All furcation defects need to be classified and their possible prognosis should be defined. The treatment of the furcation defects should be carried out accordingly. Treatment include Osteoplasty, Odontoplasty, Tunnel preparation, Root resection, Hemisection

1. Management of
Furcation Defects

3. Contents
1. Furcation Therapy
• Scaling and Root Planing
• Antimicrobials
• Odontoplasty, Ostectomy, Osteoplasty
• Tunnel preparation
• Hemisection
• Root Resection
• Regeneration
• Extraction
2. Prognosis
• Systemic Factors
• Local Factors

4. Furcation Therapy
Class I
(Early Defects)
Scaling and
root planing
Osteoplasty, Odontoplasty,
Ostectomy
Class II
Osteoplasty,
Odontoplasty,
Ostectomy
Tunnel
preparation
Regeneration
(GTR with bone
grafting)
Class II-IV
(Advanced Defects)
Tunnel
preparation
Root Resection,
Hemisection
Tooth
extraction

5. I. Scaling and Root Planing
 Effective in Class I and early Class II Furcation
 Deeper sites respond less favorably
 In most situations, it results in the resolution of the
inflammatory lesion in the gingiva.

6. Scaling and Root Planing
 Mini Five Gracey Curettes, DeMarco curettes, Quetin furcation
curettes show better access to clean furcation area than
normal curettes
 For maintenance of furcation areas, patients can use Perio- Aid,
Proxy brushes

7. II. Antimicrobials
•Adjunct to scaling and root planing
• Chlorhexidine (Mouthwash)
• Tetracycline fibers (Local Drug
Delivery)

8. III. Odontoplasty, Osteoplasty and
Ostectomy
• Surgical access significantly enhance calculus removal in
molar furcation.
• Ultrasonic Scaler helpful in cleaning
• Narrow furcations
• Dome of furcation

9. III. Odontoplasty, Osteoplasty and Ostectomy
• If the alveolar bone at the furcation entry is altered 
osteoplasty / ostectomy
• If the tooth structure is altered (overhanging margins, facial
grooves, enamel projections)  odontoplasty

10. III. Odontoplasty, Osteoplasty and
Ostectomy
• Most effective in Class I and Class II furcation with
minimal of horizontal involvement and minimal of vertical
loss
• Odontoplasty, Osteoplasty and Ostectomy techniques done
to reduce dome of furcation and alter gingival contours
facilitating patients plaque removal

11. Procedure
Reflection of soft tissue flap.
Removal of the inflammatory soft tissue
SRP of the exposed root surfaces.
The removal of crown and root substance in furcation
area (odontoplasty)
The recontouring of the alveolar bone crest (osteoplasty)
Positioning and the suturing of the mucosal flaps

12. IV. Tunnel Preparation
• Indicated in Class II and III Furcation defects.
• This type of resective treatment is proposed if the root body is
short, if it has a wide and long divergence angle between the
mesial and distal roots.
• Following hard and soft tissue resection enough space (tunnel) is
established in the furcation region to allow access for cleaning
devices to be used during self performed plaque control.

13. Tunnel preparation
• The flaps are apically positioned.
• The exposed root surfaces should be treated by
topical application of chlorhexidine digluconate
and fluoride varnish to avoid caries and risk for
root sensitivity. Interdental Aids can be used in
tunnel area to keep it plaque free

14. V. Root Separation/ Hemisection/
Bicuspidization
• This is the splitting of double rooted tooth into two
separate portions
• Mandibular molars (mostly performed)
• Indicated in Class II and
Class III Furcation defects.
• Need widely separated
roots

15. Root Separation/ Hemisection/
Bicuspidization
• Retention of both the roots of a tooth and their
capping is difficult as it is difficult to provide
adequate embrasure between two roots for
effective oral hygiene
• So, orthodontic separation of the roots is required
to allow restoration (capping) with proper
embrasure form

16. VI. Root Resection
o Indications
Class II or Class III
Furcation
• Contraindications
• Inadequate bone
support
• Fused roots
• Inoperable
endodontically
Involves the sectioning and the removal of one or two
roots of a multirooted tooth.

17. • Endodontic treatment should be completed prior to root
resection.
OTHER INDICATIONS:
• Disease is localized in one or two teeth
• Advanced bone loss that cannot be treated with regenerative
methods around one or two roots
• Advanced gingival recession or dehiscence (localized area)
• Grade III or Grade IV Furcation defect
• Root fractures, Root cavities and Root resorption
• Good Oral Hygiene

18. Which root should be removed?
• Root with Furcation involvement/ OR with greatest amount of
attachment loss
• Root with anatomic involvement like developmental grooves,
accessory canals
• Root that least complicate periodontal maintenance
Most common root resected is distobuccal root of the maxillary
first molar

19. Procedure
Reflection of both facial and palatal/lingual soft tissue flap.
Removal of the inflammatory soft tissue
SRP of the exposed root surfaces.
Endodontic treatment should be completed before root
resection
The removal of root from furcation area (Root Resection)
Odontoplasty, Osteoplasty if required can be done

20. Procedure
Furcation area would be visible, so properly prepared so
as to prevent plaque accumulation
Patient with Periodontitis, may require Resective or
Regenerative therapy in adjacent defects
After Resective or Regenerative surgery, Flap sutured
Occlusion should be adjusted, if required, as one of the
roots has been resected

21. VII. Regenerationof Furcation defects
• Furcations with deep two–walled or three-walled bony
defects showed good post-operative regeneration of
bone with bone grafts and guided tissue regeneration
(GTR) membranes.
• GTR is applied on one side in Grade II furcation and on
both buccal and lingual/palatal sides in Grade III
furcation

