| Abstract|| |
Predicting the prognosis of molars that have experienced furcation invasion, is often a frustrating experience to the dental clinician and disappointing report to the patient involved. Although multiple treatment modalities have been attempted to retain teeth with severe furcation invasion, clinical success has not been predictable. A case report involving the use of glass ionomer cement (GIC) as an occlusive barrier in the management of Class III furcation defect involving mandibular first molar is presented. A literature review on the subject matter was conducted using Medline, Google search engines, and manual library search. GIC restoration of Class III furcation invasion gives a satisfactory result. Surgical and nonsurgical treatment options are available for the management of the condition. GIC as an occlusive barrier in Class III furcation invasion is an economical and less invasive treatment option. It also makes home care easy for the patient.
Keywords: Furcation invasion, glass ionomer cement, occlusive barrier, treatment
|How to cite this article:|
Singhal R. Glass ionomer cement as an occlusive barrier in Class III furcation defect. Indian J Dent Res 2011;22:583-6
Furcation invasion implies the attachment loss in the bifurcation or trifurcation of the multirooted teeth through the progress of inflammatory periodontal disease. Glickman  classified furcation invasion into four classes. Class I is suprabony incipient lesion with no radiographic changes. Class II invasion is cul-de-sac with a definite horizontal bone loss. Radiographic changes may or may not be visible due to overlapping of the roots.
|How to cite this URL:|
Singhal R. Glass ionomer cement as an occlusive barrier in Class III furcation defect. Indian J Dent Res [serial online] 2011 [cited 2019 Nov 16];22:583-6. Available from: http://www.ijdr.in/text.asp?2011/22/4/583/90304
Class III is through and through invasion of the furcation area with soft tissue covering. Class IV is also through and through invasion, clinically visible due to soft tissue recession along with bone loss. Class III and IV invasions are both radiographically visible.
The management and long-term retention of molars exhibiting furcation invasion have always been a challenge in dentistry. The focus of treatment is to debride the remaining soft and hard tissues in the furcal area and allow access for effective oral hygiene and maintenance. Continued periodontal breakdown may lead to eventual loss of the teeth involved unless these defects can be repaired or eliminated and health of the tissues restored.
Review of literature
The nonsurgical or conservative treatment of mandibular molars with Class III furcation invasions (FI) has had a long history. Hirshfeld and Wasserman  found that repeated subgingival scaling, rootplaning and gingival curettage may be important in the long-term retention of molars with Class III FIs. Bower  stated that furcal openings of mandibular molars frequently are narrower than the blade of frequently used curettes. Owing to morphological complications present in mandibular furcation, curettes used alone may not be adequate for root preparation, and narrow diameter ultrasonic debridement tips may be more of an appropriate choice.
Extraction may be the last resort for tooth with nonrestorable furcation invasion.  A molar which is unopposed and is the terminal tooth of the arch, a solitary distal abutment with mobility or if the offending molar is adjacent to a second molar and second bicuspid with adequate bone support, it must be considered for extraction. Hamp et al.  also stated that extraction is indicated when preserving the affected tooth would not improve the overall treatment plan, or when treatment of the furcation would result in an area that the patient could not clean readily.
A less irreversible treatment for a Class III mandibular FI is that of root resection. Bassaraba  stated the indications and contraindications for root resection. Root resection is indicated in teeth that are of critical importance to the overall dental treatment plan, e.g., teeth serving as abutments for fixed and removable partial dentures; teeth that have sufficient attachment remaining for function; teeth for which a more predictable or cost effective method of therapy is not available and teeth in patients with good oral hygiene and low activity for caries.
Another approach to treating a Class III FI of a lower molar is "bisectioning." The clinician splits the mandibular molar vertically through the furcation, without removing either half, leaving two separate roots that are then treated as bicuspids (a procedure termed "bicuspidization").  , Farshchian and Kaiser  illustrated the success of a molar bisection with subsequent bicuspidization. They stated that the success of bicuspidization depends on three factors: stability of, and adequate bone support for the individual tooth sections; absence of severe root fluting of the distal aspect of the mesial root or mesial aspect of the distal root; adequate separation of the mesial and distal roots, to enable the creation of an acceptable embrasure for effective oral hygiene. According to Newell  the advantage of the amputation, hemisection or bisection is the retention of some or all of the tooth. However, the disadvantage is that the remaining root or roots must undergo endodontic therapy and the crown must undergo restorative management.
