Journal of Clinical Periodontology: 1980: 7: 73-95 Case Report Key words: Furcation ~ root resection. Accepted for publication May 2, 1979 The furcation problem Etiology, pathogenesis, diagnosis, therapy and prognosis Jens WAERHAUG Department of Periodontology Faculty of Dentistry, University of Oslo, Norway Abstract. The furcation problem was studied in a dental autopsy material, ie. extracted teeth were examined under the stereomicroscope. The folowing conclusions were reached: extraction, Plaque and Gingival Indices, degree of mobility, and other pertinent clinical data were recorded. A landmark was made on the tooth surface at the gingival margin so as to localize the margin during the examination of the extracted tooth, Immediately following the extraction, loosely attached soft tissue between the roots and in the area of the junctional epithelium were removed; any blood was washed away. The tooth was kept in a 1% solution of Water Blue for 10 min, rinsed in running water, and air-dried. The teeth were examined under the stereomicroscope. The following conclusions were reached: Subgingival plaque is common, even in the absence of supragingival plaque, among patieps who have started efficient supragingival plaque control but after subgingival plaque has been formed. Efficient supragingival plaque control may remove subgingival plaque as far as 2.5 mm below the gingival margin. Subgingival plaque, in the absence of supragingival plaque, is only occasionally asso- ciated with a marginal gingivitis, Subgingival plaque, in the absence of supragingival plaque, causes a clinically undetectable submarginal gingivitis which leads to destruction of the attachment apparatus and eventually to furcation involvement. Loss of attachment, whether it takes place on the outer surfaces or in the furcations, is strongly correlated with subgingival plaque and submarginal gingivitis. There is no correlation between visible supragingival plaque and loss of attachment in the furcations, nor is there any association between subgingival plaque in the furcations and marginal gingivitis. The conventional Plaque and Gingival Indices do not reflect the actual conditions in advanced destructive periodontal disease, including furcation involvement. Subgingival plaque control is likely to be incomplete on the outer surfaces and is a total failure in the furcations. In established furcation involvement more attachment is likely to be lost between the roots than on the cuter surfaces. ‘An early diagnosis is essential for successful management of the furcation problem, But it is extremely difficult to make a correct diagnosis because so many of the clinical criteria are misleading and because pain often precludes the probing which is necessary to establish the extent of the lesion. Root resection can be given a logical place in the overall plaque control rationale; but the indication for this treatment is strongly dependent on the anatomy of the tooth, the age of the patient and his predisposition to destructive periodontal disease. The prognosis of root resection depends on successful endodontic treatment as well as total plaque control. Increased mobility is a very late symptom in the development of the furcation involve- ment and is not involved in its etiology. 0303-6979/80/020073-23$02.50/0 © 1980 Munksgaard, Copenhagen74 WAERHAUG Furcation involvement is a condition in which periodontal fiber attachment is lost between the roots of multirooted teeth. The condition can be further specified as bi- or tri-furcation involvement, depending on whether there are two or three roots. Most of the publications on the furcation problem have dealt with problems related to the clinical management of the condition (for review see Ross 1978), and only limited at- tention has been paid to its etiology and pathogenesis. The purpose of the present investigation was to find out to what extent functional forces and subgingival plaque are involved in the etiology of the furcation involvement, and furthermore, whether or not marginal gingivitis and increased mobility reflect the degree of loss of periodontal attachment. Material and Methods The material consisted of 34 mandibular and 12 maxillary molars which had been extracted because of advanced destruction of the periodontal tissues within the furca- tion areas. In addition, 20 single roots from molar root resections were included. All the patients had been under periodontal treatment for periods ranging from a few months to several years. After an initial examination, all patients had been instructed in proper oral hygiene methods, and most of them had maintained an extremely high standard of plaque control. In most of the cases subgingival scaling had been per- formed one or several times, and in many cases periodontal surgery had been carried out. Immediately before extraction the Gin- gival and Plaque Indices as suggested by Lée & Silness and Silness & Lée (1963, 1964) were recorded. The degree of mobil- ity was classified into four categories: 0 = normal; 1 = slightly increased; 2 markedly increased; and 3 = excessively in- creased. Premature contacts in centric oc- clusion were identified by using carbon Paper, and in some cases comments were recorded on the occurrence of pain during tooth contact as well as on the occurrence of pain on probing the pockets and the furcation. Finally a landmark was made on the tooth surface at the gingival margin to locate it during the microscopic examina- tion of the extracted tooth. In a few cases the level of the gingival margin was indi- cated by painting the tooth and the gingivae with red nail varnish. Immediately following the extraction, loosely adherent soft tissue in the area of the junctional epithelium and between the roots was removed. The tooth was stained for 10 to 15 min in a 1% solution of Water Blue and rinsed in running water for another 10 min. After air-drying, ‘the tooth was examined under the stereomicro- scope. When the tooth is properly stained, the periodontal fibers which remain attached to it can be fairly clearly distinguished from the area which was adjacent to the junctional epithelium to which some of the superficial cells may adhere. The plaque, if present, is usually easy to “disclose”; and since a land- mark was made at the gingival margin, it is also easy to differentiate between supra- and subgingival plaque. One of the purposes of this study was to measure the amount of attachment loss on the different surfaces of the roots. This was done by means of a translucent measuring device with 11 diverging lines (Fig. 1). The 11 lines were so distributed that the area between the two marginal ones was divided into 10 equally wide spaces. By placing the tooth surface against this device so that one of the marginal lines covers the cemento- enamel junction and the other one the apex, the percentage of lost attachment can be estimated from the line closest to the bor- derline of remaining attachment fibers.THE FURCATION PROBLEM 78 Fig. 1. Lower second molar in a 32-year-old female. Healthy gingivae; some supragingival calculus but no plaque; normal mobility. Pa- tient attended 7 weeks earlier with PII = 3 and GI = 3; instructed same day in personal plaque control; cooperation extremely good; gingiva had retracted about 2 mm, and all visible signs of gingivitis had disappeared. On the extracted tooth it may be seen that the toothbrush had temoved plaque from subgingival calculus for a distance of 0.8 mm below gingival margin; istance from plaque to attachment fibers is 1.0 mm; plaque front has not yet reached fur- cation. This picture illustrates how the measur- ing device is placed against the tooth surface to estimate loss of attachment, which here was 25 % on buccal surface and 35 % on surfaces facing the furcation, Roots are standing very close together. Main points: toothbrush re- moves plaque below gingival margin; congru- ence between plaque front and attachment fibers. Unterer zweiter Molar einer 32-jiihrigen Frau. Gesunde Gingiva, etwas supragingivaler Zahn- stein aber keine Plaque; normale Beweglich- keit. Die Patientin stellte sich vor 7 Wochen vor und hatte zu diesem Zeitpunkt ein Pll = 3 und ein GI = 3; sie wurde am gleichen Tage in der Technik der Eigenplaquekontrolle instru- iert; ausgezeichnete Kooperation; die Gingiva erschien dann beim niichsten Besuch um etwa 2 mm retrahiert und alle sichbaren Zeichen der Gingivitis waren verschwunden. An dem extra- hierten Zahn kann beobachtet werden, dass die Zahnbiirste die Plaque vom subgingivalen Zahn- stein bis 0.8 mm unter den Gingivalsaum ent- fernen konnte; der Abstand von der Plaque zu den Attachmentfasern ist 1,0 mm; die Plaque- grenze hat die Furkation noch nicht erreicht. Dieses Bild veranschaulicht wie das Instrument zur Messung des Attachmentverlustes an die Wurzeloberfldiche angelegt wird. In diesem Falle betriigt der Attachmentverlust 25% an der bukkalen Oberfliche und 35% an den zur Furkation gehérenden Oberfliichen. Die Wur- zeln liegen nahe beieinander. Hauptsiichliche Erkenntnisse: Die Zahnbiirste entfernt Plaque unter dem Gingivalsaum. Es liegt Uberein- stimmung zwischen der Plaquegrenze und den Attachmentfasern vor. Seconde molaire inférieure chez une femme de 32 ans. Gencives saines; un peu de tartre sus- gingival, mais pas de plaque; mobilité normale. La patiente 