detailed discussion about furcation.

1. FURCATION
INVOLVEMENT & ITS
MANAGEMENT
Dr. Himanshu Shekhar
18.12.15

2. Contents
Introduction
Etiologic Factors
Diagnosis & Classification of
Furcation Defects
Local anatomic factors
 Root trunk length
 Root length
 Interradicular dimension
 Anatomy of Furcation
 Cervical Enamel Projections
Anatomy of the bony lesions
Pattern of attachment loss
Other Dental Findings
Treatment
 Therapeutic Classes of
Furcation Defects
Non-surgical Therapy
 Oral Hygiene Procedures
 Scaling & Root Planing
Surgical Therapy
 Osseous Resection
 Regenerative
 Root Resection
 Hemi-section
 Root resection/Hemi-section
Procedure
 Extraction
 Dental Implants
Prognosis

3. Introduction
The furcation is an area of complex anatomic
morphology [Bower RC 1979] that may be difficult or
impossible to debride by routine periodontal
instrumentation. [Metzler DG 1991]

4. Introduction …
The presence of furcation involvement is a sign of
advanced periodontitis
poor prognosis.

5. Definition

6. Parts of furcation:
Root complex
Root trunk
Root cone
Furcation entrance
Furcation fornix
Degree of seperation
Divergence
Coefficient of separation

10. Mandibular Molars
100% mesial roots
99% distal roots
Maxillary Molars
94% mesiobuccal roots
31% distobuccal roots
17% palatal roots

11. Is larger than the second molar.
The distal surface of the mesio-buccal root has a
concavity which is about 0.3 mm deep (Bower
1979).
This concavity gives the cross section of the
mesio-buccal root an “hourglass” configuration .

12. The mesial furcation entrance is located
about 3 mm from the CEJ, while the buccal
is 3.5 mm and the distal entrance about 5
mm apical to the CEJ (Abrams &
Trachtenberg 1974; Rosenberg 1988).

14. The mandibular first molar is larger than the second
molar, which in turn is larger than the third molar.
The cross section of the distal root is circular while
the mesial root has an “hour-glass” shape.
In addition, furrows and concavities often occur on
the distal surface of the mesial root .
The distal concavity of the mesial root is more
pronounced than that of the distal root (Bower
1979a,b; Svärdström & Wennström 1988).

15. The lingual entrance is frequently found more apical to
the CEJ (>4 mm) than the buccal entrance (>3 mm).
Thus, the furcation fornix is inclined in the bucco-lingual
direction. The buccal furcation entrance is often <0.75
mm wide while the lingual entrance is >0.75 mm in most
cases (Bower 1979).
The degree of separation and divergence between the
roots decreases from the first to the third molar.

17. In about 40% of cases the maxillary first premolars
have two root cones, one buccal and one palatal,
and hence have a mesiodistal furcation.
A concavity (about 0.5 mm deep) is often present
in the furcation aspect of the buccal root. In many
cases the furcation is located in the middle or in the
apical third of the root complex .
The mean distance between CEJ and the furcation
entrance is about 8 mm.
The width of the furcation entrance is about 0.7
mm.

18. Furcations may be present also in teeth which
normally have only one root. In fact, two-rooted
incisors , canines , and mandibular.
premolars may exist.
Occasionally three-rooted maxillary premolars and
three-rooted mandibular molars can be found .

19. Bacterial plaque
 Inflammatory consequences
 Extent of attachment loss required to produce a
furcation defect.
Local anatomic factors
 Root trunk length
 Root morphology
Local developmental anomalies
 Cervical enamel projections
 Enamel pearls
Iatrogenic
TFO
Combined Origin

20. Local factors may affect the rate of plaque deposition or
complicate the performance of oral hygiene procedures,
thereby contributing to the development of periodontitis
and attachment loss.
Studies indicate that prevalence and severity of furcation
involvement increase with age. [Hou GL JP 1978]
Dental caries and pulpal death may also affect a tooth with
furcation involvement or even the area of the furcation.
All of these factors should be considered during the
diagnosis, treatment planning, and therapy of the patient
with furcation defects.

