BICUSPIDIZATION WITH GLASS FIBRE POST-CORE AND DUAL CROWN TECHNIQUE, FOR A FURCATION INVOLVED MOLAR : AN ALTERNATIVE APPROACH.

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1 BICUSPIDIZATION WITH GLASS FIBRE POST-CORE AND DUAL CROWN TECHNIQUE, FOR A FURCATION INVOLVED MOLAR : AN ALTERNATIVE APPROACH Vyas Anup, Desai Pushkar, Rajput Geeta 1 Proffesor and HOD, Deptt. of Prosthodontics,Crown and Bridge, Sri Aurobindo College 2 of Dentistry, Indore M.P. Post Graduate Student, Deptt. of Prosthodontics,Crown and Bridge, 3 Sri Aurobindo College of Dentistry, Indore M.P., Professor, Department of Prosthodontics Dr. Z. A. Dental College, Aligarh Muslim University Aligarh University Journal of Dental Sciences Case Report INTRODUCTION : Conservative management and long-term retention of periodontally compromised teeth with advanced furcation defects has proved to be challenging to the dentists since ages. Various treatment options are available presently such as implant supported prosthesis, fixed partial dentures but higher patient expectations have led to more conservative treatment approaches in saving teeth with hopeless periodontal prognosis. When periodontal disease affects the furcation area of tooth, the chance of its exfoliation increase considerably. Bisection/bicuspidization of the decayed molars can be a practical treatment option when there is vertical bone loss involving root/roots with furcation defect. In real terms, it is the separation of mesial and distal roots of mandibular molars along with its crown portion, where both segments are then retained individually. Case Report: The furcation defect (in mandibular second molars) was clinically detected in a middle aged male, which was converted into two bicuspids by intentional bisection procedures. The definitive treatment included restoration with double crowns. Bicuspidization procedure with double metal crowns with ceramic facings truly yielded a satisfactory result. CONCLUSION: This clinical report describes a multidisciplinary treatment procedure for decayed mandibular molar that includes bicuspidization followed by prosthetic rehabilitation using double crowns system. Bicuspidization and prosthetic rehabilitation yielded a satisfactory result. Key Words : Bicuspidization, Double crown, Furcation involvement, Prosthetic rehabilitation. Source of support : Nil Conflict of interest : None INTRODUCTION : Restorative treatment planning is often confounded when periodontal attachment loss, caries or tooth fracture involves the furcation area of molars. Advances in dentistry, as well as the increased desire of patients to maintain their dentition, have lead to treatment of teeth that once would have been separated. In order to carry out this present day mandate, periodontally diseased teeth with severe bone loss at furcation area may well be retained by separation of their roots. The treatment, management and long-term retention of mandibular molar teeth exhibiting furcation invasions, always have been a challenge to the discerning general dentist or dental specialist. [1] Through bicuspidization a single molar tooth can be converted into two bicuspids. If both the roots are to be retained, there should be a considerable spread between them for restorative procedures to be successful. [2, 3] The glossary of periodontal terms defines furcation as the anatomic area of a multi-rooted tooth where the roots diverge and furcation invasion refers to the pathologic resorption of bone within a furcation. [4] Furcation invasion is the most commonly seen phenomenon in relation to mandibular molars. Maintaining the health of these teeth with an exposed bifurcation area can be a major problem. This is due to the difficulty of plaque control and the danger of root caries University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 97

