Furcation involvement is a common sequela of severe chronic periodontal disease. Its effective management has a profound influence on the outcome of periodontal therapy.
3. • Waerhaug (1980) ………best chance for success lies in early recognition and treatment.
• Multirooted teeth amongst other teeth in dentition offer unique and challenging problems
for the periodontist.
• FURCATION AREA because of the interrelationships between the size and shape of the
teeth, the roots and their alveolar housing, and the varied nature and pattern of periodontal
destruction, creates situations in which routine periodontal procedures are somewhat
limited and special procedures are generally required.
4. • FURCATION
“the anatomic area of a multi-rooted tooth where
the roots diverge’’
(American Academy of Periodontology 1992).
5. • Carnevale and colleagues (2003) ……
Root complex: the portion of the
root apical to the cementoenamel
junction (CEJ)
Root trunk: the undivided portion
of the root from the CEJ to the
furcation
Root cone: that part of the root that
Furcation fornix: the roof
of the furcation
Furcation entrance:the
point of union between the
root trunk and cones
Degree of separation: the angle
of separation between the roots
Divergence: the distance
between two roots.
6. Coefficient of separation: the
length of the root cones in relation
to the root complex
Flute : Usually concave or grooving of the
root trunk, extending from the cervical line
and blending into the actual furcation. The
surface immediately coronal to the root
separation.
7. • 1. Glickman (1953)
• 2. Goldman et al. classification (1958)
• 3. Staffileno’s classification (1969)
• 4. Easley and Drennan (1969)
• 5. Hamp et al. (1975)
• 6. Rosenberg (1978)
• 7. Ramfjord & Ash (1979)
• 8. Goldman and Cohen (1980)
• 9. Ricchetti (1982)
• 10. Tal and Lemmer (1982)
• 11. Tarnow & Fletcher (1984)
• 12. Eskow and Kapin (1984)
• 13. Fedi (1985)
• 14. Grant et al. (1988)
• 15. Basaraba (1990)
• 16. Carnevale et al. (1997)
• 17. Nevins and Capetta (1998)
• 18. Hou et al. (1998)
• 19. Glossary of periodontal terms (2001)
• 20. Walter et al. (2009)
8. Grade I: incipient involvement into a
flute of furcation with suprabony
pockets and no interradicular bone
loss
Grade II: any involvement of the
interradicular bone without a
through-and-through ability to probe
Grade IV: through-and-
through loss of
interradicular bone, with
total exposure of furcation
owing to gingival recession
Grade III: through-and-
through loss of interradicular
bone
9. Glickman's (1958) Grade I, II and III is similar to the class 1, 2 and 3 of
Staffileno (1969) and corresponds to Goldman and Cohen's (1980)
classifications of Grade I : incipient, Grade II : cul-de-sac and Grade III :
through & through furcation involvement.
10. • Devised a more complex classification based on surface location, number of bony
walls & degree of furcal exposure.
• information relative to the vertical component of furcation involvement
• As this classification does state the number of osseous walls involved in the furcation,
it is beneficial when one considers bone grafts or other new attachment procedures,
since the extent of osseous involvement at the furcation will, to a greater extent,
determine the prognosis or predictability of bone regeneration.
11. Class I furcation involvement - there is attachment loss that
involves the root flutings, but there is no horizontal component
to the involvement.
SUBTYPE 1 : Horizontal resorption into the furca is
SUBTYPE 2 : indicates a significant vertical component to the
defect.
Class II A : definite horizontal loss
of attachment but no bony ledge on
buccal on lingual surface
Class II B : buccal and lingual
bony ledge and definite vertical
component
Class III A and class III B same as
above
12. DEGREE I / CLASS 1: Represents horizontal attachment loss of less than 3
mm within the furcation involvement.
CLASS II: Represents horizontal loss greater than 3 mm but not encompassing the
total width of the furcation
CLASS III: Denotes horizontal through and through destruction.
13. Grade III (TOTAL) : through-and-
through loss of interradicular bone.
