furcation definition anatomy etiology and treatment

1. FURCATION INVOLVEMENT
PRESENTER – PUNIT
DEPARTMENT OF PERIODONTOLOGY
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2. CONTENTS
 Introduction
 Terminology
 Anatomy of multirooted teeth
 Classification of furcation involvement
 Etiology
 Microbiology
 Diagnosis
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3.  Treatment
Scaling and rootplaning
Obliteration of furcation
Gingivectomy/apically positioned flap
Furcationplasty
Tunnel procedure
Resective periodontal procedures
Regenerative procedures
Tooth extraction
 Prognostic factors
 Conclusion
 References
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4. INTRODUCTION
Furcation involvement refers to
a condition in which the
bifurcations and trifurcations of
multi-rooted teeth are invaded
by periodontal disease
Characterized by bone
resorption and attachment loss
in the interradicular space
(Newmann et al, 2012 ).
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5. DEFINITIONS:
Glickman (1950)
Commonly occurring
condition in which the
bifurcation and
trifurcation of multi-
rooted teeth are
denuded by
periodontal disease
Prichard (1965)
Bifurcation and
trifurcation
involvements are
common periodontal
lesions which occur as
a result of gingival
inflammation and
bone resorption
adjacent to and within
the furca of multi-
rooted teeth
Goldman & Cohen (1968)
Extension of pocket
into the interradicular
area of bone in
multirooted teeth
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6. TERMINOLOGIES
 Root complex is the portion of a tooth that is located apical of the
cemento-enamel junction (CEJ)
 The root complex may be divided into two parts:
the root trunk and the root cone(s)
 The root trunk represents the undivided region of the Root
 The root cone is included in the divided region of the root complex
 The furcation is the area located between Individual root cones.
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7. Divergence and degree of separation b/w palatal
and mesial roots
Degree of separation:
The angle of separation
Between two roots (cones)
Divergence: The distance
between two roots
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8. Furcation Entrance
Entrance: The transitional
area between the undivided
and the divided part of the
root
Fornix: The roof of the furcation
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9. Apico-occlusal view of a maxillary molar where
the three root cones make up the furcated region
and the three furcation entrances
Coefficient of separation : the length of
the root cones in relation to the length of
the root complex.
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10. ANATOMY OF FURCATION
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11. Furcation Entrance Diameter
 How does the furcation
entrance diameter relate to
the blade width of a new
curette?
Blade width of new
Gracey curette = 0.75mm
60% of molar furcation
entrances < 0.75 mm
Mandibular molars: buccal
wider than lingual
maxillary molars: mesial >
distal > buccal
Bower, R.C. (1979a). Furcation morphology relative to periodontal treatment.
Furcation entrance architecture. Journal of Periodontology 1979;50:23–27
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12. Maxillary molars
Cross sections
DB and palatal roots circular
MB rootDistal surface - concavity
which is about 0.3 mm deep - "hour-
glass" configuration. (Bower 1979)
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13. Mandibular molars
Mesial root larger than distal, wider bucco-
lingually
Root trunk of the 1st molar often shorter
than that of 2nd
Cross-section
Mesial larger & “hour glass”
Distal  circular
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14. Cervical Enamel Projections
13% of molars have CEPs
These projections may favor the onset of
periodontal lesions in the affected
furcations
Bower RC. Furcation morphology relative to periodontal
treatment: furcation root surface anatomy. J
Periodontol 1979;50:366-74
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15. Classifications of Furcation Involvement
1. Based on horizontal attachment loss
Glickman’s classification (1953)
Hamp’s classification (1975)
2. Based on Horizontal and vertical components
Tarnow and Fletcher’s classification (1984)
3. Based on Combination of these findings and morphology of bone
deformity
Easley and Drennan’s classification (1969)
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16. Glickman`s Classification(1953)
 GRADE I Incipient Furcation:
 Grade-I:
Incipient or early stage
Soft-tissue lesion or pocket extending into flute of
furcation
Inter-radicular bone  intact or slight bone loss
No radiographic evidence of bone loss
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17. GRADE II Furcation
 Pocket formation & loss of inter-radicular bone of varying depths
into the furcation but not through and through
 Portion of PDL and bone remain intact
 Distinct horizontal destruction of furcation area is present
 ‘ Cul de sac’ with a horizontal component
 Partial penetration of probe ; Extent of horizontal probing 
early or advanced
 Radiographs  may or may not depict involvement esp. in max
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18. GRADE III Communicating or Through and Through
Furcation
 Destruction of bone and connective
tissue wall all the way through the
furcation
 Bone is not attached to the dome of
furcation.
 Early grade III involvement- opening
filled with soft tissue
 Pocket formation  completely
probable to the opposite side of the
tooth
 Radiographic evidence  small
triangular radiolucency
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19. GRADE IV
 Interdental bone is destroyed and the soft tissues recede apically so the furcation
opening is seen clinically
 Tunnel exists between the roots of affected tooth
 Periodontal probe passes readily from one aspect
to other aspect
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20. (
)
 GRADE II degree I VERTICAL COMPONENT OF >1MM
BUT <3MM
GRADE II degree II VERTICAL COMPONENT OF >3MM
BUT
NOT THROUGH & THROUGH
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21. Hamp, Nyman & Lindhe`s Classification (1975)
 CLASS I Horizontal loss of periodontal support not exceeding one‐third of
the width of the tooth
 CLASS II Horizontal loss of periodontal support exceeding one‐third of the
width of the tooth, but not encompassing the total width of the furcation area
 CLASS III Horizontal “through‐and‐through” destruction of the periodontal
tissues in the furcation area
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22. 22
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23. TARNOW AND FLETCHER
VERTICAL CLASSIFICATION 1984
Vertical component of furcation measured
from floor of the furca to the roof of the furca
Vertical destruction to one third of
the total inter radicular height (3 mm or less).
