J Clin Periodontol 2001; 28: 730–740 Copyright C Munksgaard 2001

Printed in Denmark . All rights reserved

ISSN 0303-6979

Molar root anatomy and Khalaf F. Al-Shammari,

Christopher E. Kazor and
Hom-Lay Wang

management of furcation defects Department of Periodontics/Prevention/

Geriatrics, School of Dentistry, University of
Michigan, Ann Arbor, MI, USA

Al-Shammari KF, Kazor CE, Wang H-L: Molar root anatomy and management
of furcation defects. J Clin Periodontol 2001; 28: 730–740. C Munksgaard, 2001.

Abstract
Background, aims: Furcally-involved teeth present unique challenges to the suc-
cess of periodontal therapy. Anatomical and morphological complicating factors
dictate modifications in treatment approaches used for managing these areas.
Method: Various treatment approaches are available for furcally-involved teeth,
the choice of which depends on selected interdependent factors. Key words: root anatomy; morphology;
furcations; furcation involvement; incidence;
Results: These factors, along with various approaches used in the treatment of treatment; regeneration
furcally compromised teeth are discussed in this review, with particular emphasis
on morphology, etiology, classification and diagnosis. Accepted for publication 8 August 2000

Furcation areas present some of the
greatest challenges to the success of
periodontal therapy. Higher mortality
and compromised prognoses for molars
with furcal involvement have been re-
ported in several retrospective studies of
tooth loss. Additionally, reduced effi-
cacy of periodontal therapy has been
consistently found in multirooted teeth
with furcal involvement, regardless of
the treatment modality employed. For
example, Ramfjord et al. (1987) re-
ported that 16 of the 17 teeth lost dur-
ing the maintenance phase in the latest
Michigan longitudinal study had furcal
involvement initially. Reasons for com-
promised results in furcation areas in-
clude the lack of proper access for in-
strumentation due to furcation ana-
tomy and, consequently, a persistence
of pathogenic microbial flora (Cobb
1996). This paper will review molar root
anatomy and the etiology, diagnosis,
and treatment of furcation-involved
molars.
Classification of Furcation
Involvement
A furcation is defined as ‘‘the anatomic
area of a multirooted tooth where the
roots diverge’’, and furcation invasion
refers to the ‘‘pathologic resorption of
bone within a furcation’’ (American
Academy of Periodontology 1992). Sev-
eral classifications of furcation involve-
ment based on the degree of horizontal
and/or vertical probe penetration have
been developed. The most commonly
employed classification systems are
listed in Table 1.
Molar Root Anatomy
A thorough understanding of molar
root anatomy is essential for proper di-
agnostic and therapeutic decisions. Fac-
tors such as root trunk length, furcation
entrance, root separation, and root sur-
face area can affect diagnosis, and
consequently, the choice of the appro-
priate therapy for furcally involved mo-
lars. The furcation area can be divided
into 3 parts: (1) the roof, (2) the surface
immediately coronal to the root separ-
ation (flute), and (3) the area of root
separation (Grant et al. 1988). Bower
(1979a, b), Gher & Dunlap (1985) and
Dunlap & Gher (1985), reported the
anatomical features of maxillary and
mandibular first molars, respectively.
Table 2 summarizes these findings.
Other observations from the afore-
mentioned studies indicate that the me-
sial-palatal furcation entrance of the
maxillary first molar is located closer to
the palatal third of the tooth, while the
distal-palatal furcation is in the middle
portion of the tooth (Gher & Dunlap
1985). Therefore, a palatal approach is
indicated when probing the mesial-
palatal furcation, while the distal-pala-
tal furcation can be probed from either
the facial or palatal aspect. Also, the
distal-buccal root of the maxillary first
molar and the distal root of the man-
dibular first molar have the smallest
root surface areas of their respective
teeth (Bower 1979b). For this reason, all
other factors being equal, these roots
are preferentially removed during root
resective procedures.
Contributing Anatomical Factors
Several morphological factors related
to furcations and roots contribute to
the etiology and compromised pro-
gnoses of furcation-involved teeth.
These factors include: furcation en-
trance width, root trunk length and the
presence of root concavities, cervical
enamel projections, bifurcation ridges,
and enamel pearls.
Furcation entrance diameter
Bower et al. (1979a, b), reported that
81% of all furcation entrance diameters
 Molar root anatomy and furcations 731

Table 1. Classifications of furcation involvement

Glickman (1953)
Goldman (1958)
Hamp et al. (1975)
Ramfjord & Ash (1979)
Tarnow & Fletcher (1984)
Eskow and Kapin
Fedi (1985)
Ricchetti (1982)
Grade I. Pocket formation into the flute, but intact interradicular bone (incipient).
Grade II. Loss of interradicular bone and pocket formation, but not extending through to the opposite side.
Grade III.Through-and-through lesion.
Grade IV.Through-and-through lesion with gingival recession, leading to a clearly visible furcation area.
Grade I. Incipient.
Grade II. Cul-de-sac.
Grade III. Through-and-through.
Degree I. Horizontal loss of periodontal tissue support less than 3 mm.
Degree II. Horizontal loss of support ⬎3 mm, but not encompassing the total width of the furcation.
Degree III. Horizontal through-and-through destruction of the periodontal tissue in the furcation
Class I. Beginning involvement. Tissue destruction ⬍2 mm (⬍1/3 of tooth width) into the furcation.
Class II. Cul-de-sac. ⬎2mm (⬎1/3 of tooth width), but not through-and-through.
Class III. Through-and-through involvement.
Sub-classification based on the degree of vertical involvement
Subclass A. 0–3 mm
Subclass B. 4–6 mm
Subclass C. ⭓7 mm
same subclasses as Tarnow & Fletcher (1984), but thirds instead of 3-mm units are used.
combined the Glickman and Hamp classifications; same Glickman grades I through IV, but grade II furcations
are subdivided into degree I (⬍3 mm) or degree II (⬎3 mm)
Class I. 1 mm of horizontal measurement; the root furrow.
Class Ia. 1–2 mm of horizontal invasion; earliest damage.
Class II. 2–4 mm of horizontal invasion.
Class IIa. 4–6 mm of horizontal invasion.
Class III. ⬎6 mm of horizontal invasion.