21. prevalence of furcation
involvement
In periodontal patients > 40 years old, all second
molars have furcation involvement.
Maxillary molars (distal) > mandibular molars >
Maxillary Premolars (Larrato et al 1970)
Highest frequency of involvement, distal furcation of
maxillary first molar
Svardstrom & Wennström 1996
Greater severity of furcation involvement in smokers
Kerdvongbundit & Wikesjo 2000
Incidence of
35% in Mandibular Molars
90% in Maxillary Molars
(Ross & Thompson 1980)

22. Clinical examination of the patient should allow the
therapist to identify not only furcation defects but also
many of the local anatomic factors that may
affect the result of therapy (prognosis).
Well-made dental radiographs, although not allowing
a definitive classification of furcation involvement,
provide additional information vital for treatment
planning.

23. A key factor in both the development and the treatment of furcation
involvement.
The distance from the cementoenamel junction to the entrance of
the furcation can vary extensively.
Teeth may have very short root trunks, moderate root trunk length, or
roots that may be fused to a point.

24. Root length is directly related to the quantity
of attachment supporting the tooth.
Teeth with long root trunks and short roots
may have lost a majority of their support by
the time that the furcation becomes affected.
[Hermann DW 1983]
Teeth with long roots and short-to-moderate
root trunk length are more readily treated
because sufficient attachment remains to
meet functional demands.

25. The mesial root of most mandibular first and second
molars and the mesio-buccal root of the maxillary
first molar are typically curved to the distal side in
the apical third.
The curvature and fluting may increase the potential for
root perforation during endodontic therapy or
complicate post placement during restoration.
[Langer B 1981][Langer B 1981]
These anatomic features may also result in an
increased incidence of vertical root fracture.

26. The degree of separation of the roots is also an
important factor in treatment planning.
Closely approximated or fused roots can preclude
adequate instrumentation during scaling, root
planing, and surgery.
Teeth with widely separated roots present more
treatment options and are more readily treated.

27. The presence of bifurcational ridges, a concavity in
the dome, [Everett F 1958][Everett F 1958] and possible accessory
canals [Gutmann JL 1978][Gutmann JL 1978] complicates not only
scaling, root planing, and surgical therapy [Matia JB[Matia JB
1986]1986] but also periodontal maintenance.
Odontoplasty to reduce or eliminate these ridges may
be required during surgical therapy for an optimal
result.

28. Cervical enamel projections (CEPs) are
reported to occur on 8.6% to 28.6% of molars.
[Larato DC 1975, Masters DH 1964][Larato DC 1975, Masters DH 1964]
The prevalence is highest for mandibular and
maxillary second molars.
These projections can affect plaque removal,
can complicate scaling and root planing, and
may be a local factor in the development of
gingivitis and periodontitis.
CEPs should be removed to facilitate
maintenance.

29. CEPs are flat,
ectopic extensions
of enamel that
extend beyond
the
Normal contours
of the CEJ.
(Masters DH
1964)

30. • Predilection for maxillary third and second
molars.
• The prevalence is less than that of cervical
enamel projections.
• incidence of 2.6% (range 1.1–9.7%).
Moskow & Canut (1990)
Enamel pearls

31. Pattern of Attachment Loss
Other Dental Findings

32. Horizontal bone loss can expose the furcation as thin
facial/lingual plates of bone that may be totally lost
during resorption.
Alternatively, areas with thickened bony ledges may
persist and predispose to the development of
furcations with deep vertical components.

33. Complex multiwalled defects with deep,
interradicular vertical components may be candidates
for regenerative therapies.
Alternatively, molars with advanced attachment
loss on only one root may be treated by resective
procedures.

34. The dental and periodontal condition of the
adjacent teeth must be considered during
treatment planning for furcation involvement.

36. Glickman`s
Classification(1953)

37. This is an early lesion.
The pocket is suprabony,
involving the soft tissue.
There is slight bone loss in the
furcation area.
Radiographic change is not
usual since bone loss is
minimal.
A periodontal probe will detect
root outline or may sink into a
shallow V-shaped notch into
the crestal area.