Vertical destruction reaching two
thirds of the inter radicular height (4 to 6 mm).
Inter radicular osseous destruction
into or beyond the apical third (> 7 mm).
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24. OTHER CLASSIFICATIONS
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25. PUBLICATION AND YEAR CLASSIFICATION
1958 Goldman Grade I: Incipient
Grade II: Cul-de-sac (pouch)
Grade III: Through and through
1969 Staffileno Grade I: Soft tissue lesion
extending to the entrance of the
furcation with minor degree of
bone loss
Grade II: Loss of furcal bone but
not through and through
Grade III: Through and through
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26. PUBLICATION AND AUTHOR CLASSIFICATION
1969 Easley and Drennan Class I: Incipient involvement,
entrance of the furcation detectable
with no horizontal bone loss
Class II, Type 1: Horizontal bone loss
but no vertical component
Class II, Type 2: Horizontal bone loss
and vertical bone loss
Class III, Type 1: Through-and-
through bone loss with no vertical
component
Class III, Type 2: Through-and-
through bone loss with vertical
component
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27. PUBLICATION AND AUTHOR CLASSIFICATION
1979 Ramfjord Degree 1: Horizontal penetration <2 mm
Degree 2: Horizontal penetration >2 mm
but not through and through
Degree 3: Through and through
1998 Hou et al Three types (A, B, and C):
A:Furcations with a short root trunk i.e. less
than 1/3rd of root complex (corresponding to a
separation degree of more than 2/3rd )
B: Corresponds to a medium sized root trunk
of 50 % of root complex (separation degree
of 1/2)
C:Furcations associated with a root trunk
2/3rd of root complex (separation degree 1/3rd
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28. ETIOLOGY
ETIOLOGY
MICROBIAL
DENTAL PLAQUE
IATROGENIC
FACTORS
VERTICAL
ROOT
FRACTURES
TRAUMA
FROM
OCCLUSION
DENTAL
CARIES/PULPAL
DEATH
LOCAL ANATOMIC AND
DEVELOPMENTAL
FACTORS
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29. MICROBIAL DENTAL PLAQUE
 The primary etiological factor in the development of furcation defects is the
microbial dental plaque (Ammons et al., 2002).
 Microbial dental plaque is the microorganism colony found on the outer surface
of the tooth, covering the tooth like a biofilm (Socransky and Haffajee, 2002;
Marsch, 2004).
 Plaque’s bacteria are generally in harmony with the host and they consume
endogenous nutrients (Salivary proteins and glycoproteins).
 The existence of endogenous bacteria cause the formation of a low amount of
acid and the settlement of exogenous microorganisms (Marsh, 2000;Wilks,
2007).
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30. LOCAL ANATOMIC FACTORS
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31. Bower et al (1979), reported that 81% of all
furcation entrance diameters were 1 mm, and
58% were 0.75 mm (63% of maxillary molars and
50% of mandibular molars were 0.75 mm).
Also found no association
between the mesio-distal width
of 1stmolars and furcation
entrance diameter. Similar
findings were reported by Chiu
et al. (1991), where 49% of
furcation entrances were found
to be 0.75 mm
Considering that the average width
of a curette blade face ranges
between 0.75– 1.10 mm, the authors
concluded that the use of curettes
alone might not be suitable for root
preparation in the furcal area
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32. ROOT TRUNK LENGTH
In a study of mandibular first and second molars, it was reported
that the mean root trunk length was 3.14 mm on the buccal aspect,
and 4.17 mm on the lingual aspect
Mandelaris et al(1998)
The root trunk surface area for mandibular and maxillary molars
averages 31% and32% of the total root surface area respectively
(Dunlap & Gher 1985,Gher & Dunlap 1985)
Therefore, horizontal attachment loss leading to furcation invasion
compromises the root trunk, resulting in the loss of one third of the total
periodontal support of the tooth (Hermann et al. 1983, Grant etal. 1988)
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33.  The root trunk length plays a significant role in both the prognosis and treatment of
the tooth.
 A molar with a short root trunk is more vulnerable to furcal involvement, but has a
better prognosis after treatment since less periodontal destruction has presumably
occurred.
 Alternatively, a furcation-involved molar with a long root trunk and short roots may not
be a candidate for root resection, since these teeth lose more periodontal support with
furcal invasion.
Al-Shammari KF, Kazor CE, Wang H-L: Molar root anatomy and
managementof furcation defects. J Clin Periodontol 2001; 28: 730–
740.
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34. ROOT CONCAVITIES
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35. BOWERS ET AL 1979
reported a 17–94% incidence of root depressions in
maxillary roots and 99–100% in mandibular roots.
Booker&Loughl (1985)
In a study of 50 maxillary first premolars,reported
the presence of mesial concavities in 100% of
examined teeth
In 2-rooted maxillary premolars, they reported a
buccal root furcal depression in 100% of the
examined teeth at a level of 9.4 mm.
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36. LOCAL DEVELOPMENTAL ANOMALIES
Cervical enamel projections
 Ectopic deposits of enamel apical to the level of the normal CEJ with a
tapering form and extending towards or into the furcation areas are
called Cervical enamel projections.
