49 Furcation Involvement
and Management
1. Introduction
2. Terminology
3. Classification
4. Etiology
5. Various Anatomic Factors Which Influence the
Treatment of Furcation Lesion
6. Diagnosis
INTRODUCTION
The furcation lesion defect represents a serious
complication in periodontal therapy due to inaccessibility
to adequate instrumentation, presence of root concavities
and furrows making proper cleaning of the area difficult.
Thus, loss of periodontal attachment in the furcation area
is a condition that requires careful evaluation and
management in order to achieve stability of dentition.
TERMINOLOGY
• Furcation is the area located between individual root
cones.
• Furcation involvement is the extension of pocket
formation into interradicular area of bone of multi-
rooted tooth.
• Furcation entrance is the transitional area between the
undivided and divided part of the root.
• Furcation fornix is the roof of the furcation.
• Degree of Separation is the angle of separation between
two roots (cones) (Fig. 49.1).
• Co-efficient of Separation is the length of root cones in
relation to the length of root complex (Fig. 49.1).
Shalu Bathla
7. Prognosis
8. Management
• Objectives of Furcation Therapy
• Treatment Modalities
• Failures in Surgical Furcation Therapy
9. Landmark Studies Related
• Root amputation is the removal of one or more roots
from a multi-rooted tooth leaving the majority of
crown intact.
• Sectioning is the surgical sectioning of a tooth into
segments consisting of the root and overlying crown.
CLASSIFICATION
I. According to Glickman (1953):
Grade I: It is the incipient stage of furcation
involvement, but radiographically changes
are not usually found.
Grade II: The furcation lesion is a cul – de – sac with
a definite horizontal component. Radio-
graphs may or may not depict the furcation
involvement (Fig. 49.2).
Grade III: The bone is not attached to the dome of
the furcation. Class III furcation display the
defect as a radiolucent area in the crotch
of the tooth (Fig. 49.3).
Grade IV: The interdental bone is destroyed and soft
tissues have receded apically so that the
furcation opening is clinically visible.
386 SECTION 6: Treatment: A. Non-surgical Therapy and B. Surgical Therapy
Fig. 49.1: Terminology in relation to furcation
Fig. 49.2: Grade II furcation defect
PERIODONTICS REVISITED
Fig. 49.3: Grade III furcation defect (Occlusal view): Naber's probe
passes through and through the furcation lesion
A B C
Figs 49.4A to C: (A) Furcation probed upto the depth of 3 mm,
(B) Furcation probed more than 3 mm but not through and through,
and (C) Furcation probed through and through
II. According to Hamp et al (1975) (Figs 49.4A to C):
Degree I: Horizontal loss of periodontal support
not exceeding 1/3rd of the width of the tooth
(< 3 mm).
Degree II: Horizontal loss of periodontal support
exceeding 1/3rd of the width of the tooth
(≥ 3 mm).
Degree III: Horizontal through and through
destruction of periodontal tissue in the furcation
area.
III. According to Tarnow and Fletcher (1984): Based on
vertical component of furcation involvement
depending on the distance from the base of the defect
to the roof of the furcation they are classified into :
Subgroup A: Vertical destruction of bone upto one –
third of the inter-radicular height (1– 3 mm).
 CHAPTER 49: Furcation Involvement and Management 387

A B

C D

PERIODONTICS REVISITED
Figs 49.5A to D: Easley and Drennan defect classification: (A) No furcation involvement, (B) Class I- Incipient involvement,
(C) Class II Type-1, Type-2, (D) Class III Type-1, Type-2

Subgroup B: Vertical destruction of bone upto two –
third of the inter-radicular height (4 – 6 mm).
Subgroup C: Vertical destruction beyond the apical –
third (7 mm or more).
IV. According to Goldman and Cohen (1968)
Grade I: Incipient lesion
Grade II: Cul- de-sac lesion
Grade III: Through and through lesion
V. According to Eskow and Kapin: Based on vertical
component of furcation involvement
Subgroup A: Vertical osseous defect up to 1/3rd of root
Subgroup B: Vertical osseous defect up to 2/3rd of root
Subgroup C: Vertical osseous defect > 2/3rd of root
VI. According to Easley and Drennan: (Figs 49.5A to D)
Class I: Incipient involvement in which the fluting
coronal to the furcation entrance is affected but there
is no definite horizontal component to the furcation
involvement.
