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1. Dr.Nourhan Mohamed
Dr.Kareem El hossieny Under the supervision of :
Dr.Mohamed Hossam
Dr.Nada Mahmoud PROF Dr. HALA ABO EL ELAA

2. Introduction
 The furcation is an area of complex anatomic
morphology that may be difficult to depride by
routine periodontal instrumentation and routine
home care methods may not keep the furcation area
free of plaque
 Furcation Involvement :-Periodontal disease if left
untreated ultimately progress to attachment loss sufficient
to affect the bifurcation or trifurcation area of multirooted
teeth
 Furcation involvement is a clinical finding that can
lead to a diagnosis of advanced periodontitis and
lead to a less favorable prognosis of the affected
tooth

3. Glikman(1950) : Commonly occurring
condition in which the bifurcation or
trifurcation of multirooted teeth are
denuded by periodontal disease
1950
Prichard (1965 ) : bifurcation and trifurcation
involvments are common periodontal lesions
which occur as a result of gingival
inflammation and bone resorption adjacent
to and within the furca of multirooted teeth
1965
Goldman & cohen (1968 ) :- extension of
pocket into the interradicular area of bone
in multirooted teeth
1968

5. The primary etiological factor is
:-
1)-Plaque accumulation
2)-Inflammatory consequences
resulting from its long-term
presence

6. Extent of attachment
loss required to
produce a furcation
defect is variable and
related to the local
anatomic factors
Local factors affect
the rate of plaque
deposition
Local factors affect
the performance of
oral hygiene
procedures

7. Extent of attachment loss on
furcation depends on :
 Local anatomic factors
Local developmental anomalies
Trauma from occlusion
Dental caries
Pulpal death
Iatrogenic Co factors

8. 1-Local Anatomical Factors
1-Root trunk length
2-Root length
3-Root form
4-Interradicular dimension
5-Anatomy of furcation

9. Root trunk length
 Represents the distance between the cementoenamel
junction to the entrance of the furcation.
 The combination of root trunk length with the number
and configuration of the roots affect the ease and
success of therapy
 The shorter the root trunk the less attachment need to
be lost before the furcation is involved
 Shorter root trunks are more accessible to maintenance
procedures and may facilitate some surgical procedures.
 Longer root trunks or fused roots may not be an
appropriate candidate for treatment.

10. Root Length
Root length is directly related to the quantity
of attachment supporting the tooth.
Teeth with long root trunks and short roots
may have lost a majority of their support by
the time that the furcation becomes
affected.
Teeth with long roots and short to moderate
root trunk length are more readily treated
because sufficient attachment remains to
meet functional demands.

11. Root Form
 The mesial root of most mandibular first and second
molars and the mesiofacial root of the maxillary first molar
are typically curved to the distal side in the apical third.
 the distal aspect of this root is usually heavily fluted
 The curvature and fluting may increase the potential for
root perforation during endodontic therapy or complicate
post placement during restoration.
 These anatomic features may also result in an increased
incidence of vertical root fracture Lommel et al 1978
reported that vertical root fractures are associated with
rapid localized alveolar bone loss

12. Interradicular Dimensions
 The degree of separation of the roots is also
an important factor in treatment planning
 Closely approximated or fused roots can
prevent adequate instrumentation during
scaling, root surface debridement, and
surgery
 Teeth with widely separated roots present
more treatment options and are more
readily treated.

13. Anatomy Of Furcation
The presence of bi-furcational ridges, a concavity in the
dome, and possible accessory canals complicates not only
scaling, root surface debridement, and surgical therapy, but
also periodontal maintenance
 Odontoplasty to reduce or eliminate these ridges may be
required during surgical therapy for an optimal result.

15. Cervical enamel projections
 Cervical enamel projections (CEP)(Enamel pearl): are flat ectopic projections of enamel
that extend beyond the normal contour of the CEJ.
 Cervical enamel projections (CEPs) are reported to occur on 8.6% to 28.6% of molars. The
prevalence is highest for mandibular and maxillary second molars.
 These projections :
A) Affect plaque removal
B) Can complicate scaling and root surface debridement.
C) Maybe a local factor in the development of gingivitis and periodontitis.
CEPs should be removed to facilitate maintenance.