 It has been observed that CEP’S occur in 13% of multirooted teeth
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37. CLASSIFICATION OF CEP
 Grade I : Distinct change in CEJ contour, with enamel projecting toward
the bifurcation (<1/3 of the root trunk)
 Grade II: CEP approaching the furcation, but not actually making contact
with it (>1/3)
 Grade III: CEP extending into the furcation proper
Masters & Hoskins. J.Periodontol 1964
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38. Carranza & Jolkovsky{1991}
Cervical enamel projections
(CEPs) have been implicated as
etiologic factors in furcation
defects due to the lack of
connective tissue attachment on
enamel surfaces
Masters & Hoskins {1964} found a
CEP incidence of 28.6% for mandibular
and 17% for maxillary molars, which
correlated more than 90% to
mandibular molar furcation
involvement
Hou & Tsai {1987}
reported a 45.2% incidence of
CEPs in 78 patients. Of the teeth
with furcation involvement, 82.5%
had CEPs, while only 17.5% of
teeth without furcation
involvement had CEPs.
Mandelaris et al {1998}
reported that CEPs were found in
56.4% of all mandibular molars. CEPs
were more commonly found on the
buccal (61.9%) than the
lingual (50.8%) aspects.
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39. Enamel Pearl
The prevalence of enamel pearls is less
than that of cervical enamel projections.
Moskow & Canut (1990), reported an
incidence of 2.6% (range 1.1–9.7%)
Like CEPs, enamel pearls contribute to
the etiology of furcation involvement by
preventing connective tissue attachment.
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40. PULPAL PATHOLOGY
 The role of pulpal pathology in the etiology of furcation involvement is still unclear, the
high incidence of molar teeth with accessory canals supports such an association
Lowman et al. (1973), reported the incidence of
accessory canals to be 55% in maxillary molars and 63% in
mandibular molars
Alternatively, Kirkham (1975), found no accessory canals
in the furcation areas of 45 maxillary and mandibular
molars.
Another study done by Gutman (1978), reported a 29.4%
incidence of accessory canals in mandibular molars and
27.4% in maxillary molars
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41. TRAUMA FROM OCCLUSION
 Glickman et al (1961), reported that furcations are some of the more susceptible
areas of the periodontium to excessive occlusal forces, and suggested the
periodontal fiber orientation in furcation areas facilitated a more rapid spread of
inflammation and accounted for the increased susceptibility to occlusal forces
 Lindhe & Svanberg 1974, stated that trauma from occlusion coupled with gingival
inflammation has been implicated in greater alveolar bone loss in experimental
animals. The heavy occlusal load on molar teeth may render them susceptible to
increased bone loss in the furcation areas if inflammation is present
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42.  Wang et al. (1994), reported that teeth with mobility and furcation
involvement were more likely to lose attachment and to be extracted.
 Waerhaug (1980), however, has suggested that increased mobility
is a late symptom, rather than the cause of furcation defects.
Al-Shammari KF, Kazor CE, Wang H-L: Molar root anatomy and management of furcation
defects. J Clin Periodontol 2001; 28: 730–740.
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43. VERTICAL ROOT FRACTURES
 Lommel et al. (1978), reported that vertical root fractures are associated
with rapid, localized alveolar bone loss.
 Furcation defects can result if the fracture extends into the furcation area.
A poor prognosis is often given in these situations.
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44. IATROGENIC FACTORS
 Overhanging restorations present iatrogenic predisposing factors that may lead to
furcation involvement
 Wang et al.(1993), in a study of 134 maintenance patients reported that molars
with a crown or a proximal restoration had a significantly higher percentage of fur
cation involvement than non-restored teeth.
 While only 39.1% of molars without restorations had furcation involvement, 52.8%
of molars with class II restorations and 63.3% of molars with crowns were found
to have furcation involvement.
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45. CLINICAL FEATURES
 Sensitivity to thermal changes caused by caries or lacunar resorption of root in
furcation
 Recurrent or constant throbbing pain caused by pulp changes
 Sensitivity to percussion caused by acute inflammatory involvement of the PDL
 Acute periodontal or periapical abscess formation
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46. PREVALENCE
AUTHORS MAXILLARY MANDIBULAR DIAGNOSTIC
METHODS
Hirschfeld &
Wassermann.
1978
Max:
858/2217
38.7%
Man: 597/2054
29.0%
Clinical
McFall (1982) Max: 95/378
25.1%
Man: 60/377
15.9%
Clinical
Goldman et
al 1986
454/870
52.2%
169/865
19.5%
Radiographic
Wood 1989 87/205
42.4%
77/220
35.0%
Radiographic
/ clinical
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47. DIAGNOSTIC INSTRUMENTS
Naber’s curved 1 & 2 probes with
Gradation 3,6,9,12 mm.
No 23 explorer
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48. MAXILLARY MOLARS
The mesial furcation should be probed from the palatal
aspect of the tooth
The distal furcation can be probed from either the
buccal or the palatal aspect of the tooth.
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49. Distance of furcation from CEJ
 Buccal Furcation 3.5 mm apical to CEJ
 Distal Furcation 5 mm apical to CEJ
 Mesial Furcation 3 mm apical to CEJ
Carnevale G, Pontoriero R, Lindhe J. Treatment of furcation-
involved teeth. In: Lindhe J, ed. Clinical periodontology
and implant dentistry. Copenhagen: Munksgaard, 2008; 823-43
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50. MANDIBULAR MOLARS
 Buccal Furcation ≥ 3mm from CEJ
 Lingual Furcation≥ 4mm from CEJ
 Buccal Furcation entrance ≤ 0.7 mm
 Lingual Furcation entrance ≥ 0.75 mm
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51. BONE SOUNDING
 Bone sounding or transgingival probing with local anesthesia may aid in the
diagnosis of furcation defects by more accurately determining the underlying
bony contours.
 Greenberg et al. (1976), reported that bone sounding yielded accurate
measurements when compared to surgical entry measurements
Kalkwarf & Reinhardt,1988 stated that diagnosing furcation invasion is
therefore best accomplished using a combination of radiographs, periodontal
probing with a curved explorer or Nabers probe, and bone sounding
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52. PERIO-ENDOSCOPIC VISUALIZATION OF FURCATION
Introduced subgingivally to visualize furcation.
