeth should include both
periodontal probing and radiographic analysis.
Clinical examination is done by using Naber’s
periodontal probe, explorer or a small curette.
Indices for furcation involvement are based on
the horizontal measurement of attachment loss
in the furcation,3,4 or a combination of horizontal
and vertical measurements,5 or a combination of
these findings with the localized configuration of
the bony deformity.6
Glickman3 classified furcation involvement into
four grades; Grade I to Grade IV.
Grade I: Incipient lesion, no radiographic
changes
Grade II: Cul de sac lesion, some amount of bone
present in furcation, defects do not
communicate, can be seen radiographically
Grade III: Bone is not attached to dome of
furcation, furcation entrance covered by soft
tissue
Grade IV: Soft tissue recession exposing
furcation opening, probe passes through and
through.
Correspondence: Dr. Sonika Shakya; e-mail: tosonica@gmail.com
52 Journal of Nepal Dental Association - JNDA | Vol 14, No 2, Aug-Dec 2014
Case Report
Primary etiologic factor in development of
furcation defects is bacterial plaque and
inflammatory consequences that result from its
long-term presence. Extent of attachment loss
required to produce a furcation defect is variable
and related to local anatomic factors (e.g., root
trunk length, root morphology) and local
developmental anomalies (e.g., cervical enamel
projections).
Other factors include occlusal origin, pulpal
pathology, combined lesions, iatrogenic factors,
root fractures involving furcations and local
anatomic factors.
Treatment of Furcation Defects
The objectives 7 of furcation therapy are:
1. The elimination of the microbial plaque from
the exposed surfaces of the root complex.
2. The establishment of an anatomy of the
affected surfaces that facilitates proper self-
performed plaque control.
Different methods of therapy are:
Nonsurgical periodontal therapy
Open flap debridement
Furcation plasty
Regenerative techniques; GTR, bone grafts,
EMD
Root resection/ Hemisection
Tunneling
Management of furcation-involved teeth is one
of the more complex challenges in periodontal
therapy and the anatomy of the furcation
impedes accessibility for professional root
debridement.8 The selection of therapeutic
mode varies with the grade of furcation
involvement, the extent and configuration of
bone loss, and other anatomic factors.
Furcation sites have repeatedly shown to
respond less favourably to conventional
periodontal treatment than flat surfaces.9,10 and
also molar furcation sites were more likely to
lose further attachment than flat molar and non-
molar surfaces during a 2-year postoperative
period (21% versus 7% and 11%) 9 and (25%
versus 10% and 7%).10
Reasons for compromised results in furcation
areas include the lack of proper access for
instrumentation due to furcation anatomy and,
consequently, a persistence of pathogenic
microbial flora.11
Resective therapy, with the aim of eliminating all
plaque retaining factors, has been utilized in
periodontal defects, with advanced horizontal
bone loss and grade II or III furcation
involvement12. Tunneling is one such technique
that has been reported to create periodontal
health and prevent further attachment loss at
furcation-involved teeth.13
Tunneling
Tunnel preparation is the process of deliberately
removing bone from the furcation to produce an
open tunnel through the furcation.14 The
objective of this treatment is to obtain the
possibility of cleaning the furcal area by the
patient using an interdental brush.15 It is usually
performed in cases of advanced grade II or
grade III furcation defects a technique used to
treat advanced grade II and grade III furcation
defects. The procedure converts a severe grade
II or grade III furcation into a grade IV furcation
which is cleansable by patient using interdental
aids.
Following anatomical and clinical features of the
molar should be present for the procedure to be
a success:
Divergent mesial and distal roots, to allow
postsurgical furcal maintenance and cleaning
4,16
A short root trunk, which places the root
fornix closer to the cementoenamel
junction13. The root trunk should not be
longer than 1/3 of total root length, i.e.,
approximately 4 mm based on figures by
Paolantonio et al 17
Proximal bone support, to compensate for
any osteoplasty, ostectomy or both when
the clinician is establishing harmonious
osseous topography in the furcal area (both
buccal and lingual) 18
An adequate presurgical crown:root ratio,
greater than 1:1
Either no or minimal tooth mobility that
could not be managed by minor occlusal
adjustment
Journal of Nepal Dental Association - JNDA | Vol 14, No 2, Aug-Dec 2014 53
Case Report
Advantages:
Absence of any need for endodontic therapy
Absence of any need for new crown fabrication
Reduced treatment time and cost
Retention of a native tooth for interarch and
intraarch stability
Complications:
Only few molars have roots sufficiently long or
widely divergent roots to allow tunneling. Soft
tissues tend to rebound and obstruct the
furcation.