17. Odontoplasty for CEP removal

19.  Lindhe & Svanberg 1974 stated that
trauma from occlusion coupled with
gingival inflammation has been
implicated in greater alveolar bone
loss in experimental animals
 The heavy occlusal load on molar
teeth may render them susceptible
to increased bone loss if
inflammation is present

20.  The role of pulpal pathology in the etiology of furcation
involvement is still unclear the high incidence of molar
teeth with accessory root canals support such association
 Loman et al 1973 reported the incidence of accessory
canals to be 55% in maxillary molars and 63% in mandibular
molars
 Another study by Gutman 1978 reported 29.4% incidence of
accessory canals in mandibular molars and 27.4% in
maxillary molars
 The high percentage of molar teeth with patent accessory
canal opening into the furcation area suggest that pulpal
disease could be an initiating co-factor in the
development of furcation involvement( Endo-Perio
lesion).

21. 5-Iatrogenic factors
Over-hanging restorations retain
plaque and may cause periodontal
inflammation and attachment loss
A study of molars with and without
crowns and proximal restorations
found that molars with
restorations had a higher
prevalence of furcation
involvement and attachment loss

23. Clinical Radiographs

24. A)-Probing with specially
designed probes such as
Nabers Probe
 Careful probing helps to determine
the furcation involvement
1- Presence
2-Extent
3-Configuration
4-position of the attachment relative to
the furcation

26. Due to anatomical limitations accurate diagnosis of furcation involvement may be
problematic.
Anderegg et al used the Glickman system to classify furcation invasions in
maxillary molars and compared measurements taken during initial patient
examination with those made after surgical depridement….only 62% of furcations
were diagnosed correctly perior to surgery with 28% initially underestimated and
10% overestimated.
the accuracy of clinical detection largely depends on operator technique, and
many times, the measurement is reflective of penetration depth into the
inflamed connective tissue, instead of the actual depth of the inter-radicular
Considering the difficulties in furcation measurement the
use of bone sounding technique may aid the clinician in
more accurate diagnosis of furcation defects.

27. B) bone sounding : furcal sounding is
performed by probing the bony depth of the
furcation in both horizontal and vertical
directions under local anesthesia
 An attempt to thoroughly explore the furcation to
its deepest point in both dimensions
 Bone sounding yielded accurate measurements
when compared to surgical entry measurements
Vertical bone sounding
Horizontal bone sounding

28. factors such as tooth position, inclination,
root morphology, length of root trunk, degree
of root separation and configuration of
residual inter-radicular bone, all affect
accuracy of clinical furcation assessment
SO clinical evidence should be corelated with
radiographic findings for proper diagnosis

29.  A careful radiographic diagnosis often provides early
evidence for interradicular periodontitis
 Radiographs may aid in the diagnosis of furcation
defects but are of limited value if used as the sole
diagnostic
 Slightest radiographic change in the furcation area
should be invistegated clinically especially if there is
bone loss on adjacent roots
 Ross & thompsonb1980 reports that radiographs were
able to detect furcation involvement in 22% of
maxillary and 8% of mandibular molars. This
discrepancy was attriputed to the difference in bone
densities of the maxiilary and mandibular arches

30.  When assessing periapical radiographs in maxillary
molars, a small triangular radiographic translucency
across the mesial or distal roots of these teeth, the so-
called “furcation arrow”, may indicate a more advanced
furcation involvement
 Hardekopf et al. proposed the term “furcation arrow”
to describe the small, triangular radiolucent shadow
seen across the mesial or distal roots of maxillary
molars.
 Although the association of the furcation arrow with
degree II or III FI was significant compared with
uninvolved furcations, this image was not seen in
approximately half of these sites with degree II or III FI
 Thus, it appears that radiographs alone do not
detect FI with any predictable accuracy and that
probing the furcation areas is necessary to
confirm the presence and severity of FI

31. These limitations of diagnosing FI from two-
dimensional radiographic images has been ascribed
to variations in :
1)-the shape of the roots,
2)-superimposition of the palatal root
3)- thickness of the alveolar bone, and other morphological variables

32. CBCT in
Diagnosing
FI :-

33.  Limited information about the molars' periodontal tissue support and about the
interradicular bone from clinical investigations and two-dimensional radiographs
may lead to inappropriate treatment decisions, e.g., about which root or roots
should be removed. Intrasurgical alteration of the treatment plan after surgical
visualization of the furcations is an unpleasant consequence of this insufficiency
 Mengel et al reported that furcation involvement can be differentiated into class I
,II and III by CBCT
 MISCH et al 2006 when compared to periodontal probing and 2D intra oral
radiography 3D CBCT scanning was found to be more
effective in assessing periodontal structures

