Accepted: 28 July 2017

DOI: 10.1111/jcpe.12789

CASE REPORT OR CASE SERIES

Vertical subclassification predicts survival of molars with class

II furcation involvement during supportive periodontal care

Maurizio S. Tonetti1,2  | Allis L. Christiansen1 | Pierpaolo Cortellini1

1
European Research Group on Periodontology,
Genova, Italy Abstract
2
Department of Periodontology, Hong Kong Background: Furcation involvement is a major predictor of tooth survival. Focus has so
University, Hong Kong, China
far been on the predictive value of the horizontal component of furcation involve-
Correspondence ment. Residual periodontal support on each of the roots is likely to play a major role on
Maurizio S. Tonetti, Periodontology, Faculty of
retention of the furcated molar. Aim of this clinical audit study was to preliminarily
Dentistry, University of Hong Kong,
Hong Kong, China. assess the impact of vertical subclassification on tooth retention.
Email: tonetti@hku.hk
Methods: Tooth retention of class II furcated molars in 200 consecutive patients com-
Funding information pliant with periodontal supportive care for a minimum of 10 years was retrospectively
This study was supported by the European
Research Group on Periodontology evaluated in a single practice. Randomly selected furcated molars were retrospectively
(ERGOPerio). diagnosed in terms of vertical subclassification (residual periodontal support on the
most compromised root), and time to tooth extraction/loss was determined in clinical
records. Kaplan–Meier survival curves were constructed.
Results: Ten-­year survival of molar with class II furcation involvement was 52.5%.
Survival was 91% for subclass A, 67% for subclass B and 23% for subclass C. Mean
years of survival were 9.5–10.1, 8.5–9.3 and 6–7.3 for subclasses A, B and C, respec-
tively. Tests of equality of the survival distributions showed highly significant differ-
ences in all portions of the curve (p < .001). Stratified analyses by smoking showed
significant differences for the two groups (p < .001). Hazard rates for tooth extraction/
loss were 4.2 and 14.7 for subclasses B and C, respectively.
Conclusions: Residual periodontal support assessed as vertical subclassification of fur-
cation involvement seems to be a good predictor of survival of molar with class II hori-
zontal furcation. This has implication for prognosis, treatment planning and
development of effective molar retention strategies.

KEYWORDS
molar furcation, periodontal support, periodontitis, prognosis, tooth survival

1 |  INTRODUCTION
A recent systematic review has indicated that risk of tooth loss/ex-
traction increases in multirooted teeth with furcation involvement in
a degree and time dependent fashion (Nibali et al., 2016). These data
substantiate the well established understanding that furcated molars
have poorer prognosis and that prognosis decreases with increasing
degree of furcation involvement. They also provide greater insight into
the time horizon of loss/extraction of furcated molars and help in the
understanding of the poorly interpreted finding that while furcation in-
volvement increases the risk of tooth loss/extraction the majority of
furcated molars survive in well-­maintained populations with a 20-­year
horizon (Goldman, Ross, & Goteiner, 1986; Hirschfeld & Wasserman,
1978; McFall, 1982). Focus of these observations has been on the hor-
izontal involvement: class I, II and III according to Hamp et al. (Hamp,
Nyman, & Lindhe, 1975). The clinical assessment of the furcated molar,
however, requires the analysis of the residual periodontal support on
each root of the furcated molar, and this parameter is likely to impact

J Clin Periodontol. 2017;1–5. wileyonlinelibrary.com/journal/jcpe   © 2017 John Wiley & Sons A/S. |  1
Published by John Wiley & Sons Ltd
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2       TONETTI et al.

