Furcation - session II

“If you have built castles in the air, your work need not be lost; that
is where they should be. Now put the foundations under them.”
1

Furcation
Session II
Dr. Suman Mukherjee
2

Contents : Session II
I. Introduction
II. Anatomy of Furcation
III. Management of Furcation .
IV. Conclusions
V. References.
3

Introduction
• Furcal management is difficult even at its best.
• Therapeutic modalities for the treatment and maintenance of
furcation have long been a dilemma for periodontists and restorative
dentists.
• The selection of a procedure for furcation management is dependent
on several factors, including the severity of furcation invasion,
amount of remaining bone support, status of abutment teeth, and
strategic importance of the involved tooth. Generally, the more
severe the invasion, the more involved the therapy.
4

Anatomy of Furcation : Maxillary 1st Molar
Mesio buccal - is normally vertical, Distobuccal inclined distally and
the Palatal root has a palatal inclination.
As a rule first molar has a shorter trunk than the 2nd molar.
In the 1st molar
Mesial furcation is 3 mm from CEJ
Buccal furcation is 3.5 mm from CEJ
Distal furcation is 5 mm from CEJ
(Abrams & Trachtenberg 1974, Rosenberg 1988)
5

Maxillary Premolars
• A concavity (about 0.5mm deep) is often
present in the furcation aspect of the
buccal root.
• The furcation in many cases is located in
the middle or apical third of root complex.
• Mean distance between furcation & CEJ
is 8 mm.
• The width of furcation entrance – 0.7mm.
6

Mandibular Molars
• Mesial root larger than distal, wider
bucco-lingually
• Mesial root positioned mainly vertical
while the distal root projects distally
• Root trunk of the 1st molar often
shorter than that of 2nd
7

• 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.
• Buccal furcation entrance - < 0.75 mm
wide & lingual entrance - > 0.75 mm in
most cases (Bower 1979).
8

Probing
• The buccal furca of the maxillary molars and the buccal and lingual
furcas of the mandibular molars - normally accessible for clinical probing
• Probing furcas on the approximal tooth surfaces - difficult when
neighboring teeth are present, esp. if contact area between them is
large or close proximity of roots
Maxillary molars
• Distal furcation - located midway bucco-lingually - probing from both
sides
• Mesial furcations- located 2/3rd towards palate - probed from palatal9

CEP leads to Furcation development
• Cervical enamel projections (CEPs) are reported to occur on
8.6% to 28.6% of molars.
• The prevalence is highest for mandibular and maxillary second
molars.
• The extent of CEPs was classified by Masters and Hoskins in
1964.
10

• These projections can affect plaque
removal, can complicate scaling and
root planning, and may be a local
factor in the development of gingivitis
and periodontitis.
• CEPs should be removed to
facilitate maintenance.
12

Root Trunk
Length
• The close relationship between the
cementoenamel junction and the furcation
entrance in teeth with a short trunk may
result in early furcation involvement and
loss of attachment due to marginal
periodontitis.
13

Management of
Furcation Involvement
Nonsurgical Therapy
14

Oral Hygiene Procedures
• Nonsurgical therapy is a very effective way of
producing a satisfactory stable result.
• Ideal results with furcation are impossible to
obtain.
15

• Nonsurgical therapy, a combination of oral
hygiene instruction and scaling and root
planning, has provided excellent results in
some patients.
• The earlier the furcation is detected and
treated, the more likely it will be that a good
long-term result can be obtained.
• Nonetheless, even advanced furcation lesions
can have successful long-term treatment.
(A) The utilization of a Perio-Aid into the furcation for
plaque removal.
(B) Proxy brush is used 16

Scaling and Root Planing
• Nonsurgical maintenance by the clinician has also improved over
time as instrumentation has improved.
• In recent decades, instruments beyond simple curettes have been
used to instrument the furcation. The frustration of instrumenting the
furcation was illustrated beautifully by Bower in 1979 in his articles
showing that only 58% of furcations could be entered by typically
using curettes.
• Subsequently, other instrumentation has evolved, including DeMarco
curettes, diamond files, Quétin furcation curettes, and Mini Five
Gracey Curettes.
17