Table 2. Anatomical features of maxillary and mandibular 1st molars

Maxillary 1st molar* Mandibular 1st molar†
furcation entrance M: 3.6 mm B: 2.4 mm
B: 4.2 mm L: 2.5 m
D: 4.8 mm
root separation MB: 5.0 mm B: 3.0 mm
DB: 5.5 mm L: 4.0 mm
furcation roof 4.6 mm 4.6 mm
root depression M: 0.3 mm (94%) M: 0.7 mm (100%)
D: 0.1 mm (31%) D: 0.5 mm (99%)
P: 0.1 mm (17%)
root surface area (% total RSA) DB: 91 mm2 (19%) M: 162 mm2 (37%)
MB: 118 mm2 (25%) D: 142 mm2 (32%)
P: 115 mm2 (24%) root trunk: 134 mm2 (31%)
root trunk: 153 mm2 (32%)
†
* Bower (1979a, b), Gher & Dunlap (1985). Bower (1979a, b), Dunlap & Gher (1985).

were ⬍1 mm, and 58% were ⬍0.75 mm
(63% of maxillary molars and 50% of
mandibular molars were ⬍0.75 mm).
Considering that the average width of a
curette blade face ranges between 0.75–
1.10 mm, the authors conclude that the
use of curettes alone might not be suit-
able for root preparation in the furcal
area. They also found no association
between the mesio-distal width of 1st
molars and furcation entrance diam-
eter. Similar findings were reported by
Chiu et al. (1991), where 49% of fur-
cation entrances were found to be
⬍0.75 mm.
Root trunk length
The root trunk is defined as the area of
the tooth extending from the cemento-
enamel junction to the furcation, other-
wise defined as root separation. In a
study of mandibular first and second
molars, Mandelaris et al. (1998), re-
ported that the mean root trunk length
was 3.14 mm on the buccal aspect, and
4.17 mm on the lingual aspect. The root
trunk surface area for mandibular and
maxillary molars averages 31% and
32% of the total root surface area re-
spectively (Dunlap & Gher 1985,
Gher & Dunlap 1985). Therefore, hori-
zontal attachment loss leading to fur-
cation 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 et
al. 1988). The significance of root trunk
length relates to both prognosis and
732 Al-Shammari et al.
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-in-
volved 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.
Root concavities
Another complicating factor reducing
the efficacy of periodontal therapy in
furcations arises from root depressions
or concavities. Bower (1979b), reported
a 17–94% incidence of root depressions
in maxillary roots and 99–100% in
mandibular roots (Table 2). In a study
of 50 maxillary first premolars, Book-
er & Loughlin (1985), reported the pres-
ence of mesial concavities in 100% of
examined teeth. In 2-rooted maxillary
premolars, they reported a buccal root
furcal depression in 100% of the exam-
ined teeth at a level of 9.4 mm.
Cervical enamel projections
Cervical enamel projections (CEPs)
have been implicated as etiologic fac-
tors in furcation defects due to the lack
of connective tissue attachment on en-
amel surfaces (Carranza & Jolkovsky
1991). Several studies have assessed the
incidence of cervical enamel projections
and their correlation with furcation in-
volvement. Leib et al. (1967), was the
only study that reported no association
between CEPs and furcation involve-
ment. Masters & Hoskins (1964), how-
ever, found a CEP incidence of 28.6%
for mandibular and 17% for maxillary
molars, which correlated more than
90% to mandibular molar furcation in-
volvement. They further classified CEPs
into 3 grades (Table 3). Bissada & Ab-
delmalek (1973), reported a CEP inci-
dence rate of 8.6% in a study of 1138
molars, with mandibular molars having
CEPs twice as frequently as maxillary
molars. The association between CEPs
and furcation involvement was 50%.
Table 3. Classification of cervical enamel projections*
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 (1964).
They reported the highest incidence of
CEPs in the mandibular 2nd molar
(14.8%), followed by the maxillary 2nd
molar (9.1%), mandibular 1st molar
(7.8%), and maxillary 1st molar (3.3%).
Swan & Hurt (1976), reported that
CEPs occurred on 32.6% of all molars
in a study of 200 East Indian skulls.
Hou & Tsai (1987), reported a 45.2%
incidence of CEPs in 78 Taiwanese pa-
tients. Of the teeth with furcation in-
volvement, 82.5% had CEPs, while only
17.5% of teeth without furcation in-
volvement had CEPs. In a more recent
morphometric analysis of 134 man-
dibular first and second molars, Mand-
elaris et al. (1998), reported that CEPs
were found in 56.4% of all mandibular
molars (61.7% of 2nd and 38.3% of 1st
molars). CEPs were more commonly
found on the buccal (61.9%) than the
lingual (50.8%) aspects. Table 4 sum-
marizes studies assessing the prevalence
of CEPs.
Bifurcation ridges
2 types of bifurcation ridges have been
described: intermediate and buccal/lin-
gual ridges. Intermediate bifurcation
ridges connect the mesial and distal
roots, and are composed primarily of
cementum. Buccal and lingual ridges
are composed primarily of dentin with
overlying thin layers of cementum. Ev-
erett (1958), was the first to describe the
incidence of bifurcation ridges, re-
porting a 73% incidence of intermediate
ridges in mandibular first molars, of
which 60% were considered prominent.
Buccal and lingual ridges were found in
63% of the mandibular molars.
Burch & Hulen (1974), reported a simi-
lar incidence of 76.3%. These bifurca-
tion ridges provide yet another barrier
to successful plaque control and root
preparation. Hou & Tsai (1997), inves-
tigated the correlation of intermediate
bifurcation ridges and cervical enamel
projections with furcation involvement
in 87 furcally involved mandibular mo-
lars. Their results indicated that 63.2%
of molars with furcation involvement
had CEPs and intermediate bifurcation
ridges, with mandibular first molars
having a greater prevalence (67.9%)
than mandibular second molars
(54.8%). A highly significant difference
in clinical parameters of disease (pocket
depth, clinical attachment level, plaque
and gingival indices) was also found be-
tween mandibular first and second mo-
lars with CEPs and intermediate bi-
furcation ridges compared to those
without.
Enamel pearls
The prevalence of enamel pearls is less
than that of cervical enamel projec-
tions. Moskow & Canut (1990), re-
ported an incidence of 2.6% (range 1.1–
9.7%). Like CEPs, enamel pearls con-
tribute to the etiology of furcation in-
volvement by preventing connective
tissue attachment.
Diagnosis of Furcation Invasion
Incidence
Few reports are available in the peri-
odontal literature that examine the
prevalence of furcation invasion in
adult periodontitis patients. Bissada &
Abdelmalek (1973), reported a 30.9%
incidence of furcation-involved molars
in a study of Egyptian skulls. Nevins &
Cappetta (1998), cite a 1980 unpub-
lished thesis by Purisi on 83 cadavers
that reports a 26% incidence in the 29–
35 year old age group, and a 70% inci-
dence in the ⬎35 year old group.
Ross & Thompson (1980), reported a
90% incidence in maxillary molars and
a 35% incidence in mandibular molars.
Becker et al. (1984), reported a 42.3%
incidence of furcation involvement in
560 molars. Different incidence esti-
mates are due, in part, to difficulties in
properly diagnosing the presence and
severity of furcation involvement.
Radiographs
Radiographs may aid in the diagnosis
of furcation defects but are of limited
value if used as the sole diagnostic tool,
especially in early and moderate de-
fects. Ross & Thompson (1980), re-
ported that radiographs were able to
 Molar root anatomy and furcations 733

