FURCATION INVOLVEMENT

PRESENTER – PUNIT

DEPARTMENT OF PERIODONTOLOGY

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CONTENTS

Introduction

Terminology

Anatomy of multirooted teeth

Classification of furcation involvement

Etiology

Microbiology

Diagnosis

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Treatment

Scaling and rootplaning

Obliteration of furcation

Gingivectomy/apically positioned flap

Furcationplasty

Tunnel procedure

Resective periodontal procedures

Regenerative procedures

Tooth extraction

Prognostic factors

Conclusion

References

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INTRODUCTION

Furcation involvement refers toa condition in which thebifurcations and trifurcations ofmulti-rooted teeth are invadedby periodontal disease

Characterized by boneresorption and attachment lossin the interradicular space(Newmann et al, 2012 ).

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DEFINITIONS:

Glickman (1950)

Commonly occurring condition in which the

bifurcation and trifurcation of multi-

rooted teeth are denuded by

periodontal disease

Prichard (1965)

Bifurcation and trifurcation

involvements are common periodontal lesions which occur as

a result of gingival inflammation and bone resorption

adjacent to and within the furca of multi-

rooted teeth

Goldman & Cohen (1968)

Extension of pocket into the interradicular

area of bone in multirooted teeth

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TERMINOLOGIES

Root complex is the portion of a tooth that is located apical of the cemento-enamel junction (CEJ)

The root complex may be divided into two parts:

the root trunk and the root cone(s)

The root trunk represents the undivided region of the Root

The root cone is included in the divided region of the root complex

The furcation is the area located between Individual root cones.

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Divergence and degree of separation b/w palatal

and mesial roots

Degree of separation:The angle of separation Between two roots (cones)

Divergence: The distance between two roots

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Furcation Entrance

Entrance: The transitional

area between the undivided

and the divided part of the

root

Fornix: The roof of the furcation

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Apico-occlusal view of a maxillary molar where

the three root cones make up the furcated region

and the three furcation entrances

Coefficient of separation : the length of

the root cones in relation to the length of

the root complex.

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ANATOMY OF FURCATION

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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 > buccalBower, R.C. (1979a). Furcation morphology relative to periodontal treatment.

Furcation entrance architecture. Journal of Periodontology 1979;50:23–27

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Maxillary molars

Cross sections

DB and palatal roots circular

MB rootDistal surface - concavity

which is about 0.3 mm deep - "hour-

glass" configuration. (Bower 1979)

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Mandibular molars

Mesial root larger than distal, wider bucco-lingually

Root trunk of the 1st molar often shorter than that of 2nd

Cross-sectionMesial larger & “hour glass”Distal circular

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Cervical Enamel Projections

13% of molars have CEPs

These projections may favor the onset of

periodontal lesions in the affected

furcations

Bower RC. Furcation morphology relative to periodontal treatment: furcation root surface anatomy. J Periodontol 1979;50:366-74

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Classifications of Furcation Involvement

1. Based on horizontal attachment loss

Glickman’s classification (1953)

Hamp’s classification (1975)

2. Based on Horizontal and vertical components

Tarnow and Fletcher’s classification (1984)

3. Based on Combination of these findings and morphology of bone deformity

Easley and Drennan’s classification (1969)

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Glickman`s Classification(1953)

GRADE I Incipient Furcation:

Grade-I:

Incipient or early stage

Soft-tissue lesion or pocket extending into flute of

furcation

Inter-radicular bone intact or slight bone loss

No radiographic evidence of bone loss

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GRADE II Furcation

Pocket formation & loss of inter-radicular bone of varying depths

into the furcation but not through and through

Portion of PDL and bone remain intact

Distinct horizontal destruction of furcation area is present

‘ Cul de sac’ with a horizontal component

Partial penetration of probe ; Extent of horizontal probing

early or advanced

Radiographs may or may not depict involvement esp. in max

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GRADE III Communicating or Through and Through

Furcation Destruction of bone and connective

tissue wall all the way through thefurcation

Bone is not attached to the dome offurcation.

Early grade III involvement- opening

filled with soft tissue

Pocket formation completely probable to the opposite side of the tooth

Radiographic evidence small triangular radiolucency

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GRADE IV Interdental bone is destroyed and the soft tissues recede apically so the furcation

opening is seen clinically

Tunnel exists between the roots of affected tooth

Periodontal probe passes readily from one aspect

to other aspect

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(

)

GRADE II degree I VERTICAL COMPONENT OF >1MM

BUT <3MM

GRADE II degree II VERTICAL COMPONENT OF >3MM

BUT

NOT THROUGH & THROUGH

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Hamp, Nyman & Lindhe`s Classification (1975)

CLASS I Horizontal loss of periodontal support not exceeding one‐third of

the width of the tooth

CLASS 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

CLASS III Horizontal “through‐and‐through” destruction of the periodontal

tissues in the furcation area

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TARNOW AND FLETCHERVERTICAL CLASSIFICATION 1984

Vertical component of furcation measured

from floor of the furca to the roof of the furca

Vertical destruction to one third of

the total inter radicular height (3 mm or less).

Vertical destruction reaching two

thirds of the inter radicular height (4 to 6 mm).

Inter radicular osseous destruction

into or beyond the apical third (> 7 mm).