Quentin Curette
• Quentin Currette has a blade of 0.9
mm diameter (BL1 - Smaller)
• Larger variety (BL 2 – Larger) has a
blade of 1.3 mm diameter.
18

• Svärdström and Wennström illustrated that in the long term, furcations
could be maintained using nonaggressive techniques over a 10-year
period in patients who were participants in consistent maintenance.
• Other studies also illustrate that maintenance therapy is useful for
patients to facilitate furcation cleanliness.
• Chemotherapy has proven disappointing. Ribeiro and colleagues found
that nonsurgical therapy can effectively treat class II furcation
involvements, but using povidone-iodine did not provide additional
benefits to subgingival instrumentation.
19

• The area most critical in furcation management is maintaining a
relatively plaque-free status to the furcation.
• Attaining access is a problem in this regard, but with the previously
mentioned instruments and an effective nonsurgical approach, much
can be accomplished.
• The most critical component of multirooted tooth maintenance is
always the successful reduction or elimination of plaque retention
areas from the furcation area; meticulous oral hygiene by the patient
and effective nonsurgical therapy can play a major role in attaining this
goal.
20

Long-term clinical studies of conservative surgical and
nonsurgical therapy in molars with furcation
involvement
Author Examination
Period
No. of teeth
examined
% of teeth lost
Hirschfeld et al. 15 – 53 years 1464 31
Ross & Thompson 5 – 24 years 387 12
McFall 15 – 29 years 163 57
Goldman et. al. 15 – 34 years 636 44
Wood et. al. 10 – 34 years 164 23
Wang et. al. 8 years 87 30 21

Restorative Materials
• ZnOE
• Silver Amalgam
• GIC : The potential advantage of an occlusive barrier such as
glass ionomer includes: ease of placement; elimination of a
second stage procedure for retrieval of a membrane, since it is
permanently bonded; long junctional epithelial attachment to the
glass ionomer; does not require complete coverage by the
gingival flap; bacteriostatic due to fluoride release and lower
cost. 22

Osseous Resection
• Osseous surgical therapy can be divided into resective and
regenerative therapy.
• For many years, osteoplasty and ostectomy have been used to
make the furcation areas cleansable.
• In advanced cases, techniques were used to open the furcation into
a class IV from a severe class II or III case. This would allow easier
hygiene into the furcation area for the patient.
24

• These techniques have limited usefulness today, but in the
compromised individual whose teeth cannot be extracted or in whom
conservative therapy has failed, these surgical techniques have
been used.
• The immediate goal with these surgical approaches is to create
access for the patient to maintain good hygiene.
25

Regeneration
• In furcal lesions, bone regeneration is often thought to be relatively futile.
• Many surgical procedures using a variety of grafting materials have been
tested on teeth with different classes of furcation involvement.
• Some investigators have reported clinical success, whereas others have
suggested that the use of these materials in class II, III, or IV furcations
offers little advantage compared with surgical controls.
26

• Furcation defects with deep two-walled or three-walled components
may be suitable for reconstruction procedures.
• These vertical bony deformities respond favorably to a variety of
surgical procedures, including debridement with or without
membranes and bone grafts.
27

• Tsao and associates 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.
• Bowers and colleagues have shown that furcation bone grafting
using various membranes can improve the clinical status of these
lesions. Nonetheless, bone grafting remains an elusive goal with
variable results in furcation lesions.
28

• Another area of interest has been barrier membrane technology.
• Analysis of published studies demonstrated a great variability in the
clinical outcomes in mandibular grade II furcations treated with
different types of non bioabsorbable and bioabsorbable barrier
membranes.
• Although many barrier membrane studies show a slight clinical
improvement after treatment in both maxillary and mandibular
furcations, the results are generally inconsistent.
29

Tunneling
• Surgical exposure of the furcation, which is indicated for advanced
grade II and III lesions.
• Indicated mainly in mandibular molars with
short root trunk
a wide seperation angle and
long divergence between mesial and distal root.
31

Root Resection
• Root resection may be indicated in multirooted teeth with grades II to
IV furcation involvement.
• Root resection may be performed on vital teeth or endodontically
treated teeth.
• It is preferable, however, to have endodontic therapy completed
before resection of a root or roots.
33

