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Faculdade de Odontologia
Departamento de Odontologia Social e Pediátrica COMPLEXO Porção dos dentes abaixo da JCE
RADICULAR
Tronco Cones
Lesões de Furca radicular radiculares
Furca Terminologia
Área anatômica de um dente multirradicular onde as
raízes se separam.
Região de Furca
Glossary of Terms of the American Academy of Periodontology, 1992
Glossary of Terms of the American Academy of Periodontology, 1992
Lindhe et al. Tratado de Periodontia Clínica e Implantologia Oral. 2005
Lindhe et al. Tratado de Periodontia Clínica e Implantologia Oral. 2005
Glossary of Terms of the American Academy of Periodontology, 1992 Carranza et al., 2011
Anatomia Anatomia
Treatment of Furcation-Involved Teeth 825
Molares Superiores
MB
MB DB
DB
Mandibular molars
Fig. 39-5 Root-shape of a maxillary first molar in a horizontal
cut at the level of the coronal third of the cones. Note the The mandibular first molar is larger than the second
circular shape of the palatal root in comparison with the molar, which in turn is larger than the third molar.
mesio-distally compressed shape of the mesio-buccal root, In the first and second molars the root complex
Anatomia Anatomia
which also exhibits a concavity in the distal aspect. almost always includes two root cones, one mesial
and one distal. TheD mesial root is larger than the
M
distal. The mesial root has a position which is mainly
Maxillary premolars
vertical while the distal root projects distally. The
mesial root is wider in the bucco-lingual direction Molares Inferiores
and has a larger cross-sectional area than the distal
In about 40% of cases the maxillary first premolars root. The cross section of the distal root is circular
have two root cones, one buccal and one palatal, while the mesial root has an “hour-glass” shape. In
and hence have a mesiodistal furcation. A con-
cavity (about 0.5 mm deep) is often present in the
addition, furrows and concavities often occur on the
distal surface of the mesial root (Fig. 39-7). The distal
• Raiz mesial + vertical
furcation aspect of the buccal root. In many cases the
furcation is located in the middle or in the apical
concavity of the mesial root is more pronounced than
that of the distal root (Bower 1979a,b; Svärdström &
Treatment of Furcation-Involved Teeth
• Raiz mesial + larga 825
vestibulolingualmente
third of the root complex (Fig. 39-6). The mean dis- Wennström 1988).
tance between CEJ and the furcation entrance is about
8 mm. The width of the furcation entrance is about
The root trunk of the first molar is often shorter
than the trunk of the second molar. The furcation
• Entrada da furca lingual é + apical
0.7 mm. entrances of the mandibular first molar, similar to
Molares Inferiores
Lindhe et al. Tratado de Periodontia Clínica e Implantologia Oral. 2005 Lindhe et al. Tratado de Periodontia Clínica e Implantologia Oral. 2005
a b c
a b c
Fig. 39-4 Furcation entrances (a, mesial; b, buccal; c, distal) and the position of the roots of a maxillary first molar.
Anatomia Anatomia
MolaresMB
Inferiores
MB DB
DB
Mandibular molars
Fig. 39-5 Root-shape of a maxillary first molar in a horizontal
cut at the level of the coronal third of the cones. Note the The mandibular first molar is larger than the second
circular shape of the palatal root in comparison with the molar, which in turn is larger than the third molar.
mesio-distally compressed shape of the mesio-buccal root, In the first and second molars the root complex
which also exhibits a concavity in the distal aspect. almost always includes two root cones, one mesial
and one distal. TheD mesial root is larger than the
M
distal. The mesial root has a position which is mainly
vertical while the distal root projects distally. The
mesial root is wider in the bucco-lingual direction
Maxillary premolars
and has a larger cross-sectional area than the distal
In about 40% of cases the maxillary first premolars root. The cross section of the distal root is circular
have two root cones, one buccal and one palatal, while the mesial root has an “hour-glass” shape. In
and hence have a mesiodistal furcation. A con- addition, furrows and concavities often occur on the
cavity (about 0.5 mm deep) is often present in the distal surface of the mesial root (Fig. 39-7). The distal
furcation aspect of the buccal root. In many cases the concavity of the mesial root is more pronounced than
furcation is located in the middle or in the apical that of the distal root (Bower 1979a,b; Svärdström &
third of the root complex (Fig. 39-6). The mean dis- Wennström 1988).
