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Why Furcation is an area of complex anatomic
1. Difficult for routine periodontal instrumentation
2. Difficult to maintain by routine home care
3. clinical finding of furcation indicates advanced
periodontitis and less favourable prognosis
1. Based on horizontal attachment loss
Glickman’s classification (1953)
Hamp’s classification (1975)
2. Based on Horizontal and vertical componenets
Tarnow and Fletcher’s classification (1984)
3. Based on Combination of these findings and
morphology of bone deformity
Easley and Drennan’s classification (1969)
Furcation Involvement (FI)
Glickman’s classification (1953)
Main objectives are:
1. Elimination of the microbial plaque from root
2. Establishment of an anatomy to facilitates proper
self‐performed plaque control
3. Prevent further attachment loss
Grade-I Grade-II Grade-III or IV
• OFD and Grafting
• Tunnel preparation
• Tunnel preparation
• Root resection
• Extraction and
Indicated for Grade- I and early grade- II
Advancements in non-surgical- DeMarco curettes,
diamond files, Quetin furcation curettes, and mini Five
Svärdström and Wennström ( J Periodontol 2000)
in the long term, furcations could be maintained
over a 10-year period using NSPT.
2. Oral Hygiene Procedures
meticulous oral hygiene by the patient
rubber tips; periodontal aids; proxa toothbrushes.
1. Furcation plasty
First described by Hamp and colleagues (1975)
Result should be firm, well contoured papilla to
cover the furcation defect.
Indicated in deep grade- II and grade- III furcation defects
in mandibular molars.
Long and divergent roots (no possibility of regeneration)
Gottlow et al. (1986) published first case rep. using GTR
Most predictable results in grade- II (Pontoriero et al.
1988; Lekovic et al. 1989; Caffesse et al. 1990)
Less predictable in grade-III and maxillary grade-II
(Pontoriero et al. 1989; Pontoriero & Lindhe 1995,
Metzeler et al. 1991)
1. Horizontal type of furcation defects
2. Complex anatomy- poor debridement
3. Poor blood supply for graft material
4. recession of the flap margin and early exposure of
both the membrane and fornix
Why limited predictability ?
Advancement in regeneration
e-PTFE and DFDBA
Enamel matrix proteins
e-PTFE membrane with b- tricalcium phosphate
Dent Clin N Am - (2015)
Root resection- involves the sectioning and the
removal of one or two roots of a multirooted tooth.
Root separation- involves the sectioning of the root
complex and the maintenance of all roots.
Indicated in deep grade- III and IV.
Root resection and separation
By Bassarba et al.:
1. Teeth serving as abutments for prosthesis
2. Severe attachment loss on a single root
3. Teeth for which more predictable Rx is unavailable.
4. Teeth in patients with good oral hygiene and low
1. Poor C/R ratio on remaining roots
2. Unfavourable anatomy of retained roots
3. Long root trunks/ fused roots
4. Teeth in which Endo-Restorative Rx is not possible
5. Inability to perform oral hygiene
6. Splinting is not possible
7. Prosthetic factors
1. root that will eliminate the furcation
2. with greatest amount of bone/attachment loss
3. Greatest number of anatomic problems:
Curvature, grooves, accessory canals
4. Least complicate the future periodontal
Which root to remove ?
1. Endodontic treatment
2. Provisional restoration
Sequence of treatment (carnevale 1981)
• performed as part of the preparation of the
segment for prosthetic rehabilitation, that is prior
to periodontal surgery (Carnevale et al. 1981).
4. Periodontal surgery
• osseous resective techniques are used to eliminate
angular bone defects around the maintained roots.
• The provisional restoration is relined.
• The margins of the provisional restoration must end
≥3 mm coronal of the bone crest
• flaps are secured with sutures at the level of the
5. Final prosthetic restoration
• After complete soft tissue and hard tissue healing
Extraction is better in grade- III and IV.
Inadequte plaque control
Can’t commit to a maintenance programe
High caries activity
Poor socio-economic factor
In a 5‐year study, Hamp et al. (1975) observed the
outcome of treatment of 175 teeth with various
degrees of furcation involvementOf
32 (18%) were treated by SRP alone, (12)
49 (28%) were subjected to furcation plasty (3)
87 teeth (50%), root resection (5)
7 teeth (4%) a tunnel had been prepared (4).
Prognosis of Therapy
Hamp et al. 1992 7‐year study, 182 furcation‐ involved
57 had been treated by SRP alone
101 were treated by furcation plasty, and
24 were subjected to root resection or hemisection
>85% of the furcations treated with SRP alone, or in
conjunction with furcation plasty, maintained stable
Carnevale et al. (1998) in a 10‐year prospective
controlled clinical trial, demonstrated a 93% survival
rate of root resected teeth similar to that of success
rates of implants (Fugazzato et al. 2001)
Greater than 65-70% rate of implants placed in
poorer bone quality (Engquist, Jaffin and Berman
Recently, Huynh‐Ba et al. (2009) published a
systematic review (22 publications)
Reported tooth survival rates
Non‐surgical furcation therapy: 90.7–100% at the end
of the observation period of 5–12 years.
Grade- I : 99-100%
Grade- II: 95%
Grade- III & IV: 25%
Surgical furcation therapy (i.e. flap with or without
osseous resection, gingivectomy/gingivoplasty, but
not including furcation odontoplasty): 43.1–96% at the
end of an observation period of 5–53 years.
Tunnel preparation: 42.9–92.9% after 5–8 years of
Surgical resective therapy (i.e. root resection or root
separation): 62–100% after an observation period of
5–13 years. Reported complications were mainly root
fractures and endodontic failures.
Surgical regenerative therapy (i.e. GTR, bone grafts):
62–100% after a period of 5–12 years.
horizontal furcation depth reduction in most of the
cases No complete furcation closure, especially in
severely involved mandibular and maxillary molars.
No clear scientific evidence that any given treatment
modality is superior to the others.
Treatment modalities are more predictable for grade- I
and grade- II
4 keys for long term success
Carranza clinical Periodontology 11th edition
Jan Lindhe, Clinical Periodontology and Implant dentistry:6th ed.
Periodontal therapy: Clinical approaches and evidence of success:
Nevins and Mellonig.
Periodontal surgery a clinical atlas: N. Sato.
Color atlas of cosmetic and reconstructive periodontal surgery: E.
Ponteriero and Lindhe. GTR in the treatment of degree III
furcation defects in maxillary molars: JCP 1995, 22: 810-812.
J zambon, Unanswered Questions Can Bone Lost from Furcations
Be Regenerated?. dental clinics of north america. 2015.Dr Jignesh