Furcation the problem and its management

Furcation: The Problem and Its Management
Copyright ©2021 Periowiki.com
1

2

3
FURCATION:-
The anatomic area of a multi rooted tooth
where the roots diverge.
Glossary of periodontal terms – 2001 (4th edition)

4

5
The furcation entrance is the transitional
area between the undivided and the
divided part of the root

6
The furcation fornix
is the roof of the
furcation

7
ROOT FURCATION MORPHOLOGY

8
Maxillary molars
Trifurcated –
1) Facial furcation
2) Mesial furcation
3) Distal furcation

9
Maxillary molars
Mesial furcation - located more towards the lingual surface.
Distal furcation – located near the center of the tooth.

10

11
Mandibular molars –
-Bifurcated
-Buccal furcation
-Lingual furcation

12
Mandibular molar lingual
furcation
Mandibular molar buccal
furcation

13
I) INTRODUCTION
Why furcation involvement presents with both diagnostic and
therapeutic dilemmas?
Progress of inflammatory periodontal disease, if unabated, ultimately
results in attachment loss sufficient enough to affect the bifurcation or tri
furcation of multirooted teeth.
The furcation is an area of complex anatomic morphology that may be
difficult or impossible to be debrided by routine periodontal
instrumentation.
Routine home care methods may not keep the furcation area free of
plaque .
The presence of furcation involvement is one clinical finding that can lead
to a diagnosis of advanced periodontitis and potentially to a less
favourable prognosis for the affected tooth or teeth.

14
What factors should be considered during the
diagnosis, treatment planning and therapy of
the patient with furcation defects?
1) Bacterial plaque
2) Local anatomic factors
3) Age of the patient
4) Dental caries and pulpal death
II) ETIOLOGIC FACTORS OF FURCATION
PROBLEMS

15
PROBLEMS
In the development of furcation defects,
1) The primary etiologic factor
i) bacterial plaque
ii) Inflammatory consequences that
result from its long-term presence

16
PROBLEMS
2) Local anatomic factors:-
- Root trunk length
- Root morphology
- Cervical enamel projections
(local developmental anomaly)

17
PROBLEMS
What is the significance of local anatomic
factors in periodontitis and attachment loss?
-The extent of attachment loss required to produce
a furcation defect is variable and related to the
local anatomic factors.
-Also, local factors may affect the rate of plaque
deposition or complicate.
-Local factors affect the performance of oral
hygiene procedures. Copyright ©2021 Periowiki.com

18
PROBLEMS
3) Age of the patient :-
Studies indicate that prevalence and severity of
furcation involvement increase with age.

19
PROBLEMS
4) Dental caries and pulpal death:-
May also affect a tooth with furcation involvement or even
the area of the furcation.

20
III) DIAGNOSIS OF FURCATION DEFECTS
The dimension of the furcation entrance is variable
but usually quite small.
% of Furcations Furcation
orifice
81% 1mm or less
58% 0.75mm

21
Selection of instruments for furcation probing :-
i) Furcation entrance dimension +
ii) Furcation area local anatomy.
iii) A probe of small cross section is required if one
is to detect early furcation involvement.

22
1) Careful probing helps to determine the
furcation involvement :-
i) Presence
ii) Extent
iii) Configuration
iv) Position of the attachment relative to the furca.

23
2) Transgingival probing - is the procedure in
which tip of the probe makes direct contact
with the bone when the probe is forced under
local anesthesia through the gingiva.

24
2) Transgingival sounding goals in furcation defect
assessment:-
Furcation defect
identification
Define the anatomy
of furcation
involvement
Classify the extent of
furcation
involvement
Morphology of the
affected tooth
Position of the
tooth relative to
adjacent teeth
Local anatomy of
the alveolar bone
Configuration of
any bony defects
Presence and
extent of other
dental diseases
such as caries and
pulpal necrosis

25
2)
The vertical depth of furcation
defects during transgingival
probing
The horizontal depth of
furcation defects during
transgingival probing
Bansal M, Singh TM. The efficacy of transgingival probing in class II buccal furcation defects treated by
guided tissue regeneration.JISP. 2016;20(4):391-395.