tance between CEJ and the furcation entrance is about The root trunk of the first molar is often shorter
8 mm. The width of the furcation entrance is about than the trunk of the second molar. The furcation
DIAGNÓSTICO
Exame Clínico
VESTIBULAR
D M M D
Vestibular Palatina
LINGUAL
Vestibular Palatina
V P P V
Treatment of Furcation-Invol
a b
c
Fig. 39-10 (a) Anatomic variation
Fig. 39-11 Different degrees of furcation involvement in relation represented
to the probe in a radiograph of a thre
(penetration/superimposi
space of a mandibular molar. (a) Degree I. (b) Degree II. (c) Degree III. mandibular first premolar. (b)
rooted
Clinical photograph illustrating,
during surgery, the separation –
attachment loss that exists within the root complex. not
before encompassing
extraction the total w
– of an “abnormal”
Treatment of Furcation-Involved Teeth 827
a b Hamp et al. (1975) has suggested the following clas- area
second (Fig.
mesial 39-11b).
root of a mandibular
a sification of thebinvolved furcation: • Degree III: horizontal “t
molar.
destruction of the periodont
• Degree I: horizontal loss of periodontal support tion area (Fig. 39-11c).
not exceeding one third of the width of the tooth
(Fig. 39-11a). It is important to understan
• Degree II: horizontal loss of periodontal support entrance must be examined an
exceeding one third of the width of the tooth, but be classified according to the a
a b
Perda horizontal excede 1/3, mas não envolve toda a Destruição periodontal “lado a lado” dos tecidos de
attachment loss that exists within the root complex. not encompassing the total width of the furcatio
a b
attachment loss that exists within the root complex. not encompassing the total width of the furcation
Hamp et al. (1975) has suggested the following clas- area (Fig. 39-11b).
sification of the involved furcation: • Degree III: horizontal “through-and-through”
destruction of the periodontal tissues in the furca-
• Degree I: horizontal loss of periodontal support tion area (Fig. 39-11c).
not exceeding one third of the width of the tooth
(Fig. 39-11a). It is important to understand that each furcation
• Degree II: horizontal loss of periodontal support entrance must be examined and each entrance must
exceeding one third of the width of the tooth, but be classified according to the above criteria.
a b
CARACTERÍSTICAS ANATÔMICAS
Concavidades Radiculares
Lesões de Furca Áreas de difícil acesso para remoção de biofilme e
raspagem de cálculo
ü Características anatômicas
ü Morfologia do defeito
CARACTERÍSTICAS ANATÔMICAS
CARACTERÍSTICAS ANATÔMICAS
Extensão horizontal e vertical da perda óssea Extensão horizontal e vertical da perda óssea
Padrão de perda de inserção
Extensão horizontal e vertical da perda óssea Extensão horizontal e vertical da perda óssea
Diabetes
Fumo
Profundidade de vestíbulo
Tratamento Tratamento
Objetivos:
Fatores a serem considerados:
TRATAMENTO TRATAMENTO
Odontoplastia e Osteoplastia
TRATAMENTO TRATAMENTO
Regeneração Periodontal
Regeneração Periodontal
Confecção e rebatimento de retalho
Procedimento cirúrgico para
de espessura total
formação de osso
interradicular Remoção de tecido de granulação e • Enxertos Ósseos
raspagem
autógenos
Furca grau II em MI Colocação da membrana ou do enxerto
ósseo ou ambos
substitutos ósseos
Posicionamento e sutura do retalho ao nível
da crista • Regeneração Tecidual Guiada
Gottlow et al. New attachment formation in the human periodontium by guided tissue regeneration.1986.
