Furcation

Involvement and Treatment

Dr. Omar Soliman

Lecturer of Oral medicine and Periodontology,
Delta University
 Definition.

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 Definition.

The progress of in︎flammatory periodontal disease, if unabated, ultimately

results in attachment loss sufficient enough to affect the bifurcation or
trifurcation of multirooted teeth.
The furcation is an area of complex anatomic morphology that may be difficult
or impossible to debride by routine periodontal instrumentation. Routine home
care methods may not keep the furcation area free of pla︎que.
The presence of furcation involvement is one clinical finding that can lead to a
diagnosis of advanced periodontitis and potentially to a less-favorable
prognosis for the affected tooth or teeth. Furcation involvement therefore
presents both diagnostic and therapeutic dilemmas.

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 Definition.

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 Definition.

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 Etiologic Factors.

The primary etiologic factor in the development of furcation defects is bacterial

pla︎que and the infl︎ammatory conseq︎uences that result from its long-term
presence.
The extent of attachment loss req︎uired to produce a furcation defect is variable
and related to local anatomic factors (e.g., root trunk length, root morphology)
and local developmental anomalies (e.g., cervical enamel projections).
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Local factors may affect the rate of plaq︎ue deposition or complicate the
performance of oral hygiene procedures, thereby contributing to the
development of periodontitis and attachment loss.
The prevalence and severity of furcation involvement increase with age.
Dental caries and pulpal death may also affect a tooth with furcation
involvement or even the area of the furcation.
All of these factors should be considered during the diagnosis, treatment
planning, and therapy of the patient with furcation defects. 6
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 Diagnosis of Furcation Defects.

Careful probing is re︎quired to determine the presence and extent of furcation

involvement, the position of the attachment relative to the furca, and the extent
and configuration of the furcation defect.
The Nabors probe may be helpful to enter and measure difficult to access furcal
areas.
Transgingival sounding may further define the anatomy of the furcation defect.
CBCT.
The goal of this examination is to identify and classify the extent of furcation
involvement and to identify factors that may have contributed to the development
of the furcation defect or that could affect treatment outcome.
These factors include (a) the morphology of the affected tooth, (b) the position of
the tooth relative to adjacent teeth, (c) the local anatomy of the alveolar bone, (d)
the configuration of any bony defects, and (e) the presence and extent of other
dental diseases (e.g., caries, pulpal necrosis). 7
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 Classifications of Furcation Involvement.

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 Glickman classification.

Grade I
A grade I furcation involvement is the incipient or early stage of furcation
involvement.
The pocket is suprabony and primarily affects the soft tissues.
Early bone loss may have occurred with an increase in probing depth, but
radiographic changes are not usually found.

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 Glickman classification.

Grade II
The furcation lesion is essentially a cul-de-sac, with a definite horizontal
component. If multiple defects are present, they do not communicate with
each other because a portion of the alveolar bone remains attached to the
tooth.

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 Glickman classification.

Grade III
In grade III furcations, the bone is not attached to the dome of the furcation. In
early grade III involvement, the opening may be filled with soft tissue and may
not be visible. The clinician may not even be able to pass a periodontal probe
completely through the furcation because of interference with the bifurcational
ridges or facial/ lingual bony margins.

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 Glickman classification.

Grade IV
In grade I︎V furcations, the interdental bone is destroyed, and the soft tissues
have receded apically so that the furcation opening is clinically visible. A tunnel
therefore exists between the roots of such an affected tooth. Thus the
periodontal probe passes readily from one aspect of the tooth to another.

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Glickman classification.

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 Glickman classification.

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 Hamp Classification.

Degree I: horizontal loss of periodontal support not exceeding one third of the
width of the tooth.
Degree II: horizontal loss of periodontal support exceeding one third of the
width of the tooth, but not encompassing the total width of the furcation area.
•Degree III: horizontal “through-and-through” destruction of the periodontal
tissues in the furcation area.

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 Glickman classification.

Grade IV
In grade I︎V furcations, the interdental bone is destroyed, and the soft tissues
have receded apically so that the furcation opening is clinically visible. A tunnel
therefore exists between the roots of such an affected tooth. Thus the
periodontal probe passes readily from one aspect of the tooth to another.

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 Factors affecting furcation treatment .

Local Anatomic Factors.

Anatomy of the Bony Lesions.

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 Local Anatomic Factors.