Consists of re-usable fiber optic endoscope
which fits onto the periodontal probes &
ultrasonic instruments that have been designed
to accept it
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53. RADIOGRAPHS IN FURCATION DIAGNOSIS
 Should include paralleling, periapical & bitewing techniques.
 Sometimes superimposition of palatal root or thick bone may obscure the
furcation.
 Slightest radiographic change in furcation area
should be investigated clinically, especially if there is bone loss on adjacent
roots.
 Whenever there is marked bone loss in relation to a single molar root, it may
be assumed that the furcation is also involved.
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54.  Ross & Thompson (1980), reported that radiographs were able to detect
furcation invasion in 22% of maxillary and 8% of mandibular molars. This
discrepancy was attributed to the difference in bone densities of the maxillary
and mandibular arches
 Hardekopf et al. (1987), reported a significant association between a
radiographic ‘‘furcation arrow’’ and degree 2 and 3 maxillary interproximal
furcation invasion.
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55. OTHER DIAGNOSTIC AIDS
 CONE BEAM COMPUTED TOMOGRAPHY (CBCT)
TRANSVERSE CT CROSS SECTIONAL CT
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56. Misch et
al 2006
• When compared to periodontal probing and 2D intraoral radiography, 3D CBCT
scanning was found to be more effective in assessing periodontal structures
Qiao J,
Wang et
al 2014
• In a study comparing intrasurgical assessment of maxillary furcations to those
assessed by CBCT observed there was agreement between both assessments
• the mean length of the root trunk and the width of the furcation entrance revealed by
CBCT were consistent with their respective intrasurgical values, though CBCT
underestimated vertical and horizontal bone loss in the maxillary furcae
Milena M.
Cimbaljvic
et al 2015
• revealed that the number of FI detected by means of CBCT was larger than by means
of periodontal probing
• In cases where surgical treatment is necessary, CBCT may be suggested as an
adjunct tool for FI assessment
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57. PROGNOSIS
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58. 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
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59. FURCATION DEFECTS
MOST PREDICTABLE MANDIBULAR OR MAXILLARY
BUCCAL CLASS II FURCATION
MESIAL OR DISTAL MAXILLARY
CLASS II FURCATION
LEAST PREDICTABLE CLASS III/IV FURCATIONS
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60. TREATMENT60
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61. AIM OF TREATMENT
Treatment of a defect in furcation region of multi-rooted teeth is
intended to meet the objectives.
The elimination of microbial plaque from the exposed surface of root
complex
Prevent further attachment loss
The establishment of anatomy of affected surface that facilitates
proper self performed plaque control.
Eliminating trauma & correcting Pulpal pathology
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62. Factors to consider in Treatment of Furcation
involved Molars
 TOOTH- RELATED FACTORS
Degree of furcation involvement
Amount of remaining periodontal support
Probing depth
Tooth mobility
Endodontic conditions & root/ root canal anatomy
Available sound tooth substance
Tooth position & occlusal antagonism
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63.  PATIENT- RELATED FACTORS
Strategic value of the tooth in relation to the overall plan
Patient’s functional and esthetic demand
Patient’s age and health conditions
Oral hygiene capacity
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64. 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
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65. FURCATION INVOLVEMENT DEGREE I
 Non-surgical Treatment
 (Oral Hygiene measurements and Scaling and Root planning)
 Obliteration of furcation by restorative materials
 Furcation Plasty
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66. NON- SURGICAL APPROACH
 1st approach to all types of furcation involvements
 Non surgical Scaling & root planing often suffices in resolution of the
inflammatory condition
 Class I lesions
 Shallow cul de sac defects
 Healing re- establishes normal gingiva anatomy with properly
adapted soft tissues and morphology optimal for good patient control
 May be the treatment of choice if surgery is contraindicated for
medical or psychological reasons
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67.  Fleischer et al (I989)
Level of experience play an important role in furcation debridement,
especially with closed debridement.
 Maria et al (1986), Parashis et al (1993) & Fleischer et al.
More effective calculus removal achieved with open than closed scaling and
root planing.
 Kalkwarf et al. (1988), Schroer et al. (1991) and Wang et al. (1994)
Using clinical parameters, no advantage of open debridement over closed
was observed
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68. Quetin furcation curette
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
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69.  The type of instruments used also plays a significant role in more thorough
furcation debridement
(Fleischer et al 1989)
 In 58% of upper and lower first molars, the furcation entrance diameter is
narrower (<0.75 mm) than the width of conventional periodontal curette. So,
use of curettes alone would result in inadequate debridement of many
furcation areas
Bowers (1979)
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70.  Ultrasonic tips and curettes have been found to be equally effective in wide
furcations, but ultrasonic tips were more effective in narrow ones
(Matia et al 1986)
 Leon and Vogel (1987) reported that the use of ultrasonic scalers was more
effective than hand scaling in close debridement of advanced furcations.
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71.  The large dimensions of conventional ultrasonic-tips inhibit entry into the furcation
in some cases
 So many new designs of furcation tips were designed and developed and were
shown to be superior to conventional sonic/ultrasonic inserts with greater
accessibility and ease of instrumentation in furcation areas
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72. Oda and Ishikawa (1989)
 Designed a new ultrasonic
scaler tip made of acid resistant
stainless steel
 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
 Tip was in the shape of a spiral
with a radius of curvature of
about 9 mm and were available
in clockwise and anticlockwise
direction.
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73.  Scaling and root planing produce good clinical results during initial stages
(Grade I) of furcation involvement.
 However, long term clinical studies have shown unfavourable results of
conservative non-surgical and surgical therapy in deep furcation involvement.