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OTHER CLASSIFICATIONS

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PUBLICATION AND YEAR CLASSIFICATION

1958 Goldman Grade I: Incipient

Grade II: Cul-de-sac (pouch)

Grade III: Through and through

1969 Staffileno Grade I: Soft tissue lesion

extending to the entrance of the

furcation with minor degree of

bone loss

Grade II: Loss of furcal bone but

not through and through

Grade III: Through and through

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PUBLICATION AND AUTHOR CLASSIFICATION

1969 Easley and Drennan Class I: Incipient involvement,

entrance of the furcation detectable

with no horizontal bone loss

Class II, Type 1: Horizontal bone loss

but no vertical component

Class II, Type 2: Horizontal bone loss

and vertical bone loss

Class III, Type 1: Through-and-

through bone loss with no vertical

component

Class III, Type 2: Through-and-

through bone loss with vertical

component

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PUBLICATION AND AUTHOR CLASSIFICATION

1979 Ramfjord Degree 1: Horizontal penetration <2 mm

Degree 2: Horizontal penetration >2 mm

but not through and through

Degree 3: Through and through

1998 Hou et al Three types (A, B, and C):

A:Furcations with a short root trunk i.e. less

than 1/3rd of root complex (corresponding to a

separation degree of more than 2/3rd )

B: Corresponds to a medium sized root trunk

of 50 % of root complex (separation degree

of 1/2)

C:Furcations associated with a root trunk2/3rd of root complex (separation degree 1/3rd

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ETIOLOGY

ETIOLOGY

MICROBIAL

DENTAL PLAQUE

IATROGENIC

FACTORS

VERTICAL

ROOT

FRACTURESTRAUMA

FROM

OCCLUSION

DENTAL

CARIES/PULPAL

DEATH

LOCAL ANATOMIC AND

DEVELOPMENTAL

FACTORS

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MICROBIAL DENTAL PLAQUE

The primary etiological factor in the development of furcation defects is themicrobial dental plaque (Ammons et al., 2002).

Microbial dental plaque is the microorganism colony found on the outer surfaceof the tooth, covering the tooth like a biofilm (Socransky and Haffajee, 2002;Marsch, 2004).

Plaque’s bacteria are generally in harmony with the host and they consumeendogenous nutrients (Salivary proteins and glycoproteins).

The existence of endogenous bacteria cause the formation of a low amount ofacid and the settlement of exogenous microorganisms (Marsh, 2000;Wilks,2007).

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LOCAL ANATOMIC FACTORS

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Bower et al (1979), reported that 81% of all

furcation entrance diameters were 1 mm, and

58% were 0.75 mm (63% of maxillary molars and

50% of mandibular molars were 0.75 mm).

Also found no association

between the mesio-distal width

of 1stmolars and furcation

entrance diameter. Similar

findings were reported by Chiu

et al. (1991), where 49% of

furcation entrances were found

to be 0.75 mm

Considering that the average width

of a curette blade face ranges

between 0.75– 1.10 mm, the authors

concluded that the use of curettes

alone might not be suitable for root

preparation in the furcal area

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ROOT TRUNK LENGTH

In a study of mandibular first and second molars, it was reported

that the mean root trunk length was 3.14 mm on the buccal aspect,

and 4.17 mm on the lingual aspect

Mandelaris et al(1998)

The root trunk surface area for mandibular and maxillary molars

averages 31% and32% of the total root surface area respectively

(Dunlap & Gher 1985,Gher & Dunlap 1985)

Therefore, horizontal attachment loss leading to furcation 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 etal. 1988)

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The root trunk length plays a significant role in both the prognosis and 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-involved 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.

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

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ROOT CONCAVITIES

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BOWERS ET AL 1979reported a 17–94% incidence of root depressions in

maxillary roots and 99–100% in mandibular roots.

Booker&Loughl (1985)

In a study of 50 maxillary first premolars,reported

the presence of mesial concavities in 100% of

examined teeth

In 2-rooted maxillary premolars, they reported a

buccal root furcal depression in 100% of the

examined teeth at a level of 9.4 mm.

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LOCAL DEVELOPMENTAL ANOMALIES

Cervical enamel projections

Ectopic deposits of enamel apical to the level of the normal CEJ with a

tapering form and extending towards or into the furcation areas are

called Cervical enamel projections.

It has been observed that CEP’S occur in 13% of multirooted teeth

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CLASSIFICATION OF CEP

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. J.Periodontol 1964

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Carranza & Jolkovsky{1991}

Cervical enamel projections

(CEPs) have been implicated as

etiologic factors in furcation

defects due to the lack of

connective tissue attachment on

enamel surfaces

Masters & Hoskins {1964} found a

CEP incidence of 28.6% for mandibular

and 17% for maxillary molars, which

correlated more than 90% to

mandibular molar furcation

involvement

Hou & Tsai {1987}

reported a 45.2% incidence of

CEPs in 78 patients. Of the teeth

with furcation involvement, 82.5%

had CEPs, while only 17.5% of

teeth without furcation

involvement had CEPs.

Mandelaris et al {1998}

reported that CEPs were found in

56.4% of all mandibular molars. CEPs

were more commonly found on the

buccal (61.9%) than the

lingual (50.8%) aspects.

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Enamel Pearl

The prevalence of enamel pearls is less

than that of cervical enamel projections.

Moskow & Canut (1990), reported an

incidence of 2.6% (range 1.1–9.7%)

Like CEPs, enamel pearls contribute to

the etiology of furcation involvement by

preventing connective tissue attachment.

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PULPAL PATHOLOGY

The role of pulpal pathology in the etiology of furcation involvement is still unclear, the

high incidence of molar teeth with accessory canals supports such an association

Lowman et al. (1973), reported the incidence of

accessory canals to be 55% in maxillary molars and 63% in

mandibular molars

Alternatively, Kirkham (1975), found no accessory canals

in the furcation areas of 45 maxillary and mandibular

molars.

