1. Furcation: The Problem and Its Management

2. 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.

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

4. 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

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

6. 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

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

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

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

10. Glickman`s Classification(1953)

11. 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

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

13. 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.

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

15. 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.

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

17. Hamp, Nyman & Lindhe`s Classification (1975)

19. Tarnow & Fletcher`s Classification (1984)

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

21. Furcation Probing

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

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

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

25. 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

26. Therapy

27. 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.

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

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

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

31. 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.

33. 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

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

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

36. 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

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

38. Hemisection

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

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

41. 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

42. 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

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

45. 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

46. 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

47. 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

48. Successful Patient Outcomes
Function
Ease of Care
Esthetics
Confort
Health
Value