Table 4. Incidence of cervical enamel projections

Study
Masters & Hoskins, (1964)
Leib et al. (1967)
Bissada & Abdelmalek (1973)
Hou & Tsai (1987)
Mandelaris et al. (1998)
* N/A: not applicable.
Prevalence
28.6% mandibular; 17% maxillary
25% mandibular; 22% maxillary
8.6% overall (5.9% maxillary; 10.4% mandibular)
45.2% incidence overall
56.4% of mandibular first and second molars
Association with FI
⬎90% correlation with FI in mandibular molars
no significant association
50% association with FI
82.5% of teeth with FI had CEPs, while only 17.5% of
teeth without FI had CEPs.
N/A*

detect furcation invasion in 22% of recorded the depth of probe penetration

maxillary and 8% of mandibular mo-
lars. This discrepancy was attributed to
the difference in bone densities of the
maxillary and mandibular arches. Har-
dekopf et al. (1987), reported a signifi-
cant association between a radiographic
‘‘furcation arrow’’ and degree 2 and 3
maxillary interproximal furcation in-
vasion. The association for mesial fur-
cations was 19% for degree 1, 44% for
degree 2, and 55% for degree 3. Distal
furcations had a furcation arrow inci-
dence of 12% for degree 1, 30% for de-
gree 2, and 52% for degree 3. The
authors, however, stressed the import-
ance of correlating the radiographic
findings with clinical evidence to prop-
erly diagnose the degree of involvement.
Probing
Diagnostic limitations of the peri-
odontal probe become particularly ap-
parent in furcation areas. Ross &
Thompson (1980), reported that clinical
examination alone detected furcation
involvement in only 3% of maxillary
and 9% of mandibular molars. The
combination of radiographic and clin-
ical examinations improved detection to
65% in maxillary molars, but only 23%
in mandibular molars. The reliability of
diagnosing the degree of furcation in-
volvement with the periodontal probe
has been investigated by Moriarty et al.
(1988, 1989), and Zappa et al. (1993).
In a histological evaluation of peri-
odontal probe penetration in 12 un-
treated facial molar furcations using a
pressure-sensitive probe, Moriarty et al.
(1989), demonstrated that probing the
deepest interradicular site does not
measure the true pocket depth or
attachment level of the furcation area.
The probe tip was located an average of
0.4 mm apical to the crest of the inter-
radicular bone and in the inflamed con-
nective tissue of the furcation. This in-
dicates that the probing measurement
into the inflamed connective tissue,
rather than the true pocket depth. Mor-
iarty et al. (1988), evaluated inter-exam-
iner reproducibility of probing pocket
depth in 102 grade II or III furcations
of 80 untreated molar teeth. A pressure-
sensitive probe was employed by 3
examiners in recording measurements
at 8 sites per furcation. The results indi-
cated high reproducibility in maxillary
facial, mandibular facial and lingual
furcation sites. The horizontal measure-
ments, however, were the most difficult
to assess and were not consistently re-
cordable (only 24/102 furcations were
measured by all 3 examiners). Further-
more, the reproducibility of the facial
and lingual furcation measurements de-
creased with increasing pocket depth
and root separation. Zappa et al.
(1993) questioned the validity of clin-
ical assessments of furcation involve-
ment and the true defect depth. Six den-
tists evaluated furcation lesions in 12
patients using the Ramfjord and Hamp
indices. Measurements at the time of
surgery indicated that clinical assess-
ment overestimates the true defect
depth. The different indices used in the
study were also found to lead to discre-
pancies in assessing the degree of fur-
cation involvement.
Bone sounding
Bone sounding or transgingival probing
with local anesthesia may aid in the di-
agnosis of furcation defects by more ac-
curately determining the underlying
bony contours. Greenberg et al. (1976),
reported that bone sounding yielded ac-
curate measurements when compared
to surgical entry measurements. Diag-
nosing furcation invasion is therefore
best accomplished using a combination
of radiographs, periodontal probing
with a curved explorer or Nabers probe,
and bone sounding (Kalkwarf & Rein-
hardt, 1988).
Etiology and Contributing Factors
In addition to previously mentioned an-
atomic factors, etiologic factors associ-
ated with the development of furcation
defects include plaque-associated in-
flammation, trauma from occlusion,
pulpal pathology, vertical root frac-
tures, and iatrogenic factors (Newell
1998).
Plaque-associated inflammation
Extension of inflammatory periodontal
disease processes into the furcation area
leads to interradicular bone resorption
and formation of furcation defects. No
unique histological features were found
in the furcation areas, suggesting that
they were an extension of existing peri-
odontal pockets (Glickman 1950).
Trauma from occlusion
Although some controversy still exists,
trauma from occlusion is a suspect eti-
ologic/contributing factor in isolated
furcation defects. Since trauma from
occlusion coupled with gingival in-
flammation has been implicated in
greater alveolar bone loss in experimen-
tal animals (Lindhe & Svanberg 1974),
the heavy occlusal load on molar teeth
may render them susceptible to in-
creased bone loss in the furcation areas
if inflammation is present. 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 fa-
cilitated a more rapid spread of in-
flammation and accounted for the in-
creased susceptibility to occlusal forces.
Wang et al. (1994), reported that teeth
with mobility and furcation involve-
ment were more likely to lose attach-
ment and to be extracted. Waerhaug
(1980), however, has suggested that in-
creased mobility is a late symptom,
734 Al-Shammari et al.