Another study done by Gutman (1978), reported a 29.4%

incidence of accessory canals in mandibular molars and

27.4% in maxillary molars

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TRAUMA FROM OCCLUSION

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 facilitated a more rapid spread of

inflammation and accounted for the increased susceptibility to occlusal forces

Lindhe & Svanberg 1974, stated that trauma from occlusion coupled with gingival

inflammation has been implicated in greater alveolar bone loss in experimental

animals. The heavy occlusal load on molar teeth may render them susceptible to

increased bone loss in the furcation areas if inflammation is present

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Wang et al. (1994), reported that teeth with mobility and furcation

involvement were more likely to lose attachment and to be extracted.

Waerhaug (1980), however, has suggested that increased mobility

is a late symptom, rather than the cause of furcation defects.

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

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VERTICAL ROOT FRACTURES

Lommel et al. (1978), reported that vertical root fractures are associated

with rapid, localized alveolar bone loss.

Furcation defects can result if the fracture extends into the furcation area.

A poor prognosis is often given in these situations.

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IATROGENIC FACTORS

Overhanging restorations present iatrogenic 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 without restorations had furcation involvement, 52.8%

of molars with class II restorations and 63.3% of molars with crowns were found

to have furcation involvement.

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CLINICAL FEATURES

Sensitivity to thermal changes caused by caries or lacunar resorption of root in

furcation

Recurrent or constant throbbing pain caused by pulp changes

Sensitivity to percussion caused by acute inflammatory involvement of the PDL

Acute periodontal or periapical abscess formation

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PREVALENCE

AUTHORS MAXILLARY MANDIBULAR DIAGNOSTIC

METHODS

Hirschfeld &

Wassermann.

1978

Max:

858/2217

38.7%

Man: 597/2054

29.0%

Clinical

McFall (1982) Max: 95/378

25.1%

Man: 60/377

15.9%

Clinical

Goldman et

al 1986

454/870

52.2%

169/865

19.5%

Radiographic

Wood 1989 87/205

42.4%

77/220

35.0%

Radiographic

/ clinical

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DIAGNOSTIC INSTRUMENTS

Naber’s curved 1 & 2 probes withGradation 3,6,9,12 mm.

No 23 explorer

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MAXILLARY MOLARS

The mesial furcation should be probed from the palatal

aspect of the tooth

The distal furcation can be probed from either the

buccal or the palatal aspect of the tooth.

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Distance of furcation from CEJ

Buccal Furcation 3.5 mm apical to CEJ

Distal Furcation 5 mm apical to CEJ

Mesial Furcation 3 mm apical to CEJ

Carnevale G, Pontoriero R, Lindhe J. Treatment of furcation-

involved teeth. In: Lindhe J, ed. Clinical periodontology

and implant dentistry. Copenhagen: Munksgaard, 2008; 823-43

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MANDIBULAR MOLARS

Buccal Furcation ≥ 3mm from CEJ

Lingual Furcation≥ 4mm from CEJ

Buccal Furcation entrance ≤ 0.7 mm

Lingual Furcation entrance ≥ 0.75 mm

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BONE SOUNDING

Bone sounding or transgingival probing with local anesthesia may aid in the diagnosis of furcation defects by more accurately determining the underlying bony contours.

Greenberg et al. (1976), reported that bone sounding yielded accurate measurements when compared to surgical entry measurements

Kalkwarf & Reinhardt,1988 stated that diagnosing furcation invasion istherefore best accomplished using a combination of radiographs, periodontalprobing with a curved explorer or Nabers probe, and bone sounding

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PERIO-ENDOSCOPIC VISUALIZATION OF FURCATION

Introduced subgingivally to visualize furcation.

Consists of re-usable fiber optic endoscope

which fits onto the periodontal probes &

ultrasonic instruments that have been designed

to accept it

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RADIOGRAPHS IN FURCATION DIAGNOSIS

Should include paralleling, periapical & bitewing techniques.

Sometimes superimposition of palatal root or thick bone may obscure the

furcation.

Slightest radiographic change in furcation area

should be investigated clinically, especially if there is bone loss on adjacent

roots.

Whenever there is marked bone loss in relation to a single molar root, it may

be assumed that the furcation is also involved.

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Ross & Thompson (1980), reported that radiographs were able to detect

furcation invasion in 22% of maxillary and 8% of mandibular molars. This

discrepancy was attributed to the difference in bone densities of the maxillary

and mandibular arches

Hardekopf et al. (1987), reported a significant association between a

radiographic ‘‘furcation arrow’’ and degree 2 and 3 maxillary interproximal

furcation invasion.

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OTHER DIAGNOSTIC AIDS

CONE BEAM COMPUTED TOMOGRAPHY (CBCT)

TRANSVERSE CT CROSS SECTIONAL CT

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Misch et al 2006

• When compared to periodontal probing and 2D intraoral radiography, 3D CBCT scanning was found to be more effective in assessing periodontal structures

Qiao J, Wang et al 2014

• In a study comparing intrasurgical assessment of maxillary furcations to those assessed by CBCT observed there was agreement between both assessments

• the mean length of the root trunk and the width of the furcation entrance revealed by CBCT were consistent with their respective intrasurgical values, though CBCT underestimated vertical and horizontal bone loss in the maxillary furcae

Milena M.

