|Year : 2015 | Volume
| Issue : 1 | Page : 64-68
Novel approach of retension of maxillary molars with grade III furcation involvement with the use of glass ionomer cement
Tejaswini Patil1, Pramod Waghmare1, Amita Mali1, Priyanka Agrawal1, Kaustubh P Patil2
1 Department of Periodontology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune, Maharashtra, India
2 Department of Periodontology, Dr. D Y Patil Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India
|Date of Web Publication||18-Mar-2015|
Dr. Tejaswini Patil
Department of Periodontology, Bharati Vidyapeeth Deemed University Dental College and Hospital, Pune - 411 043, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Introduction: Treatment of advanced furcation invasion has always been questionable. The present case report used a GIC as an occlusive barrier in the treatment of maxillary Class III furcation defects. This procedure helps in saving a tooth which otherwise would have been deemed for extraction. Method: In this case report, glass ionomer cement is used as an occlusive barrier in the treatment of maxillary Class III furcation defects. One year follow-up of clinical and radiographic photo series results showed a reduction of gingival inflammation, tooth mobility and gain in attachment level with the use of glass ionomer. Conclusion: As GIC has many advantages over other restorative materials like low cost, antibacterial property, ease in use, biocompatibility with periodontal tissues, it is a good option in management of class III furcation cases.
Keywords: Furcation invasion, glass ionomer cement, grade III furcation involvement
|How to cite this article:|
Patil T, Waghmare P, Mali A, Agrawal P, Patil KP. Novel approach of retension of maxillary molars with grade III furcation involvement with the use of glass ionomer cement. J Int Clin Dent Res Organ 2015;7:64-8
|How to cite this URL:|
Patil T, Waghmare P, Mali A, Agrawal P, Patil KP. Novel approach of retension of maxillary molars with grade III furcation involvement with the use of glass ionomer cement. J Int Clin Dent Res Organ [serial online] 2015 [cited 2019 Dec 13];7:64-8. Available from: http://www.jicdro.org/text.asp?2015/7/1/64/153503
| Introduction|| |
Furcation involvement is invasion of bifurcations or trifurcations of multirooted teeth by periodontal disease. Long term studies of advanced furcation involvement have demonstrated poor survival rates.  Many treatment modalities are available to treat the furcation like scaling and root planing (non-surgical approach),  osteoplasty/ostectomy, odontoplasty,  surgery to increase the access to furcation area,  root resection/root amputation,  bicuspidization (to remove furcation), tunnel procedure,  guided tissue regeneration and a combination of graft materials and membranes.  Glickman  classified furcation invasion into four classes. Class I shows suprabony incipient lesion with no radiographic changes. Class II invasion shows cul-de-sac and a definite horizontal bone loss. Due to overlapping of the roots many of the times radiographic changes may or may not be visible. Class III furcation shows through and through invasion of the furcation area with soft tissue covering and radiograph shows bone loss. Class IV furcation also shows through and through invasion, clinically visible due to soft tissue recession, radiographs shows bone loss. Many restorative materials have been used to obliterate furcations. Such materials are amalgam, glass ionomer, polymeric reinforced zinc oxide eugenol, and resin ionomer restorative materials (IRM).  The goal was to improve plaque control by eliminating the anatomic niches within the furcation where bacteria can accumulate.
Review of literature
A resin ionomer material has many properties that allow them to be used in the subgingival region. Hirschfeld and Wasserman  stated that for the long-term retention of molars with Class III furcation involvement, repeated subgingival scaling, root planing and gingival curettage may play important role. Bower  reported that mandibular molars have narrow furcal openings than the blade of frequently used curettes. Due to narrow furcation areas of mandibular molar, only use of curettes may not be adequate for root preparation, so use of narrow diameter ultrasonic debridement tips are of an appropriate choice.
Extraction should be the last treatment option for non restorable furcation invasion. Hamp et al.,  reported that when preserving the affected tooth would not improve the overall treatment plan or when the furcation treatment would result in an area that the patient could not clean readily that time extraction is indicated.
In case reports by White and Breault  resin ionomers were placed subgingivally to repair areas of root resorption. Dragoo  demonstrated histological evidence that both epithelium and connective tissue can adhere to resin ionomer when placed in subgingival environment. Scherer and Dragoo  used modified resin ionomer restorations in subgingival locations.