• If this is not possible, the pulp should be removed, the patency of the
canals determined, and the pulp chamber medicated before
resection.
• It is distressing for both patient and clinician to perform a vital root
resection and subsequently have an unfavorable event occur, such
as perforation, fracture of the root, or an inability to instrument the
canal.
34

The indications and contraindications for root resection were well
summarized by Bassaraba. In general, teeth planned for root resection
include the following:
1. Teeth that are critically important to the overall dental treatment plan.
Examples are teeth serving as abutments for fixed or removable
restorations for which loss of the tooth would result in loss of the
prosthesis and entail major prosthetic retreatment.
2. Teeth that have sufficient attachment remaining for function. Molars with
advanced bone loss in the interproximal and interradicular zones, unless
the lesions have three bony walls, are not candidates for root amputation.
35

3. 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 have a
vertical root fracture, advanced bone loss, or caries on the root.
4. Teeth in patients with good oral hygiene and low activity for caries
are suitable for root resection. Patients unable or unwilling to perform
good oral hygiene and preventive measures are not suitable candidates
for root resection or hemisection. Root-resected teeth require
endodontic treatment and usually cast restorations.
36

These therapies can represent a sizable financial investment by the
patient in an effort to save the tooth. Alternative therapies and their
impact on the overall treatment plan should always be considered and
presented to the patient.
37

The following is a guide to determining which root should be removed in
these cases:
1. Remove the root or roots that will eliminate the furcation and allow the
production of a maintainable architecture on the remaining roots.
2. 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 placed on it such as bridge abutments
and in bruxers. Teeth with uniform advanced horizontal bone loss are not
suitable for root resection.
39

3. Remove the root that best contributes to the elimination of
periodontal problems on adjacent teeth.
40

Hemisection
• 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.
• Hemisection is most likely to be performed on mandibular molars with
buccal and lingual class II or III furcation involvements.
• As with root resection, molars with advanced bone loss in the
interproximal and interradicular zones are not good candidates for
hemisection. 42

• 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.
43

• The interradicular dimension between the two roots of a tooth to be
hemisected is also important. Narrow interradicular zones can
complicate the surgical procedure.
• The retention of both molar roots can complicate the restoration of
the tooth because it may be virtually impossible to finish margins or
to provide an adequate embrasure between the two roots for
effective oral hygiene and maintenance.
44

• Therefore, orthodontic separation of the roots is often required to allow
restoration with adequate embrasure form. The result can be the need for
multiple procedures and extensive interdisciplinary therapy.
• In these patients the availability of other treatment alternatives should be
considered, such as guided tissue or guided bone regeneration or
replacement by osseointegrated dental implants.
45

(A) Grade III furcation lesion. (B) Hemisection to divide the tooth into mesial and distal
portions. (C) Postoperative view of a hemisected mandibular molar with new crowns for
both roots.
46

Root Resection or Hemisection Procedure
48

• The removal of a root alters the distribution of occlusal forces on the
remaining roots. Therefore, it is wise to evaluate the occlusion of
teeth from which roots have been resected and, if necessary, adjust
the occlusion.
• Centric holds should be maintained, but eccentric forces should be
eliminated from the area over the root that was removed.
• Patients with advanced attachment loss may benefit from temporary
stabilization of the resected tooth to prevent movement.
49

Extraction
• The extraction of teeth with through-and-through furcation defects
(classes III and IV) and advanced attachment loss may be the most
appropriate therapy for some patients.
• 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.
52

• Some patients are reluctant to accept periodontal surgery or even
allow the removal of a tooth with advanced furcation involvement,
even though the long-term prognosis is poor.
• The patient may elect to forego therapy, opt to treat the area with
scaling and root planning or site-specific antibacterial therapies, and
delay extraction until the tooth becomes symptomatic.
• Although additional attachment loss may occur, such teeth may
survive a significant number of years.
53

Dental Implants
• The advent of osseo integrated dental implants as an alternative
abutment source has had a major impact on the retention of teeth
with advanced furcation problems.
• The high level of predictability of osseointegration may motivate the
therapist and patient to consider removal of teeth with a guarded or
poor prognosis and to seek an implant-supported prosthetic treatment
plan.
• Therefore careful evaluation of the long-term periodontal, endodontic,
and restorative prognosis must be considered before invasive
surgical therapy is undertaken to save a tooth with an advanced
54

