Perio Test II: 1

What is a furcation? The anatomical area of a multi-rooted tooth where the roots diverge
What is a furcation invasion or involvement? Pathologic invasion of the bifurcation or trifurcation area of multi-rooted
teeth. Thus, furcation involvement can be a stage of progressive
periodontal disease (plaque related), endo related (Periapical infection
draining through the furcation) or combined (perio-endo). Root fx can also
cause furcation involvement
What is the root trunk? Undivided region of the root, defined as the distance between CEJ and the
furcation. It represents about 1/3 of the attachment
What are the root cones? Divided region of the root complex. It represents about 2/3 of the
attachment
How does the Glickman classification Classifies furcations according to amount of bone loss in a horizontal plane
system work?
What is class I? Incipient—probe will barely click in
What is Class II? Cul-de-sac—partial bone loss, probe will drop in
What is Class III? Total bone loss resulting in a through and through defect—higher chance
to see on radiograph
What is a Class IV? Through and through lesion with gingival recession leading to a clearly
visible furcation area
How can these be diagnosed? Clinically with a probe or anesthesia (straight or Nabors), radiographically,
or combination
What does a straight probe do? Underestimates the furcation
What about a Nabors probe? Most accurate probe to be used in furcation involvements.
How can anesthesia be used? Helps to improve the diagnostic accuracy of furcation invasions
With an open view what do we tend to do? Either over or underestimate the degree of furcation involvement
So if you are looking for a M furcation how From the palatal direction and for distal it is best to come from the buccal
should you approach the tooth?
Where are furcations most common? In pts over 40 and most commonly on the maxillary molars—max 1 st is
most commonly with D furcation.
What is the lowest frequency of Distal site of the maxillary 2nd molar
involvement?
What is a grade I CEP? Distinct change in the CEJ (projected towards the furcation)
What is a grade II? CEP approaching the furcation
Grade III? CEP is in the furcation area
How often are they found in max and man? 28% in mandibular molars and 17% in maxillary molars
How often is there furcation involvement >90% of the time—so this should be a red flag
with CEP?
What kind of attachment is it to the CEP? Epithelial, not CT
Where are most enamel pearls seen? 75% on 3rd molars
What is the overall average of incidence of 28.4%
accessory canals in furcation of furcated
teeth?
What size are furcation entrances? <1mm 81% of the time—so narrower than the size of the gracey curette
What do bifurcation ridges connect? M and D root of mandibular molars and are composed primarily of
cementum. Present in 73% of mandibular molars, crosses from M root to
D root at midpoint
Tell me about the root trunk? Distance from CEJ to roof of furcation. Measurements vary somewhat in
individual teeth.
What is the average root trunk length for 3mm
molars?
So which tooth would have a worse 4 because it has a shorter root trunk length
prognosis, #4 or #19?
So what are the readings for root trunk F—4mm; M—3mm; D—5mm
length for the max molar?
Maxillary bicuspid? M—7mm; D—7mm
Mandibular molars? F—3mm; L—4mm
What are the most common reasons for loss Root caries—number 1, root fracture, recurrent periodontal disease; and
of a tooth following treatment of Class II or periodontal/endodontic abscesses
III furcations?
Trauma from occlusion should be Crater like defects or angular bone loss
considered a contributing factor when ____
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or _____ are seen?
Does a maxillary bicuspid with furcation Very poor because the furca is so far apical
involved have a good prognosis?
How do you treat these? SRP, access flap surgery, guided tissue regeneration and or bone graft;
root amputation—DB most common; tunneling; bicuspidization (mand
molars), and implants

4/22/08: PERIODONTAL PLASTIC SURGERY

Where is the zone of the greatest amount of keratinized tissue?

 On the facial it is greater in the anterior and less in the posterior
 On the lingual it is greater posterior to anterior
 Overall, lower lingual has the greatest band

What is the most imp factor to determine the prognosis of the tooth?
 Attachment loss

What determines the gingival contour?

 Interdental space—remember greater scalloping in the anterior than posterior d/t more space

What tooth has the greatest dehiscence (#1 thinnest site of bone on a tooth) in the mouth?
 MB root of the upper 1st molar

What is in all sensitivity toothpaste?