1. Root Trunk Length

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

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The combination of root trunk length with the number and configuration of the
roots affects the ease and success of therapy. The shorter the root trunk, the less
attachment needs to be lost before the furcation is involved. Once the furcation
is exposed, teeth with short root trunks may be more accessible to maintenance
procedures, and the short root trunks may facilitate some surgical procedures.
Alternatively, teeth with unusually long root trunks or fused roots may not be
appropriate candidates for treatment once the furcation has been affected.

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

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3. Root Form
The mesial root of most mandibular first and second molars and the mesiofacial
root of the maxillary first molar are typically curved to the distal side in the
apical third. In addition, the distal aspect of this root is usually heavily ︎fluted.
The curvature and ︎fluting may increase the potential for root perforation
during endodontic therapy or complicate post placement during
restoration.
These anatomic features may also result in an increased incidence of vertical
root fracture. The size of the mesial radicular pulp may result in removal of
most of this portion of the tooth during preparation.
1.

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

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5. Anatomy of Furcation
The anatomy of the furcation is complex. The presence of
bifurcational ridges, a concavity in the dome, and possible
accessory canals complicates not only scaling, root planing, and
surgical therapy, but also periodontal maintenance.
Odontoplasty to reduce or eliminate these ridges may be req︎uired during
surgical therapy for an optimal result.

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6. Cervical Enamel Projections
Cervical enamel projections (CEPs) are reported to occur on 8.6︎% to
28.6︎% of molars.
The prevalence is highest for mandibular and maxillary second molars.
These projections can affect pla︎que removal, can complicate scaling
and root planing, and may be a local factor in the development of
gingivitis and periodontitis. CEPs should be removed to facilitate
maintenance.

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 Local Anatomic Factors.

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 2. Anatomy of the Bony Lesions.

1. Pattern of Attachment Loss

Horizontal bone loss can expose the furcation as thin facial/lingual plates of
bone that may be totally lost during resorption. Alternatively, areas with
thickened bony ledges may persist and predispose to the development of
furcations with deep vertical components.
The pattern of bone loss on other surfaces of the affected tooth and adjacent
teeth must also be considered during treatment planning. The treatment
response in deep, multiwalled bony defects is different from that in areas of
horizontal bone loss. Complex multiwalled defects with deep, interradicular
vertical components may be candidates for regenerative therapies.
Alternatively, molars with advanced attachment loss on only one root may be
treated by resective procedures.
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 Anatomy of the Bony Lesions.

2. The dental and periodontal condition of the adjacent teeth must be

considered during treatment planning for furcation involvement. The
combination of furcation involvement and root approximation with an adjacent
tooth represents the same problem that exists in furcations without ade︎quate
root separation. Such a finding may dictate the removal of the most severely
affected tooth or the removal of a root or roots.
3. The presence of an ade︎quate band of gingiva and a moderate to deep
vestibule will facilitate the performance of a surgical procedure, if indicated.

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 Anatomy of the Bony Lesions.

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 Therapeutic Classes of Furcation Defects.

Treatment of a defect in the furcation region of a multi-rooted tooth is intended

to meet two objectives:
1. The elimination of the microbial plaque from the exposed surfaces of the root
complex.
2. The establishment of an anatomy of the affected surfaces that facilitates proper
self-performed plaque control.
3. Regeneration of the peridontium.

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 Therapeutic Classes of Furcation Defects.

Different methods of therapy are recommended:

A. Degree I furcation involvement. Recommended therapy: scaling and root
planing; furcation plasty.
B. Degree II furcation involvement. Recommended therapy: furcation plasty
(Osteoplasty and Odontoplasty); tunnel preparation; root resection; tooth
extraction; guided tissue regeneration at mandibular molars.
C. Degree III furcation involvement. Recommended therapy: tunnel
preparation; root resection; tooth extraction.

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 Therapeutic Classes of Furcation Defects.

Class I: Early Defects. Incipient or early furcation defects (Class I) are

amenable to conservative periodontal therapy. Because the pocket is
suprabony and has not entered the furcation, oral hygiene, scaling, and root
planing are effective. Any thick overhanging margins of restorations, facial
grooves, or CEPs should be eliminated by odontoplasty, recontouring, or
replacement. The resolution of in︎flammation and subseq︎uent repair of the
periodontal ligament and bone are usually sufficient to restore periodontal
health.
Class II. Once a horizontal component to the furcation has developed (Class II),
therapy becomes more complicated. Shallow horizontal involvement without
significant vertical bone loss usually responds favorably to localized ︎flap
procedures with odontoplasty, osteoplasty, and ostectomy. Isolated deep
Class II furcations may respond to ︎flap procedures with osteoplasty and
odontoplasty. This reduces the dome of the furcation and alters gingival
contours to facilitate the patient’s pla︎que removal. 34
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 Therapeutic Classes of Furcation Defects.