'était présentée 7 semaines plus t6t avec Pll = 3 et GI = 3; ce méme jour instruc- tion en matiére de soins personnels d’élimina- tion de la plaque; coopération extrémement bonne; une rétraction gingivale de 2 viron avait eu liew et tout signe clinique de gingivite avait dispar. Sur la dent extraite, on peut constater que la brosse a dents a éliminé la plaque recouvrant les dépots de tartre sous- gingival, sur une distance de 0,8 mm environ au dessous du rebord gingival; la distance entre la plaque et les fibres de Vattachement est de 1,0 mm; la plaque n'a pas encore atteint le niveau de la furcation, Cette figure montre comment le dispositif de mesure est placé le long de la face dentaire pour faire l'estimation de la perte de l'attachement, qui, dans ce cas était de 25% sur la face vestibulaire et 35 % sur les faces tournées vers la furcation. Les racines étaient trés serrées, Remarquer prin- cipalement: la brosse a dents élimine la plaque en dessous du rebord gingival: conformité entre le niveau atteint par la plaque et les fibres de Vattachement. (gingival margin = rebord gingival; calculus = tartre; plaque free -xempt de plaque). mm en-16 WAERHAUG GorNRe ies Fig. 2. Maxillary first molar in a 27-year-old male. Diagnosis: Juvenile periodontitis. Gingivectomy 3 years earlier; subgingival plaque control every 3 months since; cooperation excellent; PII = 0, GI = 0; fairly profuse bleeding and pain on probing mesial pocket; probe could be pressed into furcation on both sides; it was believed that plaque had invaded the central part of furcation Marks left by scaler indicated by arrows; no subgingival plaque except in 0.S-mm-leep resorp- tion lacuna on the mesial surface; this demonstrates a fairly common condition following subgin- gival scaling; plaque remnants had caused pain and bleeding. Subgingival amalgam filling on distal surface plaque-free because of effect of interdental brush. Main points: resorption lacuna in tooth within pocket makes complete removal of subgingival plaque impossible. Erster Molar im Oberkiefer eines 27 Jahre alten Mannes. Diagnose: Juvenile Parodontitis. Vor 3 Jahren wurde gingivektomiert; seitdem wurde subgingivale Plaquekontrolle in Abstéinden von 3 Monaten vorgenommen; ausgezeichnete Kooperation; Pll = 0, G 0. Reichliche Blutung und Schmerzsensation bei der Sondierung der mesialen Tasche; die Sonde konnte beidseitig in die Fur- kation gedringt werden; scheinbar hatte die Plaque den zentralen Abschnitt der Furkation er- reicht. Die Spuren von Zahnsteininstrumenten sind mit Pfeilen bezeichnet; keine subgingivale Plaque ausser in einer 0,5 mm tiejen Resorptionslakune an der mesialen Oberfliiche. Hier wird ein oft vorkommender Zustand nach subgingivaler Zahnsteinentfernung exemplifiziert; Plaquereste ha- ben Schmerzen und Blutung verursacht, Die subgingivale Amalgamfiillung an der distalen Ober- fiche ist plaquefrei ~ eine Folge interdentaler Zahnreinigung. Hauptstichliche Erkenntnisse: Re- sorptionslakunen an Ziihnen innerhalb der Zahnjleischtasche machen eine vollstiindige subgingi- vale Plaqueentfernung unrméglich. Premiere molaire supérieure d'un homme de 27 ans. Diagnostic: parodontite juvénile, Gingivec- tomie 3 ans plus t6t; élimination de la plaque sous-gingivale tous les trois mois depuis cette épo- que; excelente coopération; Pll = 0, GI = 0; au sondage du cul-de-sac mésial, saignement assez abondant et réaction douloureuse; des deux cdtés on pouvait presser la sonde dans la furcation; ta plaque paraissait avoir atteint la partie centrale de la furcation. Noter les marques laissées par Pinstrument a détartrer, indiquées par des fléches; pas de plaque sous-gingivale, excepté dans une lacune de résorption de 0,5 mm de profondeur sur la face mésiale; il s'agit d'un fait assez habi- tuel aprés détartrage sous-gingival; les restes de plaque étaient a Vorigine du saignement et de la douleur. L’obturation sous-gingivale d'amaigame sur la face distale reste exempte de plaque grace @ Paction d'une brosse interdentaire. Remarquer principalement: une lacune de résorption dans la dent a Vintérieur du cul-de-sac rend impossible l'élimination complete de la plaque.THE FURCATION PROBLEM 7 HORIZONTAL year-old male. Fig. 3. Maxillary molar in a Normal mobility. PIL and GI = 0..Gingivec- tomy and extremely thorough scaling of fur- cations 4 years earlier; subgingival plaque con- trol every 3 months, last time 3 months bi fore. Tooth extracted because patient com- plained of premature contact, soreness on chewing and severe pain on scaling. Mesial surface plaque-free except for entrance to fu cation. Drawing (top) shows that plaque was distributed between roots in such a way that not all of it could be reached by a curette. Main points: successful subgingival plaque c trol on outer surfaces is useless as long as plaque cannot be removed from the furcation; plaque remnants in furcation, in absence of supragingival plaque do not induce marginal gingivitis; plaque in furcation in the absence of subgingival plaque on outer surfaces gives rise to localized interradicular gingivitis, which leads to increased tissue pressure, soreness on tooth contact and pain on scaling. Oberkiefermolar eines 35 Jahre alten Mannes. Normale Beweglichkeit. Pll und GI = 0. Vor 4 Jahren Gingivektomie und extrem sorefiiltige Konkremententfernung an den Furkationsober- flichen; subgingivale Plaquekontrolle an jedem 3. Monat; letzte Plaguekontrolle vor 3 Mona- ten. Der Zahn wurde extrahiert, da der Pa- tient iiber frithzeitige Kontakte, Empfindlich- keit beim Kauen und schwere Schmerzen bei der Zahnsteinbehandlung klagte. Die mesiale Oberfliiche ist plaquefrei mit Ausnahme des Furkationseinganges. Die Skizze (oben) zeigt, dass die Verteilung der Plague zwischen den Wurzeln ein vollstindiges Erreichen der Ge- samtplaquemenge mit der Kiirette unmdglich machte. Hauptsiichliche Erkenntnisse: Es. ist unméglich erfolgreiche subgingivale Plaquekon- trolle der Zahnaussenfliichen zu erreichen, wenn es unméglich ist die Plaque in den Fur- kationen vollstiindig zu entfernen; Plaquereste in der Furkation, bei Nichtvorhandensein su- pragingivaler Plaque, induzieren keine margi- nale Gingivitis; bei Nichtvorhandensein von subgingivaler Plaque an den diusseren Zahnober- flichen gibt Furkationsplaque Anlass zu loka- lisierter interradikuldrer Gingivitis, die zu er- héhtem Gewebedruck, zur Empfindlichkeit bei Zahnkontakt und zu Schmerzen beim Sondie- ren Anlass gibt. Molaire supérieure d'un homme de 35 ans, Mobilité normale. Pil et Gl = 0. Quatre ans plus t6t: gingivectomie et détartrage extréme- ment minutieux des furcations; élimination de la plaque sous-gingivale tous les trois mois, la derniére séance ayant pris place trois mois plus tt. La dent a été extraite parce que le patient se plaignait de contact prématuré, de douleur & la mastication et de forte douleur lors du dé- tartrage. La face mésiale est exempte de plaque sauj a Ventrée de la furcation. Le schéma (en haut) montre que la plaque était répartie entre les racines de telle maniére qu’on ne pouvait tout atteindre avec une curette. Remarquer principalement: la réussite de Télimination de la plaque sous-gingivale sur les faces externes est inutile tant que Ton ne peut pas éliminer la plaque de la furcation; en Vabsence de plaque sus-gingivale, les restes de plaque dans la furca- tion ne déterminent pas de gingivite marginale; en Tabsence de plaque sous-gingivale sur les faces externes, la plaque située dans la furca- tion cause Vapparition d'une gingivite interra- diculaire localisée, donnant une augmentation de la pression dans les tissus, une sensibilité au contact dentaire et une douleur lors des détar- trages.WAERHAUG PLAQUE PLAQUE GING. MARGIN Fig. 4. Maxillary first molar in a 51-year-old male, Plaque and Gingival Indices 0 on all surfaces. Normal mobility; patient had had subgingival scaling several times by referring dentist; about 2 months before extraction, the patient was instructed in personal plaque control by a motivated and cooperation excellent; all clinical signs of ging! during observation period. Tooth and gingival margin painted with nail varnish immediately be-THE FURCATION PROBLEM 79 fore extraction to indicate exact level of gingival margin. On buccal surface (top left) subgingival plaque control had been successful, and a normal epithelial cuff was restored here; on mesial surface (top right) scaling had been partly successful, but new subgingival plaque is in the process of being re-formed; on palatal and distal surfaces subgingival scaling was a complete failure; on mesial and distal surfaces an interdental brush had removed subgingival plaque from the surface of calculus and an amalgam filling for a distance of 1 mm below the gingival margin; on the pal- atal surface ordinary toothbrush had removed plague for about 0.5 mm below gingival margin. The infrabony pocket (see inset radiograph) is clearly associated with subgingival plaque on the mesial surface (above left and right). The large amalgam overhang (see radiograph) had probably contributed to the development of a furcation involvement on the distal surface (bottom left and right). Main points: Toothbrush removes plaque for distance of 0.5-1.0 mm below gingival mar- gin; gingival margin free of inflammation in corresponding area, thus qualifying for GI = healthy gingival margin obscured