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74. CHEMOTHERAPY
 The difficulties of performing adequate debridement in furcations by mechanical
means have prompted experimentation with chemotherapeutic agents in these
areas.
 Needleman & Watts (1997) - 1% metronidazole gel irrigation into furcation
areas with grade II and III involvements during periodontal maintenance +
subgingival scaling.
 Result- Clinically, no further improvement was seen for the furcations treated
with metronidazole.
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75.  Nylund & Egelberg (1993): Subgingival irrigation with tetracycline for 3
months + mechanical debridement in furcations with grade I, II and III
involvements.
Result - One-year evaluation of attachment levels and pocket depths showed
clinically negligible (1 mm) variation in both tetracycline and saline-irrigated
furcations.
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76.  Tonetti et al (1992) : Tetracycline fibers exert a significant adjunctive pocket
depth and bleeding / reduction over that produced by scaling & root planing
alone, although this finding is confined only to the first 3 months following
fiber insertion.
Result-No difference between treatments could be observed, however, at
the 6-month follow-up visit.
 Overall, the results from the studies above do not lend clear acceptance to
the implementation of adjunctive local drug therapy in furcation
involvements, regardless of the degree of severity.
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77.  However a study done by AR Pradeep et al(2012) on clinical efficacy of
subgingivally delivered 1.2-mg simvastatin in the treatment of individuals
with class II furcation defects used as an adjunct to scaling and root planing
Vs SRP + placebo showed that the simvastatin administered group had a
significantly greater gain in mean RVAL and RHAL (P <0.05). Furthermore,
significantly greater mean percentage of bone fill was found (25.16%)
compared with placebo group (1.54%).
77
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78. Restorative materials in the treatment of
furcation involvement
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79. RESTORATIVE MATERIAL EVIDENCE OF USE
ZOE Kingsberg et al (1981) advocated the
use of polymeric reinforced zinc oxide-
Eugenol (IRM) & reported clinical
success for up to 5 years.
Kalkwart and Reinhardt (1988)
reported in their clinics progressive
bone loss around ZOE material and
increased plaque retention
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80. RESTORATIVE MATERIAL MATERIAL OF USE
SILVER AMALGAM
Van Swol et al. (1993) utilized amalgam
restoration to fill grade-II furcation
invasions. But on 1 year radiographic
follow-up noted, radiolucency at the base
of the restoration.
RESIN IONOMER & GLASS
IONOMER
Dragoo (1997) demonstrated histologic
evidence that both epithelium and
connective tissue can adhere to the resin
ionomer when placed in a subgingival
environment.
Reddy KP (2005) concluded, a glass
ionomer restorative material may be
effective as an occlusal barrier when
treating maxillary molar grade III furcation
defects.
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81. ODONTOPLASTY
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81
 Reshaping of tooth coronal to furcation to improve access for
plaque control
 Widens entrance of the furca & reduces horizontal depth of the
furcation involvement
 Removes plaque retentive areas like grooves, CEPs, cervical
enamel pearls smooth areas
 Advised for Grade I & II lesions
 Potential Complications-
Hypersenstivity
Pulpal irritation  permanent change
Pulp exposure
Increased risk of root caries

82. FURCATION PLASTY
 It is a resective surgical treatment associated with odontoplasty and osteoplasty.
 It is used mainly at the buccal and lingual furcations
 Procedure:
 Reflection of a full thickness flap
 Removal of inflammatory soft tissue
 Odontoplasty to eliminate or reduce the horizontal component of the defect and
to widen the furcation entrance
 Recontouring of the alveolar bone crest to reduce the buccal-lingual dimension of
bone in the furcation area
 Positioning and suturing of the flap
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83. The purpose of performing furcation
plasty is the establishment of a soft
tissue papilla which covers the entrance
to the inter-radicular periodontal tissues
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84. FURCATION INVOLVEMENT DEGREE II
 Furcation plasty
 Tunnel preparation
 Root resection
 Tooth extraction
 Guided tissue regeneration
 Emdogain/PRF
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85. TUNNEL PREPARATION
 Intentional creation of a Class IV furcation with entrance
accessible for oral hygiene procedure
 Done in advanced lesions i.e. Deep Grade II and Grade III
lesions
 It can be utilized only when the furcation entrance dimension
is wide enough and coronally located to allow for an easy
utilization of cleaning devices.
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86.  Usually done in mandibular molars for clear two way access.
 Implemented sometimes in maxillary molars.
However, one of the three roots may have to be resected to improve
accessibility to the furcation area.
(Hellden et al. 1989)
 Patients with low caries index & good plaque control
(Highfield et al. 1978)
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87.  During surgery, bone is
reshaped to obtain a scalloped
morphology and the soft tissues
are apically positioned
 Care must be taken that the
space obtained under the roof
of the furcation should allow
proper plaque removal
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88. 88
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89.  Advantages
 Avoidance of prosthetic reconstruction and endodontic therapy
 Disadvantages
 Furcations treated with resective osseous surgery for tunnel preparation are
expected to result in a slight loss in attachment as a consequence of the therapy
 High rate of caries development
 Hellden et al 1989
 evaluated 148 teeth with tunnel preparation for 37.5 months
 24% developed caries
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90.  Tunneling often fails because of decay in the furcation area
(Lindhe, 1983).
 Hellden and colleagues (1989) concluded that teeth with
tunnel preparations have a considerably better prognosis than
that previously reported.
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91. DISADVANTAGES
 Potential development of root caries.
 Sensitivity
 Exposure to patent lateral canals that will require endodontic
therapy in the future.
 Requirement that a patient should have good manual dexterity to
maintain optimal oral hygiene.
