The document describes a case of a 28-year old male patient who presented with pain in his lower right back teeth. Clinical examination revealed grade II furcation involvement of tooth #46, along with radiographic evidence of bone loss. The proposed treatment plan was non-surgical therapy including scaling and root planing for tooth #46, followed by treatment of the furcation involvement using bone grafting and PRF placement.

1. Case
discussions

2. A 28-year-old male patient reported to the
Department of Periodontology with chief
complaint of a dull pain in right lower back
teeth for past 10 days.
 Pain –dull gnawing persistent pain
aggravates with mastication.


3. Clinical examination
Extraorally – no abnormality of lymph nodes
and TMJ detected
Intraorally Oral hygiene was fair
 No soft tissue abnormality

4. Region of complaint- 46:
Bluish red localized inflammation of the gingiva with
exudate. Probing depth of 5mm buccally, 6mm
interdentally on mesial and 6mm on distal aspect.
Premature contacts were present wrt to 16 leading to
trauma from occlusion
Nabers probe was used to check for furcation involvement.
There was partial penetration of probe, did not pass through
and through.

5. Radiograph - radiolucency
involving the furcation wrt
46. Loss of mild crestal interdental bone mesially and
distally.
Widening of PDL space in the
inter-radicular region wrt 46.
Loss of lamina dura evident in
the roof of furcation –
furcation arrow.
Grade II furcation
involvement

6. DIAGNOSIS
Chronic localized periodontitis irt 46
Grade II furcation
involvement

7. Treatment plan
Non surgical therapy ( scaling and root planing) was done
and patient was kept on maintenance for 1 month.
Occlusal correction done to correct trauma from
occlusion.
Patient recalled after I month for evaluation and treatment
of furcation

8. Treatment for furcation
involvement

9. Osseous defect debrided
Bone graft
PRF placement

10. Post op healing after 15 days
After 6 months
Radiographic picture after 6
months

11. 50 year old female patient had reported to
the department of periodontology with the
chief complaint of deposits on teeth .
 Patient was hypertensive , on medication.
Health check up was done one month
back and BP was 140/80.
Dental history- lower anterior teeth had been
extracted uneventfully 2 years back as
they were mobile and grossly decayed

C
a
s
e
II

12. On clinical examination
Extraorally – no abnormality of TMJ, lymph
nodes detected
 Intraorallypoor oral hygeine
Generalized probing depth of more than 5mm
Grade I mobility in 36 associated with probing
depth of buccally 7mm, interdentally 9 mm
on distal and 7mm on mesial aspect.
Proximal caries on the mesial aspect.


13. 36- Furcation involvement with nabers probe
– through and through involvement, not
visible clinically.
 Radiographically- loss of interdental bone
upto apical third wrt to distal root involving
the furcation.
 On endodontic evaluation- Tooth was non
vital


14. Chronic generalized periodontitis
Diagnosis Furcation
Grade III for 36???

15. Treatment plan
Non surgical periodontal therapy( scaling and
root planing)
 Root canal treatment for 36
 Periodontal treatment for 36
Regenerative procedures?
Hemisection ?
Tunelling?

16. Raising mucoperiosteal flap
Naber s probe – grade III

17. hemisection
Placement of bone graft
and PRF
suturing

18. After 1 month
Prosthodontic 3 unit bridge

19.  Furca’ means
Division
 By
definition
A furcation is defined as the anatomic
area of a multirooted tooth where the
roots diverge.
Furcation invasion refers to pathologic
resorption of bone within a furcation.
( American Academy of Periodontology, 2001)

20. CLASSIFICATION OF FURCATION
INVOLVEMENT

GLICKMAN
(1953)

HAMP , NYMAN & LINDHE
(1975)

TARNOW & FLETCHER
(1984)

21. GLICKMAN’S CLASSIFICATION 1953
Grade-I:
• Incipient or early stage
• Soft-tissue lesion or pocket extending
into flute of furcation
• Suprabony pocket
• Inter-radicular bone  intact or slight
bone loss
• Radiographic evidence of bone loss
usually not there

22. GRADE II
• Pocket formation & loss of inter-
radicular bone of varying depths into
the furcation but not through and
through
• Portion of PDL and bone remain
intact
• ‘ Cul de sac’ with a horizontal
component
• Partial penetration of probe ;
•
Radiographs  may or may not
depict involvement esp. in maxillary
molars.

