Furcation Involvement and

Treatment
Contents:
-Introduction
-Etiopathogenesis
-Anatomical considerations
-Classification
-Diagnosis
-Treatment
-Prognosis
Introduction
Furcation is the anatomical area where
the roots divide.
Furcation involvement refers to a
condition in which the bifurcations and
trifurcations of multi-rooted teeth are
invaded by periodontal disease, bone
resorption and attachment loss in the
interradicular space.
Etiopathogenesis

1. Plaque associated Inflammation

2. Trauma from Occlusion
3. Contributing anatomical factors
Contributing anatomical factors

1. Cervical Enamel Projections

2. Root trunk length
3. Root length
4. Root form
5. Interradicular dimension
6. Anatomy of furcation
1. CERVICAL ENAMEL PROJECTIONS

 8.6%-28.6% of molars(highest—maxillary and

mandibular 2 nd molar)
 Grade I: extension from CEJ of the tooth to
furcation entrance
 Grade II: approaches entrance but doesnot enter
the furcation(no horizontal component)
 GradeIII: Extends horizontally into furcation(
Masters and Hoskins)
2. Root Trunk length:
•Teeth with shorter trunks are more prone for
development of furcation defects compared to
ones with longer root trunk length.
3. Root length
•Determines the amount of attachment or support
that a tooth will have. Teeth with long root trunks
and short roots would have lost significant amount
of support by the time the furcation is affected.
3. Root form
Flutings on the root surface coupled with
developmental grooves and concavities-- plaque
retentive areas hastening the process of
periodontal breakdown leading to early furcation
involvement.

4. Anatomy of the furcation

Bifurcational ridges, concavity in the root and
accessory canals may jeopardize plaque control as
well as treatment outcome.
5.Interradicular dimension:

Degree of separation:the angle of

separation between the roots.

Furcation Fornix:the roof of the

furcation

Divergence:distance between the two

roots.
Wide seperation of the roots
improves access,therby
facilitating instrumentation.
Enamel pearls

Incidence: 1.1% - 9.7%

 In Maxillary 2nd molar - found near the CEJ
extending into molar bifurcations
 Prevent connective tissue attachment.
Classifications of
Furcation Involvement (FI)

1. Based on horizontal component

Glickman’s classification (1953)
Hamp’s classification (1975)
2.Based on vertical component
Tarnow and Fletcher’s classification (1984)
Glickman’s classification (1953)

1. Grade I – incipient stage, suprabony pocket,

R/G change absent
2.Grade II – cul-de-sac, horizontal component.
R/G – may/maynot be present.
3. Grade III – bone not attached to dome of
furcation.
4. Grade IV –bone not attached to dome of
furcation. And soft tissue apically receded,
tunnel.
Clinically exposed
Hamp’s Classification (1975)

1 . Degree I - < 3mm horizontal bone loss

2. Degree II - > 3mm, not total width.
3. Degree III – through & through.
Tarnow and Fletcher (1984)

Based on vertical component 3 subgroups:

Subclass A– denotes furcation involvements

with vertical bone loss of 3mm or less.
Subclass B – vertical bone loss of 4-6 mm
Subclass C – bone loss
from the fornix of 7mm or more
 DIAGNOSIS
Clinical appearance
Naber’s Probe
No. 23 Explorer
Radiographs
Each furcation entrance is classified.
Radiographs
1. It should include intra oral periapical and vertical
bitewing radiographs.
2. Inter dental bone as well as that within the root
complex should be examined.
3. Inconsistency in clinical and radiographic
findings may occur.
 Treatment Aspect

Main objectives are:

1. Elimination of the microbial plaque from root
complex
2. Establishment of an anatomy to facilitates proper
self‐performed plaque control
3. Prevent further attachment loss
Factors to be considered when
deciding for mode of therapy
1.Degree of involvement
2. Crown-root ratio
3. Length of root
4. Degree of root separation
5. Strategic value of tooth
6. Root anatomy
7. Residual tooth mobility
8. Ability to eliminate the defect
9. Endodontic therapy & complications
10 Prosthetic requirements
11.Periodontal condition of adjacent teeth.
Therapeutic classese of furcation
defect
Class I: Early defects
Incipient or early furcation defects are
amenable to conservative periodontal therapy.
Oral hygiene ,scaling and root planing are
effective
Any thick overhanging margins and
restorations, facial grooves, or CEPS should be
removed by odontoplasty, recontouring or
replacement.
Class II
.once horizontal component to the furcation has
developed ,therapy becomes more complicated.
.Shallow horizontal involvement without significant
vertical bones loss usually responds favourably to
localized flap procedures with odontoplasty ,
osteoplasty and ostectomy.
.Isolated deep class II furcations may respond to
flap procedures with bone grafts and GTR
Class II to IV :Advanced defects
In such advanced cases(late class II,class III or
class IV),where there is development of a deep
vertical component, non surgical treatment is
usually ineffective, because the ability to
instrument the tooth surface is compromised.

.Periodontal surgery, endodontic therapy and

restoration of the tooth may be required to retain
the tooth.
Non-surgical therapy
Indicated for Grade- I and early grade- II
It includes
1.Oral hygiene procedures
2.Scaling and root planning
Oral hygiene procedures

.Several oral hygiene measures have been used in

the treatment of furcation.

.All include access to the furcation, and obtaining

access to the furcation requires a combination of
the awareness of the furcation by the patient and
oral hygiene tools that facilitate the access.
Many tools including,rubber tips,
periodontal aids,tooth brushes,both
specific and general, and other aids
have been used over time for
access to the patient.
2.Scaling and root planning.

.Indicated for Grade- I and early

grade- II
.In recent decades,instrument
beyond simple curettes have been
used to instrument the furcation.
Surgical approach
It includes :
1.Osseous resection
2.Regeneration
3. Root resection
4.Hemisection
5.Tunneling
6. Extraction
 Osteoplasty and Ostectomy:

1. Osteoplasty: Reshaping surfaces

of bone without removing tooth
supporting bone

2.Ostectomy: Reshaping and

removal of tooth supporting bone.
Improved plaque control through
osteoplasty is reported to be
accomplished by---Creating bony
ramps into the furcation area allowing
the gingiva to tuck into tooth
concavities
--Removing lip of the bony defect to
decrease horizontal depth of the
involvement
--Reducing pocket depth by allowing
apical adaptation of the flap.
.Recommended for Grade I and II
furcation involvements.

. In advanced cases of Grade II and

Grade III furcations ostectomy may
be extended to create a tunnel to
expose the entire furcation area.
Tunnel preperation

Indicated in deep grade- II and

grade- III furcation. defects in
mandibular molars.

Long and divergent roots (no

possibility of regeneration)
Such treatment should be
restricted to
1.Cases where other surgical
procedures are contra indicated.
2.Roots are divergent to allow
adequate postoperative plaque control
with inter proximal brushes
3.Patient has demonstrated a high
level of plaque control in the past.
REGENERATIVE PROCEDURES
Furcation defects with deep two walled or three
walled component may be suitable for
regeneration procedures.
Pictures depicting bone graft and membrane
placement in the furcation
Root Resection
Root resection- involves the sectioning and the removal of one or
two roots of a multirooted tooth.
May be indicated in grade II to grade IV furcation

Indications
1. Teeth serving as abutments for prosthesis
2. Severe attachment loss on a single root
3. Teeth for which more predictable Rx is unavailable.
4. Teeth in patients with good oral hygiene and low caries activity
Hemisection

Hemisection is the splitting of a two

rooted tooth into two separate portions.
this process is called as bicuspidization.
It is most likely to be performed on
mandibular molars with buccal and lingual
classII or classIII furcation defects.
Extraction
when attachment loss is so
extensive that no root can be
maintained or when treatment
would result in a tooth form where
plaque control by the patient is
difficult to achieve. (classes III and
IV)
PROGNOSIS
The key to long term success
appear to be:
1.Thorough diagnosis
2.Selection of patients with good
oral hygiene.
3.Excellence in non-surgical
therapy
4.Careful surgical and restorative
management.