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92. STUDIES ON TUNNELLING PROCEDURE
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93. FURCATION INVOLVEMENT DEGREE III
 Tunnel preparation
 Root resection
 Tooth Extraction
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94. RESECTIVE PROCEDURES
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95. ROOT SEPARATION AND RESECTION(RSR)
 Root separation involves the sectioning of the root complex and the
maintenance of all roots
 Root resection involves the sectioning and the removal of one or two roots of a
multi-rooted tooth
 RSR is frequently used in cases of deep degree II and degree III furcation
involved molars
 Can be done on vital or endodontically treated teeth.
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96. FACTORS TO BE CONSIDERED
 The length of the root trunk
 The divergence between the root cones
 The length and the shape of the root cones
 Fusion between root cones
 Amount of remaining support around individual roots
 Stability of individual roots
 Access for oral hygiene devices
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97. INDICATIONS OF RSR
 Teeth that are critically important to the overall dental treatment plan
 Teeth that have sufficient attachment remaining for function.
 Teeth for which a more predictable or cost-effective method of therapy is not
available. Examples are teeth with furcation defects that have been treated
successfully with endodontics but now present with a vertical root fracture,
advanced bone loss, or caries on the root.
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98. INDICATIONS OF RSR
 Teeth in patients with good oral hygiene and low activity for caries
 Root-resected teeth require endodontic treatment and usually cast
restorations
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99. SEQUENCE OF TREATMENT OF RSR
 Endodontic treatment
 Provisional restoration
 RSR
 Periodontal surgery
 Final Prosthesis
MASSIMO DESANCTIS & KEVIN G.MURPHY The role of resective
periodontalsurgery in the treatment of furcation defects
Periodontology 2000, Vol. 22, 2000, 154–168
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100. WHICH ROOT TO REMOVE?
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101. GENERAL GUIDELINES
 Remove the root(s) that will eliminate the furcation and allow the
production of a maintainable architecture on the remaining roots
 Remove the root with the greatest amount of bone and attachment
loss. Sufficient periodontal attachment must remain after surgery for
the tooth to withstand the functional demands
 Remove the root with the greatest number of anatomic problems
such as severe curvature, developmental grooves, root flutings, or
accessory and multiple root canals.
 Remove the root that complicates future periodontal maintenance.
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102. ROOT RESECTION TECHNIQUE
 Under LA, elevate full thickness mucoperiosteal
flap and debride the defect
 Removal of small amount of bone may be
required to facilitate root removal
 With contra angles hand piece & cross- cut or a
straight fissure bur, a cut directed just apical to
contact point through the furcation to sever the
root where it joins the crown
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103.  Elevate & remove the root
 With stone or diamond point smooth the resected root stump & contour the
tooth to create easily cleansable area
 Clean the area & apically posotion the flap ,suture & cover with periodontal
pack
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104.  Carnevale et al. (1991) reported on the outcomes of 185 teeth treated
with hemisection or root amputation with a 7–11-year follow-up. Out of
these 185 teeth, three teeth were lost, yielding a survival rate of 98.4%.
One tooth was lost due to each of the following reasons: caries, root
fracture and probing pocket depth >5 mm.
 Hou et al. (1999) reported a survival rate of 100% of 52 root-separated
molars in a case series comprising 25 patients followed up for a mean
observation period of 6.7 years (range 5–13 years).
104
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105.  Svardstrom & Wennstrom (2000) reported a retention rate of 89.4% of
47 molars 8–12 years following root resective procedures. Five teeth
(10.6%) had to be extracted during the follow-up period and root fracture
was the main reason for extraction (80.0%)
 Dannewitz et al. (2006) performed 19 root resections while treating 305
furcation-involved molars. Eight resected teeth were lost during the
maintenance phase, yielding a survival rate of 57.9%.
Huynh-Ba G, Kuonen P, Hofer D, Schmid J, Lang NP, Salvi GE. The effect
of periodontal therapy on the survival rate and incidence of
complications of multirooted teeth withfurcation involvement after an
observation period of at least 5 years: a systematic review.J Clin
Periodontol 2009; 36: 164–176
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106.  Following factors must be considered before selection of case for root
separation & resection :
The length of the root trunk
The divergence between the root cones
The length & shape of root cones
Fusion of root cones
Amount of remaining bone support around individual roots
Stability of individual roots
Access for oral hygiene device
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107. INDICATIONS FOR ROOT RESECTION
Periodontal Indications
• Severe bone loss
affecting one or more
roots untreatable with
regenerative procedures
• Class II or Class III
furcation invasions
• 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
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108. Contraindications for Root Resection
Restorative factors
• Internal root decay
• Presence of a cemented post in
the remaining root
Strategic considerations
• Consider adjacent teeth for
conventional prosthetic
restoration
• Consider removable
prosthesis
• Consider implants
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109. HEMISECTION- REMOVAL OF ROOT WITH
CORRESPONDING CROWN PORTION OF MANDIBULAR
MOLAR.
 Mostly done in mandibular molars with buccal & lingual Class II or
Class III furcation involvement
 Technique similar to root resection except that half of the crown is
removed along with one of the roots of mandibular molar
 Vertically oriented cut is made bucco-lingually through the buccal &
lingual developmental grooves through the pulp chamber and
furcation
 Retained mesial or distal half serve as a useful abutment
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110. Direction of
Tooth Section
Remaining single
rooted Tooth
Portion
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111. BICUSPIDIZATION
 Is the splitting of a mandibular molar & retaining both the fragments
so as to change the molar into two separate units.
 INDICATIONS
 1. Mandibular molars with Buccal & Lingual Class II or III
Furcation involvements.
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112. ROOT CONDITIONINIG AND CORONALLY ADVANCED FLAP
 Root conditioning combined with coronally advanced flap procedure.
Root conditioning is intended to decontaminate, detoxify and
demineralize the root surface, removing the smear layer and exposing
collagen matrix.