Grade I (INITIAL) : loss of
interradicular bone less than or equal
to one-third
Grade II (PARTIAL) : loss of
interradicular bone greater than one-third
but not through and through
14. subclass A : vertical loss of 1 to 3 mm
subclass B : vertical loss of 4 to 6 mm
siubclass C : vertical loss of 7+ mm
15. CLASS I :
Incipient involvement : horizontal involvement just
into the interradicular area
No interradicular bone loss
Treatment: Osteoplasty/ Ostectomy
Prognosis : Very good
CLASS Ia:
Cul - de -sac involvement, approximating the
first half of the initial one-third of the tooth
dimension. Interradicular bone loss
Treatment: Osteoplasty/ Ostectomy &/or
odontoplasty
Prognosis : Good
CLASS II:
Horizontal involvement beyond Ia, but not into
the middle third of the tooth. Interradicular
vertical & horizontal bone loss; usually a crater.
Treatment: Sectioning & Osteoplasty/
Ostectomy & endodontics, full coverage or new
attachment
Prognosis : Good
CLASS III:
Horixontal involvement, beyond one half of the
tooth dimension. Interradicular horizontal &
vertical bone loss; severe combination type
defect
Treatment: Sectioning & Osteoplasty/
Ostectomy & endodontics, splinting & full
coverage or new attachment or extraction.
Prognosis : dependant on crown/root ratios,
mobility, bone loss restorability.
CLASS IIa:
Horixontal involvement, into the middle one-
third of the tooth but not beyond one half of
the tooth dimension. Interradicular horizontal
& vertical bone loss; always a craater
Treatment: Sectioning & Osteoplasty/
Ostectomy & endodontics, full coverage or new
attachment
Prognosis : Good with sectioning; Poor with
new attachment
16. SUBCLASS B: Vertical
destruction reaching two
thirds of the inter radicular
height
SUBCLASS A: Vertical
destruction to one third of
the total inter radicular
height
SUBCLASS C: Inter radicular
osseous destruction into or
beyond the apical third
17. GOLDMEN AND COHEN
• Grade I : Incipient lesion
• Grade II : Cul de sac
• Grade III : Through and through and lesion
19. FURCATION INVOLVEMENT AND
FURCATION INVASION
• Furcation invasion : pathologic resorption of bone
within a furcation’’ (American Academy of
Periodontology 1992)
• Furcation involvemnent : causes other than
periodontal factors
• Endodontic causes
• Pulpal pathosis
• Restorations
• Root resorptions
• Trauma from occlusion
• Important to diagnose and then formulate treatment
plan
20. ETIOLOGY OF FURCATION INVASIONS
PRIMARY FACTOR - BACTERIAL PLAQUE
Predisposing factors - Anatomical considerations
• Root anatomy and concavities
• Enamel pearls and projections
• Accessory pulp canals
• Bifurcation ridges
• Location of furcation relative to CEJ
• Location and diameter of furcation entrance
21. ROOT ANATOMY
• Morphology
• Divergence
• Convergence
• Fusion
• Degree of separation of the roots:
• Wide separation of the roots improves access, thereby
facilitating instrumentation
22. PROXIMAL ROOT CONCAVITY
• Mesiobuccal root of maxillary molar and mesial root of
mandibular molar.
• Instrumentaion and plaque maintainence becomes difficult
23. BIFURCATION RIDGES
• Ridges cross from mesial to distal root at midpoint of bifurcation
• Two types of bifurcation ridges have been described.
I) Intermediate: connect the mesial and distal roots and are covered with cementum
II) Buccal / lingual ridges : composed primarily of dentin with overlying thin layers of
cementum
24. CERVICAL ENAMEL PROJECTIONS
• Causative due to lack of connective tissue attachement on enamel
surfaces (Carranza & Jolkovsky 1991).
