Furcation: The Problem and Its Management

Definition It can be defined as: an area of complex anatomic morphology that may be difficult or impossible to be debrided by routine periodontal instrumentation.

Anatomical Considerations Root trunk Furcation entrance Root surface anatomy Enamel projections Accessory canals

Root Trunk Represents the undivided region of the root. The height of the root trunk is the distance between the CEJ and the separation line between two root cones

Furcation Entrance Entrance: the transitional area between the undivided and the divided part of the root Fornix: the roof of the furcation

Furcation Entrance Diameter How does the furcation entrance diameter relate to the blade width of a new curette? Blade width of new Gracey curette = 0.75mm 60% of molar furcation entrances < 0.75 mm Mandibular molars: buccal wider than lingual maxillary molars: mesial > distal > buccal

Root Concavities Mandibular Molars 100% mesial roots 99% distal roots Maxillary Molars 94% mesiobuccal roots 31% distobuccal roots 17% palatal roots

Cervical Enamel Projections 13% of molars have CEPs These projections may favor the onset of periodontal lesions in the affected furcations

Enamel Pearls Incidence: 1.1% - 9.7% Maxillary 2nd molar found near the CEJ extending into molar bifurcations

Glickman`s Classification(1953)

Class I Incipient Furcation This is an early lesion. The pocket is suprabony, involving the soft tissue. There is slight bone loss in the furcation area. Radiographic change is not usual since bone loss is minimal. A periodontal probe will detect root outline or may sink into a shallow V-shaped notch into the crestal area

Class I Incipient Furcation The level of bone loss allows for the insertion of the periodontal probe into the concavity of the root trunk

Class II Patent Furcation In this, bone is destroyed in one or more aspects of the furcation, but a portion of the alveolar bone and periodontal ligament remain intact, permitting only partial penetration of the probe into the furca. Radiographs may or may not reveal this type of furcation.

Class II Patent Furcation The level of bone loss allows for the insertion of a periodontal probe into the furcation area between the roots.

Class III Communicating or Through and Through Furcation This type of probe penetrates completely from one side to the other side characterized by severe bone destruction in the furcation area. It is clearly shown in the radiographs as a radiolucent area in between the roots, especially in the lower molars.

Class IV As in Class III, but the gingival tissues recede apically so that furcation is clearly visible.

Hamp, Nyman & Lindhe`s Classification (1975)

Tarnow & Fletcher`s Classification (1984)

Vertical bone loss is measured in mm from the roof of the furcation

Furcation Probing

Furcation Probing Mandibular Molars Buccal Furcation Place the probe between the two buccal roots from the buccal aspect

Furcation Probing Mandibular Molars Lingual Furcation Place the probe between the two lingual roots from the lingual aspect

Furcation Radiography Should include both periapical and bitewing Location of the interdental bone and bone level within the root complex should be examined

Differential Diagnosis Pulpal pathosis may some times cause a lesion in the periodontal tissues of the furcation Trauma from occlusion may cause inflammation and tissue destruction within the interradicular area of a multirooted tooth

Therapy

Objective of Treatment The elimination of the microbial plaque from the exposed surfaces of the root complex. The establishment of an anatomy of the affected surfaces that facilitates proper self-performed plaque control.

Non-Surgical Root Preparation Scaling & root planing Most effective in grade I and shallow grade II. Deeper sites respond less favorably

Scaling and root planing In most situations, it results in the resolution of the inflammatory lesion in the gingiva.

Antimicrobials Adjunct to scaling and root planning Chlorhexidine Tetracycline fibers No clinically significant difference in clinical parameters after irrigation

Open Debridement Greater calculus removal than closed Ultrasonic Narrow furcations Dome of furcation Surgical access and increased operator experience significantly enhance calculus removal in molar furcation.

Osseous Surgery Most effective in grade II furcation Osteoplasty and ostectomy techniques Remove the lip of defect to reduce horizontal depth Bone ramps into the furcation to enhance plaque control Reduce probing depths

Root Resection Grade II or grade III Contraindications Inadequate bone support Fused roots Inoperable endodontically Patient considerations

Sequence of treatment at RSR Endodontic treatment Provisional restoration RSR Periodontal surgery Final prosthetic restoration

Factors to be Considered The length of the root trunk The divergence between the root cones The length and the shape of the root cones Fusion between root cones Amount of remaining support around individual roots Stability of individual roots Access for oral hygiene devices

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

Hemisection

Root Separation Root separation involves the sectioning of the root complex and the maintenance of all roots

Tunnel Preparation Grade III furcation Permits plaque removal Root caries (4% stannous fluoride) 25% failure rate at 5 years Recurrent periodontitis

Regeneration of Furcation Defects Guided tissue regeneration Predictable outcome of GTR therapy was demonstrated only in degree II furcation involved mandibular molars less favorable results have been reported in other types of furcation defects GTR could be considered in areas with isolated degree II furcation defects

Furcation Defects Mesial or Distal Maxillary Class II Furcations Most predictable Mandibular or Buccal Maxillary Class II Furcations Mesial or Distal Maxillary Class II Furcations Class III Furcations Least predictable

Osseous Grafting Autogenous bone Allografts Freeze dried bone Demineralized Freeze dried bone Alloplasts Hydroxyapatite Non-porous Porous Bioglass

Extraction Attachment loss is so extensive that no root can be maintained If tooth/gingival anatomy will not allow proper plaque control For endodontic or restorative reason Osseointegrated implant substitute

Prognosis Hirshfeld and Wasserman. “A long term survey of tooth loss in 600 treated periodontal patients.” J Perio 1978 600 patients followed an average of 22 years with recall every 4-6 months 1464 molars initially diagnosed with furcation invasion 70% survival of furcated molars

Patients Factors Determine patient`s goals and expectations Screen for local, behavioral and systemic factors; Oral hygiene Compliance Stress Intraoral Accessibility Uncontrolled Diabetes Smoking Healing response to Previous Therapy

Successful Patient Outcomes Function Ease of Care Esthetics Confort Health Value