rather than the cause of furcation de-
fects.
Pulpal pathology
Although the rôle of pulpal pathology
in the etiology of furcation involvement
is still unclear, the high incidence of
molar teeth with accessory canals sup-
ports such an association. Lowman et
al. (1973), reported the incidence of ac-
cessory canals to be 55% in maxillary
molars and 63% in mandibular molars.
Burch & Hulen (1974), reported ‘‘open-
ings’’ in the furcation area in 76% of
maxillary and mandibular molars. Vert-
ucci & Williams (1974), reported that
45% of mandibular first molars in their
study had accessory canals extending
into the furcation area. Alternatively,
Kirkham (1975), found no accessory
canals in the furcation areas of 45
maxillary and mandibular molars. Gut-
man (1978), reported a 29.4% incidence
of accessory canals in mandibular mo-
lars and 27.4% in maxillary molars.
Vertical root fractures
Lommel et al. (1978), reported that ver-
tical root fractures are associated with
rapid, localized alveolar bone loss. Fur-
cation defects can result if the fracture
extends into the furcation area. A poor
prognosis is often given in these situ-
ations.
Iatrogenic factors
Overhanging restorations present iatro-
genic 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 with-
out restorations had furcation involve-
ment, 52.8% of molars with class II res-
torations and 63.3% of molars with
crowns were found to have furcation in-
volvement.
Treatment of Furcation Defects
Methods for the treatment of furcation-
involved molars have shown varying de-
grees of success. The goals of therapy in
furcation areas are the same as the
goals in all of periodontal therapy: ar-
resting the disease process, and ulti-
mately, maintaining the teeth in health
and function with appropriate esthetics.
However, the differences inherent in
furcation morphology pose a serious
challenge to the efficacy of most well-
established therapeutic modalities. As a
consequence, specific treatment ap-
proaches have been proposed to deal
with those unique challenges. The
choice of the appropriate treatment ap-
proach for a given situation depends on
several factors that must be carefully
evaluated prior to initiating treatment.
Table 5 lists various treatment ap-
proaches and factors to consider when
managing furcation-involved molars.
Closed and open root preparation
Several longitudinal studies have estab-
lished thorough root debridement as the
key to successful periodontal therapy.
However, reduced efficacy has been re-
ported in the treatment of multirooted
teeth (Ramfjord et al. 1987, Kalkwarf et
al. 1988). Studies specifically assessing
the response of furcation sites to mech-
anical non-surgical treatment have all re-
ported decreased clinical response over
non-furcated counterparts (Nordland et
al. 1987, Loos et al. 1988). Surgical ac-
cess has been reported to improve the ef-
ficacy of calculus removal, although
heavy deposits still remain. Matia et al.
(1986), compared the efficacy of hand
and ultrasonic instrumentation with and
without surgical access in 50 hopeless
mandibular molars. 20 teeth were instru-
mented with curettes, 10 with and 10
without surgical exposure. Twenty more
teeth were instrumented with ultrasonic
scalers, 10 with and 10 without surgical
access, with the remaining 10 teeth serv-
ing as controls. The teeth were then ex-
tracted and the amount of residual cal-
culus was assessed via stereomicroscopy.
Results demonstrated that surgical ac-
cess was more effective than closed in-
strumentation with ultrasonic scalers
being more effective than curettes in nar-
row furcations treated with surgical ac-
cess. Even with surgical access, however,
only 7/60 surfaces were calculus free.
Fleischer et al. (1989), reported similar
results. Surgical access and operator ex-
perience were found to increase the effi-
cacy of calculus removal in furcation
areas, although total calculus removal
was rare with any of the examined ap-
proaches. However, Wylam et al. (1993),
found no statistical difference with re-
spect to the effectiveness of calculus re-
moval in furcations between non-surgi-
cal (93.2% residual plaque and calculus)
and surgical access (91.1%).
The results of the above studies
further illustrate the influence of root
morphological factors on treatment
outcome. Even when access was not the
major issue, the presence of concavities,
ridges and cervical enamel projections
make adequate instrumentation of the
furcation regions difficult if not imposs-
ible. Attempts to increase the efficacy of
scaling and root planing in deep
pockets and furcal areas have included

Table 5. Treatment approaches and factors to consider in furcation-involved molars

Treatment approaches Factors to consider
1. open and closed root preparation 1. degree of involvement
2. odontoplasty 2. crown/root ratio; length of roots
3. open debridement (pocket elimination) 3. root anatomy/morphology
4. tunneling procedures 4. degree of root separation
5. root resection: 5. strategic value of the tooth
(a) Root amputation 6. residual tooth mobility
(b) Hemisection 7. need for endodontic treatment
6. bicuspidization (root separation) 8. prosthetic requirements
7. regenerative approaches (GTR, bone grafts, BMPs) 9. periodontal condition of adjacent teeth
8. extraction/implant placement 10. ability to maintain oral hygiene
11. quality of bone/ability to place implants
12. financial considerations
13. long-term prognosis