In this classification system, Class II and III
furcations are separated into subtypes 1 and 2 on the
basis of the configuration of the alveolar bone at the
entrance to the furcation. Horizontal resorption into
388 SECTION 6: Treatment: A. Non-surgical Therapy and B. Surgical Therapy
the furca is subtype 1, whereas subtype 2 indicates a
significant vertical component to the defect.
Class II: Type 1—A definite horizontal loss of
attachment into the furcation, but the pattern of bone
loss is essentially horizontal. There is no definite
buccal or lingual ledge of bone. Type 2—There is a
buccal or lingual bony ledge and a definite vertical
component to the attachment loss.
Class III: A through and through loss of attachment
in the furcation. As with Class II furcation defects,
the pattern of attachment loss may be horizontal type
1 or there may be a vertical component type 2 of
varying depth.
ETIOLOGY
There is no difference in basic etiology and pathology
between furcation involvements and other periodontal
pockets. However, the anatomical and morphological
features of the furcations and their relationship to the
adjacent structures pose specific problems in treatment
of involved teeth.
i. The primary cause of furcation involvement is the
progressive loss of attachment that results from
inflammatory periodontal disease. Bacterial plaque
is the most common cause of marginal periodontitis,
which progressively invades one or more furcation
areas to varying degrees, resulting in irreversible
bone loss in the inter-radicular area. In most patients,
the response to bacterial plaque, in the absence of
therapy, is a progressive and site-specific attachment
loss. Although the rate of response may vary from
individual to individual, local anatomic factors that
affect the deposition of plaque or hamper its removal
PERIODONTICS REVISITED
can exert a significant impact on the development of
attachment loss.
ii. Predisposing factors:
• Cervical enamel projections (CEPs): Cervical enamel
projections that are present on the root surface in
the furcation region has been considered to be
predisposing etiologic factor for periodontal
attachment loss.
• Trauma from occlusion: Trauma from occlusion
acting as a predisposing cofactor for rapid
formation of furcation involvement is
controversial. Glickman (1961) assign a key role
to trauma, since furcation areas are most sensitive
to injury from excessive occlusal forces. Waerhaug
(1979) denied the initiating effect of trauma and
considered that inflammation and edema caused
by plaque in the furcation area tend to extrude
the tooth, which becomes traumatized and
sensitive.
• Pulpal periodontal disease: The high percentage of
molar teeth with patent accessory canal opening
into the furcation suggests that pulpal disease
could be an initiating cofactor in the development
of furcation involvement.
• Iatrogenic cofactors: Iatrogenic predisposing
cofactors i.e pin and endodontic perforations and
overhanging restorations can lead to the
formation of isolated furcation lesion by therapists
themselves. Overhanging restorations harbor
dental plaque which causes periodontal
inflammation and attachment loss.
• Root fractures involving furcations: If these root
fractures involve the trunk of a multi-rooted molar
and extend into the furcation, this can result in a
rapidly forming isolated furcation defect. The
prognosis for these situations is poor and usually
results in loss of the tooth.
VARIOUS ANATOMIC FACTORS WHICH
INFLUENCE THE TREATMENT OF FURCATION
LESION (Fig 49.6)
i. Root trunk length: Root trunk length is a key factor
that affects both the development of furcation
involvement and the mode of treatment. If root trunk
is short, less attachment has to be lost before furcation
is involved and when the root trunk is long, furcation
will be invaded later but will be difficult to
instrument. Short root trunk facilitates surgical
procedure and is more accessible to maintenance
therapy than long root trunk.
• Maxillary molars - Mesial furcation entrance is located about
3 mm from CEJ while buccal furcation entrance is approx.
about 4 mm and distal furcation entrance is located about 5
mm from CEJ.
• Maxillary premolars – Length of root trunk is approx. 8 mm.