 Potassium nitrate

Root coverage predictability is correlated to the presence or absence of interdental bone

What happens when you take piece of tissue and place from donor site of palate to the recipient site?
 Will get keratinized tissue—epithelialization comes from lateral margins because all the epithelium in the graft
sloughsunderlying tissue gives its nutrition (REMEMBER there are NO blood vessels in the epithelium).

What determines whether or not it is keratinized?

 Site of origin

Where does the coating reside?

 In the connective tissue—important b/c it is the basis for root coverage

Know the miller classifications!

Class I—marginal recession not extending to the MGJ; NO loss of interdental bone or soft tissue; possible to
obtain 100% coverage of exposed root
Class II—marginal recession extends to or beyond the MGJ; NO loss of interdental bone or soft tissue;
possible to obtain 100% coverage of exposed root
Class III—marginal tissue extend to or beyond the MGJ; loss of interdental bone and or soft tissue is apical
to CEJ, but coronal to the most apical extent of the recession; possible to obtain partial coverage of exposed
root (50-75%)
Class IV—marginal tissue extends to or beyond the MGJ; loss of interdental tissues extends to apical extent
of the recession; not possible to obtain any significant degree of root coverage

What is the determinant of root coverage?

 The amount of interdental bone

How much keratinized tissue do you need?

 In presence of good OH you could get away with little to no keratinized tissue, w/o good OH lots of controversy

Take tissue from anywhere and the epithelium will disintegrate!

Easy to correct B width, difficult to correct Height!

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28% know this %, why is it important
 % of accessory canals found in furcations overall

What is the etiology of furcations?

 Bacterial plaque in a susceptible host
When looking for a furcation on the mesial, which direction is it best to come from?
 Palatal

When looking for a furcation on the distal, which direction is it best to come from?
 Buccal

Which furcation is involved the most?

 M of maxillary 1st molar, remember the mesial is the most common and this is where you would probe if you
could only probe one space

Why is the mesial the most involved when facial of the mand 1st is just as short?
 Facial of the lower 1st molar is also just as short, but you can clean that much better because it is not an
interproximal area (which is not cleaned by a toothbrush)

With the M furcation you can probe from which direction?

 The palatal direction

MUCOGINGIVAL PROBLEMS
When do mucogingival problems result? When there has been a loss of attached and or keratinized tissues to
such an extent that the remaining tissue is considered clinically
inadequate
How much is enough when it comes to keratinized If pt has good OH, they can keep areas of little to no keratinized tissue
tissue? healthy, but if poor OH it is up in the air as to how much is enough
How do you diagnose localized gingival Visual, measurement of the amount of attached and keratinized
recession? mucosa, use of probe to determine level of the mucogingival junction,
and muscle and frenulum pull on marginal gingiva
What are etiologic and or predisposing factors? Inadequate attached gingiva, malposed teeth (affects the amount of
scalloping), tooth brushing technique, chronic inflammation, iatrogenic
(restorative), iatrogenic (ortho), factitious injury, high frenulum
attachment, alveolar housing and eruption pattern, smoking/smokeless
tobacco use—always put in the same place, ortho treatment—may
move tooth too far, and substance abuse (cocaine)
What are Miller’s classifications of gingival Class I—marginal recession not extending to the MGJ; NO loss of
recession? interdental bone or soft tissue; possible to obtain 100% coverage
of exposed root
Class II—marginal recession extends to or beyond the MGJ; NO loss
of interdental bone or soft tissue; possible to obtain 100%
coverage of exposed root
Class III—marginal tissue extend to or beyond the MGJ; loss of
interdental bone and or soft tissue is apical to CEJ, but coronal to
the most apical extent of the recession; possible to obtain partial
coverage of exposed root (50-75%)
Class IV—marginal tissue extends to or beyond the MGJ; loss of
interdental tissues extends to apical extent of the recession; not
possible to obtain any significant degree of root coverage
What are treatment options? Free autogenous gingival graft (FGG)—severed from donor,
connective tissue graft (perioplastic surgery), semi-lunar incision
+coronal repositioned flap (Tarnow); FGG + coronal repositioning of
keratinized gingiva
What is the etiology of localized ridge defects? Resorption of alveolar ridge following traumatic tooth extraction,
developmental defects, advanced periodontal disease, excessive ridge
resorption over time, and acute trauma
What are the classifications of alveolar ridge Class I—facial-lingual defect with ridge exhibiting collapse towards the
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defects? lingual (usually) or facial (rarely)
Class II—coronal-apical defect with ridge exhibiting loss vertical.
Height most difficult to correct
Class III—combination defect (commonly seen in anterior sextants)
What are the treatment options? Gingival only graft, connective tissue graft, or barrier membranes
+osseous grafting
FURCATIONS
 What is Furcation involvement?
o Pathologic involvement of bone in Furcation area. Loss of attachment and bone involvement
 Why do you need a classification system?
o Determines prognosis of tooth
 What makes furcations difficult?
o Pts cannot clean well (proxy brush)
 What is the problem with straight probes?
o Underestimate Furcation
 What if you don’t have complete Furcation visualization?
o Tend to overclassify, because you can’t see
 When you are looking for furcations where do you look?
o Know anatomy and place probe where furcation would be
 Diagnosis is best determined by?
o Probe
o Radiograph
o Bone sounding
 Where is the most common place for a furcation to develop?
o Max 1st molar on distal furcation
 Where is the least common place for furcation to develop?
o Distal max 2nd molar
 What are the contributory factors
o Anatomic
 Cervical enamel projections
 Enamel pearls
 Accessory canals
 Furcation entrance
 Rootform
 Bifurcation ridges
 Root trunk
o Supervised neglect
o Trauma from occlusion
 If you see a CEP what should you look for? (asked 2 times)
o Furcation involvement
 If you have a tooth that had RCT but has a furcation what is wrong?
o Accessory canal
 What feature of furcations makes them progress more?
o The are larger than most curette, and we can’t get in there and clean them
o This is why we flap for access
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 How far on the root trunk can we get until we are in the furcation?