Cimbaljvicet al 2015

• revealed that the number of FI detected by means of CBCT was larger than by means of periodontal probing

• In cases where surgical treatment is necessary, CBCT may be suggested as an adjunct tool for FI assessment

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PROGNOSIS

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Prognosis for individual teeth depend on:

1. Morphology of the bone deformity.

2. Root anatomy

3. Tooth morphology

4.Chronicity of the destructive process.

5.Clinical crown to clinical root ratio.

6.Mobility: Tooth mobility caused by inflammation and trauma from occlusion may be correctable, but mobility

resulting from loss of alveolar bone alone is not likely to be corrected.

7.Patients age and general health

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FURCATION DEFECTS

MOST PREDICTABLE MANDIBULAR OR MAXILLARY

BUCCAL CLASS II FURCATION

MESIAL OR DISTAL MAXILLARY

CLASS II FURCATION

LEAST PREDICTABLE CLASS III/IV FURCATIONS

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TREATMENT60

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AIM OF TREATMENT

Treatment of a defect in furcation region of multi-rooted teeth is

intended to meet the objectives.

The elimination of microbial plaque from the exposed surface of root

complex

Prevent further attachment loss

The establishment of anatomy of affected surface that facilitates

proper self performed plaque control.

Eliminating trauma & correcting Pulpal pathology

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Factors to consider in Treatment of Furcation

involved Molars

TOOTH- RELATED FACTORS

Degree of furcation involvement

Amount of remaining periodontal support

Probing depth

Tooth mobility

Endodontic conditions & root/ root canal anatomy

Available sound tooth substance

Tooth position & occlusal antagonism

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PATIENT- RELATED FACTORS

Strategic value of the tooth in relation to the overall plan

Patient’s functional and esthetic demand

Patient’s age and health conditions

Oral hygiene capacity

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Three broad strategies of furcation therapy

(Kalkwarf & Reinhardt R.A 1988)

I. Maintenance of the existing Furcation

Scaling and root planing

Obstruction of Furcation

II. Increasing access to the Furcation

Gingivectomy/Apical positioned flap

Odontoplasty Furcationplasty

Osteoplasty /ostectomy

III. Elimination of the Furcation

Root amputation/ Tooth resection

Bicuspidization

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FURCATION INVOLVEMENT DEGREE I

Non-surgical Treatment

(Oral Hygiene measurements and Scaling and Root planning)

Obliteration of furcation by restorative materials

Furcation Plasty

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NON- SURGICAL APPROACH

1st approach to all types of furcation involvements

Non surgical Scaling & root planing often suffices in resolution of the

inflammatory condition

Class I lesions

Shallow cul de sac defects

Healing re- establishes normal gingiva anatomy with properly

adapted soft tissues and morphology optimal for good patient control

May be the treatment of choice if surgery is contraindicated for

medical or psychological reasons

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Fleischer et al (I989)

Level of experience play an important role in furcation debridement,especially with closed debridement.

Maria et al (1986), Parashis et al (1993) & Fleischer et al.

More effective calculus removal achieved with open than closed scaling androot planing.

Kalkwarf et al. (1988), Schroer et al. (1991) and Wang et al. (1994)

Using clinical parameters, no advantage of open debridement over closedwas observed

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Quetin furcation curette

Quetin furcation curetteBL 2 (Larger) & BL1 (Smaller)

• shallow, half-moon radius that fits into

roof or floor of furcation & developmental

depressions

•Shanks are slightly curved for better

access

•Tips 2 widths

•-BL1 & MD1- small fine with 0.9 mm blade

width

•-BL2 &MD2- larger and wider 1.3 mm

width

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The type of instruments used also plays a significant role in more thorough

furcation debridement

(Fleischer et al 1989)

In 58% of upper and lower first molars, the furcation entrance diameter is

narrower (<0.75 mm) than the width of conventional periodontal curette. So,

use of curettes alone would result in inadequate debridement of many

furcation areas

Bowers (1979)

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Ultrasonic tips and curettes have been found to be equally effective in wide

furcations, but ultrasonic tips were more effective in narrow ones

(Matia et al 1986)

Leon and Vogel (1987) reported that the use of ultrasonic scalers was more

effective than hand scaling in close debridement of advanced furcations.

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The large dimensions of conventional ultrasonic-tips inhibit entry into the furcation

in some cases

So many new designs of furcation tips were designed and developed and were

shown to be superior to conventional sonic/ultrasonic inserts with greater

accessibility and ease of instrumentation in furcation areas

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Oda and Ishikawa (1989)

Designed a new ultrasonic scaler tip made of acid resistant stainless steel

End of the tip was spherical (0.8 mm in diameter) to protect the root surfaces and soft tissue injury and improve contact with the root surfaces

Tip was in the shape of a spiral with a radius of curvature of about 9 mm and were available in clockwise and anticlockwise direction.

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Scaling and root planing produce good clinical results during initial stages

(Grade I) of furcation involvement.

However, long term clinical studies have shown unfavourable results of

conservative non-surgical and surgical therapy in deep furcation involvement.

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CHEMOTHERAPY

The difficulties of performing adequate debridement in furcations by mechanical

means have prompted experimentation with chemotherapeutic agents in these

areas.

Needleman & Watts (1997) - 1% metronidazole gel irrigation into furcation

areas with grade II and III involvements during periodontal maintenance +

subgingival scaling.

Result- Clinically, no further improvement was seen for the furcations treated

with metronidazole.

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Nylund & Egelberg (1993): Subgingival irrigation with tetracycline for 3

months + mechanical debridement in furcations with grade I, II and III

involvements.