Classes II to IV: Advanced Defects. The development of a significant

horizontal component to one or more furcations of a multirooted tooth (late
Class II, Class III, or Class I︎V) or the development of a deep vertical component
to the furca poses additional problems. Nonsurgical treatment is usually
ineffective because the ability to instrument the tooth surfaces adeq︎uately is
compromised. Periodontal surgery, endodontic therapy, and restoration of the
tooth may be re︎quired to retain the tooth.

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 Oral Hygiene Procedures.

Nonsurgical therapy, a combination of

oral hygiene instruction and scaling
and root planing, has provided
excellent results in some patients. The
earlier the furcation is detected and
treated the more likely a good long-
term result can be obtained.
Many tools, including rubber tips︎
periodontal aids︎ toothbrushes, both
specific and general,

Dr. Omar Soliman

 Scaling and root planing

Scaling and planing of the root surfaces in the furcation entrance of a degree I
involvement in most situations result in the resolution of the inflammatory
lesion in the gingiva. Healing will re-establish a normal gingival anatomy with
the soft tissue properly adapted to the hard tissue walls of the furcation
entrance.

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 Furcation plasty.

Furcation plasty is a resective treatment modality which should lead to the

elimination of the inter-radicular defect. Tooth substance is removed
(odontoplasty) and the alveolar bone crest is remodeled (osteoplasty) at the
level of the furcation entrance. Furcation plasty is used mainly at buccal and
lingual furcations. At approximal surfaces access is often too limited for this
treatment. Furcation plasty involves the following procedures:
The dissection and reflection of a soft tissue flap to obtain access to the inter-
radicular area and the surrounding bone structures.
The removal of the inflammatory soft tissue from the furcation area followed
by careful scaling and root planing of the exposed root surfaces.
The removal of crown and root substance in the furcation area (odontoplasty) to
eliminate or reduce the horizontal component of the defect and to widen the
furcation entrance. 

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 Furcation plasty.

The recontouring of the alveolar bone crest in order to reduce the buccal–
lingual dimension of a bone defect in the furcation area.
The positioning and the suturing of the mucosal flaps at the level of the alveolar
crest in order to cover the furcation entrance with soft tissue. Following healing
a “papilla-like” tissue should close the entrance of the furcation.
Care must be exercised when odontoplasty is performed on vital teeth.
Excessive removal of tooth structure will enhance the risk for increased root
sensitivity.

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 Tunnel preparation.

Tunnel preparation is a technique used to treat deep degree II and degree III
furcation defects in mandibular molars.
This type of resective therapy can be offered at mandibular molars which
have a short root trunk, a wide separation angle, and long divergence between
the mesial and distal root.
Following the reflection of buccal and lingual mucosal flaps, the granulation
tissue in the defect is removed and the root surfaces are scaled and planed. The
furcation area is widened by the removal of some of the inter-radicular
bone. The alveolar bone crest is recontoured; some of the interdental bone,
mesial and distal to the tooth in the region, is also removed to obtain a flat
outline of the bone.
Following hard tissue resection enough space has been established in the
furcation region to allow access for cleaning devices to be used during self-
performed plaque control measures. The flaps are apically positioned to the
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surgically established interradicular and interproximal bone level.
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 Tunnel preparation.

During maintenance the exposed root surfaces should be treated by topical

application of chlorhexidine digluconate and fluoride varnish. This surgical
procedure should be used with caution, because there is a pronounced risk for
root sensitivity and for carious lesions developing on the denuded root surfaces
within artificially prepared tunnels.

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 Root separation and resection (RSR).

Root resection may be indicated in multirooted teeth with grades II to III

furcation involvements. Root resection performed on endodontically treated
teeth.
Root separation involves the sectioning of the root complex and the
maintenance of all roots.
Root resection involves the sectioning and the removal of one or two roots of a
multi-rooted tooth.

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 Root separation and resection (RSR).

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Root separation and resection (RSR).
 Root separation and resection (RSR).