• Mandibular molars – The length of root trunk at the lingual
entrance is 4 mm and at buccal entrance it is approx. 3 mm.
ii. Root length: Root length is directly related to the
quantity of attachment supporting the tooth.

Figs 49.6A to D: Anatomic variation of furcation areas
(Courtesy: Dr SK Salaria)
iii. Root form: The roots of molars may be fused, partially
fused, closely approximated, or widely divergent.
Curvature and fluting increases the potential for root
perforation during endodontics and vertical root
fracture. Marked concavities appear in the
mesiobuccal root of the maxillary first molar and both
roots of mandibular first molar.
iv. Inter-radicular dimensions: Narrow, inter-radicular
zone complicate the surgical procedure where as
widely separated roots have more treatment options
and easily hemisected, readily treated. In divergent
rooted tooth adequate instrumentation can be done
during scaling, root planing and surgery. The
dimensions of furcation entrance should be taken
into consideration during the selection of
instruments.
• Maxillary premolars – The width of furcation entrance of
maxillary premolars is approx. 0.7 mm.
• Maxillary molars – The width of buccal entrance is 0.5 mm,
mesial entrance is 0.75 mm and distal entrance is approx 0.5
mm to 0.75 mm.
• Mandibular molars – The buccal entrance is often less than
0.75 mm while the lingual entrance is more than 0.75 mm.
v. Anatomy of furcation: An intermediate bifurcation
ridges has been described in 73% of mandibular first
molars, crossing from the mesial to the distal root at
CHAPTER 49: Furcation Involvement and Management 389
the midroot of the bifurcation. Bifurcational ridges,
concavity in the dome and accessory canals
complicates scaling, root planing, surgical procedures
and maintenance.
vi. Cervical enamel projections (CEPs): They favour plaque
accumulation and complicate scaling and root
planing. Enamel projections act as local factor in the
development of gingivitis and periodontitis.
Masters and Hoskins in 1964 classified CEPs into 3 grades:
Grade I – The enamel projection extends from CEJ towards the
furcation entrance.
Grade II – Enamel projection approaches the entrance of the
furcation without entering the furcation with no horizontal
component.
Grade III – Enamel projection extends horizontally into the
furcation.
The prevalence of CEPs is highest in mandibular and maxillary
second molar teeth.
DIAGNOSIS
The position and morphology of the furcation region
complicates the clinician’s ability to identify the location
and extent of furcation defect. Furcation must be
diagnosed at the earliest possible time.
i. Radiographically: Radiographs are useful in assessing
root morphology and apicocoronal position of the
furcation but do not allow the clinician to determine
attachment loss in the furcation. Thus, two
dimensional radiographic pictures provide meager
information about furcation involvement, especially
in maxilla. High resolution spiral CT, CADIA and
digital radiography will allow cross-section views of
interior furcation lesions. It appears that radiographs
alone do not detect the furcation lesion with any
predictable accuracy and that probing the furcation
PERIODONTICS REVISITED
areas is necessary to confirm the presence and
severity of furcation defect.
ii. Clinically: Periodontal probes are useful for
determining the probing depth in a vertical direction,
but less useful for determining the degree of horizontal
involvement. For this purpose either curved Cowhorn
explorer or Naber’s probe are very useful. Furcation
probes have curved, blunt tip that allows easy access
to furcation areas. Example of furcation probes are
Nabers 1N and Nabers 2N. The probe is directed
beneath the gingival margin. At the base of pocket,
rotate the probe tip toward the tooth to fit the tip into
the entrance of the furcation. Terminal shank of Nabers
390 SECTION 6: Treatment: A. Non-surgical Therapy and B. Surgical Therapy
Fig. 49.7: Probing of molar furcation with Naber's probe
probe is positioned parallel to the long axis of tooth
surface being examined (Fig. 49.7).
• Probing of mandibular molar furcations is
relatively easy because there are only buccal and
lingual entrances each of which is located midway
mesiodistally.
• Probing of maxillary molar furcations - Buccal
entrance is accessible midway mesiodistally. Distal
furcation is present midway buccolingually, thus
can be probed from either buccal or palatal aspect.