TRATAMENTO
membrana);
• Possibilidade de debridamento das superfícies na área de
furca
• (retenção do
• Estabilidade da membrana e e espaço entre o dente e a coágulo);
membrana a a
Fig. 39-20 Tunnel preparation of a degree
b b
Fig. 39-20 Tunnel III-involved
preparation mandibular
of a degree molar. Radiograph
III-involved (a) and
mandibular photograph
molar. (b) showing
Radiograph (a) and a wide
photograph (b) showing a wide
inter-radicular space where self-performed plaque control can be obtained
plaqueby the use ofbe
anobtained
interproximal
by thebrush.
molares inferiores
used in cases of deep useddegree
in cases II and
of deep degree III II and degree III
degree
Tunnel preparation isTunnel
a technique used toistreat
preparation deep
a technique used to treat deep molars.
furcation-involved furcation-involved molars.
degree II and degree III furcation
degree II and defects
degreeinIII mandibu-
furcation defects in mandibu-
Before RSR is performedBefore the RSRfollowing
is performed factorsthe following factors
lar molars. This type larofmolars.
resectiveThis therapy
type ofcan be
resective therapy can be
must be considered: must be considered:
offered at mandibularoffered
molarsat which have a short
mandibular molars root
which have a short root
trunk, a wide separation
trunk,angle,
a wideandseparation
long divergenceangle, and•long Thedivergence
length of the root trunk.
• The In a of
length patient
the root with pro-
trunk. In a patient with pro-
between the mesial and betweendistaltheroot.
mesialThe and
procedure
distal root. The procedure
gressive periodontal gressive
disease aperiodontal
tooth with disease a short a tooth with a short
includes the surgicalincludes
exposurethe and management
surgical exposure of and management of
root trunk may have root an early
trunkinvolvement
may have an of early
the involvement of the
the entire furcation area of the furcation
the entire affected molar.
area of the affectedfurcation
molar. (Larato 1975; Gher & Vernino 1980). A
Following the reflection of buccal and lingual furcation (Larato 1975; Gher & Vernino 1980). A
Following the refl ection of buccaltoothandwithlingual
a short root trunk is aa short
good candidate
mucosal flaps, the granulation tooth with root trunk is a good candidate
mucosal fltissue
aps, the in granulation
the defect istissue in the defect is
for RSR; the amount
removed
a and the rootremoved
surfaces are scaled and planed. b and planed. forofRSR;
remaining
the amount periodontal
of remaining periodontal
a and the root surfaces are scaled
tissue support following b separation and resection
The furcation area is widened by the removal of some tissue support following separation and resection
The furcation area is widened by the removal
is oftenof suffi
somecient to ensure the stability of the
of the inter-radicular of
bone. The alveolar bone crest is alveolar bone crest is is often sufficient to ensure the stability of the
the inter-radicular bone. The remaining root cone. remaining
If the root root trunk is long, theroot trunk is long, the
recontoured; some of the interdental cone. If the
recontoured; somebone, of the mesial
interdentalfurcation
bone, mesial
involvement occurs later in the disease
and distal to the tooth in distal
the region, furcation involvement occurs later in the disease
and to theistooth
also removed
in the region, isprocess,
also removed
but, once established, the once
amount of peri- the amount of peri-
to obtain a flat outline of the bone. process, but, established,
to obtain a flat Following
outline of the hardbone. Following hard
odontal tissue support left apical tosupport
the furcation
tissue resection enough space has been established odontal tissue left apical to the furcation
tissue resection enough space in has beenmayestablished
be insuffi incient to allow RSR. Lindhecient et al. Tratado de Periodontia Clínica e Implantologia Oral. 2005
the furcation regionthe to furcation
allow access for to cleaning may be insuffi to allow RSR.
region allow access • Thefordivergence
cleaning between the root cones. The distance
devices to be used devices
during self-performed plaque- • The divergence between the root cones. The distance
to be used during self-performed
between plaque-
the root cones must be considered. Roots
control measures (Fig. 39-20). The flaps are 39-20).