Charles R. Anderegg  showed that teeth with hopeless prognosis might be retained by decreasing probing depths, bleeding upon probing, and mobility when furcation areas are sealed with a resin ionomer. A comparative study with the use of amalgam, zinc oxyphosphate cement, and glass ionomer in the treatment of surgically created furcation in nonhuman primates showed the greatest biocompatibility with glass ionomer with both histological and radiographical evaluation. 
| Case Report|| |
A 39-year-old female patient reported to the outpatient department of periodontology. She was medically fit with no family and dental history relevant to any predisposing factors. Patient showed Class III FI in maxillary left first molar [Figure 1] with clinical attachment loss of 7 mm in the furcation area with grade I clinical mobility. The radiograph of molar revealed no periapical changes [Figure 8]. Thorough scaling and root planing was done, and the patient was recalled after a week. After Phase I therapy, overall health of the dentition improved but persistent inflammation presented with the involved tooth. Oral hygiene instructions had been given to the patient with explanation of the importance of maintenance in the furcation area. After explaining various treatment options, patient selected glass ionomer cement (GIC) to be placed as an occlusive barrier over the furcation defect.
Informed consent was procured from the patient for the surgery. Patient's face was painted with povidone iodine. Following administration of local anesthesia with 2% lidocaine with a concentration of 1:200,000 epinephrine, crevicular incision was made and a full thickness mucoperiosteal flap was reflected to expose all three furcation entrances [Figure 2]. With the use of scalers and curettes, furcation area, angular and horizontal interdental defects on mesial and distal aspect of 26 were debrided, scaled, and root planed [Figure 3]. Furcation site was irrigated with dilute chlorhexidine [Figure 4]. A bonding agent was applied and modified resin reinforced GIC was placed in the furcation area and with the help of plastic instruments and Mylar strip, it was adapted in and over furcation area. Careful attention was made as to avoid the etch bonding agent and GIC to the interfurcal bone to avoid contamination of vital tissue. Petroleum jelly was applied as a protective barrier with the help of cotton pellet. Furcation entrance was settled in this manner. Then the cement was cured by using a light cure unit. In addition, angular and horizontal defects at mesial and distal aspect of 26 were filled with xenograft Bio-oss graft material [Figure 5].
The flaps were sutured in place using 3-0 direct interrupted silk sutures [Figure 6]. The patient was instructed to use 0.2% Chlorhexidine gluconate mouth wash twice daily for two weeks and advised to use floss. The patient was prescribed Amoxicillin 500 mg, three times daily for 7 days and NSAID to reduce postoperative pain and inflammation. Sutures were removed after 10 days. Patient was recalled weekly for the first month for post-surgical evaluation and reinforcement of plaque control. The patient was recalled then after 6 months for clinical re-evaluation and showed no signs of inflammation in the surgical area which was treated. The patient was again reviewed after one-year for clinical and radiographic evaluation. Clinically flap showed close adaptation to root surface with decrease in probing depth and gain in clinical attachment level. Radiographically, the area showed bone apposition around angular and horizontal interdental defects which were present mesial and distal to 26 were filled with Bio-oss graft, also showed bone fill one year post operatively. The patient was asymptomatic and was able to maintain the oral hygiene [Figure 7] and [Figure 9].
| Discussion|| |
The maxillary molar that received GIC restoration as an occlusive barrier was asymptomatic with good functional property. No adverse problems were seen in the patient after one year recall visit. Sealing the furcation entrance with the GIC prevents epithelial, bacterial, and food debris invasion into furcation area. This sealing reduces the surface area of the furcation so that home care becomes easy. Many authors for many years studied subgingival use of GIC and found therapeutic advantages over other commercially available restorative materials.  K. R. Biniraj  in a case report study stated clinical attachment level gain and bone regeneration around a glass ionomer with class III furcation defect. Singhal  in a case report also showed bone regeneration with potential advantage of GIC as an occlusive barrier in grade III furcation defect radiographically and histologically.