Mesial furcation of maxillary molar is easily
probed from the palatal aspect because mesial
furcation opens about 2/3rd of the way towards
the palate, rather than midway buccolingually.
PERIODONTICS REVISITED
iii. Transgingival probing/bone sounding: To determine the
bone contours associated with furcation lesions more
accurately, transgingival probing can be accomplished
through anesthetized soft tissues. (More is explained
in chapter no. 30 Clinical Diagnosis)
PROGNOSIS
In general, teeth with furcation involvements have a poor
prognosis.
• Prognosis of furcation involvement in maxillary first
premolar has poor prognosis.
• Prognosis of maxillary molars is not good whereas
prognosis of mandibular first molar is considered
good.
The following factors should be considered in
projecting a prognosis of tooth with furcation
involvement:
a. Extent of involvement
b. Status of bone support
c. Root separation
d. Health of neighbouring teeth
Other factors involved in establishing a treatment
prognosis are related to personal, psychologic, sociologic
and financial considerations.
MANAGEMENT
Objectives of Furcation Therapy
i. To facilitate maintenance of existing furcation defect
through scaling and root planing.
ii. To increase access to the furcation through
gingivectomy, apically positioned flap, odontoplasty,
ostectomy/osteoplasty and tunnel preparation.
iii. To prevent further attachment loss or eliminate the
furcation through root amputation, tooth resection
and hemisection.
iv. To obliterate the furcation defect by filling furcation
defects with biocompatible material such as
polymeric reinforced Zinc oxide eugenol (IRM) and
GIC.
v. To regenerate the lost attachment through GTR
procedures and bone grafting.
Following are the factors to be considered during
treatment of furcation lesion:
A. Tooth related factors:
i. Degree of furcation involved
ii. Amount of remaining periodontal support
iii. Probing depth
iv. Tooth mobility
v. Root trunk length
vi. Root length
vii. Root form
viii. Inter-radicular dimensions
ix. Anatomy of furcation
x. Cervical enamel projections
xi. Tooth position and occlusal antagonisms
xii. Endodontic conditions and root canal anatomy
B. Patient related factors:
i. Strategic value of the tooth in relation to the
overall plan
ii. Patient’s age and health condition
iii. Oral hygiene capacity

Treatment Modalities for Class I, II, III and IV Furcation
Defects
The keys to successful treatment of molar furcation
involvement are the same as for any other periodontal
problem—that is, early diagnosis, thorough treatment
planning, good oral hygiene by the patient, careful
technical execution of the therapeutic modality, and a
well designed and implemented program of periodontal
maintenance. Depending upon the severity of furcation
involvement as well as tooth position in either maxilla
or mandible, various therapeutic methods are attempted.
Class I Furcation Defects
A. Furcationplasty: In 1975, Hamp, Nyman and Lindhe
described furcationplasty as raising a mucoperiosteal
flap to provide access to the furcation area and
combining scaling and root planing, osteoplasty and
odontoplasty to remove local irritants and to open
the furcation to allow the patient access to clean the
area. It is done in Grade I and early Grade II furcation
lesions.
B. Scaling and root planing: In Grade I, furcation lesions
have not lost bone within the furcation, so closed or
open scaling and root planing procedures can resolve
inflammation. If inflammation is not resolved then
gingivectomy or apically positioned flap can be done
depending upon the width of attached gingiva.
C. Odontoplasty: Odontoplasty is defined as the
reshaping of a tooth coronal to the furcation. It widens
and shallow the furcation by raising the roof of
furcation. The rationale behind this technique is to
create improved access for plaque control and
maintenance. If CEP is found then it is removed and
the area is recontoured. Odontoplasty must be
approached with caution due to the potential
complications of hypersensitivity, pulpal exposure
and increased risk of root caries.
D. Osteoplasty: It is done to provide better gingival form
by grooving the bone between the roots and then,
festooning and beveling the bone over the roots.
E. Gingivectomy/Apical positioned flap: Can be used in
reducing or eliminating the soft tissue pockets over
the furcation region to increase access for plaque
control and allows resolution of periodontal
inflammation.