Table 6. Long-term prognosis of furcation-involved molars
Study
Hirschfeld & Wasserman (1978)
McFall (1982)
Goldman et al. (1986)
Ross & Thompson (1978)
Wood et al. (1989)
Wang et al. (1994)
†
WM: well maintained. * N/A: not applicable.
the use of fiber optic illumination with
papillary reflection (Reinhardt et al.
1985). Improved efficacy was noted
with this method, but calculus deposits
still remained on many surfaces. Par-
ashis et al. (1993), have therefore sug-
gested that the use of a rotary diamond
in combination with surgical access is
the most effective method for cleaning
furcal areas.
Most studies evaluating the response
of furcation-involved molars to tra-
ditional surgical and non-surgical ther-
apy have reported compromised pro-
gnoses. Results from some of these
studies are summarized in Table 6.
Ross & Thompson (1978), was the only
study with relatively low tooth mor-
tality. Utilizing conservative treatment
methods (no root resection or osseous
surgery), they reported 88% of 387
maxillary molars with furcation in-
volvement were maintained for 5–24
years. Criticisms of this study, however,
include obscurity in classifying the de-
gree of furcal involvement, and the use
of instruments that would limit severity
estimates (.17 explorer and periodontal
probe). According to Newell (1998),
many defects in this study were likely
incipient or shallow grade II furcal in-
volvements.
Odontoplasty
Odontoplasty may aid in the treatment
of grade I and shallow grade II fur-
cation defects through reducing post-
operative plaque and debris accumu-
lation and improving patient access for
oral hygiene measures (Goldman 1958,
Fleischer et al. 1989). Hypersensitivity
and root caries may result, however, if
excessive amounts of tooth structure
are removed.
Open debridement
Shallow grade II defects may respond
to open debridement/pocket elimin-
Molar root anatomy and furcations
Duration . teeth
15–53 years 1464
15–29 years 163
15–34 years 636
5–24 years 387
10–34 years 164
8 years 87
ation procedures. The ‘‘furcation oper-
ation’’ utilizes osseous recontouring
and/or reduction to create physiologic
bony contours and apically positioned
flaps to reduce the pocket depth (Hamp
et al. 1975).
Tunneling procedures
Tunnel preparations are used to convert
grade III and deep grade II furcations
into grade IV furcations to improve ac-
cess for oral hygiene. Hamp et al. (1975),
reported unfavorable results after 5
years in 7 molars with grade III fur-
cation involvement treated with tunnel
preparations. 3 of the 7 teeth had a
greater than 3 mm probing depth, and 4
of 7 (57%) developed root caries that led
to the extraction of 3 teeth (43%). More
favorable results were reported by Hell-
dèn et al. (1989). In an evaluation of 149
molars with grade III furcation involve-
ment treated by tunneling, they reported
that the majority of probing depths were
⬍3 mm, after an average of 37.5 months.
Ten molars (7%) were extracted, and 7
(5%) had subsequent root resection. The
incidence of root caries in the remaining
teeth was 17% (23.5% overall incidence).
Despite the decreased incidence of caries
reported in this study, tunneled teeth ap-
pear to be at a higher risk for developing
root caries compared with other surgical
procedures. For instance, the incidence
of caries on exposed root surfaces fol-
lowing routine surgical treatment was re-
ported to be less than 5% (Ravald &
Hamp 1981).
Regenerative techniques
Several studies have evaluated the use
of guided tissue regeneration (GTR)
techniques in the treatment of furcation
defects. Most studies reported favorable
results in class II mandibular furcations
(Pontoriero et al. 1987, Caffesse et al.
1990), while less favorable results were
found in mandibular class III defects
735
% tooth loss
WM† overall
19.3% 31.4%
27.3% 56.9%
16.9% 43.5%
N/A* 12%
N/A 23%
N/A 30%
(Becker et al. 1988, Pontoriero &
Lindhe 1995), and maxillary class II de-
fects (Metzler et al. 1991). Pontoriero et
al. (1987), compared ePTFE mem-
branes to surgical debridement in 21
class II and 16 class III furcation de-
fects. Complete defect closure was re-
ported in 67% of class II defects and
25% of class III defects in the group re-
ceiving ePTFE membrane treatment.
The results for class III defects, how-
ever, have not been reproduced in other
studies. Indeed, in a later publication,
Pontoriero & Lindhe (1995), reported
that none of the studied maxillary class
III defects achieved complete closure.
Metzler et al. (1991), reported the re-
sults of a study comparing ePTFE
membranes to surgical debridement in
17 paired maxillary class II furcation
defects. No statistically significant dif-
ferences were found in recession, prob-
ing depth, or clinical attachment gain
between the two groups, with unpre-
dictable hard tissue changes for the
ePTFE group. The results of these and
other studies have limited the use of
GTR to mandibular and some maxil-
lary buccal class II furcation defects.
Evans et al. (1996), reviewed 50 papers