38. The level of bone loss allows for the insertion of
the periodontal probe into the concavity of the root
trunk.

39. In this, bone is destroyed in one
or more aspects of the
furcation, but a portion of the
alveolar bone and periodontal
ligament remain intact,
permitting only partial penetration
of the probe into the furca.
Radiographs may or may not
reveal this type of furcation.

40. The level of bone loss
allows for the insertion
of a periodontal probe
into the furcation area
between the roots.

41. In class III probe penetrates
completely from one side to the
other side characterized by severe
bone destruction in the furcation
area.
It is clearly shown in the
radiographs as a radiolucent area in
between the roots, especially in the
lower molars.

42. As in Class III, but the
gingival tissues recede
apically so that furcation is
clearly visible.

43. GRADE II degree I VERTICAL COMPONENT
OF >1MM BUT <3MM
GRADE II degree II VERTICAL COMPONENT
OF > 3 MM BUT NOT THROUGH & THROUGH

44. Incorporated a descriptive classification of
furcation involvement as follows:
GRADE I: Incipient
GRADE II: Cul- de- sac
GRADE III: Through and through

46. F 0 - No furcation involvementNo furcation involvement
Hamp et al 1975 (horizontal
component)
F1- Probed 3mm in horizontal direction.F1- Probed 3mm in horizontal direction.

47. F2 -Probed deeper than 3mmProbed deeper than 3mm
F3 - Through and throughThrough and through

48. Ramjford and Ash in 1979( horizontalRamjford and Ash in 1979( horizontal
component)component)
Classified similarly but instead of 3 mm increments, they utilized
2 mm increments.
Class I: Beginning Involvement:
The tissue destruction should not extend more than 2 mm
[or not more than 1/3rd
of the tooth width] into the furcation.
Class II: Cul-de-sac Involvement:
Tissue destruction extends deeper than 2 mm [or more
than 1/3rd
of the tooth width] into the furcation opening.
Class III: Through and through.
Tissue destruction extends throughout the entire length of
furcation, so that an instrument can be passed between the
roots and emerges on the other side of the tooth

50. VERTICAL CLASSIFICATION 1984
Vertical component of furcation is measured
From floor of the furcation to the roof of the furcation

51. Hou et al. (1998): (horizontal &vertical
component)
In 1998 Hou et al. presented a new
classification of furcation involvement
based on -- root trunk , horizontal and
vertical bone loss.
The types of root trunk were classified
on the basis of the ratio of the vertical
dimension of the root trunk to root
length as type A, B and C where
Type A – Root trunk involving the
cervical third of root length.
Type B - Root trunks involving the
cervical 2/3rd
of the root length.
Type C - Root trunks involving more
than the cervical 2/3rd
root length.

52. A thorough clinical examination is the key to
diagnosis and treatment planning.
Careful probing is required to determine the presence
and extent of furcation involvement.

53. Transgingival sounding may further define the
anatomy of the furcation defect. [Mealy BL 1994]
The goal of this examination is to identify and classify
the extent of furcation involvement.

54. Factors contributed to the dev. of the furcation defect or that
could affect treatment outcome-
(1) the morphology of the affected tooth,
(2) the position of the tooth relative to adjacent teeth,
(3) the local anatomy of the alveolar bone,
(4) the configuration of any bony defects, and
(5) the presence and extent of other dental diseases
(e.g., caries, pulpal necrosis).

57. Naber’s curved 1 & 2 probes with Gradation 3,6,9,12
mm.
No 23 explorer

58. The probe’s tip is initially applied on the root trunk
just under the gingival margin in order to locate the
furcation entrance.

59.  Should include both peri-apical & bitewing.
 Sometimes superimposition of palatal root or thick
bone may obscure furcation.

60. Slightest radiographic change in furcation
area should be investigated clinically,
especially if there is bone loss on adjacent
roots.
Diminished radio density in furcation area in
which outlines of bony trabeculae are visible.
o Whenever there is marked bone loss in
relation to a single molar root, it may be
assumed that the furcation is also involved.

61. Introduced subgingivally to visualize furcation.
Consist of re-usable fiber optic endoscope which fits
onto the periodontal probes & ultrasonic instruments
that have been designed to accept it.