on tooth survival as it is likely that furcated molars can be retained until

periodontitis has progressed to the apical portion of the more com-
promised root of the molar. Tarnow and Fletcher proposed a vertical
classification of furcation involvement with the aim to assist in guid-
ing treatment choices and establishing prognosis (Tarnow & Fletcher,
1984). Aim of this pilot investigation was to assess whether vertical fur-
cation subclassification provides additional insight into the time to loss/
extraction of furcated molars. In this study, we identified 200 molars
with class II furcation involvement that received non-­surgical treatment
and access flap surgery for debridement of the furcation area combined
with minor osseous surgery, established the vertical subclassification
based on clinical and radiographic parameters at completion of active
periodontal treatment and report on 10-­year survival of these molars
in subjects complying with a supportive periodontal care programme.
2 |  MATERIALS AND METHODS
Clinical Relevance
Scientific rationale for the study: Furcation involvement is a
key predictor of tooth survival. Observations have focused
on horizontal component, and little is known about the sig-
nificance of residual periodontal support for retention of
furcated molars.
Principal findings: Residual periodontal support assessed as
vertical subclassification is a predictor of tooth survival.
Teeth with class II furcation and advanced periodontal
breakdown are at higher risk of being extracted/lost and are
lost/extracted earlier.
Practical implications: More emphasis needs to be placed on
the vertical subclassification of furcation involvement both
for prognosis and development of effective strategies to re-
tain furcated molars.

2.1 | Study design and population

This is a retrospective clinical audit study reporting the 10-­year follow- selected tooth, vertical classification was established at the area with
­up of patients with class II furcation involvement at first and second greater vertical bone loss according to the following criteria: subclass
molars. The clinical and radiographic records of a convenience sample A = attachment loss/bone loss extending to the coronal third of the
consisting of 200 consecutive patients participating in the supportive root; subclass B = attachment loss/bone loss extending to the middle
periodontal care programme at the tonettidental periodontal practice third of the root; subclass C = attachment loss/bone loss extending
in Genoa, Italy, during the June–December 2016 period and meeting to the apical third of the root. Attachment loss was used to supple-
the following criteria were analysed: 1. treated periodontitis patients ment radiographic data to improve correct estimation of the residual
presenting with at least one tooth with class II furcation involvement at bone support (Figure 1). Reproducibility of vertical subclassification
completion of active periodontal treatment; 2. at least 10 years of reg-
ular attendance to the periodontal supportive care programme defined
as compliance with the prescribed frequency regimen within 1 month
at least 70% of the time; 3. availability of complete periodontal re-
cords including diagnostic quality radiographs, full periodontal chart-
ing, smoking history and status at the completion of active periodontal
therapy; and 4. surgical access of the furcation area with a conservative
flap approach with limited osseous surgery to improve the anatomy of
the furcation-­associated defect. Smoking status was self–reported, and
the status reported at re-­evaluation was utilized to categorize subjects.

2.2 | Furcation diagnosis
Furcation involvement at first and second molars was established
from clinical records at baseline periodontal examination using a
Nabers furcation probe according the horizontal classification (Hamp
et al., 1975). A single molar with class II furcation involvement was
randomly selected as the experimental tooth for this study using ran-
dom tables to select the tooth and the sequential patient number
to identify the random table. Vertical furcation subclassification of F I G U R E   1   Schematic illustration of the vertical subclassification
the selected tooth was established according to a modification of the assessment of a lower molar with class II furcation involvement
classification proposed by Tarnow and Fletcher (Tarnow & Fletcher, according to a modification of the method of Tarnow and Fletcher
(1984). The area of residual periodontal support is estimated on the
1984) using standardized parallel technique peri-­apical radiographs
root with worse periodontal breakdown as extending to the coronal
and clinical probing depths/clinical attachment levels. Intra-­oral films
(subclass A), middle (subclass B) or apical (subclass C) third of the
were analysed on a light box by a single investigator (MST) using root length. Yellow arrows identify the area where the periodontal
a 5 ×  magnification device. In case of multiple involvement of the ligament space loses its even thickness
TONETTI et al.       3|
assignment was performed repeating readings of the initial 25 cases. T A B L E   1   Study population. Patient level baseline characteristics
Exact intra-­rater and inter-­rater agreement was found in 96% of (mean±SD or frequency and percentage)
cases. N = 200