The principle of Guided guided Tissue tissue Regeneration regeneration (GTR) was given by Nyman et al.  in 1982 for the treatment of osseous defects in human periodontitis. GTR, as defined by the American Academy of Periodontology in its glossary of periodontal terms, is the "regeneration of periodontal attachment through differential tissue responses." Barrier techniques, using materials such as expanded polytetrafluoroethylene, polyglactin, polylactic acid, calcium sulfate, and collagen are employed in the hope of excluding epithelium and the gingival corium from the root in the belief that they interfere with regeneration.  This concept has been attempted in the treatment of Class III FIs of mandibular molars.
The only variable that pervades all the studies is the vertical height of bone loss within the Class III FI. Tarnow and Fletcher  described a subclassification system of furcation classification based on the vertical measurement of bone loss, from the roof or fornix of the furcation to the level of interradicular bone. They are subclass A, a vertical loss of 0−ญญญญญญญญญญ3 mm; subclass B, a vertical loss of 4−6 mm; and subclass C, a vertical loss of 7 mm or more. Pontoriero et al.  stated that vertical bone loss of more than 3 mm will limit the success of any attempt at GTR of mandibular molars with Class III FIs. Thus, any Class III mandibular furcation with a vertical subclassification of B or C would not be indicated for a GTR procedure.
Tunneling is a periodontal surgical procedure that creates access for patient cleaning and maintenance within the furcal area of a molar tooth that has incurred severe attachment loss owing to periodontal disease. , The technique of tunneling has been adequately discussed by several authors. , However, the surgery will be successful only if certain anatomical and clinical features of the molar are present. The molars should have divergent mesial and distal roots, to allow postsurgical furcal maintenance and cleaning; 
A short root trunk, which places the root fornix closer to the cementoenamel junction;  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);  an adequate presurgical crown: root ratio, greater than 1:1; and either no or minimal tooth mobility that could not be managed by minor occlusal adjustment.
Regenerative techniques that have been successful in the treatment of class II mandibular furcation invasions have been less than predictable when performed in class III FIs.  In the past, restorative materials like polymeric reinforced zinc oxide eugenol (IRM), amalgam, glass ionomer, and resin ionomer restorative materials have been used to obliterate furcations.  The goal was to improve plaque control by eliminating the anatomic niches within the furcation where bacteria can accumulate.
Van Swol et al.  compared amalgam, zinc oxyphosphate cement, and glass ionomer in the treatment of surgically created furcation in nonhuman primates. The authors reported the greatest biocompatibility with glass ionomer via radiographic and histological evaluation. Scherer and Drago  utilized modified resin ionomer restorations subgingivally and gave histological evidence of epithelial and connective tissue adherence to the resin ionomer restorative materials
In the present case, a glass ionomer restorative material was used as an occlusive barrier in the treatment of mandibular first molar Class III furcation invasion.
| Case Report|| |
A 35-year-old female patient reported to the outpatient department of Periodontics in Subharati Dental College, Meerut with Class III FI in mandibular left first molar [Figure 1]. The molar was vital with no periapical radiographic changes [Figure 2]. Clinical attachment loss in the furcation area was 8 mm with no clinical mobility. The overall dental health of the patient was assessed for any niches of plaque retention. Medical and dental history was not relevant for any predisposing factors. Patient had generalized shallow pockets. Thorough scaling and root planing was done, and the patient was assessed for maintenance of oral hygiene. Overall health of the dentition improved after Phase I therapy, but the involved tooth presented with persistent inflammation. After explaining the various treatment options and the importance of maintaining oral hygiene especially in the furcation area, the patient elected to have glass ionomer placed as an occlusive barrier over the furcation defect.
Following administration of local anesthesia, sulcular incision was made and a full thickness flap was reflected to expose the furcation area [Figure 3]. The area was debrided, scaled, and root planed by using curettes. An occlusive barrier of modified resin reinforced glass ionomer was used to fill in the furcation area and prevent a recurrence of bacteria and/or debris accumulation into the furcation [Figure 4]. In addition, by reducing the concavities of the furcation, home care becomes easier. GIC was placed in the furcation area and adapted using plastic instruments and Mylar strip. A 2 mm space was left between the alveolar crest in the furcation area and the apical end of the restoration to allow for some amount of osseous regeneration [Figure 5]. Once adapted, the cement was cured by using a light cure unit.
The flaps were sutured using 3-0 direct interrupted silk sutures [Figure 6]. The patient was advised to use 0.2% chlorhexidine gluconate mouth rinse twice daily for two weeks and was provided with postoperative and home care instructions. The patient was prescribed antibiotics (amoxicillin 500 mg, three times daily for seven days) to reduce the risk of infection postoperatively. Sutures were removed after seven days. Patient returned weekly for the first month for postsurgical evaluation and reinforcement of plaque control. The patient was seen at three month and six-month interval for supportive periodontal care. The patient was asymptomatic on one-year recall visit and was able to maintain the oral hygiene easily.
| Discussion|| |
The mandibular molar that received GIC restoration as an occlusive barrier was functional and asymptomatic, and the patient had no adverse problems one year after the restorations were placed. Not only does the barrier seal the furcation entrance from epithelial, bacterial, and food debris invasion, but may also enable easier home care due to the reduced surface area of the furcation left to clean.