Class II Furcation Defects
A. Open flap debridement: If sufficient subgingival access
is not possible with a closed approach, for furcated
CHAPTER 49: Furcation Involvement and Management 391
molars with deep lesions, then open flap debridement
or modified widman flap yields more effective plaque
and calculus removal.
B. Guided tissue regeneration: Organic or synthetic barrier
membranes are used based on the principles of
guided tissue regeneration.
C. Bone grafting: The strong focus on bone formation as
a prerequisite for new attachment formation has led
to implantation of bone grafts or different types of
bone substitutes into furcation defects. Among these
are bone autografts, allografts, xenografts and
alloplastic materials designed as either bone
substitutes or biologic barriers.
Class III and Class IV Furcation Defects
A. Tunnel preparation: Tunneling is the process of
deliberately removing bone from the furcation to
produce an open tunnel through the furcation. It is a
resective technique use to treat advanced class II and
class III furcation defects. The objective of this
technique is to make the furcal area accessible to home
care instruments by the patient.
The factors to be considered while selecting the case
of tunnel preparation are
• Tooth should be mandibular molar for clear two
way access
• Patient should have low caries index
• Good patient compliance towards plaque control.
• Root trunk should be short with high furcation
entrance and long roots
• Root should have wide furcal entrance with the
degree of divergence more than 30°
• The floor of the pulp chamber should not be close
to the roof of the furcation to allow for possible
PERIODONTICS REVISITED
odontoplasty of the entrance.
Procedure:
Buccal and lingual flaps are reflected and the
involved area is widened by the removal of some of
the inter-radicular bone. Some of the interfurcal bone
is sacrificed vertically and is recontoured to obtain a
flat outline of the bone. Following bone resection
enough space is established in the furcation area to
allow access for cleaning devices to be used by the
patient itself. Main advantage associated with
tunneling is the avoidance of prosthetic recon-
struction and endodontic therapy.
The drawbacks associated with tunnel
preparation are threat of root caries, subsequent
pulpal pathology, reverse architecture and retained
392 SECTION 6: Treatment: A. Non-surgical Therapy and B. Surgical Therapy
plaque in furcation cavities leading to progressive
periodontal breakdown.
B. Root resection: It is often the treatment of choice for
deep grade II and III furcation lesions when
regeneration is unpredictable. Root with the greatest
bone loss should be considered for amputation.
Indications for root resection include:
• Severe and disproportionate attachment loss
around the affected root
• Furcation defects that can be eliminated by root
amputation
• Elimination of cracked or deeply fissured roots
• Elimination of an endodontically untreatable root
• Inoperable root caries
• Recession exposing most or all of the root in a
multirooted tooth
Factors determining for the root resection are:
• Bone levels in the furcation
• Accessibility for plaque removal
• Root proximity
• Position of the root in the arch
• Root morphology
• Endodontic complications
Technique (Figs 49.8A to D):
Root selection of mandibular molar: The mesial
root concavities are less accessible for plaque removal
and two narrow pulp canals of the mesial root are
more difficult to treat endodontically than distal root.
Post and core restoration are easily constructed on
the distal root. Thus, mesial root of mandibular molar
is preferred over distal root for root resection.
Root selection of maxillary molar: The most
commonly performed root resection is the distobuccal
root of maxillary first molar. When both the mesial
PERIODONTICS REVISITED
and distal furcation is involved palatal root
amputation should be considered if buccal furcation
is intact. Palatal root has an unfavourable axial
inclination and unfavourable prosthetic relationship
with the first bicuspid.
Endodontic Phase
In non vital root resection, the endodontic therapy
(root canal therapy) is done prior to root resection
and in vital root resection, the root resection is
accomplished first and then endodontic therapy.
Resective Phase
• Flap reflection: After LA is given to the selected
site, through crevicular incision full thickness
mucoperiosteal buccal and lingual flap are
reflected.