26
Vertical component of the furcation –
is measured from the floor of the furcation
to the roof the furcation

27
Nabers probe
Nabers 2N probe – in
mandibular buccal furcation

Copyright ©2021 Periowiki.com 28
Karthikeyan et al 2015

29
IV) CLASSIFICATION OF FURCATION
Zoya Chowdhary, Ranjana Mohan . Furcation involvement: Still a dilemma.
Indian Journal of multidisciplinary dentistry 2017;7(1):34-40.

30
Glickman graded furcation involvement into
the following:-
Grade I
Grade II
Grade III
Grade IV

31
According to Glickman:-
Grade I furcation (incipient or early stage) –
- Suprabony pocket present and primarily affects
the soft tissues.
-Early bone loss may have occurred with
an increase in probing depth,
-No radiographic changes seen usually

32
FIRST MAXILLARY MOLAR

33
FIRST MANDIBULAR MOLAR

34
Grade II furcation
- Furcation lesion is cul-de-sac.
- Can affect one or more furcations of the same tooth. They do
not communicate with each other, since a portion of the
alveolar bone remains attached to the tooth.
- Radiographs may or may not depict the furcation involvement.
This is particularly true of maxillary molars because of the
radiographic overlap of the roots. Although in some views the
presence of furcation arrows indicate possible furcation
involvement

35
Grade II furcation
FIRST MANDIBULAR MOLAR

36
Grade III furcation
-Probing confirms that the buccal furcation connects with the
distal furcation of both of these molars, yet the furcation is filled
with soft tissue.
- Bone is not attached to the dome of the furcation.
-Properly exposed and angled radiographs of early class III
furcations display the defect as a radiolucent area in the crotch
of the tooth.

37
Grade III furcation
MAXILLARY MOLARS

38
Grade IV furcation
-Interdental bone is destroyed.
-Soft tissues recede apically so that the furcation opening is
clinically visible.
-A tunnel therefore exists between the roots of such an affected
tooth.
-The periodontal probe therefore passes readily from one aspect
of the tooth to another

39
Grade IV furcation
MAXILLARY MOLAR

Andrea Pilloni and Mariana A. Rojas (2018)

Andrea Pilloni
and
Mariana A.
Rojas (2018)

Refer slides nos. 49 to 53 for figures

56
V) LOCALANATOMIC FACTORS IN TREATMENT
OF FURCATIONS
Tooth root trunk length –
1) Key factor in the development and treatment of
furcation development.
2) Teeth may have :-
i) very short root trunks,
ii) moderate length trunks
iii) roots than may be fused to a point near the
apex

57
Classification of molar root trunk dimensions
OF FURCATIONS
Arch Classification Dimension
Maxillary Short 3mm
Medium 4mm
Long ≥ 5mm
Mandible Short 2mm
Medium 3mm
Long ≥ 4mm

58
Short root trunk -
OF FURCATIONS
Once the furcation is exposed,
-teeth are more accessible to
maintenance procedures and
-may facilitate some surgical
procedures.
J
A
Y
P
E
E
D
I
G
I
T
A
L
.
C
O
m

59
Unusually long root trunks or fused roots -
OF FURCATIONS
J
A
Y
P
E
E
D
I
G
I
T
A
L
.
C
O
m

60
OF FURCATIONS
Tooth root length –
Root length is directly related to the quantity
of attachment supporting the tooth.

61
OF FURCATIONS
Short
root
length
Long
root
trunk
On furcation
involvement,
tooth have
lost majority
of support.

62
OF FURCATIONS
Long root
length
Short to
moderate
root trunk
length
Readily treated
as sufficient
attachment
remains to meet
functional
demands.

64
OF FURCATIONS
Tooth root form –
The mesial root of most 1st & 2nd mandibular molars and the
mesiofacial root of the 1st maxillary molar are commonly curved
to the distal 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 endodontics or complicate post placement
during restoration.