62. Thin fan of x- ray beam rotates around the patient to
get multiple axial slice of the area of interest .
These slices are merged to get the final image.

64. Pulpal pathosis may some times cause a lesion in the
periodontal tissues of the furcation.
Trauma from occlusion may cause inflammation and
tissue destruction within the interradicular area of a
multirooted tooth

67. Class I: Early Defects
Incipient or early furcation defects (Class I) are
amenable to conservative periodontal therapy.
[Goldman HM 1958]
Because the pocket is suprabony and has not
entered the furcation, oral hygiene, scaling, and root
planing are effective.
[Gutmann JL 1978]
Any thick overhanging margins of restorations, facial
grooves, or CEPs should be eliminated by
odontoplasty, recontouring, or replacement.

68. Class II
Once a horizontal component to the furcation has
developed (Class II), therapy becomes more
complicated.
Shallow horizontal involvement without significant vertical
bone loss usually responds favorably to localized flap
procedures with odontoplasty, osteoplasty, and
ostectomy.
Isolated deep Class II furcations may respond to flap
procedures with osteoplasty and odontoplasty.

69. This reduces the dome of the furcation and alters
gingival contours to facilitate the patient's plaque
removal.

70. Classes II to IV: Advanced DefectsClasses II to IV: Advanced Defects
Nonsurgical treatment is usually ineffective because
the ability to instrument the tooth surfaces adequately
is compromised. [Parashish AO 1993]
Periodontal surgery, endodontic therapy, and
restoration of the tooth may be required to retain the
tooth.

71. Furcation involvement degree I
Recommended therapy: Scaling and root planing,
Furcation plasty.
Furcation involvement degree II
Recommended therapy: Furcation plasty, Tunnel
preparation, Root resection, Tooth extraction & Guided
tissue regeneration.
Furcation involvement degree III
Recommended therapy: Tunnel preparation, Root
resection, Tooth extraction.
Lindhe et al 2008

72. Oral hygiene procedures
Scaling & Root Planing
Kooher T., Plagmann H.C. (1999) modified sonic &
ultrasonic scaler inserts to increase effectiveness of root
surface instrumentation of molars with furcation involvement

73. Odontoplasty should eliminate any facial grooves or cervical
enamel projections, enamel pearls.
Root caries is another possibility if excessive tooth structure is
removed
(Goldman 1958, Fleischer et al 1989).

75. Odontoplasty + Osteoplasty when done together,
termed furcationplasty.
This reduces the dome of furcation and alters gingival
contours to facilitate patients plaque removal.
Hamp, Nyman and Lindhe (1975)

79. Regenerative therapy induce new attachment and
reconstruction on molars with furcation defects.
Many surgical procedures using a variety of grafting
materials have been tested on teeth with different
classes of furcation involvement.
Furcation defects with deep two-walled or three-
walled components may be suitable for
reconstruction procedures.

80. BONE GRAFTS
The furcation area is characterized by defects, the walls
of which are primarily of tooth structure.
The area is capable of holding a graft, it has little or no
vascularity to support the graft, due to this reason the
success of graft is limited in furcation defects
(Sepe, Saunders)
Grafts are indicated where destruction of furcation is only
partial (grade I or II) or where deep vertical lesions have
still left some bone on the inner aspects of the roots.
(Bowers and Colleagues,2003)

81. Tsao et al have shown that the furcation defect is a
graftable lesion.
They found that lesions that were grafted had greater
vertical fill than areas treated with open flap
debridement alone.

83. GTR IN FURCATION DEFECTS
BECKER ET AL 1988 – TOTAL OF 3.7 MM GAIN FOR VERTICAL DEFECTS
PONTORIERO 1987,1988,1989,1992 – Grade ii and iii defects with Gore-
tex membrane – 90% of grade ii and 25 to 35% of grde iii Defects
were non probable - stated that grade iii furcation With less than
3mm entrance height can have complete closure
METZER ET AL 1991 - Gtr has limited therapeutic modality For mesial
and distal maxillary grade ii furcations.
LEKOVIC ET AL 1989 In his re-entry study stated that – no diff in bone
level between control and test but significant Improvements in the
probing depth reduction of upto 4.09mm.
SELVIG 1990 – Postulated – membrane potentiates or contributes To
clot stability and protection by protecting the clot from disruptive
Movements of the over lying flap.
GOTTLOW & KARRING 1992 – 5 yr follow-up study and stated that –
Attachment gain obtained could be maintained over a period up to 5
yrs
OPENPROBING
ATTACHMENT