Result - One-year evaluation of attachment levels and pocket depths showed

clinically negligible (1 mm) variation in both tetracycline and saline-irrigated

furcations.

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Tonetti et al (1992) : Tetracycline fibers exert a significant adjunctive pocket

depth and bleeding / reduction over that produced by scaling & root planing

alone, although this finding is confined only to the first 3 months following

fiber insertion.

Result-No difference between treatments could be observed, however, at

the 6-month follow-up visit.

Overall, the results from the studies above do not lend clear acceptance to

the implementation of adjunctive local drug therapy in furcation

involvements, regardless of the degree of severity.

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However a study done by AR Pradeep et al(2012) on clinical efficacy of

subgingivally delivered 1.2-mg simvastatin in the treatment of individuals

with class II furcation defects used as an adjunct to scaling and root planing

Vs SRP + placebo showed that the simvastatin administered group had a

significantly greater gain in mean RVAL and RHAL (P <0.05). Furthermore,

significantly greater mean percentage of bone fill was found (25.16%)

compared with placebo group (1.54%).

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Restorative materials in the treatment of

furcation involvement

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RESTORATIVE MATERIAL EVIDENCE OF USE

ZOE Kingsberg et al (1981) advocated the

use of polymeric reinforced zinc oxide-

Eugenol (IRM) & reported clinical

success for up to 5 years.

Kalkwart and Reinhardt (1988)

reported in their clinics progressive

bone loss around ZOE material and

increased plaque retention

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RESTORATIVE MATERIAL MATERIAL OF USE

SILVER AMALGAM

Van Swol et al. (1993) utilized amalgam

restoration to fill grade-II furcation

invasions. But on 1 year radiographic

follow-up noted, radiolucency at the base

of the restoration.

RESIN IONOMER & GLASS

IONOMER

Dragoo (1997) demonstrated histologic

evidence that both epithelium and

connective tissue can adhere to the resin

ionomer when placed in a subgingival

environment.

Reddy KP (2005) concluded, a glass

ionomer restorative material may be

effective as an occlusal barrier when

treating maxillary molar grade III furcation

defects.

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ODONTOPLASTY

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81

Reshaping of tooth coronal to furcation to improve access for

plaque control

Widens entrance of the furca & reduces horizontal depth of the

furcation involvement

Removes plaque retentive areas like grooves, CEPs, cervical

enamel pearls smooth areas

Advised for Grade I & II lesions

Potential Complications-

Hypersenstivity

Pulpal irritation permanent change

Pulp exposure

Increased risk of root caries

FURCATION PLASTY

It is a resective surgical treatment associated with odontoplasty and osteoplasty.

It is used mainly at the buccal and lingual furcations

Procedure:

Reflection of a full thickness flap

Removal of inflammatory soft tissue

Odontoplasty to eliminate or reduce the horizontal component of the defect and

to widen the furcation entrance

Recontouring of the alveolar bone crest to reduce the buccal-lingual dimension of

bone in the furcation area

Positioning and suturing of the flap

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The purpose of performing furcation

plasty is the establishment of a soft

tissue papilla which covers the entrance

to the inter-radicular periodontal tissues

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FURCATION INVOLVEMENT DEGREE II

Furcation plasty

Tunnel preparation

Root resection

Tooth extraction

Guided tissue regeneration

Emdogain/PRF

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TUNNEL PREPARATION

Intentional creation of a Class IV furcation with entrance

accessible for oral hygiene procedure

Done in advanced lesions i.e. Deep Grade II and Grade III

lesions

It can be utilized only when the furcation entrance dimension

is wide enough and coronally located to allow for an easy

utilization of cleaning devices.

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Usually done in mandibular molars for clear two way access.

Implemented sometimes in maxillary molars.

However, one of the three roots may have to be resected to improve

accessibility to the furcation area.

(Hellden et al. 1989)

Patients with low caries index & good plaque control

(Highfield et al. 1978)

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During surgery, bone is

reshaped to obtain a scalloped

morphology and the soft tissues

are apically positioned

Care must be taken that the

space obtained under the roof

of the furcation should allow

proper plaque removal

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Advantages

Avoidance of prosthetic reconstruction and endodontic therapy

Disadvantages

Furcations treated with resective osseous surgery for tunnel preparation areexpected to result in a slight loss in attachment as a consequence of the therapy

High rate of caries development

Hellden et al 1989

evaluated 148 teeth with tunnel preparation for 37.5 months

24% developed caries

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Tunneling often fails because of decay in the furcation area

(Lindhe, 1983).

Hellden and colleagues (1989) concluded that teeth with

tunnel preparations have a considerably better prognosis than

that previously reported.

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DISADVANTAGES

Potential development of root caries.

Sensitivity

Exposure to patent lateral canals that will require endodontic therapy in the future.

Requirement that a patient should have good manual dexterity to maintain optimal oral hygiene.

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STUDIES ON TUNNELLING PROCEDURE92

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FURCATION INVOLVEMENT DEGREE III

Tunnel preparation

Root resection

Tooth Extraction

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RESECTIVE PROCEDURES

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ROOT SEPARATION AND RESECTION(RSR)

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

RSR is frequently used in cases of deep degree II and degree III furcation involved molars

Can be done on vital or endodontically treated teeth.

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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

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INDICATIONS OF RSR

Teeth that are critically important to the overall dental treatment plan

Teeth that have sufficient attachment remaining for function.