65
OF FURCATIONS
Tooth root form –
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 the majority of the portion of the tooth
during preparation.

66
OF FURCATIONS
Interradicular dimensions –
more treatment
options and are
more readily
treated
Widely separated
roots Roots are
separated
but close.
Fused roots
separated only
in their apical
portion.
preclude adequate instrumentation
during scaling, root planing and surgery.

67
OF FURCATIONS
Anatomy of furcations –
Complicates
scaling, root
planing and
periodontal
maintenance
Bifurcational
ridges
Concavity of
dome
Accessory
canals

68
OF FURCATIONS
Cervical enamel projections –
8.6% to 28.6% of molars
Highest prevalence - mandibular and maxillary second molars.
Affect plaque removal, complicate scaling and root planing, and
may be a local factor in the development of gingivitis and
periodontitis.
They should be removed to facilitate maintenance.

69
OF FURCATIONS
Furcation involvement by grade III cervical enamel projections.

70
OF FURCATIONS
Masters and Hoskins (1964)

71
VI) THE ANATOMY OF THE BONY LESIONS
Pattern of attachment loss:-
• can expose the furcation
as thin facial/lingual
plates of bone that may
be totally lost during
resorption.
Horizontal
bone loss

72
areas with thickened bony ledges
may persist and
predispose to the
development of
furcations with
deep vertical components.

73
Factors to be considered during treatment plan
The pattern of bone loss on:-
other
surfaces of
affected
tooth
adjacent
tooth

74
Treatment plan
Complex multiwalled
defects
with deep interradicular
vertical components
Regenerative therapy

75
Treatment plan
molars with
advanced
attachment loss
on only one root
Resective
procedures

76
VII) OTHER DENTAL FINDINGS
Maxillary 1st molar –
Buccal furcation communicates
with distal furcation
+
advanced attachment loss
on the distal root
+
Approximation with the mesial 1) Distobuccal root resection
of the maxillary second molar. maxillary 1st molar
or
2) Maxillary 1st molar
extraction

77
VII) OTHER DENTAL FINDINGS
Adequate band of gingiva
&
Moderate to deep vestibule
facilitate the performance of a surgical
procedure should it be indicated

78
VII) TREATMENT OF FURCATION DEFECTS

79
A) OBJECTIVES OF FURCATION THERAPY
1)Facilitate maintenance,
2)Prevent further attachment loss,
3)Obliterate the furcation defects as a periodontal
maintenance problem.

80
B) Therapy for Early Furcation Defects: Class I
As the pocket is suprabony and has not entered the
furcation :-
i)oral hygiene,
ii)scaling
iii)root planing are effective.
Thick overhanging margins of restorations, facial grooves,
or cervical enamel projections should be eliminated by:-
i)odontoplasty,
ii)recontouring or
iii)replacement.

81
C) Therapy for furcation involvement: Class II
-Therapy becomes more complicated
Shallow horizontal involvement without
significant vertical bone loss
Isolated deep class II furcations
or
flap procedures
with
osteoplasty
and
odontoplasty

82
D) Therapy for advanced furcation involvement:
Class II-IV
Significant horizontal component to one or
more furcations of a multirooted tooth
(late class II, class III or IV")
and/or
development of a deep vertical component
to the furca

83
E) Surgical therapy for Furcation involvement
Root Resection
Indicated in - multirooted teeth with grade II to IV
furcation involvements.
Performed on - vital or endodontically treated teeth.

84
Root Resection
Preferable - to have endodontic therapy completed before
resection of a root(s).
If this is not possible, then :-
-pulp should be removed,
-patency of the canals determined, and
-pulp chamber medicated before resection.

85
Root Resection
When
planning for
root resection
of teeth
consider:-
Consider the
critical
importance of
teeth to the
overall dental
treatment
Teeth with
furcation defects
that have been
treated successfully
with endodontics
but now present
with vertical root
furcation ,
advanced bone loss
or caries on one
root
Teeth in patients
with good oral
hygiene and low
activity
for caries are
suitable candidates
Teeth that have
sufficient
attachment
remaining for
function.