submarginal gingivitis which had caused extensive loss of at- tachment. Erster Oberkiefermolar eines 51 Jahre alten Manes. Plague- und Gingivalindizes zeigen 0-Werte an allen Oberflichen. Normale Mobilitit; der Zahnstein des Patienten ist von dem iiberweisenden Zahnarzt mehrmals behandelt worden; etwa 2 Monate vor der Extraktion wurde der Patient durch einen Dentathygienisten in der Eigenplaquekontrolle instruiert; der Patient ist stark moti- viert und die Kooperation ist ausgezeichnet; alle klinischen Zeichen der Gingivitis verschwanden wiihrend der Beobachtungsperiode. Unmittelbar vor der Extraktion wurde der Zahn und der Gin- givalsaum mit Nagellack bestrichen um die exakte Lage des Zahnfleischsaumes festzuhalten. An der bukkalen Oberfliche (oben links) war die subgingivale Plaquekontrolle erfolgreich, ein nor- males inneres Saumepithel konnte sich bilden; an der mesialen Oberfliiche (oben rechts) war die Zahnsteinbehandlung teilweise erfolgreich, jedoch hat sich bereits erneut subgingivale Plaque ge- bilder; an den palatinalen und distaien Oberfliichen missgliickte die subgingivale Zahnsteinbe- handlung vollig; an den mesialen und distalen Oberfltichen hatte eine Interdentalbiirste die sub- gingivale Plaque von der Oberfliche des Zahnsteins und einer Amalgamfiillung bis zu einem Ab- stand von I mm unter dem Zahnfleischsaum entfernt; an der palatinalen Oberfliiche hatte die Zahnbiirste die Plaque bis zu etwa 0,5 mm unterhalb des Gingivalrandes entfernt. Die Knochen- tasche (siehe eingefalltes Réntgenbild) héingt zweifellos mit der subgingivalen Plague an der me- sialen Zahnoberfliche zusammen (oben links und rechts). Der grosse Amalgamiiberhang (siehe Réntgenbild) hat scheinbar zur Entwicklung eines Furkationsengagements an der distalen Ober- fldche (unten links und rechts) beigetragen. Hauptsiichliche Erkenntnisse: Die Zahnbiirste entfernt die Plaque in einem Abstand von 0,5-1,0 mm unterhalb des Gingivalsaumes; der Gingivalsaum entspricht einem GI = 0, ist also in dem entsprechenden Abschnitt entziindungsfrei; diese ge- sunde Gingiva verdunkelt die submarginale Gingivitis, die einen ausgepriigten und umfassenden Attachmentverlust verursacht hat, Premiére molaire supérieure d'un homme de 51 ans. Indices de Plaque et de Gingivite = 0 sur toutes les faces. Mobilité normale; le dentiste nous ayant adressé le patient avait plusieurs fois Pratiqué des détartrages sous-gingivaux; environ deux mois avant extraction avait pris place Vin- struction par hygiéniste dentaire concernant les soins personnels d’élimination de la plaque; le patient était fortement motivé et la coopération excellente; tous les signes cliniques de gingivite avaient disparu pendant la période d’observation. Dent et rebord gingival enduits de vernis & on- gles immédiatement avant Vextraction pour indiquer le niveau exact du rebord gingival. Sur la face vestibulaire (en haut d gauche), 'élimination de la plaque sous-gingivale avait été réussie, et un manchon épithélial normal s’y était reconstitué; sur la face mésiale (en haut & droite) le dé- tartrage avait été partiellement réussi, mais une nouvelle plaque sous-gingivale est en train de se reformer; sur les faces palatine et distale, le détartrage sous-gingival est un échec complet; sur les faces mésiale et distale, une brosse interdentaire a éliminé la plaque sous-gingivale de la sur- face du tartre et d'une obturation d’amalgame sur une distance de 1 mm en dessous du rebord mar- ginal; sur la face palatine, la brosse a dents ordinaire a éliminé la plaque sur environ 0,5 mm en dessous du rebord gingival. Le cul-de-sac intra-osseux (voir radiographie encadrée) est nettement associé a la plaque sous-gingivale sur la face mésiale (en haut d gauche et 2 droite). Le volu neux surplomb de obturation d'amalgame (voir radiographic) a probablement contribué & stallation de Vatteinte de la furcation sur la face distale (en bas a gauche et a droite). Remarquer principalement: la brosse @ dents élimine la plaque sur une distance de 0,5-1,0 mm en dessous du rebord gingival; rebord gingival exempt d'inflammation dans la zone correspondante, ce qui donne GI = 0; le rebord gingival sain cachait une gingivite submarginale qui avait provoqué une importante perte de Vattachement,80 WAERHAUG Table 1. Observations on the presence or ab- sence of gingivitis, supragingival plaque and subgingival plaque on 244 surfaces of 34 maxil- lary molars (34 X 4 = 136), 12 mandibular mo- lars (12 X 4 = 48), 13 roots from hemisectioned maxillary molars (13 x 3 = 39) and seven roots from hemisectioned mandibular molars (7 x 3 =2) Beobachtungen iiber das Vorkommen von Gin- sivitis, supragingivaler und subgingivaler Plaque an 244 Oberflichen von 34 Oberkiefermolaren (34 X 4 = 136), 12 Unterkiefermolaren (12 X 4 = 48), 13 Wurzeln hemisektionierter Ober- kiefermolaren (13 X 3 = 39) und 7 Wurzeln hemisektionierter Unterkiefermolaren (7 X 3 = 2) Observations sur la présence ou Vabsence de gingivite, de plaque sus-gingivale et de plaque sous-gingivale sur 244 faces de 34 molaires supérieures (34 X 4 = 136), 12 molaires infé- rieures (12 X 4 = 48), 13 racines provenant de Uhémirésection de molaires supérieures (13 X 3 = 39) et 7 racines provenant de V'hémirésection de molaires inférieures (7 X 3 = 21) No. % Surfaces with gingi 627 Surfaces with gingivitis and supragingival plaque at the same time 5824 Surfaces with subgingival plaque alone 9539 Surfaces with gingivitis in absence of supra- and presence of subgingival plaque 9 37 Surfaces free of both supra- and subgingival plaque 844 Another problem to be elucidated was the correlation between loss of attachment and apical growth of subgingival plaque on the various surfaces. This was done with a stereomicroscope using a measuring occular at a magnification of < 10. The measuring error was estimated to be less than 0.1 mm. ‘Observations Relationship of marginal gingivitis 10 the presence or absence of supra- and subgingival plaque Supragingival plaque and_ gingivitis were originally measured by means of the Plaque and Gingival Indices. A similar quantifica- tion was also tried for subgingival plaque, but eventually abandoned because the etio- logical significance of the subgingival plaque could be better expressed in terms of the distance it had advanced towards and beyond the cemento-enamel junction, or its distance from the attachment fibers. There- fore, in the final analyses, neither the supra- nor the subgingival plaque was quantified; only their presence or absence was identi- fied. In Table 1 it may be seen that gingivitis was found adjacent to 67 (27 %) of the 244 surfaces; supragingival plaque was present on 26 % of them; supragingival plaque and gingivitis occurred simultaneously on 24 % of the surfaces; on 39% of the surfaces there was subgingival, but no supragingival plaque; on 3.7 % of the surfaces gingivitis and subgingival plaque occurred simulta- neously; but in the absence of supragingival plaque 34% of the surfaces were free of both supra- and subgingival plaque. Some typical specimens of the extracted teeth are shown in Figs. 1-9. The reader is advised to consult the legends which are written as case reports. Degree of loss of attachment on the outer surfaces (mesial, distal, buccal, lingual) as compared with the surfaces facing the furcations The average loss of attachment was found to be 47.3% on the outer surfaces and 62.8 % on those facing the furcation (Table 2). These marked differences in attachment level are illustrated in Figs. 1, 3, 5-9.THE FURCATION PROBLEM 81 Fig. 5. Mandibular molar in a 46-year-old male. Normal mobility; Pll = 2, GI =2 on lingual surface shown above left. In center and to right tooth has been split through the furcation, and roots turned through 90° to show interradicular surfaces; attachment loss is much more advanced between roots than on lingual and buccal surfaces; plaque front and margin of attachment fibers run remarkably parallel at distance of about 0.5 mm. Main points: Much more attachment lost on surfaces facing furcation than on outer surfaces; parallelism between plaque front and border- line of attachment fibers. Unterkiefermolar eines 46 Jahre alten Mannes. Normale Zahnbeweglichkeit; PU = 2, G1 = 2 auf der lingualen Fliche, die oben gezeigt wird. In der Bildmitte und rechts ist der Zahn in der Fur- katur geteilt und die Wurzeln sind um 90° gedreht worden um die interradikuldren Oberfléchen zeigen zu kénnen; der Attachmentverlust erscheint zwischen den Wurzeln bedeutend ausgeprii ter als an den lingualen und bukkalen Oberflichen; die Plaquegrenze und der Rand der Attach- ment fasern verlaujen auffillig parallel zueinander in einem Abstand von etwa 0,5 mm. Haupt- stichliche Erkenntnisse: An den zur Furkation gehérenden Oberflichen wurde bedeutend mehr Attachment verloren als an den dusseren Zahnoberfliichen; Paralleler Verlauf zwischen der Pla- quegrenze und der Grenclinie der Attachmentjasern. Molaire inférieure d'un homme de 46 ans. Mobilité normale; Pl] = 2, Gl =2 sur la face lin- guale montrée en haut @ gauche. Au centre et & droite, la dent a été divisée au niveau de la fur- cation, et les racines ont été tournées de 90° pour montrer les faces interradiculaires; la perte de Vattachement est beaucoup plus avancée entre les racines que sur les faces linguales et vestibulai- res; le niveau atteint par a plaque et ta limite