Teeth for which a more predictable or cost-effective method of therapy is not

available. Examples are teeth with furcation defects that have been treated

successfully with endodontics but now present with a vertical root fracture,

advanced bone loss, or caries on the root.

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INDICATIONS OF RSR

Teeth in patients with good oral hygiene and low activity for caries

Root-resected teeth require endodontic treatment and usually cast

restorations

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SEQUENCE OF TREATMENT OF RSR

Endodontic treatment

Provisional restoration

RSR

Periodontal surgery

Final Prosthesis

MASSIMO DESANCTIS & KEVIN G.MURPHY The role of resective periodontalsurgery in the treatment of furcation defects Periodontology 2000, Vol. 22, 2000, 154–168

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WHICH ROOT TO REMOVE?

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GENERAL GUIDELINES

Remove the root(s) that will eliminate the furcation and allow the production of a maintainable architecture on the remaining roots

Remove the root with the greatest amount of bone and attachment loss. Sufficient periodontal attachment must remain after surgery for the tooth to withstand the functional demands

Remove the root with the greatest number of anatomic problems such as severe curvature, developmental grooves, root flutings, or accessory and multiple root canals.

Remove the root that complicates future periodontal maintenance.

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ROOT RESECTION TECHNIQUE

Under LA, elevate full thickness mucoperiosteal

flap and debride the defect

Removal of small amount of bone may be

required to facilitate root removal

With contra angles hand piece & cross- cut or a

straight fissure bur, a cut directed just apical to

contact point through the furcation to sever the

root where it joins the crown

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Elevate & remove the root

With stone or diamond point smooth the resected root stump & contour the

tooth to create easily cleansable area

Clean the area & apically posotion the flap ,suture & cover with periodontal

pack

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Carnevale et al. (1991) reported on the outcomes of 185 teeth treated

with hemisection or root amputation with a 7–11-year follow-up. Out of

these 185 teeth, three teeth were lost, yielding a survival rate of 98.4%.

One tooth was lost due to each of the following reasons: caries, root

fracture and probing pocket depth >5 mm.

Hou et al. (1999) reported a survival rate of 100% of 52 root-separated

molars in a case series comprising 25 patients followed up for a mean

observation period of 6.7 years (range 5–13 years).

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Svardstrom & Wennstrom (2000) reported a retention rate of 89.4% of

47 molars 8–12 years following root resective procedures. Five teeth

(10.6%) had to be extracted during the follow-up period and root fracture

was the main reason for extraction (80.0%)

Dannewitz et al. (2006) performed 19 root resections while treating 305

furcation-involved molars. Eight resected teeth were lost during the

maintenance phase, yielding a survival rate of 57.9%.

Huynh-Ba G, Kuonen P, Hofer D, Schmid J, Lang NP, Salvi GE. The effect of periodontal therapy on the survival rate and incidence of complications of multirooted teeth withfurcation involvement after an observation period of at least 5 years: a systematic review.J Clin Periodontol 2009; 36: 164–176

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Following factors must be considered before selection of case for root

separation & resection :

The length of the root trunk

The divergence between the root cones

The length & shape of root cones

Fusion of root cones

Amount of remaining bone support around individual roots

Stability of individual roots

Access for oral hygiene device

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INDICATIONS FOR ROOT RESECTION

Periodontal Indications

• Severe bone loss affecting one or more roots untreatable with regenerative procedures

• Class II or Class III furcation invasions

• Severe recession or dehiscence of a root

Endodontic or Conservative Indications

• Inability to successfully treat and fill a canal

• Root fracture or root perforation

• Severe root resorption

• Root decay

Prosthetic Indications

• Severe root proximity inadequate for a proper embrasure space

• Root trunk fracture or decay with invasion of the biological width

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Contraindications for Root Resection

Restorative factors

• Internal root decay

• Presence of a cemented post in the remaining root

Strategic considerations

• Consider adjacent teeth for conventional prosthetic restoration

• Consider removable prosthesis

• Consider implants

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HEMISECTION- REMOVAL OF ROOT WITH

CORRESPONDING CROWN PORTION OF MANDIBULAR

MOLAR.

Mostly done in mandibular molars with buccal & lingual Class II or

Class III furcation involvement

Technique similar to root resection except that half of the crown is

removed along with one of the roots of mandibular molar

Vertically oriented cut is made bucco-lingually through the buccal &

lingual developmental grooves through the pulp chamber and

furcation

Retained mesial or distal half serve as a useful abutment

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Direction of Tooth Section

Remaining singlerooted Tooth

Portion

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BICUSPIDIZATION

Is the splitting of a mandibular molar & retaining both the fragments

so as to change the molar into two separate units.

INDICATIONS

1. Mandibular molars with Buccal & Lingual Class II or III

Furcation involvements.

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ROOT CONDITIONINIG AND CORONALLY ADVANCED FLAP

Root conditioning combined with coronally advanced flap procedure.

Root conditioning is intended to decontaminate, detoxify and demineralize the root surface, removing the smear layer and exposing collagen matrix.

Agents commonly used

- Citric acid

- Tetracycline HC1

- FibronectinOthers - EDTA, Detergents, Phosphoric acid, Bile salts.

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Acid etching of the debrided planed root surface removes the smear layer on the

denuded root surface and exposes Type I collagen chemotactic to fibroblasts.

Polson and Proye 1983 suggested that a fibrin linkage to the exposed collagen

fibrils is a precursor to the connective tissue attachment. This fibrin network may

serve to prevent apical migration of epithelium allowing migration of periodontal

precursor cells to the root.