84. LINDHE 2003 – REVIEW – 21 CLINICAL
TRAILS
(423 MANDIBULAR GRADE II
FURCATION MOLARS)
1) No difference between bioresorbale and non resorbable
membranes.
2) Gtr significantly improved the horizontal clinical
attachment (cal-h) result over ofd ( 2.5mm vs
1.3mm).
3) Gtr significantly improved vertical attachment and
reduction in pd.
4) Cal-h in maxillary furcation was only 1.6mm
5) Both the 1st
and the 2nd
mandibular molars were equal.

86. Conclusions: Overall, GTR was consistently more
effective than OFD in reducing open horizontal
furcation depths, horizontal and vertical attachment
levels and pocket depths for mandibular or maxillary
class II furcation defects.
However, these improvements were modest, variable
and there was only a limited number of studies
available to appraise the effects, thus limiting general
conclusions about the clinical benefit of GTR
Future studies should aim to identify factors
associated with achieving consistent and more
pronounced benefits over open flap debridement.

88. Results: The meta-analysis showed that the GTR and
GTR WITH OG groups obtained greater furcation
closure rate, vertical/horizontal bone fill, and
vertical/horizontal attachment level gain than the
OFD group in mandibular molars.
The GTR group obtained greater vertical/horizontal
bone fill and vertical attachment level gain than the
OFD group in maxillary molars.
The GTR OG group achieved better clinical
outcomes than the GTR group did in all the
comparing outcomes in mandibular molars.

89. GTR with bone grafts in furcations:GTR with bone grafts in furcations:
The predictability of connective tissue attachment gain is
high using GTR for furcation involvement, but new bone
formation is not predictable in the same area.
(Schallhorn,Becker).
Reports have shown that bone regeneration is increased
by the use of bone grafts in combination with GTR for
new bone formation.
(Schallhorn and McClain).
• The success is likely due to the fact that bone grafts
facilitate space making and membrane placement.

90. GRADE II FURCATION IN MAXILLARYGRADE II FURCATION IN MAXILLARY
MOLAR TREATED WITH BONE GRAFT &MOLAR TREATED WITH BONE GRAFT &
RESORBABLE & NON RESORBABLERESORBABLE & NON RESORBABLE
MEMBRABEMEMBRABE
A) Grade II furcation in
buccal aspect of maxillary
molar
B) DFDBA placed in the
defect

91. D) Surgical reentry
after 1 year of healing
C) a. treated with non
resorbable (Gore Tex )
membrane.
b.Treated with resorbable
vicryl mesh membrane

92. B) Teflon membrane sutured
in position & supported by
interproximal alveolar bone.
A) Grade II furca in lingual
aspect of mandibular first molar

93. D) Surgical reentry after 6
months of healing
C) Flap sutured back in
position

94. BIOLOGIC MEDIATORS
• Enamel matrix derivative (EMD),Enamel matrix derivative (EMD),
• Platelet-derived growth factor (PDGF),Platelet-derived growth factor (PDGF),
• Platelet concentrates (PRP, PRF),Platelet concentrates (PRP, PRF),
• Bone morphogenetic proteins (BMPs),Bone morphogenetic proteins (BMPs),
• Fibroblast growth factor (FGF),Fibroblast growth factor (FGF),

95. Rossa C et al 2000:
Regeneration of Class III
furcation defects in dogs with
bFGF + GTR.
Concluded : bFGF in smaller
doses – may enhance
regenerative results in Class III
furcation lesions , leading to
greater filling with both
mineralised & non- mineralised
tissues.
Nevins et al 2003:
•Periodontal regeneration in
humans (in intrabony defects &
molar class II furcation ) – rhPDGF-
BB & Allogenic bone
•Concluded : use of purified
rhPDGF-BB + Allograft  robust
periodontal regeneration in both
Class II furcation & intrabony
defect.
•1st
report of demonstrating
periodontal regeneration
histologically in human class II
furcation defects.