apicallyThe flaps are apically between the root cones must be considered. Roots
control measures (Fig. with a short divergence are
positioned to the positioned
surgically to established inter- established inter- with a technically
short divergence more diffi -
are technically more diffi-
the surgically cult to separate than roots which are wide
radicular and interproximal bone cult to separate than apart. In
roots which are wide apart. In
radicular andlevel.
interproximal bone level. addition, the smaller the divergence is, the thesmaller
During maintenanceDuring the exposed root surfaces addition, the smaller divergence is, the smaller
maintenance the exposed also rootis surfaces
the inter-radicular
should be treated by should
topical application oftopical
chlorhexi- also(furcation) space. In cases
is the inter-radicular (furcation) space. In cases
be treated by application of chlorhexi-
where the divergencewhere between
dine digluconate anddine fluoride varnish.and Thisfluoride
surgicalvarnish. This surgical the two roots is between
divergence small, two roots is small,
digluconate the possibility of increasing the inter-radicular dis-
procedure should be used with caution, because the possibility of increasing the inter-radicular dis-
procedure should be used with caution, because
tance with an orthodontic
there is a pronouncedthere
risk for tance root
withmovement
an orthodontic may be root movement may be
is aroot sensitivity
pronounced riskandforfor
root sensitivity and for
considered (Fig. 39-21). The furcation space may
carious lesions developing considered (Fig. 39-21). The furcation space may
cariouson the denuded
lesions developing root on sur-the denuded
also berootincreased
sur- by
faces within artificially prepared alsoodontoplasty
be increasedperformed by odontoplasty performed
faces withintunnels (Hamp
artificially et al. tunnels (Hamp et al.
prepared during surgery. Figure 39-22 surgery.
illustrates that odonto-
1975). during Figure 39-22 illustrates that odonto-
1975). plasty was performedplasty on (1)was theperformed
distal part on of the
(1) the distal part of the
mesial root and (2) themesialmesialrootpartand of the
(2) distal root part of the distal root
the mesial
Root separation and Root resection
separation (RSR) and resection (RSR) and deep finishing lines prepared for the subse-
and deep finishing lines prepared for the subse-
Root separation involves
Root the sectioning
separation of thethe
involves rootsectioningquent restoration
of the root (Di quent
Febo etrestoration
al. 1985). (Di Febo et al. 1985).
complex and the maintenance
complex and of alltheroots. Root resec-of all •roots.
maintenance The length and the shape
Root resec- • Theoflength
the root andcones. Following
the shape of the root cones. Following
tion involves the sectioning and the
tion involves theremoval
sectioning of one separation,
and the removal short andseparation,
of one small root cones short and (Fig.small
39-23)root cones (Fig. 39-23)
TRATAMENTO TRATAMENTO
Tunelização Tunelização
Confecção e rebatimento de retalho de
Procedimento cirúrgico • Tronco radicular curto espessura total
para criação de um
Remoção de tecido de granulação e raspagem
espaço interradicular • Amplo ângulo de separação entre as
acessível para raízes Desgaste corono-radicular para
higienização, ou para alargar a entrada da furca
seu modelamento • Grande divergência entre as raízes
anatômico mesial e distal Recontorno de crista óssea alveolar
TRATAMENTO TRATAMENTO
TRATAMENTO TRATAMENTO
TRATAMENTO TRATAMENTO
TRATAMENTO TRATAMENTO
Ressecção Radicular
Exodontia
Confecção e rebatimento de retalho
de espessura total
Indicações:
• Tratamento de defeitos de furca grau II profundo e
Separação das raízes ao nível da furca
grau III em molares superiores
Remoção da raiz escolhida
TRATAMENTO
PROGNÓSTICO
Exodontia
Grau I Grau II Grau III
RTG Secção
Raspagem e
alisamento Plastia de furca Tunelização
radicular
Remoções
Separações radiculares
radiculares ou seletivas ou
hemissecções ressecções
PROGNÓSTICO PROGNÓSTICO
PROGNÓSTICO PROGNÓSTICO
PROGNÓSTICO
CONSIDERAÇÕES FINAIS