86
Root Resection
A tooth with an isolated furcation defect in an otherwise
intact dental segment may present few diagnostic
problems.
However, the existence of multiple furcation defects of
varying severity when combined with generalized
advanced periodontitis can be a treatment planning
challenge.

87
Root Resection
Buccal view :- 1st mandibular molar –
grade II furcation , 2nd mandibular molar
– grade III furcation
Lingual view
Mesial root
resection of 46
3 months post
operative view

88
Root Resection
The following is a guide to determine
which root should be removed
1) Remove the root(s) that will eliminate the furcation
and allow the production of a maintainable architecture
on the remaining roots.
2) Remove the root with the greatest amount of bone
and attachment loss.
3) Teeth with uniform advanced horizontal bone loss
are not candidates for root resection

89
Root Resection
The following is a guide to determine
which root should be removed
4) Remove the root that best contributes to the elimination
of periodontal problems on adjacent teeth.
5) Remove the root with the greatest number of anatomic
problems such as severe curvature, developmental grooves, root
flutings, or accessory and multiple root canals.
6) Remove the root that least complicates future periodontal
maintenance. Copyright ©2021 Periowiki.com

90
Hemisection
1) Also known as bicuspidization or separation.
2) It is the splitting of two rooted tooth into two separate
portions.
3) Performed most likely on –
mandibular molars – with – buccal or lingual class II or III
furcation involvements.

91
Hemisection
4) Not good candidates for hemisection :-
- molars with advanced bone loss in :- interproximal and
interradicular zones.

92
Hemisection
Bone loss –
i) extent
ii) pattern
Root –
i) trunk
ii) length
iii) Anatomy
Osseous defect
elimination ability
Endodontic and
restorative
considerations
5) After hemisection, to retain one or both the roots is based
on :-

93
Hemisection
6) The anatomy of the mesial roots of mandibular molars
often leads to their extraction and the retention of the
distal root to facilitate both endodontics and
restorative dentistry.

94
Hemisection
7) Importance of interradicular dimension between the
two roots of a tooth to be hemisected :-
- Narrow interradicular zone:-
i) complicates surgical procedure
ii) makes it virtually impossible to finish margins
iii) makes it virtually impossible to provide
adequate embrasure between the two roots for
effective oral hygiene and maintenance.

95
Hemisection
7) Importance of interradicular dimension between the
two roots of a tooth to be hemisected :-
- Narrow interradicular zone:-
Orthodontic separation of the
roots is commonly required to
allow restoration with adequate
embrasure form
Treatment alternatives:-guided
tissue regeneration
or
guided bone regeneration
or
osseointegrated dental implants
should be considered

96
Hemisection
A case of deep grade II buccal furcation and root approximation
Buccal view - 3 weeks postoperative.
As the embrasure space is minimal,
these roots will be separated with
orthodontics to facilitate restoration

97
The root resection/ hemisection procedure
-The most commonly performed root resection is the distobuccal
root of the maxillary first molar.

98
Patients with advanced periodontitis commonly have root resection
performed in conjunction with other surgical procedures :-
The bony lesions that may be present on adjacent teeth are then
treated using resective or regenerative therapies.
After resection the flap(s) are then approximated to cover any
grafted tissues or to slightly cover the bony margins around the
tooth.
Sutures are then placed to maintain the position of the flaps.
The area may or may not be covered with a surgical dressing.

99
Patients with advanced attachment loss may
benefit from temporary stabilization of the
resected tooth to prevent movement.
A temporary wire splint has been bonded to the
molars to prevent tipping of the distal root of
the mandibular second molar.

100
Prognosis for root resection/ hemisection
Root-resected or hemisected teeth have provided
evidence that such teeth can function successfully for
long periods.
The keys to long term success appear to be:-
- thorough diagnosis,
-selection of patients with good oral hygiene,
-careful surgical and restorative management.

101
Reconstruction
Many surgical procedures using a variety of grafting
materials have been tested on teeth with different classes of
furcation involvement.
Some investigators have reported clinical success with these
techniques.
Whereas others have suggested that the use of these
materials in class II, III, or IV furcations offers little
advantage compared with surgical controls.