Age at completion of active therapy (years) 48.8 ± 13.1

2.3 | Active treatment Females (%) 118 (59%)
Smokers 70 (35%)
In the context of a treatment philosophy aimed at tooth reten-
tion and with limited extractions of compromised molars during Full-­Mouth Plaque Scores 13.1 ± 7.5

active phase of treatment to those with attachment loss/bone Full-­Mouth Bleeding Score 6.0 ± 5.9

loss to the apex and hypermobility, all subjects received an infec- Means ± SD. FMPS, Full-­mouth plaque score; FMBS, full-­mouth bleeding
tion control phase of treatment consisting of oral hygiene instruc- score.
tions, risk factor control and mechanical root debridement with or
without adjunctive antibiotics. This was followed by a periodontal T A B L E   2   Location and position of furcation involvement
re-­evaluation and conservative periodontal surgery to access the
N = 200
furcation area and limited resective osseous surgery to decrease the
associated pocket. Upper 1st molar 76
Upper 2nd molar 33
Lower 1st molar 71
2.4 | Supportive periodontal care
Lower 2nd molar 20
After completion of active treatment, subjects were enrolled in an in- Mesial furcation 40
dividualized supportive periodontal care programme with a prescribed Distal furcation 59
frequency ranging from 3 to 5 months essentially as described (Lang,
Buccal furcation 63
Suvan, & Tonetti, 2015; Lang & Tonetti, 2003).
Lingual furcation 38
Residual PPD at deepest furcation site 5.8 ± 1.3
2.5 | Tooth survival
The first 10 years of participation in the SPC programme were used
to determine the occurrence and time of extraction. All subjects were
3.2 | Tooth survival
followed for 10 years from completion of active periodontal ther- Table 3 reports the number at risk and summary of events (tooth ex-
apy. All extractions were considered independently of the probable traction/loss) for the three groups. Significantly different hazard rates
reason(s). No consideration as to the prevailing cause was given in were observed for furcation involvement with subclasses B and C
this analysis. compared to subclass A. Figure 2 displays the 10-­year Kaplan–Meier
survival curves of molars with class II furcation involvement according
to the vertical subclassification. 95% CI of time to event in years was
2.6 | Data analysis
9.5–10.1 for subclass A, 8.5–9.3 for subclass B and 6–7.3 for sub-
Data were entered in an excel database, proofed for entry errors and class C. Tests of equality of the survival distributions showed highly
imported into SPSS. Analyses were performed using SPSS version 23. significant differences in all portions of the curve (p < .001). Stratified
Kaplan–Meier survival tables were utilized using the vertical subclassi- analyses by smoking status of the different subclasses are shown in
fication as the grouping variable and stratifying data based on smoking Figure 3a,b. Highly significant differences for the two groups were
status. Equality of survival distributions for different levels was tested observed for all portions of the curve (p < .001).
using the Log-­rank test for the whole curve, the Breslow test for the
earlier portions of the curve and the Tarone–Ware test for the later
T A B L E   3   Summary of events and hazard rate by furcation
portions. Hazard ratios were calculated using Cox regression analysis
subclass
using subclass A as the reference variable.
Number at 10-­year Hazard rate
risk Events survival, % (95% CI)
3 | RESULTS
Subclass A 22 2 90.9 –
Subclass B 100 33 67 4.2 (1.1–17.5)
3.1 | Study population
Subclass C 78 60 23.1 14.7 (3.6–60.2)
Table 1 reports the characteristics of the selected population at com- Total 200 95 52.5 –
pletion of active periodontal therapy. The distributions of the included
Hazard rates were calculated with Cox regression analysis using subclass A
furcated molars as well as the depth of the periodontal pocket are as a reference. Hazard rates were significantly different (p = .049 for sub-
reported in Table 2. class B and p < .001 for subclass C).
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4       TONETTI et al.
F I G U R E   2   Kaplan–Meier survival curves of molars with
class II horizontal furcation involvement according to vertical
subclassification. Subclass A (green line), subclass B (blue line),
subclass C (red line)
4 |  DISCUSSION
The main finding of this clinical audit report is that long-­term survival
of furcated molars compromised by class II horizontal involvement in
this well maintained and compliant population is influenced by the
amount of residual bone support present upon completion of active
periodontal therapy categorized as vertical subclassification of the
furcation. These initial observations draw the attention of the field
to a different, and possibly more insightful, way of stratifying prog-
nosis of furcated molars. Future studies validating this approach are
required before routine clinical implementation of this approach.
It is important to better understand the population to correctly
interpret these data. Extraction of molars during the active phase of
periodontal therapy was limited to those with circumferential attach-
ment loss/bone loss to the apex and hypermobility, frequently with