Agents commonly used
- Citric acid
- Tetracycline HC1
- Fibronectin
Others - EDTA, Detergents, Phosphoric acid, Bile salts.
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113. Acid etching of the debrided planed root surface removes the smear layer on the
denuded root surface and exposes Type I collagen chemotactic to fibroblasts.
Polson and Proye 1983 suggested that a fibrin linkage to the exposed collagen
fibrils is a precursor to the connective tissue attachment. This fibrin network may
serve to prevent apical migration of epithelium allowing migration of periodontal
precursor cells to the root.
Crigger et al (1978), Nilveus et al (1980), Bogle et al (1981)- in their respective
animal studies have demonstrated increased amounts of new connective tissue
attachment in furcation defects following acid conditioning compared with non-acid
treated control.
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114. BONE GRAFTS
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115. 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.
i) Contain bone forming cells (osteogenesis)
ii) Serve as a scaffold for bone formation (osteoconduction)
iii) 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.
115
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116. AUTHORS CONTRIBUTIONS
Schallhorn O.(1967) observed probing depth reduction and
bone fill of degree II furcation objects
following transplantation of illiac grafts.
Gantes et al (1988) dFDBA
Kenny et al (1988) Porous hydroxyapatite
Pepelassi et al (1991) Composite graft of tricalcium posphate,
plaster of paris and doxycycline
Yukna et al (1994) HTR
Akbay (2005) reported that autogenous PDL grafts has
potential in promoting healing of furcation
lesions.
Tsao YP (2006) reported that solvent-preserved,
mineralized human cancellous allograft,
with or without collagen membrane, can
significantly improve bone fill in
This study suggested
that the use of PDL
grafts may have
beneficial effects in the
treatment of furcation
defects.
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117. Bone replacement grafts alone have had limited success in managing Class II
and III furcation defects. Problems associated with bone replacement grafts
have included graft containment, epithelial exclusion, microbial
contamination and variable inductivity of the graft
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118. GUIDED TISSUE REGENERATION
118
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119. 119
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120. Guided Tissue Regeneration is defined as procedure attempting to
regenerate lost periodontal structures through differential tissue
responses.
Barriers - excluding epithelium and gingival corium from the root surface in
the belief that they interfere with regeneration.
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.
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121. Clinical indications - first mandibular molar with a Class II furcation lesion.
Other furcation lesions in other areas of the mouth have also been approached
with this therapeutic principle, although rendering different outcomes.
The first generation of GTR studies were carried out using non-resorbable
expanded polytetra fluoroethylene membranes.
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122. Pontoriero et al (1988) demonstrated significant clinical
attachment when this regenerative therapy
was used.
Paul et al (1992) and Laurell et
al (1994)
used resorbable barrier membranes namely
bovine derived collagen membranes and
polylactic acid based membranes respectively,
in the treatment of Class II furcation defects
Pontoriero et al (1989) observed that the use of ePTFE was less
effective in the treatment of mandibular Class
III furcations
Sanz and Giovannoli (2000) placement of a barrier membrane should not
be indicated in the treatment of maxillary
molars with furcation involvement
Eickholz P et al (2006) reported horizontal clinical attachment level
(CAL-H) gain achieved after GTR therapy in
Class II furcations was stable after 10
years(83%). It failed to show a significant
difference in stability of CAL-H gain between
non-resorbable ePTFE barrier and the other a
bioabsorbable (polyglactin 910
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123. Lindhe (2003), in a review of 21 clinical trials (423
mandibular grade II furcations), observed that
 1.There was no significant difference between bioabsorbable and nonabsorbable
membranes.
 2. GTR significantly improved the horizontal clinical attachment level (CAL-H) over open flap
surgery: 2.5 versus 1.3 mm.
 3. Complete closure was variable (0–67%).
 4. GTR significantly improved vertical attachment and a reduction in pocket depth.
 5. CAL-H in maxillary furcation was only 1.6 mm, and the results were variable.
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124. AAP paper on periodontal regeneration in furcations (Wang et al
2005) found the following:
 1.GTR provided additional benefits over OFD in clinical attachment level, reduced
probing in furcations.
 2. Bone replacement grafts enhance GTR treatment outcomes in furcations.
 3. Clinically, GTR procedures for furcations should be limited to mandibular and maxillary
buccal grade II furcation defects.
 4. Only limited results are obtainable for mandibular (grade III) and maxillary medial and
distal grade I or III furcation defects.
 5. Bone grafts have been found to enhance GTR outcomes in furcations but not in
intrabony defects.
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125. ENAMEL MATRIX
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126.  Emdogain found its beginnings more than a decade ago when a
breakthrough in the basic biology of tooth development revealed a native
complex of enamel matrix proteins and the key role they play in the
development of tooth supporting tissues. These “matrix proteins” mediate
the formation of acellular cementum on the root of the developing
tooth, providing a foundation for all of the necessary tissues
associated with a true functional attachment.
E. Venezia M. Goldstein B.D. BoyanZ. Schwartz. THE USE OF
ENAMELMATRIX DERIVATIVE IN THE TREATMENT OF PERIODONTAL
DEFECTS:A LITERATURE REVIEW AND META-ANALYSIS. Crit Rev Oral Biol
Med 15(6):371-391 (2004)
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127. (Lyngstadaas et al.,
2001).
• Attachment rate, growth
factor production (TGF-
b1, IL-6, and PDGF-AB),
proliferation, and
• metabolism of human
PDL cells in culture
were all significantly
increased in the
presence of EMD
(Gestrelius et al., 1997b;
Kawase et al., 2000).
EMD favors
mesenchymal cell
growth over growth of
epithelial cells.