96. PROCESS BY WHICH ONE OR MORE ROOTS OF A TOOTH
ARE REMOVED AT THE LEVEL OF FURCATION WHILE
LEAVING THE CROWN & REMAINING ROOTS IN FUNCTION

97. Modified from Basaraba.N ; Root amputation & Hemi section Dent clin North Am 13 (1) 121 ; 1969
INDICATIONS
1.Severe vertical bone loss on one Root of a multirooted
tooth not amenable for Regeneration.
2. Furcation involvement not treatable / maintainable.
3. Periodontally involved abutment with hopeless one Root.
4. Vertical or horizontal Root fracture.
5. Endodontic therapy impossible on one Root of multirooted tooth.
1.Severe vertical bone loss on one Root of a multirooted
tooth not amenable for Regeneration.
2. Furcation involvement not treatable / maintainable.
3. Periodontally involved abutment with hopeless one Root.
4. Vertical or horizontal Root fracture.
5. Endodontic therapy impossible on one Root of multirooted tooth.
CONTRAINDICATIONS
1. Advanced bone loss around more than one Root with
unfavorable crown-Root ratio
2. Fused roots that cannot be separated.
3. If remaining root(s) would be inadequate to serve as prosthetic
abutment.
4. Poor socio-economic conditions
5. In the presence of inadequate oral hygiene.
1. Advanced bone loss around more than one Root with
unfavorable crown-Root ratio
2. Fused roots that cannot be separated.
3. If remaining root(s) would be inadequate to serve as prosthetic
abutment.
4. Poor socio-economic conditions
5. In the presence of inadequate oral hygiene.

98. 1. Remove the Root that has least amount of Remaining bone
support & greatest amount of attachment loss.
2. Remove the Root that will eliminate the Furcation and
produce an easily maintainable architecture.
3. Remove the Root with greatest number of anatomic problems
like severe curvature, developmental grooves or accessory
and multiple canals.
4. Remove the Root that is difficult for endodontist to treat.
5. Remove the Root that least complicates future periodontal
maintenance.
6. Remove the Root that best contributes to the elimination of
periodontal problems on adjacent teeth.
The most commonly resected Root is distobuccal of
Maxillary first molar due to less surface area and divergence
The most commonly resected Root is distobuccal of
Maxillary first molar due to less surface area and divergence

100. RESECTIONOFAROOTWITHADVANCEDBONELOSS

101. Resective treatment of multi-rooted teeth
only root resection and tooth
hemisection.
(The Guidelines for Periodontal Therapy
produced by the American Academy of
Periodontology in 1992)
 ROOT AMPUTATION
VITALVITAL
NON VITALNON VITAL
 HEMISECTION & BICUSPIDIZATION

102. REMOVAL OF THE ROOT APICAL TO FURCATION WITH
OUT REMOVAL OF THE CORRESPONDING CROWN
STRUCTURE.
May be indicated in multi-rooted teeth with advanced gradeII
to grade IV furcation involvement.

103. Hemisection is the splitting of
a two-rooted tooth into two
separate portions.
This process has been called
bicuspidization or separation
because it changes the
molar into two separate
roots.
Molars with advanced bone
loss in the interproximal and
interradicular zones are not
good candidates for
hemisection.

104. After sectioning of the teeth, one or both roots
can be retained.
This decision is based on the extent and
pattern of bony loss, root trunk and root length,
ability to eliminate the osseous defect, and
endodontic and restorative considerations.
The anatomy of the mesial roots of mandibular
molars often leads to their extraction and the
retention of the distal root to facilitate both
endodontic and restorative therapy.

106. HEMISECTION Is the surgical removal of a Root of
multirooted tooth along with the
corresponding portion of the crown.
INDICATIONS 1. Vertical root fracture or root perforation during
endodontic therapy
2. Endo dontically treated Mandibular molar with advanced
bone loss on only one root.
3. Grossly decayed one portion of crown with calcified
corresponding root.
HEMISECTION Is the surgical removal of a Root of
multirooted tooth along with the
corresponding portion of the crown.
INDICATIONS 1. Vertical root fracture or root perforation during
endodontic therapy
2. Endo dontically treated Mandibular molar with advanced
bone loss on only one root.
3. Grossly decayed one portion of crown with calcified
corresponding root.
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.
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.