Crigger et al (1978), Nilveus et al (1980), Bogle et al (1981)- in their respective

animal studies have demonstrated increased amounts of new connective tissue

attachment in furcation defects following acid conditioning compared with non-acid

treated control.

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BONE GRAFTS

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The strong focus on bone formation as a prerequisite for new attachment formation has led to implantation of bone grafts or different types of bone substitutes into furcation defects.

i) Contain bone forming cells (osteogenesis)

ii) Serve as a scaffold for bone formation (osteoconduction)

iii) Matrix of the grafting material contains bone inductive substances (osteoinduction),

Which would stimulate both the regrowth of alveolar bone and the formation of new attachment.

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AUTHORS CONTRIBUTIONS

Schallhorn O.(1967) observed probing depth reduction and

bone fill of degree II furcation objects

following transplantation of illiac grafts.

Gantes et al (1988) dFDBA

Kenny et al (1988) Porous hydroxyapatite

Pepelassi et al (1991) Composite graft of tricalcium posphate,

plaster of paris and doxycycline

Yukna et al (1994) HTR

Akbay (2005) reported that autogenous PDL grafts has

potential in promoting healing of furcation

lesions.

Tsao YP (2006) reported that solvent-preserved,

mineralized human cancellous allograft,

with or without collagen membrane, can

significantly improve bone fill in

mandibular ClassII furcation defects.

This study suggested

that the use of PDL

grafts may have

beneficial effects in the

treatment of furcationdefects.

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Bone replacement grafts alone have had limited success in managing Class II

and III furcation defects. Problems associated with bone replacement grafts

have included graft containment, epithelial exclusion, microbial

contamination and variable inductivity of the graft

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GUIDED TISSUE REGENERATION

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Guided Tissue Regeneration is defined as procedure attempting to

regenerate lost periodontal structures through differential tissue

responses.

Barriers - excluding epithelium and gingival corium from the root surface in

the belief that they interfere with regeneration.

Using GTR, Gottlow et al (1986) demonstrated clinical and histological

resolution of angular as well as furcation defects in humans.

These barriers can be

absorbable/non-absorbable

natural/synthetic.

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Clinical indications - first mandibular molar with a Class II furcation lesion.

Other furcation lesions in other areas of the mouth have also been approached

with this therapeutic principle, although rendering different outcomes.

The first generation of GTR studies were carried out using non-resorbable

expanded polytetra fluoroethylene membranes.

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Pontoriero et al (1988) demonstrated significant clinical

attachment when this regenerative therapy

was used.

Paul et al (1992) and Laurell et al (1994)

used resorbable barrier membranes namely

bovine derived collagen membranes and

polylactic acid based membranes respectively,

in the treatment of Class II furcation defects

Pontoriero et al (1989) observed that the use of ePTFE was less

effective in the treatment of mandibular Class

III furcations

Sanz and Giovannoli (2000) placement of a barrier membrane should not

be indicated in the treatment of maxillary

molars with furcation involvement

Eickholz P et al (2006) reported horizontal clinical attachment level

(CAL-H) gain achieved after GTR therapy in

Class II furcations was stable after 10

years(83%). It failed to show a significant

difference in stability of CAL-H gain between

non-resorbable ePTFE barrier and the other a

bioabsorbable (polyglactin 910

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Lindhe (2003), in a review of 21 clinical trials (423

mandibular grade II furcations), observed that

1.There was no significant difference between bioabsorbable and nonabsorbable membranes.

2. GTR significantly improved the horizontal clinical attachment level (CAL-H) over open flap surgery: 2.5 versus 1.3 mm.

3. Complete closure was variable (0–67%).

4. GTR significantly improved vertical attachment and a reduction in pocket depth.

5. CAL-H in maxillary furcation was only 1.6 mm, and the results were variable.

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AAP paper on periodontal regeneration in furcations (Wang et al

2005) found the following:

1.GTR provided additional benefits over OFD in clinical attachment level, reduced

probing in furcations.

2. Bone replacement grafts enhance GTR treatment outcomes in furcations.

3. Clinically, GTR procedures for furcations should be limited to mandibular and maxillary

buccal grade II furcation defects.

4. Only limited results are obtainable for mandibular (grade III) and maxillary medial and

distal grade I or III furcation defects.

5. Bone grafts have been found to enhance GTR outcomes in furcations but not in

intrabony defects.

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ENAMEL MATRIX

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Emdogain found its beginnings more than a decade ago when a

breakthrough in the basic biology of tooth development revealed a native

complex of enamel matrix proteins and the key role they play in the

development of tooth supporting tissues. These “matrix proteins” mediate

the formation of acellular cementum on the root of the developing

tooth, providing a foundation for all of the necessary tissues

associated with a true functional attachment.

E. Venezia M. Goldstein B.D. BoyanZ. Schwartz. THE USE OF ENAMELMATRIX DERIVATIVE IN THE TREATMENT OF PERIODONTAL DEFECTS:A LITERATURE REVIEW AND META-ANALYSIS. Crit Rev Oral BiolMed 15(6):371-391 (2004)

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(Lyngstadaas et al., 2001).

• Attachment rate, growth factor production (TGF-b1, IL-6, and PDGF-AB), proliferation, and

• metabolism of human PDL cells in culture were all significantly increased in the presence of EMD

(Gestrelius et al., 1997b; Kawase et al., 2000).

EMD favorsmesenchymal cell

growth over growth of epithelial cells.

Furthermore, it had been shown earlier that

EMD also seems to exhibit a cytostatic

effect upon cultured epithelial cells

(Spahr et al., 2002).