Root sensitivity:
Pulp reaction: The procedure might provoke a
pulp reaction as it exposes a large root surface
area relative to the root length. Accessory root
canals on the exposed root surface can connect
periodontal and endodontic tissues. The
frequency of accessory canals in the furcation
area varies between 23% 19 and almost 60%.20
However. Langeland et al.21 demonstrated on
extracted human teeth that, although pulpal
inflammation can occur in the presence of
periodontal disease from involved accessory
canals, total pulpal necrosis apparently occurs
only when main apical foramina are involved by
bacterial plaque.
Caries risk: Molars subjected to tunnel
preparation were reported to be at risk for root
caries in the furcation area. However, root caries
in this category of patients is thought to be only
a minor problem as failures after tunnel
preparation fall within the range of other
treatment alternatives.13 Topical application of
fluoride or chlorhexidine varnishes is mandatory
to overcome caries development in the furcation
areas.
CASE REPORTS
A 45 year old male patient was referred to the
Periodontics Unit of Bir Hospital for periodontal
treatment. On examination the patient had
generalized recession and mobility of teeth. He
had mild gingivitis at the time of examination
and his oral hygiene status was fair. Clinical and
radiographic examination showed grade III
furcation involvement in upper first and second
molars. In the left lower first molar (36), there
was a grade III furcation involvement and tooth
was undergoing root canal treatment (Fig.1)
Non surgical periodontal therapy was started. At
reevaluation, only furcation sites were bleeding
on probing. Open flap debridement was planned
for pockets greater than 5 mm. Tunneling
procedures was planned for left lower first
molar.
Procedure
For the tunnel preparation apically displaced flap
was raised on buccal side and gingivectomy
performed on lingual side (Fig. 2) . Following the
reflection of buccal and lingual mucosal flaps,
the granulation tissue in the defect was removed
and the root surfaces were scaled and planed.
The furcation area was widened by the removal
of some of the inter-radicular bone (Fig 3). The
alveolar bone crest is recontoured; some of the
interdental bone, mesial and distal to the tooth
in the region, is also removed to obtain a flat
outline of the bone. Following hard tissue
resection enough space had been established in
the furcation region to allow access for cleaning
devices to be used during self-performed plaque
control measures. The flaps were apically
positioned to the surgically established
interradicular and interproximal bone level (Fig.
4). Periodontal packs placed (Fig. 5). Sutures
were removed after 1 week (Fig. 6).
Fig. 1 Fig. 2
Fig. 3 Fig. 4
Fig. 5 Fig. 6
54 Journal of Nepal Dental Association - JNDA | Vol 14, No 2, Aug-Dec 2014
Case Report
Patient was advised to use interdental brush
through the prepared tunnel. Patient was
recalled every 2 weeks for the 1st month to
observe his oral hygiene practice.
Fig.7 Post op after 1 month Fig.8 Post op after 24 months
DISCUSSION
The clinician’s decision to choose one treatment
plan over another when confronted with a
advanced grade II and grade III furcation
invasion of a mandibular molar is influenced by
many factors. The tunneling technique presents
some advantages in comparison to the other
treatment alternatives for furcation
involvements. Nevertheless, the treatment
approach depends on the grade of furcation
involvement, periodontal disease, bone loss in
the furcation lateral and apical to the defect, and
tooth mobility.
The radiographic examination showed that the
mesial root on 36 had 50% of remaining bone
and the distal root had 1/3 rd of total bone
height and significant amount of bone loss in the
furcation area. It had a short root trunk and a
wide diameter of the furcation entrance which
are mandatory for proper postoperative plaque
control management by the patient. The patient
had started root canal therapy for the tooth due
to history of severe pain. Clinically the tooth was
grade I mobile. We observed that the patient
had fair oral hygiene status and if motivated he
could maintain a high standard of oral hygiene.
Looking into all the above factors we planned for
a tunneling procedure for the tooth no.36.