34.  In a recent study, it was demonstrated that estimates from a three-
dimensional cone-beam computed tomography of the furcation
involvement of maxillary molars have a high degree of agreement
with those from intrasurgical assessments. Overall, 84% of the
CBCT data were confirmed by the intrasurgical findings. While
14.7% were underestimated ,CBCT data lead to an overestimation
in only 1.3% compared to the intrasurgical analysis

36. Cardinal symptoms
 1) Impaired Function :- morphology of the root complex favours the
development of periodontitis lesion in the furcation area and in advanced cases may
even promote the development of a Painful Periodontal Abscess and the tooth
perceived as “ Elongated ” and “ mobile ”.
 2)Redness Swelling increased Temperature within the periodontal
pocket :- due to enhanced vascularity and increased dilatation and permeability of
vessels in the connective tissue.
 3) Attachment loss : one of the specific features of furcation lesions
development of horizontal attachment loss which means that the pocket has now a
lateral extension.

39. Grade I
 Incipient or early stage of furcation involvement .
 Pocket is suprabony. No horizonal component
 Primarly affects the soft tissue.
 Early bone loss with increase in probing depth.
 No radiographic changes is usually found.

40.  Grade II
 Can affect one or more of the furcations
of the same tooth.
 furcation lesion is “Cul-de – sac” with
definite horizontal component
 In presence of multiple defects, defects
don’t communicate with each other due
to presence of a portion of alveolar bone
that remains attached to the tooth.
 The extent of the horizontal probing of
the furcation determine whether the
defect is early or advanced.
 Presence of vertical bone loss.
 (therapeutic complication)
 Radiographs may or may not show the
furcation involvement especially
maxillary molars(due radiographic
overlap of the roots


41. In this lesion ,the bone is destroyed in
one or more aspects of the furcation
,but the portion of alveolar bone and
periodontal ligament remain intact,
permitting only partial penetration of
the probe into the furcation.
Radiographs may or may not reveal
this type of furcation `

42.  Grade III  Bone is not attached to the dome of furcation .
 In the early grade III Involvement , the opening
may be filled with soft tissue and may not be
visible.
 The inability of the clinician to pass the
periodontal probe through the furcation : due to
interference of the faciolingual bony margins.
 Properly exposed and angled radiographs of early
class III furcation involvement, display the
defect as a radiolucent area in the crotch of the
tooth.
Clinical and radiographic
picture showing advanced
grade III furcation
involvement
Early grade III furcation
lesion “ radiolucent
area”
The opening of the
furca is filled with
soft tissue.

43. Grade IV
In such lesions,Interdental bone
loss is destroyed and soft tissues
have recessed apically , so the
furcation opening is clinically
visisble

44. OTHER
CLASSIFICATION
INDICES

46. Treatment

47. 1)- Facilitate
maintenance
1
2)- prevent
further
attachment loss
2
3)-Obliterate the
furcation defect
as a periodontal
maintenance
problem
3

48. Class of furcation
involvement
Extent and
configuration of
bone loss

49.  Conservative periodontal therapy because :
1- The pocket is suprabony and has not entered the furcation
2- Oral hygiene , scaling and root surface debridement are effective
 Removal of any overhanged restorations , facial grooves or
CEPs should be eliminated by odontoplasty,recontouring or
replacement.
 The resolution of inlammation and subsequent repair of the
periodontal ligament and bone are usually suficient to restore
periodontal health.

50.  Once a horizontal component to the furcation has developed (class II), therapy
becomes more complicated.
 Shallow horizontal involvement without significant vertical bone loss usually
responds favourably to localized lap procedures with odontoplasty, osteoplasty, and
ostectomy.
 Isolated deep class II furcations may respond to flap procedures with osteoplasty
and odontoplasty . This treatment reduces the dome of the furcation and alters
gingival contours to facilitate the patient’s plaque removal

52. Development of more horizontal defect , Late class II
class III or class Iv or deep vertical component of the
furcation
Non-surgical treatment is usually ineffective because the
ability to instrument the tooth surface adequately is
compromised
Periodontal surgery , endodontic therapy and restoration
of the tooth maybe required to retain the tooth