des fibres de Vattachement ont un parcours remar- quablement. paralléle, a une distance d’environ 0,5 mm. Remarquer principalement: perte de l'at- tachement beaucoup plus importante sur les faces tournées vers la furcation que sur les faces ex- ternes; parallélisme entre le contour du niveau atteint par la plaque et la limite des fibres de Pattachement, Correlation between gingivitis and loss of units were inflamed, were compared with attachment the 32 teeth, adjacent to which the GI score With the purpose of establishing to what was 0 on all surfaces. In Table 3 it is seen extent loss of attachment is related to that the average loss of attachment on the visible marginal gingivitis the 34 teeth, outer surfaces was 47.7 % in the gingivitis adjacent to which one or more gingival group and 48.2% in the nongingivitis82 WAERHAUG = i. Fig. 6. Maxillary first premolar in a 33-year-old male (tooth not included in material). Case diag- nosed as juvenile periodontitis. Normal mobility; Pll = 0, GI = 0 on all surfaces. Flap operation and thorough scaling 4 months earlier; tooth extracted because of unspecific pain on chewing and pain on probing pocket. Tooth painted with nail varnish to indicate gingival margin. Buccal sur- face (right) plaque-free below gingival margin, and so is mesial surface (left), but spots of calcu- lus (c) have been left behind; vertical lines indicate how tooth was split up; distal surface (cen- ter right) plaque-free below GM on both sides, but in furcation some plaque left behind, and this has led to continued plaque formation there. In center left is shown interradicular surface of buccal root following “hemisection”; root seen from two different angles; plaque advanced to distance of 12 mm below CEJ; average speed about 2 microns per day (about 16 mm in 21 years); distance from plaque in furcation to attachment fibers on mesial surface (left) is 3.5 mm Main points: successful subgingival plaque control on all surfaces except for furcation; extremely rapid advancement of subgingival plaque in furcation; subacute submarginal gingivitis in furca- tion Jed to pain, and Joss of attachment at unusually large distance from plaque Erster Primolar im Oberkiefer eines 33-jahrigen Mannes (dieser Zahn ist nicht in dem hier be- schriebenen Material enthalten), Diagnose: Juvenile Parodontitis. Normale Zahnbeweglichkeit. PU = 0, GI =0 an allen Oberfliichen. Vor 4 Monaten wurde eine Lappenoperation und sorgfiil- tige Konkremententfernung vorgenommen; der Zahn wurde wegen unspezifischer Schmerzen beim Kauen und bein Sondieren der Taschen extrahiert. Zur Kennzeichnung des Gingivalsaumes wur- de der Zakn mit Nagellack eingefarbt. Die bukkale Fliche (rechts) ist unter dem Zahnfleisch- saum plaquefrei und das gleiche gilt fiir die mesiale Oberfliche (links), Zahnsteinreste (c) sind jedoch noch vorhanden: Vertikale Linien verdeutlichen wie der Zahn geteilt worden ist; die distale Oberfldiche (Mitte rechts) ist auf beiden Seiten bis unter den Zahn{leischsaum (GM) plaquefrei, in der Furkation ist jedoch noch etwas Plaque vorhanden und das hat dort zu weitergehendem Plaquewachstum Anlass gegeben. In der Mitte links wird die interradikulare Oberfliiche nach der »Hemisektion« gezeigt; die Wurzel wird von zwei verschiedenen Winkeln aus betrachtet; die Pla- que drang bis zu einem Abstand von 12 mm unterhalb der Schmelz-Zementgrenze vor; durch- schnittliche Geschwindigkeit etwa 2 Mikron pro Tag (etwa 16 mm in 21 Jahren); der Abstand von der Plaque in den Furkationen zu den Attachmentfasern betriigt an der mesialen Oberfitiche 3,5 mm, Hauptsiichliche Erkenntnisse. Erfolgreiche subgingivale Plaquekontrolle an allen Ober- flichen mit Ausnahme der Furkation; extrem schnelles Einwachsen subgingivaler Plaque in die Furkation; die subakute submarginale Gingivitis in der Furkation verursachte Schmerzen sowie Attachmentverlust in uniiblich weiter Entjernung vor der Plaque. Premiére prémolaire supérieure d'un homme de 33 ans (dent ne faisant pas partie du matériel considéré). Cas diagnostiqué comme parodontite juvénile. Mobilité normale; PII = 0, G1 = 0 sur toutes les faces. Une opération & lambeau et un détartrage minutieux ont été faits 4 mois plus t6t; Ja dent a été extraite en raison de douleurs non spécifiques a la mastication et de douleur lorsTHE FURCATION PROBLEM 83 Table 2. Average loss of attachment on outer surfaces (mesial, distal, buccal, lingual) as com- pared with surfaces facing the furcation, ex- pressed as a percentage of root length Durchschnittlicher Attachmentverlust an den Zahnaussenfliichen (mesial, distal, bukkal, lin- gual) — verglichen mit dem Attachmentyerlust an den Furkationsflichen und ausgedriickt in »Prozent der Gesamtwurzellinge« Comparaison entre la perte moyenne de 'at- tachement sur les faces externes (mésiales, distales, vestibulaires, linguales) et sur les faces tournées vers la furcation, exprimée en pour- centage de la longueur des racines % — Range Outer surfaces 473 20-92 Sufaces facing furcation 62.8 25-90 group. On the surfaces facing the furcations corresponding values were 60.6 and 63.9 %, respectively. Correlation between downgrowth of subgingival plaque and loss of attachment Loss of attachment can be precisely quanti- fied by measuring the distance from the CEJ to the remaining attachment fibers. By the same standards, the relationship of subgingival plaque to the loss of attachment can be assessed by measuring the distance from the front of the plaque mass to the Table 3. Average loss of attachment on the outer surfaces (mesial, distal, buccal, lingual) (O.S.) and on the surfaces facing the furca- tions (F) of the 32 teeth with all the four sur- faces free of gingivitis as compared with the 34 teeth with one or more inflamed gingival units Durchschnittlicher Attachmentverlust der Zahn- aussenflichen (mesial, distal, bukkal, lingual) (O.S.) und der Furkationsoberfliichen (F) bei 32 Zihnen, bei denen das an alle vier Zahn- oberfidichen anliegende Zahnfleisch (vier Gin- givaleinheiten) gingivitisjrei war, verglichen mit 34 Ziihnen mit einer oder mehreren entziindeten Gingivaleinheiten Perte moyenne de V'attachement sur les faces externes (mésiales, distales, vestibulaires, lin- guales) — OS -, et sur les faces tournées vers les furcations — F ~, dans 32 dents dont les 4 faces étaient exemptes de gingivite et dans 34 dents présentant une inflammation dans une ou plusieurs localisations gingivales Average percentage loss of attachment Type of gingivae No. OS. F. Teeth with healthy gingivae 32 48.2 63.9 Teeth with one or more inflamed gingival units 34 47.7 60.6. attachment fibers. In the present study measurements were made on all four outer surfaces as well as on the surfaces facing the furcations (Table 4). On the 147 outer du sondage du cul-de-s ic. Dent enduite de vernis a ongles pour indiquer le rebord gingival. La face vestibulaire (@ droite) est exempte de plaque en dessous du rebord gingival, ainsi que la face mésiale (& gauche), mais des dépéts de tartre ont été laissés (C); les lignes verticales indiquent comment la dent a été divisée; la face distale (au centre a droite) est exempte de plaque en des- sous du rebord gingival des deux cétés, mais, dans la furcation, il est resté un peu de plaque, ce qui a déterminé la formation ultérieure de plaque a cet endroit, Au centre & gauche, on voit la face interradiculaire de la racine vestibulaire aprés I'«hémirésection»; la racine est vue sous deux angles différents; la plaque a progressé jusqu’ @ 12 mm au dessous de la jonction émail-cé- ment; vitesse moyenne environ 2 microns par jour (environ 16 mm en 21 ans); la distance entre Ja plaque dans la furcation et les fibres de Vattachement sur la face mésiale (a gauche) est de 3,5 mm. Remarquer principalement: réussite de Vélimination de la plaque sous-gingivale sur toutes les faces & Vexception de Ia furcation; progression extrémement rapide de la plaque sous-gingivale dans la furcation; gingivite submarginale subaigué dans la furcation, causant les douleurs; et perte de Vattachement a une distance exceptionnellement grande de la plaque.84 WAERHAUG Fig. 7. Schematical drawing of mandibular first molar in 33-year-old female. Normal mobility; PI and GI scores like 0. Tooth split up in furcation to show roots from interradicular surfaces. Patient had been under systematic plaque control by hi 9 years and had yielded excellent cooperation, Sub- gingival scaling by hygienist had kept all outer surfaces, and even entrance to furcations, plaque-free, but scaling had had no effect be- tween roots for which reason plaque had mi- grated in apical direction there; plaque-front and borderline of attachment fibers run parallel at distance of 0.3 mm. There was premature contact and some tenderness on chewing. Main points: close congruence between plaque front and attachment fibers; no effect of subgingival scaling in furcation even if favorable results on outer surfaces, much more attachment lost in furcations than on outer surfaces. Schematische Zeichnung des ersten Molaren im Unterkiefer einer 33-jéhrigen Frau. Normale Beweglichkeit; PII und GI ~ Bewertungsein- heiten = 0. Der Zahn wurde in der Furkation gespalten um die interradikuldren Wurzelfli chen zeigen zu kénnen. Die Plaquekontrollen surfaces the average distance was 0.86 mm; the range was 0.2—2.4 mm, and six measure- ments were 2 mm or