Tunneling, however, does have several
disadvantages as well like potential development
of root caries and sensitivity.
Hamp and colleagues 4 in a five-year study in
which they treated 310 furcated teeth, found
that four of seven tunneled teeth developed
caries. On the other hand, in a retrospective
study of 156 tunneled maxillary and mandibular
teeth, Hellden and colleagues22 found that 75
percent of the teeth were caries-free after 8.9
years. Little and colleagues23 found that 84
percent of tunneled molars (five maxillary and
13 mandibular) were caries-free at six years after
treatment.
Vandersall24 presented a case report of a 23-
year observation period of the tunneling
treatment approach and stated that with
frequent (three- to six-month) supportive
periodontal treatments, along with the use of
fluoride rinses or gels and dentifrices by a
patient with meticulous oral hygiene, root caries
in tunneled mandibular molars very well may be
less a problem than earlier perceived. The
patient has become well adapted to the tunnel
and has maintained excellent oral hygiene and is
enjoying full functional occlusion. Patient is on
recall for every six months for supportive
periodontal therapy and his plaque and bleeding
scores are very low.
CONCLUSION
Treating molar teeth with severe furcation
involvement presents a difficult challenge to the
clinician though a number of treatment options
are available. Tunnel preparation of furcation-
involved molars is a treatment alternative worth
considering. Tunneling, in a properly selected
patient who is motivated to perform careful oral
hygiene, can result in comfortable, functional,
healthy retention of the affected tooth, with a
minimal commitment of time and money.
REFERENCES
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4. Hamp SE, Nyman S, Lindhe J. Periodontal
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56 Journal of Nepal Dental Association - JNDA | Vol 14, No 2, Aug-Dec 2014
... In fact, a study evaluating the incidence of caries in molars that underwent tunneling therapy showed that after 37.5 months, 24% of 149 treated teeth had carious lesions in the furcation region 15 . Another possible complication from the tunneling technique is the occurrence of dental hypersensitivity since this surgery exposes a large number of dentinal tubules and accessory canals with the oral medium 16 . ...
... The tunneling technique is considered effective only if the patient can fully cooperate with the oral hygiene techniques and participate in periodontal support therapy consultations 16 . The patient treated in the present case report, despite being a heavy smoker, presented a pattern of oral hygiene and motivation that allowed the tunneling technique to succeed after 12 months of follow-up. ...
Article
Full-text available
The aim of this study is to describe a case report of lower molar treatment with grade III furcation by the tunneling technique in a heavy smoker patient. Case presentation: In the present study, a 40-year- -old man, a heavy smoker (> 20 cigarettes / day) presented a grade III furcation injury on dental element 46 after a clinical and radiographic examination. After non-surgical periodontal therapy, the patient was treated with the execution of the tunneling of the furcation of the tooth 46, which was effective in the control of the disease and in the maintenance of the dental element after 12 months of follow up. Final considerations: The tunneling technique was effective in the control of periodontal disease in a heavy smoking patient, with a good standard of hygiene and motivation, and good clinical results were maintained after 12 months of follow-up.
... Not all the molars have enough divergence of the roots in order to carry out this procedure, there can be obstruction of the furcation as soft tissue rebounds, it leads to the exposure of root surface leading to pulpal reaction causing root sensitivity, this procedure can increase the risk for the caries so topical fluoride or chlorhexidine should be applied [7]. ...
Article
Treatment of molar teeth with severe furcation involvement allows for differing therapies of which the tunneling procedure has been least studied. While subsequent root caries in furcal exposed teeth was believed a major shortcoming, successful periodontal therapy is primarily dependent upon the stability of the attachment and intrafurcal and interproximal bone. We evaluated in each of 18 subjects (10 female, 8 male) a molar tooth with deep grade II/III furcation involvement at time of presentation (T-0), to 1st post-surgical recall following a tunneling procedure (T-1), to most immediate last recall (T-2; mean time T-0 to T-2, 5.80±0.83 years). Assessments included O'Leary's plaque index (P1-I), attachment levels (AL), root caries and radiographic bone loss. The mean P1-I from T-0 to T-2 decreased 56.8% with some plaque at T-2 detected in furcations of 7/18 teeth. AL across all time periods were not significantly difference except for palatal/lingual AL which from T-0 to T-2 were significantly different. Root caries was found in only 3 teeth at T-2. Adequate radiographs were available for 8 surgically tunneled mandibular molars for analysis of 5 measurements of osseous levels i.e. the mesial and distal levels of the intrafurcal and the interproximal osseous crests, and the distal interproximal osseous crest of a mesial adjacent single-rooted reference tooth which received osseous surgery at the same time. Mean time change values (T-1 to last radiograph taken. T-2a; mean time 3.0±0.7 years) showed no significant difference among the 5 points measured. These results indicate no difference in AL nor loss of furcal or proximal crestal bone in surgically tunneled mandibular molars when compared with an adjacent tooth receiving osseous surgery.