53. Nonsurgical
Therapy
Surgical
Therapy
- Oral Hygiene Procedures
- Scaling and root surface
debridement
- Osseous Resection
- Regeneration
- Extraction
- Dental Implants
- Root resection

54. Oral Hygiene Procedures :
 Nonsurgical therapy is a very effective way of producing a satisfactory stable result.
 Ideal results with furcation are impossible to obtain.
 Nonsurgical therapy, a combination of oral hygiene instruction and scaling and root
planning, has provided excellent results in some patients.
 The earlier the furcation is detected and treated, the more likely it will be that a good
long-term result can be obtained.
 Several oral hygiene procedures have been used over time. All include access to the
furcation. Obtaining access to the furcation requires a combination of the awareness of
the furcation by the patient and an oral hygiene tool that facilitates that access. Many
tools, including rubber tips, periodontal aids, both specific and general toothbrushes,
and other aids have been used over time for access to the patient .

56. Scaling and Root surface debridement
 Nonsurgical maintenance by the clinician has also improved over time as
instrumentation has improved.
 simple curettes have been used to instrument the furcation.
 Subsequently, other instrumentation has evolved, including DeMarco curettes,
diamond iles, Quétin furcation curettes, and Mini Five Gracey Curettes.
 Svärdström and Wennström34 illustrated that in the long term, furcation could be
maintained using nonaggressive techniques over a 10-year period in patients who
were participants in consistent maintenance.
 Other studies also illustrate that maintenance therapy is useful for patients to
facilitate furcation cleanliness. Chemotherapy has proven disappointing. Ribeiro
and colleagues32 found that nonsurgical therapy can effectively treat class II
furcation involvements, but using povidone-iodine did not provide additional
benefits to subgingival instrumentation

58. Osseous Resection
 Osseous surgical therapy can be divided into resective and regenerative therapy.
This also applies to the furcation areas when surgical therapy is contemplated.
 For many years, osteoplasty and ostectomy have been used to make the furcation
areas cleansable. In advanced cases, techniques were used to open the furcation
into a class IV from a severe class II or III case. This would allow easier hygiene into
the furcation area for the patient.
 The immediate goal with these surgical approaches is to create access for the
patient to maintain good hygiene
 These techniques have limited usefulness today, but in the compromised individual
whose teeth cannot be extracted or in whom conservative therapy has failed, these
surgical techniques have been used.

59. Regeneration
 In furcal lesions, bone regeneration is often thought to be relatively useless.
 The periodontal literature has well-documented therapeutic efforts designed to induce
new attachment and reconstruction on molars with furcation defects.
 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,24 whereas others have suggested that the use of these materials in class II, III,
or IV furcations offers little advantage compared with surgical controls.
 Furcation defects with deep two-walled or three-walled components may be suitable for
reconstruction procedures. These vertical bony deformities respond favourably to a
variety of surgical procedures, including debridement with or without membranes and
bone grafts.
 Tsao and associates39 have shown that the furcation defect is a graftable lesion. They
found that lesions that were grafted had greater vertical ill than areas treated with open
lap debridement alone.
 Bowers and colleagues7 have shown that furcation bone grafting using various membranes
can improve the clinical status of these lesions.

60. Extraction
 The extraction of teeth with through-and-through furcation
defects (classes III and IV) and advanced attachment loss may be
the most appropriate therapy for some patients.
 This is particularly true for individuals who cannot or will not
perform adequate plaque control, who have a high level of caries
activity, who will not commit to a suitable maintenance program,
or who have socioeconomic factors that may preclude more
complex therapies.
 Some patients choose to treat the area with scaling and root
planning or site-specific antibacterial therapies, and delay
extraction until the tooth becomes symptomatic. such teeth may
survive a significant number of years.

61. Dental Implants
 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.
 careful evaluation of the long-term
periodontal, endodontic, and restorative
prognosis must be considered before
invasive surgical therapy is undertaken to
save a tooth with an advanced furcated
lesion .

62.  Root resection may be indicated in
multirooted teeth with grades II to IV
furcation involvement
 Root resection may be performed on vital
teeth or endodontically treated teeth. It is
preferable, however, to have endodontic
therapy completed before resection of a
root or roots.