Before RSR is performed the following factors must be considered:

1. The length of the root trunk.
In a patient with progressive periodontal disease a tooth with a short root trunk
may have an early involvement of the furcation.
A tooth with a short root trunk is a good candidate for RSR; the amount of
remaining periodontal tissue support following separation and resection is often
sufficient to ensure the stability of the remaining root cone.
If the root trunk is long, the furcation involvement occurs later in the disease
process, but, once established, the amount of periodontal tissue support left
apical to the furcation may be insufficient to allow RSR.

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2. The divergence between the root cones.
The distance between the root cones must be considered.
Roots with a short divergence are technically more difficult to separate
than roots which are wide apart. In addition, the smaller the divergence is,
the smaller also is the inter-radicular (furcation) space. In cases where the
divergence between two roots is small, the possibility of increasing the
interradicular distance with an orthodontic root movement may be considered.
The furcation space may also be increased by odontoplasty performed during
surgery.

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 3. The length and the shape of the root cones.
Following separation, short and small root cones tend to exhibit an increased
mobility. Such roots, in addition, have narrow root canals which are difficult to
ream. Short and small roots consequently should be regarded as poor abutments
for prosthetic restorations.

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4. Fusion between root cones.
When a decision has been made to perform RSR, it is important that the
clinician first determines that the cones within the root complex are not fused.
This is generally an uncomplicated diagnostic problem for mandibular molars
or for the buccal furcation of maxillary molars. At such teeth the separation
area between the roots can easily be identified both with the probe and in a
radiograph.
It is more difficult to identify a separation line between mesiobuccal (or
distobuccal) and palatal roots of a maxillary molar or maxillary first premolar
with a narrow root complex. In such situations, a soft tissue flap must often be
raised to allow the operator to get proper access to the approximal tooth
surfaces. The mesial (or distal) entrance of the furcation must be probed to a
depth of 3–5 mm to ascertain that a fusion does not exist between the roots
scheduled for RSR.

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5. Amount of remaining support around individual roots.
This should be determined by probing the entire circumference of the separated
roots. It should be observed that a localized deep attachment loss at one surface
of one particular root (e.g. on the buccal surface of the palatal root, or the distal
surface of the mesio-buccal root of a maxillary molar) may compromise the
long-term prognosis for an otherwise ideal root.

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 Root separation and resection (RSR).

6. Stability of individual roots.

This must be examined following root separation. Rule of thumb: the more
mobile the root cone is, the less periodontal tissue support remains.
7. Access for oral hygiene devices.
After completion of therapy the site must have an anatomy which facilitates
proper self-performed tooth cleaning.

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 Regeneration of furcation defects.

• The possibility of regenerating and closing a furcation defect has been

investigated.
• Predictable outcome of GTR therapy was demonstrated only in degree II
furcation- involved mandibular molars, where a clinical soft tissue closure or
a decreased probing depth of the furcation defect was recorded.
• Less favorable results have been reported when GTR therapy was used in other
types of furcation defects such as degree III furcation-involved mandibular and
maxillary molars and degree II furcations in maxillary molars.

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 Regeneration of furcation defects.

• The reason for the limited predictability of GTR therapy in furcation-involved

teeth may be related to several factors:
• The morphology of the periodontal defect, which in the root complex often has
the character of a “horizontal lesion”. New attachment formation is hence
dependent on coronal upgrowth of periodontal ligament tissue.
• The anatomy of the furcation, with its complex internal morphology, may
prevent proper instrumentation and debridement of the exposed root surface.
• The varying and changing location of the soft tissue margins during the early
phase of healing with a possible recession of the flap margin and early exposure
of both the membrane material and the fornix of the furcation.

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 Extraction .

• The extraction of a furcation-involved tooth must be considered when the

attachment loss is so extensive that no root can be maintained or when the
treatment will not result in a tooth/gingival anatomy which allows proper self-
performed plaque-control measures.
• Moreover, extraction can be considered as an alternative form of therapy when
the maintenance of the affected tooth will not improve the overall treatment
plan or when, due to endodontic or caries- related lesions, the preservation of
the tooth will represent a risk factor for the long-term prognosis of the overall
treatment.
• The possibility of substituting a furcation-involved tooth with an
osseointegrated implant should be considered with extreme caution and only if
implant therapy will improve the prognosis of the overall treatment. In fact, the
implant alternative has obvious anatomic limitations in the maxillary and
mandibular molar regions. 62
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BONE DESTRUCTION CAUSED
BY SYSTEMIC DISORDERS.

bone loss initiated by local inflammatory processes may be

magnified by systemic influence on the response of alveolar
bone.

This is termed . The bone factor concept .