more. On the 135 sur- faces facing the furcation the average dis- wurden bei diesem Patienten withrend der letzten 9 Jahre von einem Hygienisten syste- matisch vorgenommen und hatten ausgezeich- nete Kooperation zur Folge. Die subgingivale Zahnsteinentfernung durch den Hygienisten hielt die dusseren Zahnoberfliichen und sogar den Furkationseingang plaquefrei, die Zahn- steinbehandlung hatte jedoch zwischen den Wurzeln keinen Effekt und aus diesem Grunde wanderte die Plaque weiter in apikale Richtung; Plaquegrenze und Grenilinie der Attachment- fasern verlaufen parallel in einem Abstand von 03 mm. Es kam zu vorzeigtigen Kontakten und zu einer Empfindlickkeit bei Kauen. Hauptsichliche Erkenntnisse: Starke Anhiingig- keit zwischen der Plaquegrenze und den At- tachmentfasern; kein Effekt bei subgingivaler Zahnsteinentfernung in der Furkation wenn auch giinstige Behandlungsresultate an den dusseren Oberfltichen vorlagen; bedeutend aus- gepriigterer Attachmentverlust in den Furka- tionen als an den Aussenflichen. Représentation schématique de la premiére mo- laire inférieure d’une femme de 33 ans. Mobi- lité normale; Pi et GI ont des scores cor- respondant @ 0. Dent divisée au niveau de la furcation pour montrer les racines par leurs faces interradiculaires. Systématiquement suivie par hygiéniste dentaire depuis 9 ans pour as- surer la maitrise de la plaque, la patiente a fait preuve d'une excellente coopération. Le détartrage sous-gingival par Vhygiéniste a main- tenu toutes les faces externes, et méme Ventrée de la furcation, exemptes de plaque, mais le détartrage n'a pas eu d’effet entre les racines et la plaque a donc pu y progresser en direc- tion apicale; le niveaw atteint par la plaque et la limite des fibres de lattachement ont un parcours paralléle @ 0,3 mm de distance. Il y avait contact prématuré et une certaine sen- sibilité @ la mastication. Remarquer principale- ment: proche conformité entre le niveau at- teint par la plaque et celui des fibres de Vat- tachement; manque d'effet du détartrage sous- gingival dans la furcation, méme si les résultats sont favorables sur les faces externes, perte de Vattachement beaucoup plus importante dans la furcation que sur les faces externes. tance was 0.91 mm; the range was 0.2-4 mm, and on 19 surfaces the values were 2 mm or more. The close congruence between the plaque front and the attachment fibersTHE FURCATION PROBLEM 85 Fig. 8. First mandibular molar a in 42-year-old female, Patient had been under systematic plaque-control by hygienist for about 6 years, and had maintained excellent oral hygiene as ex- pressed by PII and GJ = 0 on all surfaces; mobility normal. Tooth split up to show interra cular surfaces. On mesial root plaque front had advanced more than half-way to apex and dis- tance to attachment fibers is about 0.2-0.3 mm; on distal root plaque front located closer to furcation, and distance to attachment fibers is 3.5 mm at widest. To right roots placed back in original position and distance between them is no more than 1.0 mm, suggesting that plaque on mesial root had destructive effect on distal root as well. Erster Unterkiefermolar einer 42 Jahre alten Frau. Die Plaguekontrolle bei dieser Patientin ist etwa 6 Jahre lang von einem Hygienisten vorgenommen worden, der ausgezeichnete orale Hygiene erreichte, wie dem PI und GI = 0 an allen Oberfliichen entnommen werden kann; Zaknbeweg- lichkeit normal. Der Zahn wurde gespalten um die interradikuldren Fliichen zeigen zu kénnen. An der mesialen Wurzel hat sich die Plaquegrenze mehr als den halben Weg zum Apex hin vor- gearbeitet und der Abstand zu den Attachmentfasern betriigt etwa 0,2-0,3 mm; an der distalen Wurzel befindet sich die Plaquegrenze niiher an der Furkation und der Abstand zu den Attach- mentfibern betriigt 3,5 mm (weitester Weg). Werden die Wurzein in ihre urspriingliche Lage zuriickgebracht, ist die Entfernung zwischen ihnen nicht weiter als 1,0 mm. Dieses wiederum lisst vermuten, dass die Plaque der distalen Wurzel ihren destruktiven Effekt auch auf die me- siale Wurzel ausdehnte. Premiere molaire inférieure d'une femme de 42 ans, La patiente, suivie systématiquement depuis environ 6 ans par hygiéniste dentaire pour assurer la maitrise de la plaque, a maintenu une excel- lente hygiéne bucco-dentaire, ainsi qu’en témoignent Pll et GI = 0 sur toutes les faces; mobilité normale. Dent divisée pour montrer les faces interradiculaires. Sur la racine mésiale, la plaque 4 progressé plus qu’ a mi-chemin de V'apex, et la distance entre la plaque et les fibres de 'attache- ment est d'environ 0,2-0,3 mm; sur la racine distale, V'atteinte de la plaque reste proche de la fur- cation, et la distance entre plaque et fibres de Vattachement est de 3,5 mm @ lendroit le plus large. A droite, les racines replacées dans leur position originale, la distance entre elles n'étant que 1,0 mm, ce qui fait supposer que la plaque de ta racine mésiale avait un effet destructeur sur la racine distale aussi. is illustrated in Figs. 1, 4 PAL. 5,7 and 8 Effectiveness of subgingival plaque control MESial root. The unusually great variation on the outer surfaces in the distances is shown in Figs. 6 and 8 Marks left by scalers (proof of scaling) were Distal root. found on only 125 of the outer surfacesWAERHAUG 86 ) -60mm (normal LI © ©200008- koeTHE FURCATION PROBLEM 87 (Table 5). Forty-six (37 %) of the surfaces were plaque-free (Figs. 2, 3, 4(BUC., and 6 BUC.). The distance from the gingival mar- gin to the attachment fibers in the plaque- free cases was on average 2.4 mm, the range being 1.3 to 7 mm. On 79 (63 %) of the outer surfaces subgingival plaque was found, as demonstrated in Figs. 4MES., PAL. and DIST. and 8. Success in one area and failure in another area is seen in Figs. 4MES. and 6DIST. (In Table 5 these surfaces are listed as failures.) A complete failure is demonstrated in Fig. 4PAL. Effectiveness of subgingival plaque control in the furcation Evidence that subgingival scaling had been performed was found in only 41 furcations. On 19 surfaces the plaque had started to invade the furcation, but it had not yet reached its central part. In six out of these 19 furcations the plaque control had been successful (see Figs. 2DIST. and 4BUC). In the remaining 13 furcations some plaque had been left behind. In 22 instances the plaque had gained access to the central part of the furcation at the time of scaling, and in all these cases some plaque had been left behind, sometimes in large amounts, as was the case in Figs. 3-9. Correlation between loss of attachment and degree of mobility A total of 34 teeth exhibited normal mo- bility, and on these teeth, the average loss of attachment was 41 % on the outer sur- Fig. 9. Schematic drawing from interradicular space in lower first molar in 54-year-old fe- male. PII and GI — 0 on all surfaces; tooth in premature contact; patient complained of dif- fuse pain on function and extreme pain on probing furcation. On basis of distribution of plaque in furcation and observations in radio- graph histopathological events are suggested: Plaque causes subacute inflammation with in- creased exudation and tissue tension which may amount to 18 mm Hg or more (Starling 1896, Landis 1927); tissue tension in furcation has occlusally directed force component which presses tooth out of socket. Main points: sore- ness on function and probing, and premature contact are result of increased tissue tension caused by submarginal gingivitis in furcation. Schematisierte Zeichnung des interradikularen Raumes bei einem ersten unteren Molaren einer S4-jéhrigen Frau, Pll- and Gl-Werte sind an allen Oberfltichen=0; der Zahn be- findet sich in Primiirkontakt mit seinem A tagonisten; die Patientin beklagt sich itber dit fuse Schmerzsensationen wiihrend der Funktion und extreme Schmerzen bei der Sondierung der Furkation. Auf Grund der Plaqueverteilung in der Furkation und auj Grund von Beobachtung mit Hilfe von Réntgenbildern wird folgendes histopathologische Geschehen vermutet: Die Plaque verursacht eine subakute Entziindung mit erhohter Exsudation und Gewebsspannung, die bis zu 18 mm Hg oder mehr ansteigen kann (Starling 1896, Landis 1927); bei der Gewebs- spannung in der Furkation liegt auch eine ok- klusal gerichtete Kraftkomponente vor, die den Zahn aus der Alveole pressen will. Hauptsich- liche Erkenntnisse: Empfindlichkeit bei der Funktion und bei der Sondierung, sowie auch der friihzeitige Kontakt sind das Resultat er- hohter Gewebsspannung, hervorgerufen durch submarginale Gingivitis in der Furkation. Représentation schématique de Vespace inter- radiculaire dans la premiére molaire inférieure dune jemme de S4 ans, Pll et Gl=0 sur toutes les faces; dent en contact prématuré; la patiente se plaignait de douleurs diffuses pen- dant ia fonction et de douleur extréme lors du sondage de la furcation. En se basant sur la répartition de la plaque dans la furcation et sur les observations radiographiques, la séquence histopathologique suivante se trouve suggérée: la plaque provoque une inflammation subaigué avec augmentation de la tension dans les tissus, qui peut atteindre 18 mm Hg ou plus (Starling 1896, Landis 1927); la tension dans les tissus au niveau de la jurcation a une composante de force en direction occlusale, pressant la dent hors de son alvéole. Remarquer principalement: douleur @ la fonction et lors du