23. Grade-III:
• Complete loss of inter-
radicular bone
• Radiographic evidence--
small triangular
radiolucency
• Pocket formation --
completely probable to
the opposite side of the
tooth
• Furcation not visible
clinically– occluded by
gingival tissue

24. Grade-lV:
• Same as Grade III except that loss of periodontal attachment &
gingival recession -- furcation clearly visible to a clinical examination.

25. CLINICAL AND
RADIOGRAPHIC CO
RELATION OF
GRADE 2, 3 AND 4.

26. Tarnow & Fletcher (1984)
Takes into account vertical bone loss from roof of furcation apically

Subclass A: Vertical destruction to one third of the total inter
radicular height (3 mm or less).

Subclass B: Vertical destruction reaching two thirds of the inter
radicular height (4 to 6 mm).

Subclass C: Inter radicular osseous destruction into or beyond the
apical third (> 7 mm).

27. Etiology of furcation invasions
 PLAQUE ASSOCIATED
 OCCLUSAL ORIGIN
 ENDODONTIC ORIGIN
 COMBINED ORIGIN
 IATROGENIC FACTORS
 ROOT FRACTURES INVOLVING FURCATIONS

28. DIAGNOSIS
2 Basic traditional methods are:
 CLINICAL PROBING
 RADIOGRAPHIC ASSESSMENT

29. Clinical probing
The buccal furcation entrance of maxillary
molars and buccal and lingual furcation
entrances of the mandibular molars are
normally accessible for examination using
either of the following:
a) A curved graduated periodontal probe
b) An explorer
c) A small curette


30. 




Probing of maxillary premolars  often difficult due to
limited access
Flap  explorative (surgical) procedure in the area
Maxillary molars
Distal furcation - located midway bucco-lingually -probing from both sides
Mesial furcations- located 2/3rd towards palate -probed from palatal aspect

31. RADIOGRAPHS IN
FURCATION
DIAGNOSIS
Should include both paralleing periapical and vertical bite
wing
Slight radiographic change in the furcation area should
be investigated clinically, esp if there is bone loss on
adjacent roots
Diminished radiodensity in furcation area in which
outlines of bony trabeculae are visible suggests furcation
involvement
Whenever there is marked bone loss in relation to a
single molar root, it may be assumed that the furcation is
also involved

32. Three broad strategies of furcation therapy
(Kalkwarf & Reinhardt R.A 1988)
I. Maintenance of the existing Furcation
Scaling and root planing
Obstruction of Furcation
II. Increasing access to the Furcation
Gingivectomy/Apical positioned flap
Odontoplasty
Furcationplasty
Osteoplasty /ostectomy
III. Elimination of the Furcation
Root amputation/ resection
Bicuspidization

33. Recommended methods of
therapy
Degree I
 SRP
 Furcation plasty
 Degree II
 Furcation plasty
 GTR at mandibular molars
 Tunnel preparation
 Root resection
 Degree III

 Tunnel preparation
 Root resection
 Tooth Extraction

34. Indications of surgical
procedures

A significant amount of horizontal involvement
of one or more furcations of multirooted teeth

Inability to adequately instrument the furcation
by scaling and root planing

Severe bone loss accompanying the furcation
which may require regenerative techniqiues

Carried out mostly in advanced grade II and
grade III and grade IV furcations

35. 1.‘Cul de sac’ involvement of furcation according to Glickman’s classification of
furcation is:
a.
Grade I
b.
Grade II
c.
Grade III
d.
Grade IV
2.The classification of furcation involvement based on vertical component was
given by:
a.
Glickman
b.
Hamp and Co-workers
c.
Tarnow and Fletcher
d.
Miller
3.Which of following tooth furcation involvement has a better prognosis?
a.
Mandibular molar
b.
Maxillary 1st premolar
c.
Maxillary molar
d.
None of the above

36. 4. The clinical probing of a furcation is done with the help of:
a.
William’s graduated probe
b.
UNC 15 probe
c.
Naber’s probe
d. All of the above
5.The root most commonly removed in root resection procedure
in maxillary 1st molar is :
a.
Mesiobuccal
b.
Palatal
c.
Distobuccal
d. Any of the above
6.Probing of mesial furcation of maxillary molars is done from:
a.
Buccal aspect
b.
Distal aspect
c.
Palatal aspect
d.
Mesial aspect