MASTER & HOSKINS (1964)
Grade I: distinct change in the CEJ contour, enamel projecting toward
bifurcation ( less than 1/3rd of the root trunk)
Grade II: CEP approached the furcation, but not actually making
contact (>1/3rd)
Grade III: CEP that extends directly into the furcation proper
25. ENAMEL PEARL
• AAP - Enamel pearl is “a small focal mass of
enamel formed apical to the CEJ”
• Prevalence :2.69%
• More common in 1st max and least in mand 1st
molars .
26. ACCESSORY PULP CANALS
The high percentage of molar teeth with patent accessory canal opening into the
furcation suggests that pulpal disease could be an initiating cofactor in the
development of furcation involvement
Furcation involvement - combined endodontic periodontic defect
28. • A furcation probe is a type of periodontal probe used to evaluate the bone support in the
furcation areas of bifurcated and trifurcated teeth.
• Furcation probes have curved, blunt-tipped working-ends that allow easy access to the
furcation areas.
• Examples of furcation probes are the Nabers 1N and 2N, ZA2, ZA3, HO2, NS2, NP2C
and ACE probes.
• Tal (1982) described a probe which permits direct measurements of the depth of the
furcal defects
• Consists of Millimeter scale; Flexible metal spring tube ensheathing a rigid stilleto, 0.3
mm thick
Atlas of cosmetic and reconstructive periodontal surgery, 3rd edition
31. • To determine the bone contours associated with furcation
involvement more accurately, TRANSGINGIVAL PROBING OR BONE
SOUNDING can be accomplished through anesthetized soft tissues.
• This technique has been shown to yield accurate measurements
when compared with those made at the time of open flap surgery
(Greenberg 1976)
32. RADIOGRAPHS
• As an adjunct to clinical probing
• Paralleling periapical and bitewing
• Maxillary furcations are not readily seen in
radiographs taken at right angles to the
teeth and suggested that better visualization
of the furcations is possible by varying the
angle of the beam.
Superimposition of palatal root and other bone
structures
33.
34. SUBTRACTION RADIOGRAPHY
• This technique permits visualization of change in image densities at different time
intervals and allows detection of mineral changes as little as 5%.
• Computer-assisted densitometric image analysis (CADIA), has shown favorable results
over digital subtraction radiography when used to study alveolar bone density changes in
furcations (Bragger et al., 1988; Bragger et al., 1989).
35. • CT scans offer more detailed information on furcation involvement than
clinical probing. Especially before surgical treatment, three-dimensional
radiographic imaging can be a useful tool to assess the degree of furcation
involvement and optimize treatment decisions.
Laky M, Majdalani S, Kapferer I, Frantal S. Periodontal Probing of Dental Furcations Compared With Diagnosis by
Low-Dose Computed Tomography: A Case Series. J Periodontol 2013;84:1740-1746.
36. CONE BEAM CT (CBCT)
• A CBCT image showing a Class III furcation involvement . Various authors (Mengel et
al., 2005; Vandenberghe et al., 2007) have reported that furcation involvement can be
differentiated into Class I, II and III furcations clearly with both CT and CBCT.
• However, in terms of image quality the CBCT scans were superior to the CT scans, with
the periodontal ligament space in particular being represented exactly in all three planes,
and that CBCT resolution can be as small as 0.2 mm, as compared to 0.5-1 mm for CT
37. RECENT ADVANCES IN IMAGING
• 1. Natural frequency analysis
• 2. Ultrasonography
• 3. Optical coherence tomography
38.
39. • The major principle of treatment of furcation involved tooth is
• to eliminate the etiologic factor, the furcation per se, and
• to create a predictably maintainable environment.