Article
Periodontally involved multirooted teeth constitute a particular problem in periodontal therapy because of the difficulty of eliminating pocketting and producing a post-operative result which allows effective plaque control to be exercised within the involved furcation area. Various methods of treating involved furcations are described together with thier limitations.
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Abstract This paper describes: (1) a system for classification and treatment of furcation involvements, and (2) a 5-year post-operative evaluation of 100 patients treated for periodontal breakdown in the bi/tri-furction areas. The results of this study demonstrate that it is possible to arrest further destruction within the root furcation area. The successful treatment of the multirooted teeth was probably the consequence of: (1) the quasi total elimination of plaque retention areas from the bi/tri-furcation area, and (2) meticulous oral hygiene by the patients.
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Glosario con definiciones de uso frecuente en la Odontología y Periodontología.
Article
T he present study evaluated the long‐term prognosis of tunnel preparations performed in a large number of teeth with advanced periodontal furcation defects. One hundred seven (107) patients, in which 156 teeth had been treated by tunnel preparations, were recalled for an evaluation, which was based on a questionnaire, a clinical examination, and radiographs; 102 patients attended (149 teeth = 95%). The mean observation time per tooth was 37.5 months (range 10 to 107 months). The results showed that 10 teeth (6.7%) had been extracted and 7 teeth (4.7%) hemisected. The indication for 12 of these extractions or hemisections was root caries. Among the remaining 132 teeth, 23 (15.4%) showed initial or established caries. There was no relationship between caries development and length of the observation time. Thus, approximately 75% of the teeth were still caries‐free and in function. The findings demonstrated that tunnel preparations have a considerably better prognosis than previously reported and should be considered a valid treatment alternative.
Article
12 patients were studied longitudinally to monitor the effects of basic periodontal therapy in molar and non-molar teeth. Periodontal sites were grouped into molar furcation sites, molar flat-surface sites and non-molar sites. Clinical measurements were taken at baseline and directly followed by full mouth root debridement. Subsequently, measurements were taken every 3rd month until 24 months. At each of these appointments, the patients were monitored for their oral hygiene performance and given supragingival prophylaxis. The mean results indicated that initially moderately deep and deep molar furcation sites responded less favorably to therapy compared to non-molar sites and molar flat-surface sites of similar probing depth. Initial improvements in probing measurements for moderately deep and deep molar furcation sites were limited and also tended to revert during the observation interval. Identification of individual sites with probing attachment loss disclosed that 25% of molar furcation sites lost probing attachment as compared to 7% for non-molar sites and 10% for molar flat-surface sites. These results corroborate previous findings and call for additional or alternative treatment regimens for periodontal furcation pockets.
Article
The healing response of non-molar sites, molar flat surface sites, and molar furcation sites was investigated in 19 adult periodontitis patients following a periodontal therapy of plaque control and root debridement. A total of 2472 sites were monitored by recordings of dental plaque, bleeding on probing, probing depth, and probing attachment levels every 3rd month for 24 months. The results demonstrated that in sites with initial probing depth of 4.0 mm or greater, molar furcation sites responded less favorably to the therapy as compared to molar flat surface sites or non-molar sites. This was demonstrated by higher mean scores for bleeding on probing, less reduction in probing depth, and a mean loss of probing attachment of 0.5 mm over 24 months. Site analyses using linear regression showed a higher % of deeper sites with probing attachment loss for the molar furcations than either molar flat surface or non-molar sites. Among sites initially 7.0 mm or deeper, 21% of molar furcations were identified as showing probing attachment loss as compared to 7% of the molar flat surface sites and 11% of the non-molar sites.