102
Furcation defects with deep two-walled or significant
three-walled components may however be candidates for
regeneration procedures.
These vertical bony deformities respond favorably to a
variety of other surgical procedures such as debridement
with or without membranes and bone grafts.
Reconstruction

103
Reconstruction
GTR Treatment in Furcation Grade II Periodontal Defects with the
Recently Reintroduced Guidor PLA Matrix Barrier
Anton Friedmann, Andreas Stavropoulos, Hakan Bilhan 2020

104
Reconstruction
Anton Friedmann, Andreas Stavropoulos, Hakan Bilhan 2020

105
Reconstruction
Anton Friedmann, Andreas
Stavropoulos, Hakan Bilhan
2020

106
Reconstruction
Use of Platelet-Rich Fibrin in the Treatment of Grade 2 Furcation Defects:
Systematic Review and Meta-Analysis (2020)
Conclusion:
•Adjunctive use of PRF to OFD seems to enhance the periodontal regeneration in
the treatment of grade 2 furcation defects.
•The combination of PRF and bone graft (DFDBA, ALN gel, BCCG, β-TCP) did
not show better clinical results, except for vertical clinical attachment level
(VCAL), although the amount of literature with low risk of bias is scarce.
•Further well-designed studies to evaluate the combination of these two materials
are therefore needed.

107
Extraction
The extraction of teeth with through and through
furcation defects (class III and IV) and advanced
attachment loss may be the most appropriate therapy
for some patients.

108
Extraction
True for individuals who :-
i) cannot or will not perform adequate plaque
control,
ii) have a high level of caries activity,
iii) will not commit to a suitable maintenance
program,
iv) Some patients are reluctant to accept
periodontal surgery

109
Extraction
The patient may elect to forego therapy, opt to treat
the area with scaling and root planing or site-
specific antibacterial therapies and delay removal of
the tooth until the tooth becomes symptomatic.
Although additional attachment loss may occur, it is
not uncommon for such teeth to last a significant
number of years.

110
Extraction
The advent of osseointegrated dental implants as an
alternative abutment source has had a major impact
on the retention of teeth with advanced furcation
problems.
The high level of predictability of osseointegration
may motivate the therapist and patient to consider
removal of teeth with a guarded or poor prognosis
and to seek an implant-supported prosthetic
treatment plan.

111
References
William R Ammons Jr. and Gerald W. Harrington . Furcation: The
Problem and Its management. In: Carranza’s Clinical Periodontology 9th
edition.
Karthikeyan et al. Furcation measurements: realities and limitations. Journal of
International Academy of Periodontology 2015;17/4:103-115.
Pilloni A, Rojas MA. Furcation Involvement Classification: A Comprehensive
Review and a New System Proposal. Dent J (Basel). 2018;6(3):34. Published
2018 Jul 23. doi:10.3390/dj6030034
Anton Friedmann, Andreas Stavropoulos, Hakan Bilhan, "GTR Treatment in
Furcation Grade II Periodontal Defects with the Recently Reintroduced Guidor
PLA Matrix Barrier: A Case Series with Chronological Step-by-Step
Illustrations", Case Reports in Dentistry, vol. 2020, Article
ID 8856049, 10 pages, 2020.

112
References
Tarallo F, Mancini L, Pitzurra L, Bizzarro S, Tepedino M, Marchetti E.
Use of Platelet-Rich Fibrin in the Treatment of Grade 2 Furcation
Defects: Systematic Review and Meta-Analysis. J Clin Med.
2020;9(7):2104.
Periowiki.com holds copyright of this power point presentation only.
Patient case photographs, screen shots of tables credit – Google, textbooks and
journal articles (details mentioned in the ppt).

Furcation the problem and its management

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Furcation the problem and its management

Similar to Furcation the problem and its management (20)

More from Periowiki.com

More from Periowiki.com (14)

Recently uploaded

Recently uploaded (20)

Furcation the problem and its management