(a)
F I G U R E   3   Kaplan–Meier survival curves stratified by smoking status of molars with class II horizontal furcation involvement according to
vertical subclassification. (a) non-­smokers, (b) smokers. Subclass A (green line), subclass B (blue line), subclass C (red line)
loss of pulp vitality or molars with limited strategic value to preserve
natural posterior support. In the included subjects, the choice to treat
the furcation area with access flap surgery was dependent on the de-
sire to complete root debridement at sites/teeth where other types
of furcation treatment were felt to be inapplicable due to an unfa-
vourable cost-­effectiveness profile. This is evident by looking at the
distribution of the vertical subclassification: only 11% of teeth had a
subclass A involvement where other treatment options are considered
to be more predictable. It is likely that negative anatomical characteris-
tics were present in these cases. Furthermore, 39% of furcated molars
had less than one-­third of residual bone support at the beginning of
the 10-­year observation period. This must be kept in mind while com-
paring the relative low 10-­year survival rate reported in this study: this
material includes molars that would have been extracted during active
phase of therapy in many of the populations included in systematic
reviews (Nibali et al., 2016). Additional insight comes from the distri-
bution in terms of first and second molars and by the fact that that no
third molars are included: extractions of some of the more compro-
mised molars with limited strategic value during the active phase of
treatment have probably skewed the profile.
Careful analysis of the time distribution of events clearly indicates
that, while curves separate almost immediately due to the early loss
of some subclass C molars, subclass A and B molars have a longer
survival and curves start separating after the first 4–5 years of ob-
servation. Stratified analysis by smoking status indicates that smok-
ing shifts the survival curves to the left (Figure 3a,b) and that the
effect is particularly important in subclass C involved molars. These
observations are consistent with a recent analysis of the University
of Berne maintenance population (Salvi et al., 2014): a multivariate
analysis pointed to the importance of both local aspects in the fur-
cation (horizontal classification, tooth location and probing depth)
and patient characteristics such as smoking and compliance with the
SPC programme. Further support of the predictive value of vertical
subclassification comes from a population study without regular peri-
odontal therapy that identified increased incidence rate ratio of tooth
(b)
TONETTI et al.
extraction/loss in molars with higher degree of horizontal furcation
involvement and associated with greater probing depths/attachment
loss (Nibali et al., 2017).
The validity of these initial observations is limited among other
factors by the experimental design and the single specialist practice
setting and requires confirmation in further studies. Two critically
important considerations can be done on the basis of these results.
I) Vertical classification seems to be an important predictor of sur-
vival and may therefore assist in prognosis and treatment planning
independently of its importance in assessing the indications of root
separation and resection or regenerative options. It seems that early
extraction of subclass A and B furcation involvement may be prema-
ture as such teeth may function well for a significant period of time
as indicated by a mean survival time approaching the 10-­year mark
for subclass A teeth. II) In the more advanced cases, vertical subclas-
sification is frequently associated with the combination of an intra-
bony defect with the furcation defect and it may be possible to extend
tooth retention in such cases by applying periodontal regeneration to
increase residual support to the compromised root. Such concept may
change the emphasis of periodontal regeneration in furcation defects
from closure of the furcation towards improving periodontal support
with the aim of moving a tooth in the subclass C or B trajectory to a
subclass A trajectory. In a separate study, we are reporting a prelimi-
nary study describing such approach (Cortellini and Tonetti, in prepa-
ration). These data indicate that it is possible to significantly increase
the residual bone support of furcated molars with an intrabony de-
fect (subclasses B and C) and achieve 100% medium-­term survival.
Implications are important as shifting from a subclass C to a subclass
B or A furcation involvement may have so far unrecognized relevance
to tooth retention and thus may be an important treatment goal in a
subset of cases.
CO NFLI CT OF I NTE RE ST
Authors report no conflict of interest related to this study.
|
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How to cite this article: Tonetti MS, Christiansen AL, Cortellini P.
Vertical subclassification predicts survival of molars with class
II furcation involvement during supportive periodontal care. J
Clin Periodontol. 2017;00:1–5. https://doi.org/10.1111/
jcpe.12789