40. THREE BROAD STRATEGIES OF FURCATION THERAPY (Kalkwarf & Reinhardt
R.A 1988)
I. Maintenance of the existing Furcation
Scaling and root planing
Obstruction of Furcation
II. Increasing access to the Furcation
Gingivectomy/Apical positioned flap
Odontoplasty & Furcationplasty
Osteoplasty /ostectomy
III. Elimination of the Furcation
Root amputation/ Tooth resection
Bicuspidization
41. DEGREE OF INVOLVEMENT
GRADE I
GRADE II
THERAPY
Scaling and root planning
Odontoplasty
Furcation plasty
Furcationplasty
Tunnel preparation
Root resection
Tooth extraction
GTR at mandibular molars
Lindhe and Nyman 1998, classified treatment depending on degree of involvement
43. • Minor distance (<5 mm; degrees I and I1 involvement) : scaling and
root planing with proper oral hygiene program
• 5-6 mm (Degree II involvement) : initial cause related treatment is
frequently supplemented with surgery involving, osteoplasty,
odontoplasty
• Deeper into the furcation area, >5 mm; (degree I1 involvement) or a
through and through defect (degree I11 involvement) : tunnel
preparation or root resection
44. PROGNOSIS
• Prognosis for individual teeth depend on:
• 1. Morphology of the bone deformity.
• 2. Root anatomy
• 3. Tooth morphology
• 4.Chronicity of the destructive process.
• 5.Clinical crown to clinical root ratio.
• 6.Mobility: Tooth mobility caused by inflammation and trauma from occlusion
may be correctable, but mobility resulting from loss of alveolar bone alone is not
likely to be corrected.
• 7.Patients age and general health
45. I. Non- surgical/Closed scaling and Root Planing: vs Surgical/Open
Scaling and Root planing:
• Maria et al (1986), Parashis et al (1993) and Fleischer et al in favour and Kalkwarf et al
(1988), Schroer et al (1991) and Wang et al (1994) against it.
• In conclusion, although scaling and root planing combined with flap surgery is more
effective at removing calculus, the clinical evaluations do not indicate a dramatic
difference between surgical and nonsurgical treatments irrespective of the degree of
furcation involvement.
46. • Quetin furcation curette BL 2 (Larger) &
BL1 (Smaller)
• • shallow, half-moon radius that fits into
roof or floor of furcation & developmental
depressions •Shanks are slightly curved for
better access
• •Tips - 2 widths
• •-BL1 & MD1- small fine with 0.9 mm
blade width
• •-BL2 &MD2- larger and wider 1.3 mm
width
47. • Oda and Ishikawa (1989) designed a new
ultrasonic scaler tip made of acid resistant
stainless steel.
• The end of the tip was spherical (0.8 mm in
diameter) to protect the root surfaces and soft
tissue injury and improve contact with the root
surfaces.
48. • The difficulties of performing adequate debridement in furcations by mechanical
means has prompted experimentation with chemotherapeutic agents in these areas.
• Needleman and Watts (1989): 1% metronidazole gel irrigation
• Nylund and Egelberg (1990): 50 mg/ml Tetracycline irrigation every 2nd week for 3
months.
• Minabe et al (1991): Tetracycline immobilized in a cross-linked collagen film.
• Tonetti et al (1998): Tetracycline impregnated fibers
• A.R. Pradeep (2013) : 1 % Alendronate Gel
49. OBLITERATION OF FURCATION - OCCLUSIVE BARRIER
Filling of advanced furcation defects with biocompatible material to eliminate anatomic
niches for bacteria accumulate.
Potential advantages of an occlusive barrier:
Easy to place
Doesn’t require a suture for stability
Elimination of a second stage procedure
50. Different materials which have been used:
Amalgam
Polymer – reinforced zinc oxide eugenol
Resin ionomer cement
Glass ionomer cement
51. II. Surgical/Open Scaling and Root planing:
• If sufficient subgingival access is not possible with a closed approach, for
furcated molars with deep lesions, then open scaling using flap procedure
such as Modified Widman flap yields more effective calculus removal with
Furcation involvement.
• Thus replaced flap results in some pocket reduction by formation of a long
junctional epithelial adhesion.
52. INCREASING ACCESS TO THE FURCATION :
GINGIVECTOMY/APICAL POSITIONED FLAP :
Can be used in Reducing or eliminating the soft tissue pockets over the
furcation region to increase access for plaque control and allows
resolution of periodontal inflammation.
53. FURCATIONPLASTY :
• Odontoplasty i.e. removal of tooth substance in the furcation area in order to
widen a narrow entrance of the furca and to reduce the horizontal depth of the
involvement.