The GICs have properties like marginal integrity, fluoride release and antimicrobial activity.  These properties allow GIC to be placed close to or even under the gingival margin. Many studies have proven its ability of attachment to soft tissue graft.  Arzu et al.,  showed that subepithelial connective tissue graft (SCTG) can be successfully performed to treat the gingival recession associated with a glass ionomer restored root surface. In addition, Harris  showed successful use of SCTG over a glass ionomer restored surface in the treatment of cracked tooth. Certain resin ionomer restorative materials possess properties that are biocompatible with periodontal tissues. This biocompatibility may be related to the anti microbial activity of the fluoride release of resin ionomer materials that affects the composition of bacterial plaque and plaque biochemistry by altering carbohydrate metabolism.  Resin ionomer cements have properties that bind well to periodontal furcation defects and is the choice of cement as it needs no suture, no bone tack and no additional retrieval procedure is required once the initial procedure is complete.  They have low cure shrinkage, insoluble in oral fluids, adhere to tooth structure, a low coefficient of thermal expansion, and low cost.  At 1 year post operative, there was significant decrease in probing depths and gain in attachment level using resin based ionomer cement at the furcation involved area. A positive co-relation was noted at 1 year between redness and bleeding on probing. Gingival tissues also adhered to the root surfaces which were treated with ionomer cements. Certain materials like resin ionomer cements may act to seal external or internal bacterial contamination between restorative margin on the tooth and surrounding tissues so as to maintain gingival health. Further studies will report on the integration between ionomer cements and bone tissue. Bio-oss xenograft material was also placed in the mesial and distal interdental defect of tooth concerned with furcation involvement. Clinically and radiographically there was a significant bone fill observed at 1 year postoperative. The goal of this study was to maintain furcation involved teeth with the use of resin ionomer cement with poor prognosis teeth. The use of a glass ionomer to regenerate the attachment apparatus in the treatment of advanced furcation involvement was not the goal of the treatment. There was no intention to regenerate any tissue, hard or soft. Along with the success of GIC in the furcal area there are few cases reported with the use of GIC and its failures in retaining grade III furcation teeth. Anderegg et al.,  reported failure of two teeth which were sealed with resin ionomer cement within a year of the study. The goal of selecting this mode of therapy was simply to retain hopeless maxillary molars with advanced furcation defects.
| Conclusion|| |
To determine clinical effectiveness of GIC, studies with larger sample size and control must be done. Within the limitations of this case report it can be concluded that GIC acts as an occlusive barrier with good sealing and physical properties of adherence with soft tissue in grade III furcation involved maxillary molars.
| References|| |
Hamp SE, Nyman S, Lindhe J. Periodontal treatment of multirooted teeth. Results after 5 years. J Clin Periodontol 1975;2:126-35.
Carranza FA Jr, Takei HH. Treatment of Furcation Involvement and Combined Periodontal-Endodontic Therapy. In Carranza FA, Newman MG. Clinical periodontology. 8 th
ed. Philadelphia, WB Saunders, 1996;643-5.
Freidman N. Mucogingival surgery: The apically repositioned flap. J Periodontol 1962;33:328-40.
Langer B, Stein SD, Wagenberg B. An evaluation of root resections. A ten-year study. J Periodontol 1981;52:719-22.
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.
Pontoriero R, Lindhe J, Nyman S, Karring T, Rosenberg E, Sanavi F. Guided tissue regeneration in degree II furcation-involved mandibular molar. A clinical study. J Clin Periodontol 1988;15:247-54.
Anderegg CR, Metzler DG. Relation of multi-rooted teeth with class III furcation lesion utilizing resins. Report of 17 cases. J Periodontol 2000;71:1043-7.
Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49:225-37.
Bower RC. Furcation morphology relative to periodontal treatment: Furcation entrance architecture. J Periodontol 1979;50:23-7.
White C Jr. Repair of root resorption lesion. A case report. J Periodontol 1998;69:596-600.
Scherer W, Dragoo MR. New clinical applications for resin-ionomer. Pract Periodontics Aesthetic Dent 1995;7:1-4.
Biniraj KR, Sagir M, Sunil MM, Janardhanan M. Clinical attachment level gain and bone regeneration around a glass ionomer restoration on root surface wall of periodontal pocket. J Indian Soc Periodontol 2012;16:442-5.
Singhal R. Glass ionomer cement as an occlusive barrier in Class III furcation defect. Indian J Dent Res 2011;22:583-6.
Santamaria MP, da Silva Feitosa D, Nociti FH Jr, Casati MZ, Sallum AW, Sallum EA. Cervical restoration and the amount of soft tissue coverage achieved by coronally advanced flap: A 2-year-follow-up randomized controlled clinical trial. J Clin Periodontol 2009;36:434-41.
Alkan A, Keskiner I, Yuzbasioglu E. Connective tissue grafting on resin ionomer in localized gingival recession. J Periodontol 2006;77:1446-51.
Harris RJ. Treatment of a cracked tooth with a resin-ionomer restoration and a connective tissue graft: A case report. Int J Periodontics Restorative Dent 2000;20:612-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]