Furcation involvement-periodontology

1. Furcation
involvement

2. Classification of
furcation
involvement.

3.  Glickman classification (1958) (horizontal CAL).
 Hamp et al. (1975) (horizontal CAL).
 Tarnow& Fletcher (1982) (vertical CAL).

4. Grade I:
Incipient/ early stage
Early bone loss / increase
probing depth
No radiographic changes
Grade II:
Can affect one or more furcations
of the molar
Not communicated with each other
Remaining alveolar bone attached to
tooth
With or without vertical bone loss
RG: may or may not not be
evident (superimposed buccal or
lingual bone) and (superimposed roots)
Glickman classification (1958)

5. Grade III:
Loss of bone at the dome of
furcations
Through & through
RG : RL at furcation area
Clinically : covered by soft tissue
Grade IV:
Interdental bone destroyed
Through & through
Soft tissue recession apically
Furcation opening is clinically
visible
A tunnel exists between roots
Glickman classification (1958)

8. Hamp et al. (1975)

11. Tarnow and Fletcher 1984

12.  — Clinical examination (Careful probing)
 ① Nabor’s probe
 ② Transgingival sounding
 — Radiographic examination
Diagnosis of furcation defects By:

14. —To determine the extent and configuration of the furcation
defect and classify it
—To determine the position of the attachment level relative to the
furcation
—To identify factors that contributed in the furcation involvement
or might affect the treatment outcome
Aim of proper diagnosis of furcation defects:
Diagnosis of furcation defects

15. The furcation is an area of complex anatomical morphology.
The progression of inflammatory periodontal disease can ultimately
lead to loss of attachment in bifurcation & trifurcation of
multirooted teeth.
The accumulation of plaque biofilm is the main factor leading to CAL
in the furcation area.
Etiologic Factors

16. However, local factors contribute to
progression of CAL in furcation area:
Local factors affect:
—Rate of plaque deposition
—Complicate the performance of oral hygiene procedures

17. Local Anatomic Factors
Not only affect the progression of the disease but also affect the
treatment outcome (prognosis)
a) Morphology of the affected tooth
b) Position of the tooth relative to adjacent teeth
c) The anatomy and configuration of the alveolar bone defect
d) Other dental diseases (caries, pulp necrosis)

18. C)The anatomy and configuration of the alveolar bony lesions
—Horizontal bone loss
—Deep vertical defects
Also consider:
—Pattern of bone loss on other roots of same tooth
—Pattern of bone loss in adjacent teeth
Other dental findings
During treatment planning we must consider:
—Pulp involvement of the tooth affected
—Dental condition of adjacent teeth
—Periodontal condition of adjacent teeth
—Degree of root approximation with adjacent tooth
Local Anatomic Factors

19. • Cervical enamel projections
• Root trunk length
• Root length
• Root form
• Interradicular dimension
a) Morphology of the affected tooth
The anatomy of the furcation area itself may interfere with plaque
control by the patient & efficient mechanical debridement.
Local Anatomic Factors

20. The extension of enamel towards the furcation area.
prevalence: 8% - 28% in mandibular and maxillary second
molars.
These projections can affect plaque removal, can complicate
scaling and root planing, and may be a local factor in the
development of gingivitis and periodontitis. CEPs should be
removed to facilitate maintenance.
Cervical enamel projections

21. Masters & Hoskins 1964

22. Root trunk length
 This is a key factor in the development & treatment of
furcation.
 It represents the distance from the CEJ to the entrance of
Furcation
Teeth may have:
—short root trunks
—moderate root trunks or
—the roots may be fused to a point near the apex.

24. How root trunk length affect the
prognosis????
Short root trunks:
early furcation involvement/ BUT more accessible for
surgical & maintenance procedures
Long root trunks/ fused roots:
once furcation is involved ……….have poor prognosis

25. Root length is directly related to the quantity of
attachment supporting the tooth.
—Short roots + long root trunk:
when furcation is involved, majority of attachment is lost so
they have poor prognosis
—Long roots + short/ moderate root trunks:
better prognosis
Root length

26. Mesial root of mandibular molars and Mesiobuccal root of maxillary
molars are Curved distally at apical third & Heavily fluted
Complications:
—Increase potential for perforation during endo ttt
—Difficulty in post placement
—Increase incidence of vertical root fracture because of the size of
mesial radicular pulp…..removal of large portion of the tooth during
preparation
Root form

27. The degree of separation between the roots is also important in
treatment planning & response to therapy.
The furcation entrance dimension may be less than 0.75mm which
is less than dimension of curette.
This will complicate mechanical debridement and
surgical procedures
Widely seperated roots: better prognosis
Inter radicular dimension

28. Treatment

29. It is aimed to prevent further attachment loss
and improve the maintenance of furcation area.

30. Factors to be considered
before deciding the
treatment plan
Anatomical considerations:
o Crown-root ratio
o Length of root
o Degree of root separation
o Root anatomy
Mobility
Ability to eliminate the defect
Strategic value of the tooth
Endodontic therapy &
complications
Prosthetic requirements
Periodontal condition of
adjacent teeth

