simplified presentation of how to diagnose, treat F.I of multi-rooted teeth.

1. Furcation Involvement in
General Dental Practice
Belal Nabil

2. Def.
• Bone resorption and
attachment loss in
interradicular space that results
from Plaque-associated
periodontal disease and
increases the risk of tooth loss
(Cattabriga et al)
• The pathologic resorption of
bone in the anatomic area of a
multirooted tooth where the
roots diverge

3. Epidemiology:
• A) prevalence of severe periodontal disease:
• Varies from 5% to 20% of different populations, tooth loss seems to
be inevitable even in successful outcome patients.
• Molar are most affected and least responsive to treatment.
• B) prevalence of furcation involvement:
• Increases in severity with ageing.
• Maxillary molars more affected (25-52%) than mandibular molars (16-
35%).
• First molars are more affected than second molars.
• More frequent in smokers (72%) than non-smokers (36%).

4. Etiology and exacerbating factors:
• A) Etiology:
• (Kalkwarf and Reinhardt)
1. Anatomic factors: root caries, restorations, root trunk length.
2. Enamel projections: uncertain role but found in (8.6 – 28.6%) of
molars (Carranza).
3. Occlusal trauma: still controversial whether it is a definite cause or
contributing factor.
• (Waehaug)
Subgingival plaque.

5. • B) exacerbating factors: (Gattani et al)
1. Root concavities: deepest concavity in MB root of upper 6 and M root of lower
6 (Bower 1979)
2. Cervical enamel projections: significant relation between CEP and class 2 and 3
Furca (swan and Hurt). The projections divided into three grades: Grade 1 : very
slightly extending from CEJ. Grade 2: approaching furca. Grade 3: extending
into furca. In maxilla 1>3>2 while in mandible 1>2>3 (Lieb et al)
3. Accessory pulp canals: 28% (Gutman) to 46% (Vertucci) or 76% (burch and
halen)
4. Bifurcation ridges: found in 73% of lower first molars connections between
mesial and distal roots at furca level.
5. Root trunk length: the longer the root trunk the less incidence of furca
involvement.
6. Width and location of furca. entrance:
low correlation between MD width and furca entrance.

6. Classifications:
• There are many classifications of furca involvement but for simplicity
the most common and the recent one will be outlined:
A) Hamp et. al:
• Degree I: Horizontal loss of periodontal tissue support less than 3
mm.
• Degree II: Horizontal loss of support 3 mm, but not encompassing the
total width of the furcation.
• Degree III: Horizontal through-and-through destruction of the
periodontal tissue in the furcation.
B) Tarnow and Flectcher:
Sub class A: 0-3 mm
Sub class B: 4-6 mm
Subclass C: > 7mm

7. Diagnosis:
• A) Clinically:
1. Probing: (Cattabiga et al)
• Reproducible in facial of upper molars and buccal and lingual of lower ones.
• Interproximally: the reproducibility decreases with increasing pocket depth and root
separation as probe penetrates deeper make it more difficult to contact the root.
2. Bone sounding :
• Under LA increases the accuracy of diagnosis (Mealy et al)
• Detection done by passing of curved instrument (Pigtail explorer, Nabers 2N or worn
out curet)
• Diagnosis not complete until surgical access (Kalkwarf)
• Severity should be assessed as follow:

8. B) Radiographically: (Cattabiga et al):
• Easier in lower molars due to superimposition of palatal root in
upper molars.
• In upper molars: appearance of furcation arrow: arrow-head
shaped radiolucency superimposed on either one or both
buccal roots of upper molars.
• RL presence in root trunk not necessarily due to FI, as it may be
due to PDL reasons (Trauamatic occlusion) or Endo reasons
(Root perforation)
• Furca involvement more frequent in upper molars by
radiographic examination than clinical inspection, while the
opposite was true for lower molars ( Ross and Thompson)

9. Treatment Modalities:
• All treatment techniques of FI can be categorized into:
• Non surgical: Scaling, root planning and oral hygiene practice to control plaque and plaque
retentive factors.
• Surgical: surgical technique can subdivided into resective and regenerative.
• Clinical evaluations do not indicate a dramatic difference between surgical and non-surgical
treatment (Cattabiga et al)
• Combined therapy (surgical and allografts)  greater pocket reduction and pocket fill than
surgical debridement alone.

