Furcation: The Problem and Its

Management
 Definition
 It can be defined as: an area of complex
anatomic morphology that may be difficult or
impossible to be debrided by routine
periodontal instrumentation.
 Anatomical Considerations
 Root trunk
 Furcation entrance
 Root surface anatomy
 Enamel projections
 Accessory canals
 Root Trunk
Represents the undivided
region of the root.
The height of the root
trunk is the distance
between the CEJ and the
separation line between
two root cones
 Furcation Entrance

Entrance: the
transitional area
between the
undivided and the
divided part of
the root
Fornix: the roof of
the furcation
 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
 Root Concavities
 Mandibular Molars
– 100% mesial roots
– 99% distal roots

 Maxillary Molars
– 94% mesiobuccal
roots
– 31% distobuccal roots
– 17% palatal roots
 Cervical Enamel Projections

 13% of molars have

CEPs

 These projections
may favor the onset
of periodontal lesions
in the affected
furcations
 Enamel Pearls

 Incidence: 1.1% - 9.7%

– Maxillary 2nd molar
found near the CEJ
extending into molar
bifurcations
 Classification

Glickman`s Classification(1953)
 Class I Incipient Furcation
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
 Class I Incipient Furcation

The level of bone loss

allows for the insertion
of the periodontal probe
into the concavity of the
root trunk
 Class II Patent Furcation
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.
 Class II Patent Furcation

The level of bone loss allows for the insertion of a

periodontal probe into the furcation area between the
roots.
Class III Communicating or Through
and Through Furcation
This type of 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.
 Class IV

As in Class III, but the

gingival tissues recede
apically so that furcation
is clearly visible.
Hamp, Nyman & Lindhe`s
Classification (1975)
Tarnow & Fletcher`s
Classification (1984)
Vertical bone loss is measured in mm from the
roof of the furcation
Furcation Probing
 Furcation Probing

Mandibular Molars
Buccal Furcation

Place the probe between

the two buccal roots
from the buccal aspect
 Furcation Probing

Mandibular Molars
Lingual Furcation

Place the probe between

the two lingual roots
from the lingual aspect
 Furcation Radiography
 Should include both
periapical and bitewing
 Location of the
interdental bone and
bone level within the
root complex should be
examined
 Differential Diagnosis

 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
 Objective of Treatment

 The elimination of the microbial plaque from

the exposed surfaces of the root complex.
 The establishment of an anatomy of the
affected surfaces that facilitates proper self-
performed plaque control.
 Non-Surgical Root Preparation
 Scaling & root planing
– Most effective in grade I and shallow grade II.
– Deeper sites respond less favorably
In most situations, it results in
the resolution of the
inflammatory lesion in the
gingiva.
 Antimicrobials
 Adjunct to scaling and root planning
– Chlorhexidine
– Tetracycline fibers

 No clinically significant difference in clinical

parameters after irrigation
 Open Debridement
 Greater calculus removal than closed
 Ultrasonic
– Narrow furcations
– Dome of furcation
 Surgical access and increased operator
experience significantly enhance calculus
removal in molar furcation.
 Osseous Surgery

 Most effective in grade II furcation

 Osteoplasty and ostectomy

techniques
– Remove the lip of defect to
reduce horizontal depth
– Bone ramps into the furcation to
enhance plaque control
– Reduce probing depths
 Root Resection
 Grade II or grade III  Contraindications
– Inadequate bone
support
– Fused roots
– Inoperable
endodontically
– Patient considerations
 Sequence of treatment at RSR

 Endodontic treatment

 Provisional restoration

 RSR

 Periodontal surgery

 Final prosthetic restoration

 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
 Hemisection
 Mandibular molars
– Grade III furcation
– Need widely separated roots
– Soft tissue positioned below level of pulp
chamber
Hemisection
 Root Separation

 Root separation involves the sectioning of the

root complex and the maintenance of all roots
 Grade III furcation
– Permits plaque removal
– Root caries (4% stannous
fluoride)
– 25% failure rate at 5 years
– Recurrent periodontitis
 Regeneration of Furcation Defects

 Guided tissue regeneration

 Predictable outcome of GTR
therapy was demonstrated
only in degree II furcation
involved mandibular molars
 less favorable results have been
reported in other types of
furcation defects
 GTR could be considered in
areas with isolated degree II
furcation defects
 Furcation Defects
Most predictable Mandibular or
Buccal Maxillary
Class II Furcations

Mesial or Distal
Maxillary Class II
Furcations

Class III Furcations

Least predictable
 Osseous Grafting
 Autogenous bone
 Allografts
– Freeze dried bone
– Demineralized Freeze dried bone

 Alloplasts
– Hydroxyapatite
 Non-porous
 Porous
– Bioglass
 Extraction
 Attachment loss is so extensive that no root can
be maintained
 If tooth/gingival anatomy will not allow proper
plaque control
 For endodontic or restorative reason
 Osseointegrated implant substitute
 Prognosis
 Hirshfeld and Wasserman. “A long term
survey of tooth loss in 600 treated periodontal
patients.” J Perio 1978

– 600 patients followed an average of 22 years

with recall every 4-6 months
– 1464 molars initially diagnosed with furcation
invasion
– 70% survival of furcated molars
 Patients Factors
 Determine patient`s goals and expectations
 Screen for local, behavioral and systemic factors;
– Oral hygiene
– Compliance
– Stress
– Intraoral Accessibility
– Uncontrolled Diabetes
– Smoking
– Healing response to Previous Therapy
 Successful Patient Outcomes

 Function
 Ease of Care
 Esthetics
 Confort
 Health
 Value