EMD has a marked inhibitory effect on the

growth of the Gram negative periodontal pathogens, without a similar effect on the

Gram-positive bacteria In addition, it was

demonstrated to have some antimicrobial

effect in vivo (Arweileret al., 2002)

This may explain EMD's biological 'guided tissue regeneration' effect observed in vivo, analogous to the mechanical prevention of barrier

membranes

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Sculean et al., 2001

EMD may also promote periodontal regeneration by

reducing dental plaque. In anex vivo dental plaque model, it was found that EMD had an

inhibitory effect on dental plaque viability

Soren Jepsen et al (2004)

• compared the efficacy of EMD Vs GTR in grade II mandibular furcation defects.

• Clinical parameters like gingival marginal level, bleeding on probing, Horizontal and vertical attachment levels, were assessed at baseline, 8 and 14 months

• Though both treatments led to clinically significant improvement the defects treated with EMD had a better horizontal defect closure, less pain and discomfort post surgery when compared to the patients receiving GTR.

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EXTRACTION

Extraction is the treatment of choice, when: (Lindhe 1997)

1) The patient’s oral hygiene will not maintain the tooth.

2) The patient does not choose to comply with restorative

recommendations without which the tooth cannot survive.

3) Adjacent teeth would serve as adequate abutments.

4) Financial considerations preclude acceptance of treatment.

5) Extraction will improve the prognosis of the adjacent teeth by improving bone levels resulting from socket fill.

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FAILURE IN FURCATION THERAPY

Inadequate plaque control and maintenance

Poor resection technique

Improper restoration after initial periodontal therapy

Root caries, and

Patients who respond poorly despite the best treatment efforts all

contribute to failures subsequent to furcation therapy.

Endodontic failure and root fracture are the most frequent causes of failure.

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CURRENT CONCEPTS

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Swaid FF, Riberio FV et.al 2011.

Investigated the use of Periodontal ligament cells in tissue engineering with

GTR in Class II furcations in dogs. This histological study revealed promising

results.

Anuj Sharma (2011) assessed the efficacy of PRF & OFD Vs OFD alone in

grade II Mandibular defects. Using a split-mouth design, 18 patients with 36

mandibular degree II furcation defects were randomly allotted and treated either

with autologous PRF and OFD or OFD alone. Plaque index, sulcus bleeding

index, probing depth, relative vertical and horizontal clinical attachment level,

gingival marginal level, and radiographic bone defect were recorded at baseline

and 9 months postoperatively

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All clinical and radiographic parameters showed

statistically significant improvement at the sites treated with PRF and OFD

compared to those with OFD alone.

John Casper (2012) investigated the use of Porous titanium granules (PTG)

in the treatment of class II buccal furcation defects in mandibular molars in

humans.

Study showed that PTG is safe to use in close proximity to root surfaces, but

no significant improvements in clinical endpoints of defect resolution were

observed.

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Masao Ozasa et al (2014) employed the furcation periodontitis model in

beagle dogs to evaluate the effects of ADMPC (Adipose tissue derived

Multilineage Progenitor cells). The furcation bone defects were surgically

created and the autologous transplantation of ADMPC and fibrin gel was

performed. Six weeks after transplantation periodontal regeneration was

assessed using microCT which showed a significant increase in bone

formation at sites where ADMPCS where applied when compared tocontrol sites.

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Sambhav Jain et al(2014) in a case report assessed the efficacy of PRF

and β Tricalcium phosphate in mandibular molar with recession and grade II

Furcation defect. They observed complete root coverage with gain in CAL I

Month postop. However extent of bone fill could not be assessed as the

patient did not report for follow up.

Anuj sharma (2016) in an RCT on Rosuvastatin 1.2 mg in situ gel

combined with 1:1 mixture of autologous platelet-rich fibrin and porous

hydroxyapatite bone graft in mandibular class II furcation defects observed

significant improvements of clinical and radiographic parameters in this

group compared with OFD alone.

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CONCLUSION

The skill and dexterity of the clinician is definitely put to test while treating

teeth with furcation involvement. Longevity of the tooth involved , depends

on the degree of furcation involvement, the anatomy of the tooth, its

position in the arch as well as on regular supportive care in addition to

diligent oral hygiene maintenance by the patient

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REFERENCES:

Newman M, Takei H,Klokkevold P, Carranza F. “Clinical Periodontology”

10th ,12th Edition. Saunders, Elsevier.

Rose L.F, Mealey B.L, Genco R.J, Cohen D.W- Periodontics, surgery,

implants – 1st edition Elsevier mosby- 2004

Lindhe, Lang, Karring, ‘Clinical Periodontology and Implant Dentistry’ 6th

Edition’, Blackwell Munksgaard, 2015

Müller & Eger Furcation diagnosis J Clin Periodontol 1999; 26: 485–498.

The role of resective periodontal surgery in the treatment of furcation

defects. Periodontology 2000, Vol. 22, 2000, 154–168.

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Huynh-Ba et al.The effect of periodontal therapy on the survival rate and

incidence of complications of multirooted teeth with furcation involvement

after an observation period of at least 5 years: a systematic review. J Clin

Periodontol 2009; 36: 164–176.

Marker. J Clinical Reliability of the ‘‘Furcation Arrow’’ as a Diagnostic

Periodontol 2006;77:1436-1441.

Walter C, Weiger R, Zitzmann NU. Accuracy of three-dimensional imaging

in assessing maxillary molar furcation involvement. J Clin Periodontol

2010; 37: 436–441.

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