10. 1) NSPT
(Root Curettage)
For class 1 lesions only, needs monitoring.
In class 1 no different outcome between hand
and ultrasonic instrumentation, but in class 2
and 3 ultra sonic is better (Leon and vogel)
2) Apically repositioned flaps:
(with or without odontoplasty
osteoplasty)
Furcation plasty is the reshaping of
interradicular bone (osteoplasty)
and/or tooth substance
(odontoplasty) at the level of
the furcation entrance to
reestablish soft tissue morphology
and allow access for cleaning
Best method for calculus removal with rotary
device (Parashis).
Odontoplasty: reshaping of the tooth to widen
inter-radicular area and to remove or reshape
the horizontal component of FI. Limited to C1
and shallow C2.
Osteoplasty: Elemination of bony ledge and
placement vertical grooves in bone just coronal
to furca make more gradual contours (better
OHP)
3) Tunneling:
Survival rate associated with this
procedure ranges from 57.1% to
92.9% after an observation period
of at least 5 years (Huynh-Ba et. Al)
Very conservative in class 2 and class 3.
Make patient able to use interdental brush to
remove plaque.
No need for prosthetic replacement.
Indicated when furca entrance wide enough
and coronally located.
Limited for lower molars and upper molars after
resection of one root.
4 out of 7 developed root caries, 44%
extracted during initial treatment (Hamp
et al).
149 teeth class 3 FI, 75% caries free
(Hellder et al)
Topical application of fluoride or
chlorhexidine varnishes is mandatory to
overcome caries development in the
furca area  risk of root caries(Zimmer).

11. 5) Root resection:
Survival rates ranged from
57.9% to 100% after a mean
observation period
of 5–10 years. (Huynh-Ba et.
Al)
Uncontrolled bone loss, root proximity prevents
proper maintenance, tooth/ root fracture, RCT or PA
pathology in one canal, when recession exposing
entire root cannot be corrected by regeneration,
ostectomy and odontoplasty contraindicated.
701 resected molars and 1472 implants, the Success
rates reached 96.8% and 97.0% (Fugazzotto 2001)
Class 1 furca., Severe bone loss around
remaining roots.
RCT cannot be done in the remaining
Root(s) (calcified canals or fused roots).
10 years of 100 cases 38% failure (Langer
et al) due to root fracture, endo failure
or perio. Disease.
6) Regeneration:
To recreate lost PDL
attachment in class 2 and 3.
Theory: regeneration may
occur if cells from PDL
allowed to repopulate on the
affected root surfaces by
acting as barrier excludes
gingival connective and
epithelial tissue from healing
forming new attachment of
bone.
Survival rates ranging
from 83.3% to 100%. (Huynh-
Ba et. Al) affected by initial
severity of FI (Jepsen et al
2004)
GTR : C 2: Promising results (Becker et al).
Evidence shows more favorable outcome than open
flap debridement. Factors:
1. Deep pockets: complete closure
2. Root trunk: longer less attach.
3. Furcation fornix: apically attach.
4. Bone coronal to fornix: MD attach.
Combined (GTR + Bone) more horizontal bone gain.
C 3: No evidence of partial closure (Pontoriero).
(long-term results):
Horizontal gains  attach. (0.75 to 4 mm)
 bone (0.2 to 4.5 mm)
can improve  class 2 to class 1.
 C1 prognosis.
Mean horizontal attach. Gains could be maintained
for 5 years, with (non) resorbable barriers
Enamel Matrix Derivative:
C 2:
Lower molars: 1 of 10 defects completely
closed, reduction in 2mm in pocket depth
(Chistazi)
Upper molars: 15 FI, 2 completely closed
and 9 converted into C1 (Casarin et al)
Combined therapy: 11 pts with 11 buccal
lower C2, 2 years  7 converted C1
 4 complete closure
C 3:
EMD alone or with GTR did not result in
predictable regeneration of lower C3
(Sanz & Giovannoli 2000).

13. mainly related to
endodontic
complications and
root fractures
and not to
periodontal disease
recurrence.

14. Adjunctive therapy:
Chemotherapy:
• No further improvement seen of adjunctive 1% Metronidazole in class 2 or
3 with subgingival scaling (Needleman and watts)
• Using immobilized tetracycline in collagen film (SR) alone or with root
planning lead to decrease of BOP and probing depths. And after 8 weeks,
spirochetes count
• Tetracycline-containing fibers exert a significant adjunctive pocket depth
and bleeding reduction over that produced by scaling and root planing
alone (Tonneti et al).
• Overall:
1. No clear acceptance to implementation of adjunctive local drug therapy
in furca areas regardless severity degree.
2. Drugs do not seem to add long-term advantages of root planning only

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