2 incident to inadequate oral hygiene procedures. An open furcation is subject to rapid plaque accumulation and calculus formation and is an ideal local environment for the multiplication of microorganisms. The patient, faced with a difficult problem in maintaining an open furcation, often fails in efforts to maintain adequate plaque control. Various treatment procedures have been discussed in the literature viz; root amputation, hemisection, radisection, and bisection. Root amputation denotes the removal of one or more roots of multi rooted tooth keeping other roots intaced. Term hemisection indicates the removal of root with its associated crown portion of mandibular molars. Nevertheless, radisection is a novel terminology for removal of roots of maxillary molars. Bisection/bicuspidization is the separation of mesial and distal roots of mandibular molars long with its crown portion, where both segments are then retained individually. [5]A multidisciplinary treatment procedure for such clinical situations that includes restorative dentistry, endodontics, periodontics, and prosthodontics is necessary to preserve the teeth in whole or in part. These teeth can act as independent single units of mastication or as abutments in simple fixed bridges. Hence, tooth resection measures are employed to preserve maximum tooth structure rather than sacrificing the whole tooth. This clinical report describes a multidisciplinary treatment procedure for decayed mandibular molar that includes bicuspidization followed by post placement core build up and prosthetic rehabilitation using double crowns technique. Bicuspidization and subsequent prosthetic rehabilitation yielded a satisfactory result. options discussed with the patient for the chief complaint included: extraction of the decayed tooth structure followed with a fixed dental prosthesis, implant supported prosthesis or bicuspidization with post and core build-up followed by dual crowns. Patient opted for the most conservative treatment that is bicuspidization with dual crowns was planned. Figure 1: (a) (b): Grossly decayed lower right second molar, with very short clinical crown Figure 2: (a) (b): Radiographs showing the presence of grade II furcation and root canal treated lower right second molarb CASE REPORT : A 44 year old male patient reported to the department of Prosthodontics, Crown And Bridge, Sri Aurobindo College Of Dentistry And PG Institute, Indore, with a chief complaint of fractured teeth in lower right back region of jaw since 7-8 months. History of present illness revealed that patient underwent root canal treatment with 47, 2 years back followed by metal crown with the same. Then about7-8 months back the crown failed, since then patient has not gone through any treatment. Intra oral examination revealed cariously decayed 47, with very short clinical crown (Fig 1a and 1b). On probing there was a pocket of 4 mm with 47 with grade II furcation involvement. Radiographic examination confirmed the presence of grade II furcation and root canal treated 47 with short obturation (Fig 2a and 2b). Patient's medical history was not contributory. Treatment Figure 3: Intraoral view showing bicuspidization followed by glass fibre post and core build up. Figure 4: Intraoral view showing dual temporary acrylic crowns with lower right second molar. University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 98

3 In the view of above findings, it was decided to first carry out: 1) Periodontal prophylactic therapy which included scaling, followed by crown lengthening with 47, 2) Endodontic treatment with excavation of soft caries of involved molar. 3) Under local anaesthesia, bicuspidization to separate the crown by vertical cut method using a long shank tapered fissure carbide bur. These would also aid in maintenance of good hygiene and plaque control, 4) Glass Fibre-Post placement followed by core build up. The patient responded well to the treatment. After satisfactory tissue healing, restoration of molar bicuspids and definitive prosthodontic treatment were started. Various treatment modalities for restoring the tooth were thought which included temporary acrylic crowns, all metal crowns, porcelain fused to metal crown and all ceramic crowns. Porcelain fused to metal crown and all ceramic crowns were ruled out as the patient could not bear the expenses. The patient desired a fixed prosthesis hence all metal double crowns with porcelain facings were the best option considering the patients needs. The post spaces were prepared in mesial and distal root about 3 mm short of apex. Followed by cementation of fibre post (Hi-Rem Post, Overfibers, Italy) and core build up with Fluorocore 2+, Dentsply, USA (Fig3). India) were cemented with temporary cement (RelyX TempNE, 3M ESPE, USA) on same appointment on both core build-ups individually (Fig 4). Patient was followed for 15 days during this period patient was completely asymptomatic. After 15 days temporary crowns were removed and gingival retraction was done with Magic foam cord (Coltene Whaledent Inc).Final impression was taken with virtual putty and light body (Ivoclar Vivadent,Liechtenstein,USA),by double mix single step technique. Thorough assessment of porcelain veneered metal double crowns were carried out (occlusal interference corrected if any) on master cast (Fig 5 and 6) and in patient's mouth (Fig7). Double crowns were permanently cemented using luting Glass ionomer cements (GC Gold Label 1, GC India) (Fig 8 and 9). Figures7: Occlusal view of luted dual crowns. Figure 5: Type IV gypsum master cast with individual die. Figures8: Lateral view of dual crowns: function and aesthetics were restored. Figure 6: Master cast with final crowns Tooth preparations were performed and supragingival chamfer finish lines were placed to aid in oral hygiene procedures (Fig 3). The temporary acrylic crowns (DPI, Figure 9: Post treatment radiograph showing bicuspidization with glass fibre post and dual crowns. University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 99