involving some 1016 furcations to deter-
mine the closure frequency of grade II
furcation defects with various regenera-
tive techniques: bone replacement
grafts, coronally positioned flaps,
guided tissue regeneration barriers and
open flap debridement. General im-
provement in clinical furcation status
was reported only about 50% of the
time, with complete furcation closure in
only 20% of furcation defects, and par-
tial defect fill (a change from grade II
to grade I) in an additional 33% of
cases. The most favorable results were
reported using a combination of guided
tissue regeneration and bone replace-
ment grafts (91% overall improvement),
while the least favorable results were
found with open flap debridement (15%
overall improvement). The authors con-
736 Al-Shammari et al.

cluded that if furcation closure is the
primary goal of therapy, regenerative
techniques do not appear to commonly
meet that goal.
Growth Factors
More recently, the use of growth factors
and bone morphogenic proteins
(BMPs) has shown promising results in
the treatment of furcation defects. Ani-
mal studies have reported significant re-
generation in class III mandibular fur-
cation defects in beagle dogs using
platelet-derived growth factor-BB (Park
et al. 1995), and osteogenic protein-1
(Giannobile et al. 1998). Park et al.
(1995), reported significant new bone
and periodontal ligament formation in
class III furcation lesions at 8 and 11
weeks using PDGF-BB. At 11 weeks,
the newly formed bone filled 87% of the
defects compared to 60% bone fill with
GTR alone. Giannobile et al. (1998), re-
ported that human osteogenic protein-
1 (OP-1, 7.5mg/g) in a collagen vehicle
led to significantly greater new bone, ce-
mentum, and periodontal ligament for-
mation in surgically created class III
furcation defects compared to surgical
debridement with the collagen vehicle
or surgical debridement alone. In the
first human study of growth factors,
Howell et al. (1997), reported that fur-
cation lesions responded most favor-
ably to the application of both platelet-
derived growth factor and insulin-like
growth factor-I. These and other
studies have established the promising
regenerative potential of growth factors
and BMPs in furcation areas, but ad-
ditional studies are needed to fully es-
tablish the value of these biologic modi-
fiers in the treatment of human furcal
defects.
Root resection
The surgical removal of all or a part of
a tooth root can be classified into either
root amputation or hemisection, de-
pending on crown management. Root
amputation is the removal of a root
from a multirooted tooth, while hemi-
section refers to the surgical separation
of a multirooted tooth in such a way
that a root and the associated portion
of the crown may be removed (Ameri-
can Academy of Periodontology 1992).
Although the advent of dental implants
has led to a decline in the use of root
resective procedures, they can provide
an effective alternative in some situ-
ations. Table 7 lists the indications and
contraindications of root resection
techniques.
Various studies have evaluated the ef-
fectiveness of root resection in treating
molars with furcation involvement.
Bergenholtz (1972), reported long term
results of 45 teeth treated with root re-
section (21 teeth after 2–5 years, and 17
teeth after 5–10 years). Only 3 teeth
(6%) were extracted, two for peri-
odontal and one for endodontic rea-
sons. Hamp et al. (1975), evaluated 310
multirooted teeth with varying degrees
of furcation involvement, of which 135
were extracted during initial therapy. Of
the remaining teeth, 32 received scaling
and root planing, 49 had furcation op-
erations, 7 tunnel preparations, and 87
root resection. None of the resected
teeth were lost, and carious lesions were
detected on only 5 tooth surfaces. The
authors attributed their success to the
elimination of plaque retentive areas in
the furcations, meticulous patient oral
hygiene, and regular maintenance care.
Klavan (1975), reported that only one
of 34 root-resected maxillary molars
were extracted after 3 years, and that
was due to a periodontal abscess. Erp-
enstein (1983), reported only 3 of 34
root-resected teeth (9%) followed for 4–
7 years were lost for periodontal rea-
sons (2 due to pocketing and 1 due to
excessive mobility).
In contrast, less favorable results
were reported in other studies. Langer
et al. (1981), retrospectively evaluated
the success rate of 100 root-resected
molars (50 maxillary and 50 mandibu-
lar). Only 6% of the teeth failed after 4
years, which increased to 15.8% in the
first 5 years and to 38% after 10 years,
indicating that 84% of the failures oc-
curred after 5 years. Progressive peri-
odontal breakdown accounted for
26.3% (10 teeth) of the failures. Other
causes of failure were root fractures
(47.4%; 25 teeth), endodontic failures
(18.4%; 7 teeth), and cement washout
(7.9%; 3 teeth). There were almost twice
as many mandibular failures as maxil-
lary failures (25 versus 13), with root
fractures being the primary cause of