107. After appropriate local anesthesia, a
full-thickness mucoperiosteal flap is
elevated.
With contra-angel hand piece & cross-
cut bur sever the root where it joins
the crown . Remove the root.
With stone or diamond point smooth
the resected root stump & contour the
tooth to create easily cleansable area
Clean the area & replace the flap ,
sutured & cover with periodontal
pack .
Root Resection Procedure
The most common root resection involves the distobuccal root of the
maxillary first molar, [Basten CH 1996].

108. Tunneling is a periodontal surgical procedure
that creates access for patient cleaning, and
maintenance within the furcal area of a molar
tooth that has incurred severe attachment loss
owing to periodontal disease.

109. 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.

110. 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.

111. The goal was to improve plaque control by
eliminating the automatic niches within the furcation
where bacteria can accumulate.
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.

112. SILVER AMALGUM:
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.

113. The extraction of teeth with through-and-through furcation
defects (Classes III and IV) and advanced attachment loss.
This is particularly true for individuals who cannot or will not
perform adequate plaque control, who have a high level of
caries activity, who will not commit to a suitable maintenance
program, or who have socioeconomic factors that may preclude
more complex therapies.
Some patients are reluctant to accept periodontal surgery.
Although additional attachment loss may occur, such teeth may
survive a significant number of years. [ Ross I 1978]

114. The advent of osseointegrated dental
implants as an alternative abutment
source has had a major impact on the
retention of teeth with advanced furcation
problems.

115. LASERs in
Furcations
A study to evaluate the influence of PhotodynamicPhotodynamic
Therapy (PDT)Therapy (PDT) on bone loss in furcation areas in
rats with experimentally-induced periodontal disease
was conducted
 Concluded that within the parameters used in this study,Concluded that within the parameters used in this study,
PDT may be an effective alternative for control of bone lossPDT may be an effective alternative for control of bone loss
in furcation areas in periodontitisin furcation areas in periodontitis
Photodynamic
Therapy
de Almeida JM 2008

117. Treated 20 Human Mandibular class ii Furcation
Defects using PDL cells & observed
Significant Regeneration & bone fill.

118. • Degree I could be successfully managed by
nonsurgical mechanical debridement.
• Tunneling  Dental Caries  Extraction
• Resective surgeries  Endodontic failures & Vertical
root fractures
• Complete furcation closure was not predictably
achieved following GTR or the application of EMD in
maxillary and mandibular molars.

119. 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
8.Therapists knowledge and skill.

120.  Grade I & II Furcation ----- Good Prognosis.
 Grade III (early stage) ----- Fair Prognosis
 Grade III (advanced) & IV -- Poor Prognosis
Prognosis is poor for short, tapered roots and
relatively large crowns.
Because of disproportionate crown to root ratio and reduced
root surface available for periodontal support, the
periodontium is more susceptible to injury by occlusal forces.

121. Molars with varying degrees of FI can be effectively
treated and preserved similar to that of teeth with intact
furcations.
Effective management of furcation defects requires
knowledge of the anatomic problems associated with FI
and the application of treatment methods that are
consistent with the nature and extent of the involvement.
The keys to successful treatment of molar FI are
Early diagnosis, thorough treatment planning, good oral
hygiene by the patient, careful technical execution of the
therapeutic modality and a well designed and
implemented program of periodontal maintenance.

122. 1.CARRANZA 10th
and 11th
edition.
2.Lindhe –clinical periodontology.
3. Periodontology 2000, Vol. 9, 1995, 69-89
PERIODONTOLOGY 2000
“Management of furcation involvement”
GIANFRANCCOA RNEVALREO, BERTOP
ONTORIER&O M ARKUBS. HURZELER.
4. Jop 2011 Oct;82(10):1396-403. E pub 2011 Feb 2.
5. Journal of Clinical Periodontology
Volume 36, Issue 7, pages 581– 588, July 2009.

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