(A) Clinical picture of a class III
furcation involvement.
(B) Radiographic appearance is far
more grave than the clinical
appearance.
(C) After the tooth is removed, a
computed tomography image is
taken to plan treatment for implant
replacement.
(D) The implant restored.
55

The keys to long-term success appear to be
(1) thorough diagnosis,
(2) selection of patients with good oral
hygiene,
(3) excellence in nonsurgical therapy, and
(4) careful surgical and restorative
management.
56

Conclusion
• Predictable successful treatment of periodontitis-affected furcation of
multirooted teeth is still a dilemma for the clinicians.
• Since several therapeutic approaches are proposed, i.e.,
conservative, resective or regenerative, a proper diagnosis of these
lesions is demanding.
• The ideal management of the furcation would be preventative -
controlling plaque and occlusal forces
57

References
• Caranzza 13th edition
• Lindhe 6th edition
• Cohen‟s Atlas of Cosmetic & Reconstructive Periodontal Surgery
• Kevin G.Murphy .The role of resective periodontal surgery in the treatment
of furcation defects. Periodontology 2000;22:154–168. 5. Garrett
S.Periodontal regeneration around natural teeth. Ann Periodontol
1996: 1: 621666
• Muller HP, Eger T. Furcation diagnosis. J. Clin. Periodontol 1999; 26:485-
498
58

• Al-Shammari KF, Kazor CE, Wang HL. Molar root anatomy and
management of furcation defects. J. Clin Periodontology 2001; 28;
730740
• Caffesse RG, Mota LF, Quin'ones CR, Morrison EC. Clinical
comparison of resorbable and nonresorbable barriers for guided
periodontal tissue regeneration. J Clin.Periodontol 1997: 24: 747752.
• Marcello Cattabriga. The conservative approach in the treatment of
furcation lesions. Periodontology 2000;22: 133–153
59

Flute
• It’s a vertical groove.
62

Specific Endodontic t/t failure that can
cause furcation involvement
• Accessory canal opening in the furca – perforation during endo
therapy
• Accessory canals connecting the pulp chamber floor to the furcation
have been found in 36% maxillary first molars, 12% of maxillary
second molars, 32% of mandibular first molars and 24% of
mandibular second molars.
63

Why maxillary 1st molars most
commonly involved
64
Larata 1970

65
First molars were more affected regarding grades II and III involvement
than the second molars (Tal & Lemmer 1982).

• Found that teeth with gingival inflammation showed significantly
higher attachment loss than teeth without inflammation (Albandar et
al. 1998).
• (Neely et al. 2001, Schatzle et al. 2003). Over time, attachment loss
in the furcation sites can eventually lead to furcation involvement. In
other words, gingival inflammation might increase the risk of
furcation involvement.
• Schatzle et al. (2003) found that the quantity of plaque is associated
with the degree of gingival inflammation. Increasing attachment loss
was proportionally associated with gingival index and this
association was significant, whereas plaque per se was not
significantly associated with attachment loss
66

• The fact that plaque does not affect the progression of
periodontal disease was also confirmed in the studies carried
out in Sri Lanka (Loe et al. 1986, Neely et al. 2001). Thus, the
higher quantity of plaque is associated with higher scores on
the gingival index and may indirectly eventually lead to an
increased risk of furcation involvement.
67

Orthodontics in furcation management
• The position of the various roots in the jaw in relation to neighboring
teeth makes oral hygiene more difficult. By separating the remaining
roots after the resection of one root and the alignment of these roots
within the dental arch, access to the newly established interproximal
areas from the buccal or palatal sides would become possible and
comparable to single-rooted teeth.
Mayer T. Basdra EK: A combined surgical and orthodontic treatmenl of class III furcations.
Report of a case. J Clin Pcriodontol 1997; 24: 233-236.
68

Premolars have poorer prognosis than
molars?
69

Osteoplasty vs Osteotomy
• Osteoplasty is defined as a plastic procedure by which non
supporting bone is reshaped to achieve a physiologic gingival
and osseous contour.
• Osteotomy is defined as the plastic removal of radicular & inter
radicular supporting bone to eliminate osseous deformities.
- Friedmann 1955
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