Table 7. Indications and contraindications for root resection

Indications Contraindications
1. class II or III FI 1. inadequate bone support on the remaining roots or unfavorable ana-
2. severe bone loss involving one or more roots tomical factors (long root trunk, fused roots)
3. root fracture, perforation, resorption, or deep root caries 2. significant discrepancies in adjacent interproximal bone height
4. root proximity with adjacent teeth 3. remaining roots cannot be restored/endontically treated
5. failed endodontic treatment or inoperable/calcified canals.

Table 8. Study results evaluating root resection in furcally-involved molars

. Duration Total Root
Study cases (years) failures Perio Endo fx Caries
Bergenholtz (1972) 45 2–10 3 (6%) 2 1 – –
Klavan (1975) 34 3 1 (3%) 1 – – –
Hamp et al. (1975) 87 5 0 – – – –
Langer et al. (1981) 100 10 38 (38%) 10 7 18 3
Erpenstein (1983) 34 4–7 7 (20.6%) 1 6 – –
Bühler (1988) 28 10 9 (32%) 2 5 1 1
Carnevale et al. (1991) 488 3–11 28 (5.7%)* 3 4 12 9
Carnevale et al. (1998) 175 10 12 (7%) 3 4 2 3
* Tooth loss was 18 teeth (4%).

