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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
1. American Academy of Periodontology. Glossary of
periodontal terms. 4th ed. Chicago: AAP; 2001:20.
2. Svärdström G, Wennström JL. Prevalence of
furcation involvements in patients referred for
periodontal treatment. J Clin Periodontol 1996;
23(12):1093-9.
3. Carranza FA, Takei HH. Treatment of furcation
involvement and combined periodontal-
endodontic therapy. In: Carranza FA, Newman
MG. Clinical periodontology. 8th ed. Philadelphia:
Saunders; 1996:640.
4. Hamp SE, Nyman S, Lindhe J. Periodontal
treatment of multirooted teeth. Results after 5
years. J Clin Periodontol 1975; 2:126-35.
Journal of Nepal Dental Association - JNDA | Vol 14, No 2, Aug-Dec 2014 55
Case Report
5. Tarnow D, Fletcher P. Classification of the vertical
component of furcation involvement. J
Periodontol 1984; 55:283-84.
6. Easley JR, Drennan GA. Morphological
classification of the furca. J Can Dent
Assoc 1969; 35:104-7.
7. Lindhe J. Land N. Karring T. Clinical periodontology
and implant dentistry. 5th Ed. Copenhagen:
Munksgaard 2008;Chap39:823-47.
8. Matia, J. I., Bissada, N. F., Maybury, J. E., Ricchetti,
P. Efficiency of scaling of the molar furcation area
with and without surgical access. Int Journal
Periodontics and Restorative Dent 1986; 6:24–35.
9. Nordland, P., Garrett, S., Kiger, R., Vanooteghem,
R., Hutchens, L. H., Egelberg, J. The effect of
plaque control and root debridement in molar
teeth. J Clin Periodontol 1987;14: 231–36.
10. Loos, B., Nylund, K., Claffey, N., Egelberg, J. Clinical
effects of root debridement in molar and non-
molar teeth. A 2-year follow-up. J Clin Periodontol
1989;16: 498–504.
11. Cobb CM. Non-surgical pocket therapy:
Mechanical. Ann Periodontol 1996;1:443-90.
12. Desanctis M, Murphy K. The role of resective
periodontal surgery in the treatment of furcation
defects. Periodontol 2000 2000; 22: 154–68.
13. Rudiger SG: Mandibular and maxillary furcation
tunnel preparations – literature review and a case
report. J Clin Periodontol 2001; 28: 1–8.
14. David C, Rober J. The mandibular molar class III
furcation invasion: A review of treatment options
and a case report of tunneling. J Am Dent Assoc.
2002;133(1):55-60.
15. Goldman HM. Therapy of the incipient bifurcation
involvemnet. J Periodontol. 1958;29:112.
16. Highfield JE. Periodontal treatment of multirooted
teeth. Aust Dent J 1978;23:91-8.
17. Paolantonio, M., di Placido, G., Scarano, A.,
Piattelli, A. Molar root furcation: morphometric
and morphologic analysis. Int J Periodontics and
Restorative Dent 1998;18: 489– 501.
18. Carranza FA, Newman MG. Clinical
periodontology. 8th ed. Philadelphia: Saunders;
1996:643-51.
19. Vertucci, F. J., Williams, R. G. Furcation canals in
the human mandibular first molar. Oral Surg Oral
Med Oral Path 1974;38:308–14.
20. Niemann, R. W., Dickinson, G. L., Jackson, C. R.,
Wearden, S. & Skidmore, A. E. Dye ingress in
molars: furcation to chamber floor. J Endod
1993;19:293–296.
21. Langeland, K., Rodrigues, H., Dowden, W.
Periodontal disease, bacteria, and pulpal
histopathology. Oral Surg Oral Med Oral Path
1974;37: 257–70.
22. Hellden LB, Elliot A, Steffensen B, Steffensen JE.
The prognosis of tunnel preparations in treatment
of Class III furcations: a follow-up study. J
Periodontol 1989;60:182-7.
23. Little LA, Beck FM, Bagci B, Horton JE. Lack of
furcal bone loss following the tunneling
procedure. J Clin Periodontol 1995;22:637-41.
24. Vandersall DC, Detamore RJ. The mandibular
molar class III furcation invasion: a review of
treatment options and a case report of tunneling.
J. Am. Dent Assoc. 2002;133: 55-60.
56 Journal of Nepal Dental Association - JNDA | Vol 14, No 2, Aug-Dec 2014