63. The indications and contraindications for teeth planned for root resection include the
following:
1. Teeth that are critically important to the overall dental treatment plan . Ex (
teeth serving as abutments for fixed or removable restorations for which loss of
the tooth would result in loss of the prosthesis and entail major prosthetic
retreatment.
2. Teeth that have sufficient attachment remaining for function.
 Molars with advanced bone loss in the interproximal and interradicular zones, unless
the lesions have three bony walls, are not candidates for root amputation

64. 3. Teeth for which a more predictable or cost-effective method of therapy is not
available.
Examples are teeth with furcation defects that have been treated successfully with
endodontics but now have a vertical root fracture, advanced bone loss, or caries on
the root.
4. Teeth in patients with good oral hygiene and low activity for caries are suitable for
root resection. Patients unable or unwilling to perform good oral hygiene and
preventive measures are not suitable candidates for root resection or hemisection.
Root-resected teeth require endodontic treatment and usually cast restorations

65. Careful diagnosis usually allows the therapist to determine the feasibility of root
resection and the identiication of which root to remove before surgery
Every attempt should be made to determine this before surgical exposure.The
following is a guide to determining which root should be removed in these cases:
1. Remove the root or roots 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. Sufficient
periodontal attachment must remain after surgery for the tooth to withstand the
functional demands placed on it such as bridge abutments and in bruxers. Teeth with
uniform advanced horizontal bone loss are not suitable for root resection.

66. 3. Remove the root that best contributes to the elimination of periodontal problems
on adjacent teeth.
For example, a maxillary first molar with a class III buccal-to-distal furcation is
adjacent to a maxillary second molar with a two-walled intrabony defect between the
molars and an early class II furcation on the mesial furcation of the second molar.
Local anatomic factors affecting the teeth may or may not be present. The removal of
the distobuccal root of the first molar allows the elimination of the furcation and
management of the two-wall intrabony lesion and also facilitates access for
instrumentation and maintenance of the second molar.
4. Remove the root with the greatest number of anatomic problems such as severe
curvature, developmental grooves, root lutings, or accessory and multiple root
canals.
5. Remove the root that least complicates future periodontal maintenance

67.  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 with buccal and
lingual class II or III furcation involvements.
 After sectioning of the teeth, one or both roots can be retained. This decision is
based on the extent and pattern of bony loss, root trunk and root length, ability to
eliminate the osseous defect, and endodontic and restorative considerations.
 The anatomy of the mesial roots of mandibular molars often leads to their
extraction and the retention of the distal root to facilitate both endodontic and
restorative therapy.

68.  The interradicular dimension between the two roots of a tooth to be hemisected
is also important. Narrow interradicular zones can complicate the surgical
procedure. The retention of both molar roots can complicate the restoration of
the tooth because it may be virtually impossible to finish margins or to provide an
adequate embrasure between the two roots for effective oral hygiene and
maintenance

69.  Therefore, orthodontic separation of the roots is often required to allow restoration
with adequate embrasure form .

70.  The most common root resection involves the distobuccal root of the maxillary first molar
- local anesthesia
- full-thickness mucoperiosteal lap is elevated in both sides.
- debridement resection of the root begins with the exposure of the furcation on the root to be
removed
- The removal of a small amount of facial or palatal bone may be required to provide access for
elevation and facilitate root removal
- Vertical cut is made with a high-speed, surgical-length fissure or crosscut fissure carbide bur.
- The placement of a curved periodontal probe into or through the furcation aids in orienting the angle
of the resection.
- If the sectioning cut passes through a metallic restoration, the metallic portion of the cut should be
made before lap elevation to prevents flap contamination

71. - If a vital root resection is to be performed, a more horizontal cut through the root is
advisable.
- An oblique cut exposes a large surface area of the radicular pulp and/or dental pulp
chamber. This can lead to postoperative pain and can complicate endodontic therapy.
- After sectioning, the root is elevated from its socket Removal of the root provides visibility
to the furcation aspects of the remaining roots and simpliies the debridement of the
furcation with hand, rotary, or ultrasonic instruments.

72. - If necessary, odontoplasty is performed to remove portions of the developmental ridges
and prepare a furcation that is free of any deformity that would enhance plaque retention
or adversely affect plaque removal
- The removal of a root alters the distribution of occlusal forces on the remaining roots.
Therefore, it is wise to evaluate the occlusion of teeth from which roots have been resected
and, if necessary, adjust the occlusion. Centric holds should be maintained, but eccentric
forces should be eliminated from the area over the root that was removed.