22. • The aim of the technique based on the covering of bone
defects with barrier membranes, is to ensure that the defect
is filled with mineralized tissue (aided by graft) and to give
time for periodontal cells to form new bone, cementum and
periodontal ligament, by preventing growth of epithelium.
• Studies have shown good results with regeneration in Grade II
and Grade III Furcation defects when treated by Bone Grafts,
Sticky bone along with membranes like PRF (Platelet rich
fibrin), Amnion membrane (Resorbable; don’t need suturing)

23. GTRlimits
• The anatomy of the Furcation defect with complex
morphology  more in maxillary than mandibular
tooth
• The changing location of the soft tissue margins
during the early phase of healing with a possible
recession of the flap margin and exposure of
membrane, leading to failure

24. GTR Success rate improves if
• The membrane material is properly placed
• A plaque control program is put in place.
This should include daily rinsing with a chlorhexidine
mouthwash and professional tooth cleaning once a week for
the first month, and once every 2-3 weeks for another 6
months of healing following the surgical procedure.

25. VIII. Extraction option
• Through and through furcation defects (Advanced cases)
• Advanced attachment loss
• Un-adequate plaque control
• High caries activity
• Non compliance of the patient

26. Prognosis

27. Prognosis of teeth with Furcation
defects
•Prognosis can be defined as the
stability of supportive tissues.
Periodontal stability can be evaluated
as the continuation of the clinical
attachment level and radiographic
bone measurements.

28. 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

29. SYSTEMIC FACTORS INFLUENCING
SUCCESSFUL REGENERATION
1. 1. Smoking:- Epidemiological and longitudinal
studies have shown an increased prevalence of
periodontal disease and progression rate and present
less favorable response following both non-surgical and
surgical periodontal therapy among smokers compared
to non-smokers.

30. Mechanismsof the negative periodontaleffects of smoking
are :-
decreased vascular
flow
altered neutrophil
function
decreased IgG
production and
lymphocyte
proliferation
increased
prevalence of
periopathogens
altered fibroblast
function
difficulty in
eliminating
pathogens by
mechanical therapy
Negative local
effects on growth
factor production

31. 2. Stress
• The proposed mechanisms for the negative
periodontal effects of stress include :-
• neglect of oral hygiene, changes in diet, increase in smoking
and other pathogenic oral behaviors, bruxism, alterations in
gingival circulation, changes in saliva, endocrine imbalances
and lowered host resistance.

32. 3. Diabetes mellitus
• Various features or events seem to be responsible for delayed
wound healing in uncontrolled diabetic patients.
• Decreased tissue oxygenation, microvascular complications,
increased collagenase production, deficiency in growth factors
activity, deregulation of cytokines at the wound site, and
decreased migration of periodontal ligament cells, which can
interfere in the regenerative process.

33. 4. Other systemic conditions
• A negative prognosis might be anticipated in HIV-positive
patients with other clinical or immunological deficiencies, in
patients with rheumatoid arthritis, and other immune-
complex diseases.
• High doses of irradiation in patients with a history of head and
neck tumors might be detrimental to the regenerative
process.

34. 5. Plaque Control
• It could be stated that plaque-infected teeth will lose
attachment after any type of surgery. Numerous reports
indicate that good oral hygiene, as reflected in low plaque
scores, is associated with better regenerative responses.

35. LOCAL FACTORS INFLUENCING
SUCCESSFUL REGENERATION
• 1. Furcal Anatomy
The furcal anatomy-related factors are the presence
of cervical enamel projection, enamel pearls, root or
root trunk concavities, bifurcation ridge, accessory
canals, furcation entrance dimension and length of
root trunk.

36. Cervical enamel projections and enamel pearls
contribute to plaque accumulation and furcal invasion
removed by odontoplasty

37. Root concavity
• Contribute to plaque accumulation
• Clinical significance because of the ability of cementum to
hold toxic bacterial products .
• Thus, ultrasonic, hand and rotary instruments must be used
for more effective decontamination in furcation areas, as well
as the chemical conditioning of the scaled roots.

38. Bifurcation ridge
• The bifurcation ridge is an anatomic structure formed mostly
of cementum that originates from the mesial surface of the
distal root, runs across the bifurcation and ends high up on
the mesial root.
• This creates niches for plaque accumulation and has been
found mainly in mandibular molars.
• Odontoplasty should be considered in the presence of severe
bifurcation ridges to ensure proper root surface preparation.

39. Length of root trunks
• Short root trunk length is considered to be less favorable for
membrane coverage, coronal positioning and flap adaptation
against the tooth.

40. 2. Thickness of Gingival Tissue
• The amount and quality of the gingival tissue that will
cover the membrane is also important.
• Inadequate gingival width and thin keratinized tissue 
can lead to gingival recession.

41. • The revascularization of any flap may be further
compromised by blockage of the potential blood supply
from the periodontal ligament and bone defect to the
connective tissue of flap by a membrane.
• The thicker the connective tissue  the better the
potential circulatory pool and the greater the chance for
flap survival.
• Flaps with thin connective tissue are at greater risk for
inflammation induced post-surgical recession than thick
flaps.

42. 3. Tooth Mobility
Mobile teeth should be splinted
prior to surgery in furcation defects.
Presurgical hypermobility has
negative effect on surgical healing

43. CONCLUSION
• All furcation defects need to be
classified and their possible prognosis
should be defined. The treatment of the
furcation defects should be carried out
accordingly.

44. THANK YOU