• Osteoplasty - recontouring of bony defects in the furcation area, if indicated.
• Repositioning and suturing of the flap
54. Furcation Plasty—Odontoplasty and Osteoplasty
• Hamp and colleagues (1975) described furcation plasty as raising a
mucoperiosteal flap to provide access to the furcation area and
combining scaling and root planing, osteoplasty odontoplasty to
remove local irritants and open the furcation to allow the patient
access to clean and maintain the area.
• The result should be a firm, well-contoured papilla to cover the
interradicular space. This procedure is recommended for grade I and
early grade II lesions (Glickman)
55. • The purpose of the procedure is to
establish a condition in the dentogingival
region which facilitates self performed
plaque control.
• It results in the establishment of a soft
tissue papilla which covers the entrance to
the inter-radicular periodontal tissues.
56.
57. TUNNEL PROCEDURE
• Intentional creation of a Class III furcation – entrance accessible for oral hygiene
procedure.
• Very conservative approach.
• Objective - cleaning the furcation area by the patient using an interdental tooth
brush.
• Main advantage - avoidance of prosthetic reconstruction and endodontic therapy.
58.
59. INDICATIONS FOR TUNNEL PRERPARATIONS
• Deep grade II or grade III furcation involved teeth
• Root anatomy :
• Short root trunk (not be longer than 1/3 of the total root length) and a wide
diameter of the furcation entrance
• long and divergent roots
• generally indicated for the mandibular molars
Rudiger SG: Mandibular and maxillary furcation tunnel preparations – literature review and a case report. J Clin Periodontol 2001; 28:
1–8.
60. PULP REACTIONS
• The tunneling procedure might provoke a pulp reaction as it exposes a
large root surface area relative to the root length.
• Accessory root canals on the exposed root surface can connect
periodontal and endodontic tissues.
CARIES RISK
Rudiger SG: Mandibular and maxillary furcation tunnel preparations – literature review and a case report. J Clin Periodontol
2001; 28: 1–8.
62. Root amputation / Root resection : involves the removal of one or more roots of a
multirooted tooth, at the same time permitting retention of the remaining tooth portion.
Hemisection is defined as removal or separation of the root with its accompanying
crown portion.
Radisection is a newer terminology for removal of roots of maxillary molars.
Bisection / Bicuspidization is the separation of mesial and distal roots of mandibular
molars along with its crown portion, where both segments are then retained individually.
64. ROOT RESECTION
A round bur is used for bone removal over the affected root. B and B', A 701L bur is used for the second cut. C and
C', A flame-shaped enamel finishing bur is used for the oblique horizontal third cut. D and D', Oblique cut
completed and final internal contouring established with round and oval enamel finishing burs.
65.
66. INDICATIONS FOR ROOT RESECTION AND
SEPARATION TREATMENT:
Periodontal
Indications :
Severe bone loss
affecting one or more
roots untreatable
with regenerative
procedures.
Class II or Class III
furcation invasions
or involvements.
Severe recession or
dehiscence of a root.
Endodontic or
Conservative Indications
:
Inability to successfully
treat and fill a canal
Root fracture or root
perforation
Severe root resorption
Root decay
Prosthetic Indications
Severe root proximity
inadequate for a
proper embrasure
space.
Root trunk fracture
or decay with invasion
of the biological width.
67. CONTRAINDICATIONS TO ROOT RESECTION AND SEPARATION
TREATMENT:
• General contraindications to periodontal surgery
- Systemic factors
- Poor oral hygiene
• Factors associated with local anatomy
- Fused roots
- Unfavorable tissue architecture
68. • Endodontic factors :
- Retained roots endodontically untreatable
- Excessive endodontic instrumentation of retained roots
- Excessive deepening of pulp chamber floor
• Restorative factors :
- Internal root decay
- Presence of a cemented post in the remaining root
69. BICUSPIDIZATION
Separation of a two-rooted tooth (mandibular molar) & restoration of the crown
portion of each section has been described to enhance plaque control & to convert
the part of the tooth most susceptible to caries attack (dentin & cementum in the
furcation) into metal.