sondage, ainsi que contact prématuré sont le résultat de Vaug- mentation de tension dans les tissus, causée par la gingivite submarginale dans la furcation.88 WAERHAUG Table 4. Distance from the subgingival plaque front to the closest attachment fibers on 147 outer surfaces as compared with 135 surfaces facing the furcation, The measurements on the outer surfaces were limited to those on which the subgingival plaque control had not obviously increased the distance Der Abstand von der subgingivalen Plaque- grenze zu den niichstgelegenen Attachmentfa- sern an 147 Aussenfldichen, verglichen mit 135 Furkationsoberflichen. Die Messungen an den Aussenflichen sind auf solche Fille beschriinkt worden, bei denen die subgingivale Plaquekon- srolle den Abstand nicht offenbar vergrdssert hatte Comparaison entre la distance allant du niveau atteint par la plaque sous-gingivale aux plus proches des fibres de Vattachement sur 147 faces externes et sur 135 faces tournées vers la furcation. Les mesures faites sur les faces ex- ternes n'étaient faites que sur les faces oi Télimination de la plaque sous-gingivale n’avait pas manifestement augmenté la distance No. Average Values dist. in of 2 mm mm — or more Outer surface 1470.86 6 Surface facing 1350.91 19 furcation faces and 52 % on the surfaces facing the furcation (Table 6). On the 18 teeth with slightly increased mobility, the average values were 47 and 64 %, respectively. Occurrence of premature contacts, soreness or pain Premature contact in centric occlusion was observed on 17 teeth (26 %). Most patients gave a positive answer to the question “has the tooth ever been tender or sore” and some had noticed that they had been con- stantly chewing or bruxing on the particular tooth. All 10 molars (15%) that were extracted because of a periodontal abscess were painful, and they were extruded to the extent that they prevented occlusal contact Table 5. Success or failure of subgingival scal- ing on 125 surfaces where marks left by the instrument proved that such treatment had been done Erfolg oder Misserfolg subgingivaler Konkre- mententfernung an 125 Oberfliichen. Spuren der Instrumente in der Hartsubstanz bewiesen, dass die 0.a. Behandlung durchgefithrt worden war Succés ou échec du détartrage sous-gingival sur 125 faces oi des traces d'instruments mon- traient qu'un tel traitement avait été pratiqué No. % Suceess 46 37 Failure 79 63 Total 125 100 between the remaining teeth. On eight out of these 10 molars, the distance from plaque to attachment fibers in the furca- tion was 2 mm or more. Table 6. Loss of attachment on the outer sur- faces (O.S.) and the surfaces facing the furca- tion (F) in relation to degree of mobility Die Relation zwischen Attachmentverlust an Aussenfliichen (O.S.), Furkationsoberflichen und dem Lockerungsgrad Perte de l'attachement sur les faces externes (OS) et sur les faces tournées vers la furcation (F): comparaison avec ie degré de mobilité Average percentage of loss of attachment Mobility Os. F. Normal 41.1 56.7 Slightly increased 46.6 64.0 Markedly increased 60 4 Excessively increased 6 81THE FURCATION PROBLEM 89 Table 7. Pain reaction and tendency to bleed- ing in pockets with and without subgingival plaque in the absence of supragingival plaque Schmerzempfindung und Blutungstendenz bei Taschen mit und ohne subgingivale Plaque beim Nichtvorhandensein von supragingivaler Plaque Réaction douloureuse et tendance au saigne- ment dans les culs-de-sac avec et sans plaque sous-gingivale, en Vabsence de plaque sus-gingi- vale Pain Bleeding Plaque No.+ No.— No.+ No.— Total Without 6 14 2 18 20 With 21011 22032 Total 27°25 (2852. Pain and bleeding on probing of plaque-free and plaque-containing pockets During the collection of the material it be- came increasingly clear that the pain reac- tion on probing was so strong in some cases that it precluded proper assessment of the extent of the furcation involvment. In many cases the patient complained of dif- fuse pain similar to that of chronic pulpitis. In addition, in areas where there was no supragingival plaque, bleeding on probing varied widely from surface to surface. Therefore, it was decided to find out to what extent pain and bleeding were as- sociated with the presence of subgingival plaque. Thirteen teeth with a PII and GI of 0 were examined. Bleeding and pain on probing were clearly less common in pock- ets without plaque (Table 7). Discussion In evaluating the observations that have been described above, it should be kept in mind that the material is highly selected, insofar as all the patients had been previ- ously exposed to extensive periodontal care and therefore the findings are not valid for the population as a whole. For the pur- pose of elucidating the furcation problem, however, in a population under advanced dental treatment, the material should be well suited, because all teeth represented cases in which conventional periodontal treatment had failed, and because the cause of the failure was so well disclosed on the extracted teeth, There are many problems associated with making systematic observations on multi- rooted teeth because of the wide variation in anatomy, Furthermore, crowns and fill- ings placed on the root surface make exact location of the CEJ impossible. Finally, in many cases the level of the attachment fibers varied widely on the same surface (Figs. 1-9). The figures reported should therefore be regarded as careful estimates. It was not surprising that supragingival plaque was present on 58 out of 67 sur- faces adjacent to which gingivitis had been scored. This is in agreement with findings reported in a large number of controlled studies. The data presented in Table 1 on supra- gingival plaque, gingivitis and subgingival plaque clearly demonstrate, however, that the conditions below the gingival margin are extremely difficult to predict from clinical examination. From the viewpoint of diagnosis it is more thought provoking that on 95 surfaces with a Plaque Index Score of 0 large amounts of subgingival plaque were found, yet on only nine of these surfaces was the subgingival plaque associated with a Gingival Index score of 1 or more, This high proportion of surfaces (39 %) with subgingival plaque, in the ab- sence of supragingival plaque, is undoubt- edly the result of the treatment routine to which the patients had been exposed. Many of them had been scheduled for periodontal surgery, and prior to treatment had been90 WAERHAUG motivated and thoroughly instructed to a high standard of plaque control. On the day of surgery, many of the molars with furcation involvment, beyond the possibility of successful treatment, were extracted, and are included in the material. Therefore, it was to be expected that most of the surfaces of these teeth would be plaque-free above the gingival margin; but it was surprising that so many surfaces, with large accumula- tions of subgingival plaque in the depth of the pocket, were plaque-free for a distance of 0.5-2.5 mm immediately below the gin- gival margin (Figs. 1, 4PAL., MES. and DIST., and 8). These observations corrob- orate previous findings on the effect of the round interdental brush below the gin- gival margin (Waerhaug 1976). The ab- sence of subgingival plaque immediately below the gingival margin explains the absence of marginal gingivitis; and the in- flammation, induced by the subgingival plaque in the soft tissue wall of the pocket, could not be seen at all, for which reason the corresponding gingival unit was given the GI score 0. The observation that, in patients who maintain a high standard of plaque control, the submarginal gingivitis escapes the attention of the dentist, is in agreement with histological observations on the healing of the dento-epithelial junction following subgingival plaque control (Waer- haug 1978). Given the above findings, it could not be expected that plaque, left behind in the furcations several millimeters below the gingival margin, would give clinical signs of gingivitis (Figs. 3, 4 and 6-8). Conversely, it was not surprising that there was no cor- relation between marginal gingivitis and loss of attachment on the outer surface nor on the surfaces facing the furcation (Table 3). In fact, loss of attachment in these loca- tions was convincingly associated with sub- gingival plaque which had grown down to an average distance from the periodontal fibers of 0.86 and 0.91 mm, respectively (Table 4). On 258 out of the 283 surfaces (91 %) on which measurements were made, the values ranged between 0.2 and 1.9 mm. The close congruence between the plaque front and the borderline of the attachment fibers is very striking on surfaces where subgingival scaling had not interfered with the original picture (Figs. 1, 4PAL., 5, 7 and 8 Mesial root), This parallel develop- ment suggests a cause and effect relation- ship. It is highly unlikely that the loss of attachment would have elicited the down- growth of plaque; it is much more likely that the plaque caused the loss of attach- ment. This would be in agreement with ob- servations on loss of attachment in juvenile periodontitis (Waerhaug 1977). The pres- ent material has clearly shown that the pathogenesis of attachment loss within the furcation is associated with downgrowth of subgingival plaque as it is on outer root surfaces. However, the somewhat higher average distance in furcations (0.91 mm compared to 0.86) indicates that the condi- tions may not be entirely similar. This dif- ference on average reflects the fact that there were many more surfaces with mea- surements of 2 mm or more in the furca- tions (19) than on the outer surfaces (6). There are at least two possible explana- tions for this difference: 1) the plaque on one root may have had a destructive effect on the attachment fibers of the other root or roots, as is suggested in Fig. 8, This interpretation agrees with observations made in histologic sections from human material, that plaque attached to one tooth, can destroy the attachment fibers of its neighbor (Wacrhaug 1978). 