Table 9. Studies evaluating single-tooth implants in molar regions*
Study
Becker & Becker (1995)
Balshi et al. (1996)
Bahat & Handelsman (1996)
Levine et al. (1997)
* Only studies of 20 or more molar implants are presented.
mandibular failures (15/25) and peri-
odontal breakdown accounting for
most maxillary failures (7/13). Bühler
(1988), reported the failure rate of 28
root-resected teeth after 10 years. The
results showed that no failures occurred
during the first 4 years, 10.7% (3 teeth)
failed in 5–7 years, and a total of 32.1%
(9 teeth) failed after 10 years.
Carnevale et al. (1991), reported the
results of a retrospective analysis of 488
root-resected teeth. 62% of the teeth
were followed for 3–6 years (303 teeth),
and 38% (185 teeth) for 7–11 years. 28
failures (5.7%) were reported, of which
18 (4%) were lost. The most common
cause of failure was root fracture, fol-
lowed by caries. Periodontal breakdown
was responsible for failure in only 3
teeth. In contrast to Langer et al. (1981)
and Bühler (1998) most failures oc-
curred early (3–6 year group) rather
than later (7–11 year group). The
authors attributed the high success rate
to an optimal hygiene regimen and fre-
quent maintenance recall. A more re-
cent investigation by Carnevale et al.
(1998), reported the success rate of root
resective therapy 10 years after treat-
ment to be 93%. Only 12/175 teeth (7%)
were extracted, 4 for endodontic rea-
sons, 3 for root caries, 3 for periodontal
reasons, and 2 for root fracture.
Results of the studies evaluating the
long-term effectiveness of root resection
have indicated a success rate ranging
from 62–100%. Most reported failures
were non-periodontal in nature, with
periodontal failures accounting for only
0–10% of the total failures. Since endo-
dontic complications and root fractures
were common causes of failure, factors
that may influence the outcome of root
resection procedures include: 1) the pa-
tency of the root canal system 2) oc-
clusal forces 3) the length of the edentu-
lous span and 4) the length, width, and
shape of the root (Nevins & Cappetta
1998). Table 8 summarizes the results of
root resective therapy studies.
Molar root anatomy and furcations
. molar
Duration implants
2 years 24
3 years 22
16 months (mean) 54
12 months (mean) 94
Restorative considerations
Several factors need to be considered in
the restoration of root resected molars
due to the unique anatomical features
that result after the procedure. Since
molar roots are narrower mesiodistally
and wider buccolingually than most
single rooted teeth (Gher & Vernino
1980), modifications of the preparation
design are required. A flat emergence
profile from the preparation margin is
essential for the establishment of an en-
vironment conducive to the mainten-
ance of adequate plaque control, al-
though complete removal of residual
ledges when performing the resection is
often difficult to accomplish. Newell
(1991) reported that 30% of root re-
sected molars had residual roots and
ledges subgingivally. Incomplete re-
moval of furcation flutes and root con-
cavities creates plaque-retentive factors
that may lead to the recurrence of peri-
odontal defects (Nevins & Cappetta
1998). In addition, the use of posts and
cores should be avoided if possible to
reduce the risks of root fracture (Abou-
Rass et al. 1982), and an occlusal
scheme with a narrow occlusal table
and reduced cuspal inclines should be
established to minimize excessive oc-
clusal loads (Newell 1998).
Endosseous implants
Given the predictability and high suc-
cess rates reported for endosseous den-
tal implants (Adell et al. 1981, Buser et
al. 1991, Enquist et al. 1995), and the
variable success rates reported for root
resection procedures presented in the
previous section, the question may arise
whether the use of single tooth implants
after extraction may provide a more
predictable alternative than root re-
sective therapy for periodontally in-
volved molars. Direct comparisons be-
tween the two treatment approaches,
however, are difficult to perform due to
variations in study designs. Studies re-
737
Failures
1
1
2
3
porting the success rates of single tooth
implants are limited, and those address-
ing molar teeth only are even fewer in
number (Table 9).
Becker & Becker (1995) retrospec-
tively reported a 95.7% success rate for
24 molar implants placed in 22 patients
and followed up for an average of two
years. Balshi et al. (1996) reported a
98.6% success rate in a study of 47 pa-
tients, 22 of whom received one implant
and 25 received two implants in the mo-
lar regions. Bahat & Handelsman
(1996) reported a 96.3% success rate in
their study of 59 implants placed in the
posterior areas of the jaws (54 molar
implants) of 45 patients followed up for
an average of 16 months. Levine et al.
(1997) reported on 94 molar implants
followed up for an average of one year
having a 96.8% success rate. These
studies yielded high success rates of
single tooth molar implants over their
short-term follow up periods. However,
additional controlled prospective trials
of longer duration are needed to fully
establish their long-term predictability
in periodontal patients.
Table 10. Treatment approaches for fur-
cation-involved molars based on the degree
of involvement
class I O scaling and root planing
O odontoplasty
class II O scaling and root planing
O odontoplasty
O open debridement/furcation
operation
O GTR (mandibular molars)
O root resection
O tunnel preparation
O extraction/implant placement
class III O open debridement/furcation
operation
O GTR (questionable success)
O root resection
O tunnel preparation
O extraction/implant placement
738 Al-Shammari et al.
Conclusion
The various approaches available for
the treatment of furcally-involved teeth
have resulted in different degrees of suc-
cess, indicating that the choice of ther-
apy depends on several interdependent
factors. An understanding of the
special anatomical and morphological
features of root furcations and the limi-
tations those features present is essen-
tial for successful treatment outcomes.
A summary of treatment strategies
based on the degree of furcal involve-
ment is presented in Table 10.
Zusammenfassung
Wurzelanatomie von Molaren und Manage-
ment von Furkationsdefekten
Hintergrund, Ziel: Furkationsinvolvierte
Zähne präsentieren eine einzigartige Heraus-
forderung für den Erfolg der parodontalen
Therapie. Anatomische und morphologische
komplizierende Faktoren diktieren Modifi-
kationen im Behandlungsvorgehen, was für
diese Region genutzt wird.
Methoden: Verschiedene Behandlungsmetho-
den sind für furkationsinvolvierte Zähne ver-
fügbar, die Wahl hängt von ausgewählten
voneinander abhängigen Faktoren ab.
Ergebnisse: Diese Faktoren werden zusam-
men mit verschiedenen Methoden, die in der
Behandlung von furkationsinvolvierten Zäh-
nen genutzt werden, in diesem Reviewartikel
diskutiert. Besondere Betonung gilt der Mor-
phologie, Ätiologie, Klassifikation und Dia-
gnose.
Résumé
Anatomie radiculaire molaire et gestion des lé-
sions de furcations
Origine, but: Les dents dont la furcation est
atteinte présentent un défi unique en ce qui
concerne le succès d’un traitement parodon-
tal. Des facteurs de complications anatomi-
ques et morphologiques entrainent des modi-
fications des approaches thérapeutiques utili-
sés dans la gestion de ces zones.
Méthode: Divers approches thérapeutiques
sont disponibles pour les dents dont la furca-
tion est atteinte, leur choix dépendent de fac-
teurs sélectionnés interdépendants.
Résultats: Ces facteurs, ainsi que les différen-
tes approches utilisées dans le traitement de
ces dents, sont discutés dans cette revue criti-
que, en insistant particulièrement sur la mor-
phologie, l’étiologie, la classification et le dia-
gnostic.
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Address:
Hom-Lay Wang
University of Michigan
School of Dentistry
1011 N. University Ave.
Ann Arbor, Michigan 48109–1078
USA
Fax: 734 763 5503
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