A B
C D
A. Maxillary molar
B. Root resection cut to separate the root from root trunk
C. Extraction of separated root
D. Final recontouring of the root trunk
Figs 49.8A to D: Root resection of maxillary molar
• Cut: Small amount of bone covering the root
(which is to be resected) is removed to provide
access for elevation and root removal. Cut is made
with high speed surgical length fissure or cross
cut fissure carbide bur. Cut is then directed from
just apical to the contact point of the tooth,
through the tooth, to the other orifices of furcation.
In vital root resection the cut is made more
horizontally, so as to expose less surface area of
pulp chamber.
• Root removal: After sectioning, the root is elevated
from its socket. Before flap closure it is important
to check for any residual root spurs and ledges
that can act as subgingival overhangs to retain
plaque and cause future periodontal destruction.
• Suturing: Sutures are placed over the approx-
imated flap.
Restorative Phase
The removal of a root alters the direction of
occlusal forces on the remaining roots. Occlusion of
that tooth is evaluated and adjusted. Crowns should
be placed. But before giving permanent restoration
the quality of the endodontic filling, residual ledges
should be examined radiographically and clinically.
C. Hemisection: Hemisection is the splitting of a two
rooted tooth into two separate teeth. This process is
also called as bicuspidization.

Indications:
• Strategic teeth with Grade III furcation invol-
vement
• Teeth with divergent well supported roots
Contraindications:
• When the remaining periodontal support is
inadequate
• Tooth that cannot be treated endodontically
• Where adequate restorations of the remaining
tooth including splinting cannot be performed.
Procedure( Fig. 49.9):
• Cut: Vertically oriented cut is made faciolingually
through the buccal and lingual developmental
grooves of the tooth, through the pulp chamber
and through the furcation. The metallic portion
of the cut should be made before flap elevation
which will prevent the contamination of the
surgical field with metallic particles.
• Flap raised: Buccal and lingual flaps are raised and
the area is curetted. Osseous surgery is completed
by removing the residual internal osseous crater
on the mesial or distal aspect of the remaining
root.
• Tooth reshaping: Roof of furcation is carefully
perforated with dull rounded bur in a slow
handpiece. Each half of the tooth is reshaped into
a single rooted tooth and will be prepared to
receive crown.
• Orthodontic separation of the roots is required to
allow restoration with adequate embrasure form.
D. Tooth resection: Tooth resection involves removal of
one or more roots of tooth as well as corresponding
portion of the crown.
Fig. 49.9: Hemisection of mandibular molar
CHAPTER 49: Furcation Involvement and Management 393
Advanced Class IV Furcation Defects
Tooth Extraction
Indications for removal of a tooth with a Grade III and
IV furcal defects are:
i. Individuals who do not maintain oral hygiene
ii. Patients with high level of caries activity
iii. The existence of an unopposed molar which is the
terminal tooth in the arch.
iv. Financial consideration preclude acceptance of
treatment.
v. If an otherwise heroic effort for a tooth with a
questionable prognosis would be better handled
by an implant.
Failures in Surgical Furcation Therapy
Failures in surgical furcation therapy are due to the
following reasons:
i. Inadequate plaque control and maintenance
ii. Poor root resection
iii. Improper restoration
iv. Endodontic failures
v. Cracked roots
vi. Root caries
vii. Patients who respond poorly despite best
treatment
LANDMARK STUDIES RELATED
Bower RC. Furcation morphology relative to
periodontal treatment: Furcation root surface anatomy.
Journal of Periodontology 1979;50:366-74.
A random sample of 114 maxillary and 103 first
permanent mandibular molar teeth were selected from a
collection of extracted teeth at University of Michigan
PERIODONTICS REVISITED
Dental School. Measurement of furcation entrance
diameter was performed using a dissecting microscope.
Following were the results: Maxillary first molar furcation-
in 85% of buccal furcations the diameter was 0.75 mm or
less, whereas in 49% of mesiopalatal and 54% of
distopalatal furcations the entrance diameter were 0.7 mm
or less. Mandibular first molars - in 63% of the cases the
buccal furcation entrance diameter and 37% of lingual
furcation entrance diameter was 0.75 mm or less. The blade
face width of 12 commonly used curette types was
measured using a Vernier caliper and recorded. Blade face
width of all the curettes was within the range of 0. 75 mm