2) Chronic or acute periodontal abscesses are likely to Jead to lysis of the attachment fibers over a wider distance than usual. Periodontal abscesses originating in the furcation were the cause of extraction of 10 of these molars; and it is noteworthy that on eightTHE FURCATION PROBLEM 91 of them, the distance from the plaque to the attachment fibers was 2 mm or more on the surfaces facing the furcation (Fig. 6). These observations may explain why perio- dontal abscesses are so detrimental to the supporting tissues. Part of the reason that more attachment was lost in the furcations than on the outer surfaces (Table 2) is the anatomy of multi- rooted teeth. But it may be more significant that subgingival plaque control in the furca- tion area had invariably failed, whereas plaque control had been successful on 37 % of the outer surfaces (Table 5). When choosing an approach to subgin- gival plaque control, it should be appre- ciated that failure is almost certain if the pocket depth is more than 3 mm (Waerhaug 1978). Therefore, surgical elimination of deep pockets to make subgingival plaque visible and accessible to the scaler is partic- ularly important on molars. This is so, not only because of the furcation problem in particular, but because treatment of the posterior teeth in general is made more dif- ficult by poor access and lack of direct vision. The uselessness of conventional subgingi- val plaque control in furcation cases ur- gently calls for an alternative therapy. The alternative is root resection, which has been practiced for a century on an empirical basis. The most seriously involved root has been resected and removed, knowing that the remaining root or roots will last longer. The best prognosis is achieved when the re- section is done at an early stage, ie. as soon as it can be concluded that the plaque between the roots cannot be removed by scalers or curettes. Another important cause of failure is not following the basic rules of the plaque con- trol. And finally the endodontic therapy may fail. In the management of the established furcation involvment, several factors must be taken into consideration, such as the pa- tient’s age, motivation, predisposition to pe- riodontal disease, and the anatomy of the teeth. If all the above-mentioned factors are favorable, the first thing to consider is the probable length of time that the tooth will last without root resection. This is where the patient's age and predisposition must be weighed against one another. The predisposition can be expressed as the speed with which the subgingival plaque has mi- grated apically. There is good reason to assume that this speed has been fairly con- stant over the years and that it will con- tinue to be so. Thus, if the subgingival plaque front has advanced only about 4 mm below the CEJ and reached the central part of the furcation by the age of 60, it is not likely that it will reach close to the apex within a normal life span and the tooth is likely to function satisfactorily for the rest of life without a hemisection. However, if the plaque front has reached the same level by the age of 30, it will probably reach apex within the next 10 to 20 years; in this situation the patient has the right to be given the possibility of prolonging the life of the tooth by root resection. If this decision is made, the tooth should be split as soon as possible to avoid further loss of attachment between the roots. The observations on mobility and loss of attachment (Table 6) did not support the assumption that functional forces had been involved in the etiology of the furcation lesion. Admittedly the loss of attachment increased with increasing mobility, but i creased mobility was a very late and it consistent clinical sign insofar as the mobil- ity was normal in 34 out of the 66 cases, although about half of the supporting tis- sue had been lost, and considerably more than 50 % of the attachment had been lost in the 18 cases in which mobility was only slightly increased. There is no histopatho-92 WAERHAUG logical basis to explain how functional forces, in the absence of increased mobility, could have damaged the attachment fibers. (Lindhe & Svanberg 1974). It is remarkable that so much of the supporting tissues could be lost without an increase in mobility. There are two reasons why such teeth re- main : 1) Molars usually have two or three roots which support one another, and reduce the movement to much less than would have been the case, if the roots had been standing alone. This is seen when a molar with normal mobility is hemisec- tioned; then the individual roots may be- come highly mobile. 2) In the present material 34 % of the outer surfaces were plaque-free both above and below the gin- gival margin (Table 1) and the subjacent periodontal membrane was healthy, thus re- stricting movement within the normal range. The severe inflammation and loss of attach- ment in the furcations were prevented from manifesting themselves as increased mobility (Figs. 1-9). In the present material pronounced ex- trusion was observed in all cases of perio- dontal abscesses, and on 17 teeth there were premature contacts combined with some degree of soreness. In all these teeth, the furcation areas were loaded with subgin- gival plaque which may have initiated any- thing from a mild chronic to a violent acute inflammation. If the inflammation is acute, as with the periodontal abscesses, the tooth will be extruded to the extent that contact on the neighboring teeth is pre- vented, and the extremely high tissue pres- sure will cause severe pain. If the inflamma- tion is chronic the increase in tissue pres- sure will be more moderate and may lead only to a premature contact, and to soreness rather than pain. Both these symptoms are likely to be disregarded by the patient. The conventional approach to the treat- ment of premature contacts and trauma from occlusion is to eliminate the prematur- ities by selective grinding. Obviously, in cases of the type presented here the grind- ing would have had no lasting effect be- cause the cause of the extrusion — the plaque in the furcations - would soon cause a relapse into premature contact. It has repeatedly been pointed out that diagnosis of destructive submarginal gingiv- itis poses major problems, because neither the subgingival plaque nor the classical signs of inflammation can be seen. Fairly reliable indirect evidence can be attained by probing the pockets, however. The sub- marginal gingivitis is likely to be associated with pain and bleeding just as is the mar- ginal gingivitis. In Table 7 it can be seen that pain and bleeding were more frequently absent in pockets without plaque. And con- versely, pain and bleeding were more com- mon in pockets with plaque, but were still absent in about one-third of the pockets with plaque. It follows that profuse bleeding and pain on probing strongly indicate the presence of submarginal gingivitis and sub- gingival plaque, whereas absence of these clinical criteria does not give a reliable in- dication of health. This study (Table 7) has indicated a new approach to the diagnosis of submarginal gingivitis, but the problem merits further investigation on more material and with more specific criteria. For this purpose extracted teeth are eminently suited. It is important that epidemiologists who are studying destructive periodontal disease are aware of the fact that the conventional morbidity indices do not evaluate sub- gingival plaque and destructive submarginal gingivitis, nor take account of the furcation problem. Until now the common solution to the furcation problem has been extraction. With the above knowledge about its etiology, it should be possible to prevent its develop- ment and to some extent, treat established cases.THE FURCATION PROBLEM 93 Zusammenfassung Die Einbeziehung der Furkation in das Krankheitsgeschehen bei Parodontopathien (Furkationsengagement), Atiologie, Pathogenese und Diagnose Die Problematik bei der Einbeziehung der Fur- kation in das Krankheitsgeschehen bei Paro- dontopathien (Furkationsengagement) wurde an einem Material von 66 extrahierten Zahnen studiert, deren Extraktion aufgrund vorliegen- dem Furkationsengagement indiziert war. Vor der Extraktion wurden die Plaque- und Gin- givalindizes, der Lockerungsgrad und andere in- teressante klinische Daten registriert. Auf der Zahnoberfliiche wurde in Hohe des Gingival- saumes eine Markierung angebracht, damit seine Lage dann spiiter wahrend der Unter- suchung des extrahierten Zahnes lokalisiert werden konnte. Direkt nach der Extraktion wurde lockeres Weichgewebe zwischen den Wurzeln und in der Nihe des