4 Patient was motivated and instructed to maintain proper oral hygiene using tooth brush followed by interproximal brushing and interdental flossing. DISCUSSION: Previously the cases of furcal caries and large perforations were considered untreatable. If there is a sever bone loss involving either of the surfaces of the root, another approach called hemisection can be used.[1,6] Bicuspidization is a valuable treatment option to save multirooted teeth having the hopeless prognosis. Farshchian and Kaiser have reported the success of a molar bisection with subsequent bicuspidization. [7] They stated that the success of bicuspidization depends on three factors: 1. Stability and adequacy of bone support for the individual tooth sections. 2. Absence of severe root fluting of the distal aspect of the mesial root or mesial aspect of the distal root. 3. Adequate separation of the mesial and distal roots, to enable the creation of an acceptable embrasure for effective oral hygiene. Appropriate case selection and thorough investigation is crucial prior to the bicuspidization procedure. Also, patient's oral hygiene status and attitude, caries susceptibility index and medical and drug history should be taken into account. In literature, several authors have listed the following indications and contraindications for bicuspidization [8-12]. Bicuspidization is indicated in cases of root fractures, severe bone loss affecting one or more roots untreatable with regenerative procedures,class II or III furcation invasions or involvements, cases with inability to successfully treat and fill a canal, molars with severe root proximity which are inadequate for a proper embrasure space and root trunk fractures or decay with invasion of the biological width However bicuspidization is contraindicated in cases of poor oral hygiene, fused roots,unfavourable tissue architectures, retained and endodontically untreatable roots and in unwilling patients. In case when the tooth has lost part of its root support, it will require a restoration to permit it to function independently or to serve as an abutment for a splint or crown or bridge. Unfortunately, a restoration may lead to periodontal destruction, if the margins are defective or if non-occlusal surfaces do not have anatomic and physiologic form. This confirms the significance of accurate marginal adaptation of the final restoration [13-16]. In the present case, a variety of occlusal factors were considered during wax pattern fabrication for double crown. This includes the location and size of centric and eccentric contacts and the steepness of cuspal inclines that may play a significant role in causing tooth mobility. At the metal trial stage, the occlusal contacts were reduced in size and repositioned more favourably. Also, lateral excursive forces were reduced by making cuspal inclines less steep and eliminating balancing cuspal inclinations. CONCLUSION : The management of furcation involvement presents one of the greatest challenge to a restorative dentist. Prosthodontic rehabilitation of bisectioned molars with double crown may be considered as a suitable alternative to extraction in multirooted teeth with hopeless prognosis. The clinical outcome and long term performance of bicuspidization and double crowns are predictable with high success rates [16]. Bicuspidization with definitive prosthetic rehabilitation have received acceptance as a traditional and reliable dental treatment and teeth so treated have endured the demands of function. These cost effective, minimally invasive restorations not only improve masticatory function but enhance esthetics and self confidence, allowing patients to develop socially. Dental restoration therefore plays a significant role in maintaining periodontal health. In addition to cosmetic enhancement, fixed and removable prosthesis serves many purposes, including the improvement of masticatory efficiency and speech, prevention of food impaction and prevention of tilting and extrusion of teeth with resultant disruption of occlusion. REFERENCES: 1. Vandersall DC, Detamore RJ. The mandibular molar Class III furcation invasion. A review of treatment options. J Am Dent 2002; 133: Tarnow D, Fletcher P. Classification of the vertical component of furcation involvement. J Periodontol 1984; 55: Frankln S. Weine. Text book of Endodontology.Sixth edition 4. Parmar G, Vashi P. Hemisection: A case report and review. J Endod 2003;15: Glickman I. Clinical Periodontology. 10th ed. Philadelphia: Saunders; p University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 100

5 6. Pontoriero R, Nyman S, Lindhe J, Rosenberg E, Sanavi F. Guided tissue regeneration in the treatment of furcation defects in man. J Clin Periodontol 1987; 14: Farshchian, F and Kaiser, DA Restoration of the split molar: bicuspidization. Am. J. Dent 1988; 1: Weine FS. Endodontic Therapy, 5th Edition. St. Louis: Mosby; Saxe SR, Carman DK. Removal or retention of molar teeth: the problem of the furcation. Dent Clin North Am 1969; 13: Gantes BG, Synowski BN, Garrett S, Egelberg JH. Treatment of periodontal furcation defects: mandibular Class III defects. J Periodontol 1991; 62: Lindhe JK. Clinical periodontology and implant dentistry. 4th ed. Oxford: Blackwell Publishing Ltd, 2003: Ross IF, Thompson RH. A long term study of root retention in the treatment of maxillary molars with furcation involvement. J Periodontol 1978; 49: Garrett S, Gantes B, Zimmerman G, Egelberg J. Treatment of mandibular Class III periodontal furcation defects: coronally positioned flaps with and without expanded polytetrafluoroethylene membranes. J Periodontol 1994; 65: Detamore RJ. Ten-year report of a bifurcated mandibular first molar. J Ind Dent Assoc 1983; 62: Haueisen H, Heidemann D. Hemisection for treatment of an advanced endodontic-periodontal lesion: a case report. Int Endod J 2002; 35: Kurtzman GM, Silverstein IH, Shatz PC. Hemisection as an alternative treatment for vertically fractured mandibular molars. Compend Contin Educ Dent 2006; 27(2): CORRESPONDING AUTHOR: Dr. Anup Vyas Prof. and HOD Sri Aurobindo College of Dentistry Gram Bhawrasala, Indore Ujjain State Highway, Indore M.P anupvyasv2@gmail.com, MOB University Journal of Dental Sciences, An Official Publication of Aligarh Muslim University, Aligarh. India 101