31. Maintain the furcation
Oral hygiene, scaling & root planing.
Increase the access to the furcation
 Odontoplsty
to reshape (thick overhanging margins) or (facial grooves)
in order to prevent plaque accumulation.
 gingivectomy to expose the furcation area..
This may be associated with odontoplasty to widen the
entrance to the furcation.
Treatment of Grade I

32. Advanced defects :
 Increase access to the furcation
 Odontoplasty & osteoplasty.
 Tunnel preparation.
 Closure of the furcation with
new attachment
 Regenerative techniques for
molar furactions (bone grafts/
GTR (guided tissue regeneration)
 Remove the furcation
 Root resection/ hemisectioning.
Treatment of Grade II
Shallow horizontal
involvement with no vertical
bone loss:
 Increase access to the
furcation
 simple flap with odontoplasty
and ostoeplasty

33. It is the surgical exposure of the entire furcation. It is by transforming
the grade II lesion to grades III and IV for better access.
Indications:
a. advanced class II & class III furcation involvement in mandibular
molars.
b. short root trunk, long, divergent roots to allow adequate plaque
control with interproximal brushes
c. Patients with good compliance to oral hygiene
Tunnel preparation

35. Tunnel preparation is not performed anymore
because of:
o Potential development of root caries.
o Sensitivity
o Exposure to patent lateral canals that will require
endodontic therapy in the future.
o Requirement that a patient should have good manual
dexterity to maintain optimal oral hygiene.

36.  Remove the furcation
 Root resection or amputation: After periodontal flap reflection, surgical removal of
the root portion of the affected tooth is most commonly performed in maxillary
first molars.
 Hemisection or root separation: It is the surgical removal of the root along with the
crown. Most commonly done in mandibular molars.
 Bicuspidization/root separation: Splitting of a two rooted tooth into two separate
portions. Frequently performed in mandibular molars.
 Closure of the furcation with new attachment
 GTR (guided tissue regeneration) may be used ( with less predictable results)
Treatment of Grade III& IV

37.  Root resections (amputations) are utilized when the furcation
invasion is too advanced to be corrected by the previous
techniques.
 Access to the furcation can be gained by removing one or more of
the affected roots.
Root Resection

38.  Extensive bone resorption around roots of affected tooth
 These procedures are only done if the roots that will be kept
have sufficient support for proper function.
Contraindications:
Narrow curved and partially obliterated canals of remaining
roots as this will make endodontic therapy difficult.
Fused roots
Extremely long root trunks
Insufficient periodontal support
Uncooperative Patient who will not perform proper oral hygiene
Indications:

39. 1. Remove the root that will eliminate the furcation.
2. Remove the root with the greatest amount of bone
and attachment loss.
3. Remove the root that best contributes to the
elimination of periodontal problems on adjacent teeth.
(ex: distobuccal root of upper 1st molar and upper 2nd
molar)
4. Remove the root with the greatest number of
anatomic problems such as severe curvature,
developmental grooves, root flutings,
or accessory and multiple root canals.
The following is a guide to determining which root
should be removed in these cases:

40. ● Hemisection is the splitting of a two-rooted tooth into two separate
portions. This process has been called bicuspidization or separation because
it changes the molar into two separate roots.
● Hemisection is most likely to be performed on mandibular molars .
● As with root resection, molars with advanced bone loss in the
interproximal and interradicular zones are not good candidates for
hemisection.
Hemisection

41.  After sectioning of the teeth, one or both roots can be retained. This
decision is based on :
 the extent and pattern of bone loss,
 root trunk and root length,
 ability to eliminate the osseous defect,
 endodontic and restorative considerations.
Hemisection

42. Endodontic therapy.
Non surgical periodontal therapy
Periodontal surgery (only for reading)
1. Elevation of buccal & palatal/lingual mucoperiosteal flaps.
2. After debridement resectionof the affected root, starts with
removal of small amount of bone; buccaly or palatally to facilitate
root sectioning.
3. A curved explorer,toothpicks or orthodontic wire is inserted in
furcation to guide the cuts.
Root Resection/Hemisection Procedure

43.  A horizontal cut is made below the coronal level of
furcation.
 This is followed by oblique cuts to facilitate separation of
the root.
 Following separation of the root & its elevation give
special attention to:
 Bone defects in area of furcation with bone recontouring.
 Preparation of tooth structure to eliminate any
overhangs of tooth structure.
 The remaining half of the crown is carefully contour ed
and smoothed and the flaps are repositioned.
 After healing, the tooth is crowned and usually forms
part of a bridge.

45. 45

46. 46

47. Extraction is the treatment of choice, when: (Lindhe 1997)
 1) The patient’s oral hygiene will not maintain the tooth.
 2) The patient does not choose to comply with restorative
recommendations without which the tooth cannot survive.
 3) Adjacent teeth would serve as adequate abutments.
 4) Financial considerations preclude acceptance of treatment.
EXTRACTION

48. THANK YOU …