Epithelansatzes entfernt; eventuell vorhandenes Blut wurde abgespiilt. Der Zahn wurde dann 10 Minuten lang in einer 1 %-igen Wasserblaulésung aufbewahrt, danach in rin- nendem Wasser gereinigt und dann luftgetrock- net. Die Zihne wurden mit dem Stereomikro- skop untersucht. Folgende Schlussfolgerungen erscheinen berechtigt: Auch bei dem Nichtvorhandensein supragi givaler Plaque kommt subgingivale Plaque hiu- fig bei solchen Patienten vor, die nach der Bil- dung subgingivaler Plaque angefangen haben cine effektive supragingivale Plaquekontrolle zu betreiben. Effektive supragingivale Plaquekontrolle ver- mag die Entfernung subgingivaler Plaqueforma- tion bis zu 2,5 mm unterhalb des Gingivalsau- mes zu erreichen. Bei Nichtvorhandensein su- pragingivaler Plaque ist subgingivale Plaque nur gelegendlich mit marginaler Gingivitis verge- sellschaftet In Abwesenheit supragingivaler Plaque ver- ursacht subgingivale Plaque Klinisch nicht zu bemerkende submarginale Gingivitis, die zur Destruktion des Halteapparates und eventuell zum Furkationsengagement fihrt. Ob an den Aussenfliichen des Zahnes oder in seiner Furkation — der Attachmentverlust ist deutlich von dem Vorhandensein subgingivaler Plaque und submarginaler Gingivitis abhiingig. Es besteht weder eine Beziehung zwischen sichtbarer supragingivaler Plaque und dem At- tachmentverlust in den Furkationen, noch eine Korrelation zwischen subgingivaler Plaque in den Furkationen und marginaler Gingivitis. Die konventionellen Plaque- und Gingival- indizes sind nicht imstande die bei fortge- schrittenen destruktiven Parodontalkrankheiten yorliegenden Bedingungen, einschliesslich des Furkationsengagements, zu veranschaulichen. Subgingivale Plaquekontrolle verbleibt an den Aussenoberflichen des Zahnes unvollkom- men und ist in den Furkationen undurchfihr- bar. Bei bereits vorhandenem Furkationsenga- gement ist es Klar, dass zwischen den Wurzeln mehr Attachment verloren geht als an den Aussenfliichen. Fiir die erfolgreiche Behand- lung ist die Friihdiagnose entscheidend, Es ist jedoch diusserst schwer eine korrekte Diagnose zu stellen, weil viele der klinischen Kriterien missweisend sind und weil die notwendige Sondierung zur Feststellung der Grisse der Lasion oft durch intensive Schmerzempfindung verhindert wird. Die Wurzelresektion hat ihren klaren Platz in der, auf die vollstindige Plaquekontrolle zielende, Therapie. Die Indikation fiir diese Be- handlung ist jedoch abhiingig von der Zahnana- tomie, dem Alter des Patienten und von even- tuell vorliegender Priidisposition fiir destruktive parodontale Krankheiten. Die Prognose der Wurzelresektion ist sowohl von der erfolgreichen endodontischen Therapie als auch von der totalen Plaquekontrolle ab- hiingig. Erhdhte Zahnbeweglichkeit ist ein Spitsymptom bei der Entwicklung des Furka- tionsengagements und hat nichts mit ihrer Atiologie zu tun. Résumé Le probleme de la furcation. Etiologie, pathogénie, diagnostic, thérapeutique et pronostic dans Vatteinte de la furcation Le probléme de la furcation a été étudié par «autopsie dentaire>, en ce sens que le matériel de cette étude consistait en 66 molaires qui avaient été extraites en raison de cette affec- tion. Avant l'extraction, "Indice de Plaque et Vindice Gingival, le degré de mobilité et les autres données cliniques appropriées ont été enregistrées. Un repére a été pratiqué sur la surface dentaire au niveau du rebord gingival, de fagon A permettre de localiser le rebord pen- dant examen de la dent extraite. Immédiate- ment aprés lextraction, les tissus mous attachés de fagon ache entre les racines et dans la région de ’épithélium de jonction ont éé éli-94 WAERHAUG minés; toute trace de sang a été supprimée par lavage. La dent a été placée pendant 10 minutes dans une solution de Water Blue a 1 %, puis rincée a l'eau courante et séchée a lair. Les dents ont été examinées au stéréo-microscope. Les constatations effectuées ont permis de tirer les conclusions suivantes: La plaque sous-gingivale est fréquemment présente, méme en I'absence de plaque sus-gin- givale, parmi les patients qui n’ont commencé & faire une élimination efficace de la plaque sus-gingivale qu’aprés la formation de plaque sous-gingivale, L’limination efficace de la plaque sus-gin- givale peut réussir a enlever la plaque sous- gingivale jusqu’é un niveau de 2,5 mm au des- sous du rebord gingival. En absence de plaque sus-gingivale, la plaque sous-gingivale n'est que rarement as- sociée A une gingivite marginale. La plaque sous-gingivale, en I'absence de plaque sus-gingivale, cause une gingivite sub- marginale non décelable en clinique, mais con- duisant & une destruction de l'attachement et aboutissant & une atteinte de la furcation. La perte de l'attachement, qu'elle prenne place sur les faces externes ou dans les furca- tions, est fortement corrélée avec la plaque sous-gingivale et la gingivite submarginale. Tl n’y a pas de corrélation entre la plaque sus-gingivale visible et la perte de I'attache- ment dans les furcations, ni d’association entre la plaque sous-gingivale dans les furcations et la gingivite marginale. Les Indices de Plaque et de Gingivite habi- tuellement utilisés ne reflétent pas les condi- tions existant réellement dans la parodontite destructrice avancée, avec atteinte de la furca- tion. L’élimination de fa plaque sous-gingivale risque fort d’étre incompléte sur les faces extemnes et représente un échec total dans les furcations. Lorsque Vatteinte de la furcation s'est in- stallée, la perte de V'attachement est probable~ ment plus sévére entre les racines que sur les faces externes. Un diagnostic précoce est essentiel pour la réussite lorsqu’on s’attaque au probleme de la furcation. Mais il est extrémement difficile de faire un diagnostic correct, parce qu’un grand nombre des critéres cliniques sur lesquels on se base sont propres a induire en erreur, et parce que le sondage des lésions pour en déterminer T’étendue est souvent empéché par la douleur. La résection de racines peut trouver une place logique lorsqu’on envisage les moyens dobtenir T'élimination totale de la plaque, mais Vanatomie de la dent, lage du patient et sa prédisposition aux parodontites destructri- ces sont des facteurs dont la forte influence doit étre considérée pour décider si ce traite- ment est indiqué, Le pronostic de la résection des racines dépend aussi du succes du traite- ment endodontique et de la maitrise complete de la plaque. L’augmentation de la mobilité dentaire est un symptéme trés tardif dans latteinte de la furca- tion et n’est pas un Facteur étiologique de cette affection. References Axelsson, P. & Lindhe, J. (1978) Effect of controlled oral hygiene on caries and perio- dontal disease in adults. Journal of Clinical Periodontology 5, 133-151. Landis, E. M. (1927) Micro-injection studies of capillary permeability; relation between cap- illary pressure and rate at which fluid passes through walls of single capillaries. American Journal of Physiology 82, 217-238. Lindhe, J. & Svanberg, G. (1974) Influence of trauma from occlusion in progression of experimental periodontitis in the beagle dog. Journal of Clinical Periodontology 1, 3-14. Lindhe, J. & Nyman, S. (1975) The effect of plaque control and surgical pocket elimina- tion on the establishment and maintenance of periodontal health. A longitudinal study of periodontal therapy in cases of advanced dis- ease. Journal of Clinical Periodontology 2 61-79. H. & Silness, J. (1963) Periodontal disease in pregnancy. Acta Odontologica Scandina- vica 21, 533-559. Rosling, B., Nyman, S. & Lindhe, J. (1976) The effect of systematic plaque control on bone regeneration in infrabony pockets. Journal of Clinical Periodontology 3, 38-53. Ross, J. F. (1978) A long-term study of root retention in treatment of maxillary molars with furcation involvement. Journal of Perio- dontology 49, 238-244. , J. & Lée, H. (1964) Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontologica Scandinavica 22, 121~135. Starling, E. H. (1895/96) On the adsorption of fluids from the connective tissue bases. Jour- nal of Physiology (London) 19, 312-326.THE FURCATION PROBLEM 95 Theilade, E., Wright, W. H., Jensen, S. B. & Lée, H. (1966) Experimental gingivitis in man. II. A longitudinal clinical and bacterio- logical investigation. Journal of Periodontal Research 1, 1-13. Waerhaug, J. (1976) The interdental brush and its place in operative and crown and bridge dentistry. Journal of Oral Rehabilitation 3, 107-113. Waerhaug, J. (1977) Subgingival plaque and loss of attachment in periodontosis as ob- served on extracted teeth. Journal of Perio- dontology 48, 125-130. Waerhaug, J. (1978) Healing of the dento- epithelial junction following _ subgingival plaque control. I. As observed in human biopsy material. Journal of Periodontology 49, 1-8. Waerhaug, J. (1979a) The angular bone defect and its relationship to trauma from occlu- sion and subgingival plaque. Journal of Clin- ical Periodontology 6, 61-82. Waerhaug, J. (1979) The infrabony pocket and its relationship to trauma from occlu- sion and subgingival plaque. Journal of Pe- riodontology 40, 355-365. Address: Jens Werhaug Department of Periodontology Dental Faculty, University of Oslo Geitmyrsvn. 69, Oslo 4, Norway (Postbox 1109, Blindern)This document is a scanned copy of a printed document. 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