Various studies ,, have shown radiographic and histological evidence of GIC biocompatibility. The regeneration of attachment apparatus is also seen in experiments on human subjects.  A 2 mm space was, therefore, left in between the restoration and the bone in the furcation area to allow for some amount of regeneration.
The potential advantage of an occlusive barrier such as glass ionomer includes: ease of placement; elimination of a second stage procedure for retrieval of a membrane, since it is permanently bonded; long junctional epithelial attachment to the glass ionomer;  does not require complete coverage by the gingival flap; bacteriostatic due to fluoride release  and lower cost.
Within the limitations of the current case report, GIC restorative material may be an effective occlusive barrier in the treatment of Class III mandibular furcation defects.
| References|| |
|1.||Glickman I. Clinical Periodontology. Philadelphia: Saunders; 1953. 10th ed, p. 992-3 |
|2.||Hirschfeld L, Wasserman B. A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 1978;49:225-37. |
|3.||Bower RC. Furcation morphology relative to periodontal treatment: Furcation entrance architecture. J Periodontol 1979;50:23-37. |
|4.||Saxe SR, Carman DK. Removal or retention of molar teeth: The problem of the furcation. Dent Clin North Am 1969;13:783-90. |
|5.||Hamp SE, Nyman S, Lindhe J. Periodontal treatment of multi-rooted teeth: Results after 5 years. J Clin Periodontol 1975;2:126-35. |
|6.||Bassaraba N. Root amputation and tooth hemisection. Dent Clin North Am 1969;13:121-32. |
|7.||Augsburger RA. Root amputations, and hemisections. Gen Dent 1976;24:35-8. |
|8.||Farshchian F, Kaiser DA. Restoration of the split molar: Bicuspidization. Am J Dent 1988;1:21-2. |
|9.||Newell DH. The role of the prosthodontist in restoring root-resected molars: A study of 70 molar root resections. J Prosthet Dent 1991;65:7-15. |
|10.||Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982;9:290-6. |
|11.||American Academy of Periodontology. Glossary of periodontal terms. 4th ed. Chicago: AAP; 2001. p. 44. |
|12.||Tarnow D, Fletcher P. Classification of the vertical component of furcation involvement. J Periodontol 1984;55:283-4. |
|13.||Pontoriero R, Lindhe J, Nyman S, Karring T, Rosenberg E, Sanavi F. Guided tissue regeneration in the treatment of furcation defects in mandibular molars: A clinical study of degree III involvements. J Clin Periodontol 1989;16:170-4. |
|14.||Cohen ES. Atlas of cosmetic and reconstructive periodontal surgery. 2nd ed. Philadelphia: Lea and Febiger; 1994. p. 370-80. |
|15.||Carranza FA, Newman MG. Clinical periodontology. 8th ed. Philadelphia: Saunders; 1996. p. 643-5. |
|16.||Highfield JE. Periodontal treatment of multirooted teeth. Aust Dent J 1978;23:91-8. |
|17.||Pontoriero R, Lindhe J. Guided tissue regeneration in the treatment of degree III furcation defects in maxillary molar. J Clin Periodontol 1995;22:810-2. |
|18.||Anderegg CR, Metzler DG. Relation of multirooted teeth with class III furcation lesion utilizing resins. J Periodontol 2000;71:1043-7. |
|19.||Van Swol RL, Eslami A, Sadeghi EM, Ellinger RF. A new treatment of furcation defects involving strategic molars. Int J Periodontics Restorative Dent 1989;9:185-95. |
|20.||Sherer W, Dragoo MR. New clinical applications for resin ionomer. Pract Periodo Aesth Dent 1995;7:1-4. |
|21.||Dragoo MR. Resin ionomer and hybrid ionomer cements: Part II. Human clinical and histology wound healing responses in specific periodontal lesions. Int J Periodontics Restorative Dent 1997;17:75-87. |
|22.||Smith D. Glass Ionomer Cements. A prospective symposium on esthetic restorative material. Chicago: American Dental Association. ADA Council on Dental materials. Instru equip; 1993. p. 49-58. |
Department of Periodontics, Faculty of Dental Sciences, Chhatrapati Shahuji Maharaj Medical University (Erstwhile K.G.M.C), Lucknow, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]