Indication : Grade III furcation involvement & divergent well supported roots.
Disadvantages : Time, expense & attention to detail required for successful
completion of the case.
72. BONE GRAFTING
The strong focus on bone formation as a prerequisite for new attachment
formation has led to implantation of bone grafts or different types of bone
substitutes into furcation defects.
•Contain bone forming cells (osteogenesis)
•Serve as a scaffold for bone formation (Osteoinduction).
•Matrix of the grafting material contains bone inductive substances
(Osteoinduction), which would stimulate both the regrowth of alveolar bone
and the formation of new attachment.
73. •Schallhorn O (1967) observed probing depth reduction and bone fill of degree II
furcation following transplantation of iliac grafts.
•Gantes et al (1988): dFDBA
•Kenny et al (1988): Porous hydroxyapatite
•Pepelassi et al (1991): Composite graft of tricalcium phosphate, plaster of Paris and
doxycycline
•Yukna et al (1994): HTR bioplant
74. • Bone replacement grafts alone have had limited success in
managing Class II and III furcation defects.
• Problems
Containment of graft,
Epithelial exclusion, and
Variable inductivity of the graft.
75. GUIDED TISSUE REGENERATION
•Guided Tissue Regeneration is defined as procedure attempting to regenerate lost
periodontal structures through differential tissue responses.
•Using GTR, Gottlow et al (1986) demonstrated clinical and histological resolution of
angular as well as furcation defects in humans.
•These barriers can be
absorbable/non-absorbable
natural/synthetic.
Degree I1 and degree I11 furcation involvements
76. • It was found that root resorption rather than new attachment
occurred if the detached root surface was repopulated by cells derived
from bone or gingival connective tissue.
• A new connective tissue attachment with cementum and inserting
collagen fibers was formed only when periodontal ligament cells were
allowed to repopulate the root surface.
77. Grade II furcation have most predictable outcome of regenerative therapy
• Options starts with SRP
• Open flap debridement
• LDD
• Root conditioning
• Root resection, Hemisection
• Extraction
• With advent of regenerative therapy was attempted in furaction defects also with use
of biomimetic agents like enamel matrix derivatives, platelet-rich plasma, platelet-
derived growth factor, and bone morphogenic proteins
78. Meta analysis of re entry results was done to give an idea of best regenerative treatment for
molar grade II furcation.
• Parameters assessed were VPD, VCAL, HBL, and VBL
• Treatments employed were
• Resorbable membrane
• Non resorbable membrane
• Open flap debridement
• Allograft / xenograft + resorbable or Allograft / xenograft + non resorbable membrane
79. 1)The use of resorbable membranes was significantly better compared to non-
resorbable membranes
2)Guided tissue regeneration by using resorbable or non-resorbable membranes
produced better results compared to open flap debridement for all four parameters
3)The addition of allograft/xenograft to a resorbable membrane enhanced VPD
reduction, attachment level gain, and HBL increase compared to resorbable
membranes alone
4)Guided tissue regeneration by using a nonresorbable membrane and an allograft
resulted in improved bone level gains compared to a non-resorbable membrane alone
5)Tooth and patient factors influenced the outcome of regeneration and these factors
should be addressed presurgically
Kinaia BM, Steiger J, Anthony L. Neely, Shah M, Bhola M. Treatment of Class II Molar Furcation Involvement: Meta-Analyses of
Reentry Results. J Periodontol 2011;82:413-428.
80. TOOTH EXTRACTION
Earlier Saxe and Carmen (1969) had stated that the indications for removal of a tooth
with a Grade III furcal defects are:
1) The existence of an unopposed molar which is the terminal tooth in the arch.
2) A first molar with adjacent second premolar and second molar each with adequate
bone support.
3) A solitary distal abutment tooth which exhibits mobility.
81. CONCLUSION
The decision to retain and treat teeth with furcations has been recognized
as feasible and predictable when appropriate parameters are addressed.
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