o
 From above chart, what is the worse prognosis, 6 mm attachment loss on max molar or max bicuspid?
o Max molar, less distance to furcation
 What is better to avoid furcation involvement, long root trunk or short root trunk?
o Long root trunk
 How does furcation involvement effect the long term prognosis of a tooth?
o Poor long term prognosis (31%-44% loss rate after 20 years)
 What are the most common causes of Class II or Class II furcations?
a. Root caries
b. Root fracture (if endo treated)
c. Recurrent periodontal disease
d. Periodontal/endodontic abscess

 Why would you do enameloplasty on a furcation area?

o Makes it bigger to be able to clean effectively
 How do you treat furcation teeth?
o Scaling and rt planning
o Osteo-dentin-ameloplasty (better access)
o Access flap surgery-open scaling and root planning
o Guided tissue regeneration and/or bone graft
o Root amputation
o Tunneling (cause root carries)
o Bicuspidization (cut molar in half)
o Cavitron (more narrow and reaches in furcation)
 What could cause a breakdown of furcation bone that is NOT periodontal disease?
o Trauma from occlusion
o Crater like defects or angular bone loss
 What feature of the furcation involvement of a maxillary bicuspid makes its prognosis so poor?
o Furca is so far apical
 What are 2 causes of furcation involvement that do not start from periodontal disease?
o Traumatic occlusion
o Accessory canal (endo-perio lesion)
o Super-eruption