Furthermore, it had
been shown earlier that
EMD also seems to
exhibit a cytostatic
effect upon cultured
epithelial cells
(Spahr et al., 2002).
EMD has a marked
inhibitory effect on the
growth of the Gram
negative periodontal
pathogens, without a
similar effect on the
Gram-positive bacteria
In addition, it was
demonstrated to have
some antimicrobial
effect in vivo (Arweiler
et al., 2002)
This may explain EMD's biological
'guided tissue regeneration' effect
observed in vivo, analogous to the
mechanical prevention of barrier
membranes
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128. Sculean et al., 2001
EMD may also promote
periodontal regeneration by
reducing dental plaque. In an
ex vivo dental plaque model,
it was found that EMD had an
inhibitory effect on dental
plaque viability
Soren Jepsen et al (2004)
• compared the efficacy of EMD Vs GTR in grade II
mandibular furcation defects.
• Clinical parameters like gingival marginal level,
bleeding on probing, Horizontal and vertical
attachment levels, were assessed at baseline, 8
and 14 months
• Though both treatments led to clinically
significant improvement the defects treated with
EMD had a better horizontal defect closure, less
pain and discomfort post surgery when compared
to the patients receiving GTR.
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129. EXTRACTION
 Extraction is the treatment of choice, when: (Lindhe 1997)
 1) The patient’s oral hygiene will not maintain the tooth.
 2) The patient does not choose to comply with restorative
recommendations without which the tooth cannot survive.
 3) Adjacent teeth would serve as adequate abutments.
 4) Financial considerations preclude acceptance of treatment.
 5) Extraction will improve the prognosis of the adjacent teeth by
improving bone levels resulting from socket fill.
129
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130. FAILURE IN FURCATION THERAPY
 Inadequate plaque control and maintenance
 Poor resection technique
 Improper restoration after initial periodontal therapy
 Root caries, and
 Patients who respond poorly despite the best treatment efforts all
contribute to failures subsequent to furcation therapy.
Endodontic failure and root fracture are the most frequent causes of failure.
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131. CURRENT CONCEPTS
131
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132.  Swaid FF, Riberio FV et.al 2011.
Investigated the use of Periodontal ligament cells in tissue engineering with
GTR in Class II furcations in dogs. This histological study revealed promising
results.
 Anuj Sharma (2011) assessed the efficacy of PRF & OFD Vs OFD alone in
grade II Mandibular defects. Using a split-mouth design, 18 patients with 36
mandibular degree II furcation defects were randomly allotted and treated either
with autologous PRF and OFD or OFD alone. Plaque index, sulcus bleeding
index, probing depth, relative vertical and horizontal clinical attachment level,
gingival marginal level, and radiographic bone defect were recorded at baseline
and 9 months postoperatively
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133. All clinical and radiographic parameters showed
statistically significant improvement at the sites treated with PRF and OFD
compared to those with OFD alone.
 John Casper (2012) investigated the use of Porous titanium granules (PTG)
in the treatment of class II buccal furcation defects in mandibular molars in
humans.
Study showed that PTG is safe to use in close proximity to root surfaces, but
no significant improvements in clinical endpoints of defect resolution were
observed.
133
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134.  Masao Ozasa et al (2014) employed the furcation periodontitis model in
beagle dogs to evaluate the effects of ADMPC (Adipose tissue derived
Multilineage Progenitor cells). The furcation bone defects were surgically
created and the autologous transplantation of ADMPC and fibrin gel was
performed. Six weeks after transplantation periodontal regeneration was
assessed using microCT which showed a significant increase in bone
formation at sites where ADMPCS where applied when compared to
control sites.
134
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135.  Sambhav Jain et al(2014) in a case report assessed the efficacy of PRF
and β Tricalcium phosphate in mandibular molar with recession and grade II
Furcation defect. They observed complete root coverage with gain in CAL I
Month postop. However extent of bone fill could not be assessed as the
patient did not report for follow up.
 Anuj sharma (2016) in an RCT on Rosuvastatin 1.2 mg in situ gel
combined with 1:1 mixture of autologous platelet-rich fibrin and porous
hydroxyapatite bone graft in mandibular class II furcation defects observed
significant improvements of clinical and radiographic parameters in this
group compared with OFD alone.
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136. CONCLUSION
The skill and dexterity of the clinician is definitely put to test while treating
teeth with furcation involvement. Longevity of the tooth involved , depends
on the degree of furcation involvement, the anatomy of the tooth, its
position in the arch as well as on regular supportive care in addition to
diligent oral hygiene maintenance by the patient
136
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137. REFERENCES:
 Newman M, Takei H,Klokkevold P, Carranza F. “Clinical Periodontology”
10th ,12th Edition. Saunders, Elsevier.
 Rose L.F, Mealey B.L, Genco R.J, Cohen D.W- Periodontics, surgery,
implants – 1st edition Elsevier mosby- 2004
 Lindhe, Lang, Karring, ‘Clinical Periodontology and Implant Dentistry’ 6th
Edition’, Blackwell Munksgaard, 2015
 Müller & Eger Furcation diagnosis J Clin Periodontol 1999; 26: 485–498.
 The role of resective periodontal surgery in the treatment of furcation
137
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138.  Huynh-Ba et al.The effect of periodontal therapy on the survival rate and
incidence of complications of multirooted teeth with furcation involvement
after an observation period of at least 5 years: a systematic review. J Clin
Periodontol 2009; 36: 164–176.
 Marker. J Clinical Reliability of the ‘‘Furcation Arrow’’ as a Diagnostic
Periodontol 2006;77:1436-1441.
 Walter C, Weiger R, Zitzmann NU. Accuracy of three-dimensional imaging
in assessing maxillary molar furcation involvement. J Clin Periodontol
138
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