MUCOGINGIVAL PROBLEMS
 Mucogingival surgery = peri-plastic surgery
 How much attached gingiva is enough?
o Research: over an 8 year period, people with good oral hygiene and 1 mm attachment, have a 92% chance of
not losing attachment
o Therefore, <1 mm is enough if you have good oral hygiene
 You cannot treat gingival recession if you do not treat etiology
 If you have poor plaque control, what is the epithelial reaction to plaque?
o Inflammation Ingrowth of rete pegs into connective tissue
o When CT is thin (like it is around teeth) ingrowth of rete pegs strangles the blood vessels, and epithelium
dies!
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 Largest band of keratinized tissue
o Mandible lingual
o Max??
 The % of root coverage is determined by?
o Interproximal bone
 Purpose of the free gingival graft?
o Increase the thickness of keratinized tissue not to cover roots (connective tissue grafts cover roots)
 What happens when you graft tissue?
o Epithelium disintegrates, and bare CT remains
o Epithelium later will regenerate
o Therefore, graft must include CT
 So where is the DNA coding that determines what the epithelium type of covering will be produced?
o In the connective tissue
 Are there any blood vessels in epithelium
o No
 What are the advantages of thick grafts?
o Plenty of CT for forming epithelium
o Less shrinkage
 What has better color match, free gingival graft or CT graft?
o Ct graft
Mucogingival Problems 26Apr05
Describe the trend of attached gingiva in the mouth. Facial: widest in anterior, narrowest in posterior;
Lingual: widest in posterior, narrowest in anterior
T/F: Less than 1mm of attached gingiva is adequate for T, if inflammation if controlled
health.
A patient taking procardia has a pocket depth of 8mm; but as 2mm; procardia will likely give you a pseudopocket;
you withdraw your probe, a click is felt at 6mm. What is the the click was the CEJ.
attachement loss?
Name 234 ways to mess up an RPD. Forget it…expect disappointment
Name as many etiologic and/or predisposing factors for Inadequate attached gingiva, malposed teeth, tooth
localized gingival recession. brushing with Mac’s pencil, chronic inflammation,
iatrogenic (restorative), iatrogenic (ortho), iatrogenic
(uhoh), factitious injury (chewing on Mac’s pencil while
he was taking this test), high frenulum attachment,
alveolar housing and eruption pattern, tobacco use,
cocaine use
Describe the 4 Miller classes of gingival recession. I: marginal recession not to MGJ, no loss of
(MGJ = mucogingival junction, b/st = bone & soft interdental b/st
tissue) II: marg recession to/past MGJ, no loss of interdental
b/st
III: marg recession to/past MGJ, loss of inderdental
b/st
apical to CEJ but coronal to most apical extent of
recession
IV: marg recession to/past MGJ, loss of interdental
b/st to
The most apical extent of recession
Describe the possible root coverage that can be obtained for I: 100%, II: 100%, III: 50-75%, IV: 0%
each Miller class of gingival recession.
What determines the tissue of a graft? The underlying connective tissue at the source of the
graft
Which with have primary contraction: thick or thin? Thick (more initial shrinkage); thin = secondary
contraction due to shrinking in the mouth

Describe the Glickman classification system of furcation Cl I: btn 1&2mm, feel catch but not seen on rad;
defects. Cl II: >2mm, cul-de-sac, may be on rad or not;
Cl III: total bone loss resulting in a through-and-through,
may see on rad;
Cl IV: through-and-through that is visible due to
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recession
Which class is the only time to do GTR? II (GTR is guided tissue regeneration)
What are the two components of GTR? Bone graft and collagen membrane
What instrument provides reproducible and valid Nabers probe
information about furcation involvement?
According to Ross, what is the most common site of Maxillary molars (max 1st distal)
furcation involvement?
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According to Hirshfeld &Wasserman, what is the order 1st molars, 2nd molars, Maxillary 1st bicuspids
of frequency of occurrence of furcation involvement?
Describe the 3 grades of cervical enamel projections I: distinct change in the cej projected toward the
(ceps) furcation; II: cep approaches the furcation; III: cep is in
the furcation area
According to Masters and Hoskins, what is the 28.6% of mandibular molars, 17% of maxillary molars;
prevalence of ceps in the molars? What is the >90% of isolated mandibular molars with furcation
relationship of ceps and mandibular molar furcation involvement had ceps
involvement?
Where are enamel pearls usually found? 75% of them are found on 3rd molars
Give the %s of accessory canals in each molar. 36% of Mx1stM, 32% of mn1stM, 24% mn2ndM, 12% of
Mx2ndM {U, -4,-8,-12)
How often is the furcation entrance narrower than a 58%
standard Gracey currette in 1st molars?
How often do mandibular molars have bifurcation 73%
ridges?
Give all root trunk average lengths in mm. MxM: f=4, m=4, d=5; MxPM: m&d=7;
mnM: f=3, l=4
What is the general ratio of attachment loss to (n)mm = 7(n)%
attachment surface area?
What factor should be considered as a contributing Trauma from occlusion
factor when crater-like defects or angular bone loss is
encountered?
T/F: Trauma from occlusion can cause attachment loss. F; perio disease must already be in place for trauma
from occlusion to cause attachment loss
Name 5 indications for root resection. Class II or III FI; severe bone loss involving one or more
roots; root fracture, perforation, resorption, deep root
caries; root proximity with adjacent teeth; failed endo or
inorperable/calcified canals
Name 3 contraindications for root resection. Inadequate bone support on the remaining roots or
unfavorable anatomical factors (long root trunk, fused
roots); significant discrepancies in adjacent interproximal
bone height; remaining roots can’t be restored/treated w/
endo