Furcation involvement

CONTENTS - Introduction

-Anatomical considerations-Classification-Epidemiology-Etiopathogenesis-Diagnosis-Management

-Factors affecting clinical outcome -Conclusion -References

Introduction

Furcation is an area of complex anatomic

morphology, that once involved is difficult to

debride by routine periodontal instrumentation.

Furcation – anatomic area of a multirooted tooth where the roots diverge.

AAP 1992

Furcation invasion – pathologic resorption of bone within the furcation.

AAP 1992

Furcation involvement – invasion of the bifurcations/ trifurcations of multirooted tooth by periodontal disease.

Anatomical considerations

81% of furcation have orifice of 1mm or less and 58% 0.75mm or less (Bowers 1979)

Classification

Glickman 1953.

Grade I – incipient stage, suprabony pocket, R/G change absent

Grade II – cul-de-sac, horizontal component. R/G – may/maynot be present.

Grade III – bone not attached to dome of furca.

Grade IV –soft tissue apically receded, tunnel.

Classification

Classification

Title Goldman 1958

Grade I : incipient. Grade II : cul-de-sac. Grade III : through & through.

Hamp et al 1975. Degree I - < 3mm Degree II - > 3mm, not total width. Degree III – through & through.

Ramford & Ash 1979. Class I : beginning involvement. Tissue destruction <

2mm Class II : cul-de-sac > 2mm but not through & through. Class III : through & through.

Classification

Title Lindhe & Nyman 1983

Degree I : initial horizontal loss < 1/3 width of

root.

Degree II : partial horizontal loss > 1/3, but not

through & through.

Degree II : total through & through loss

Title Riochetti 1982

Class I : 1mm of horizontal measurement.

Class I a : 1-2 mm of horizontal invasion, earliest damage.

Class II : 2-4 mm

Class II a : 4-6 mm

Class III : > 6mm

Title Basaraba 1990

Class I : initial/incipient furcal invasion

Class II : partial/ patent furcal invasion

Class III : communicating furcal invasion.

Title

• Hain & Canter 1968 Similar to Hamp et al. Sub classified furcation by no of walls

remaining.

Title Fedi 1985

Combined Glickman & Hamp classification. Grade I to IV. Grade II furcations subdivided degree I (< 3mm) degree II (> 3mm)

Title Vertical component

Tarnow & Fletcher 1984. 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

Title Eskow & Kapin 1984

Same classification as Tarnow & Fletcher, but thirds instead of 3mm units are used.

Title Easley & Drenman1969

Based on the ledges & morphology of remaining bone.

Class I : fluting coronal to furcation affected. no definite horizontal component.

Class II : Type I – essentially horizontal, no buccal/lingual ledge.

Type II - buccal/lingual ledge, definite vertical component.

Class III : through & through.

Epidemiology Incidence and Distribution

Lorato (1981) found that:

Average no. of furcation involvement increased with age.

Furcation involvement most common in 1st permanent molars

In maxillary molars, buccal aspects more often invaded.

Maxillary premolars-Lower incidence of furcation.

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Plaque associated Inflammation

Trauma from Occlusion

Contributing anatomical factors

Etiopathogenesis

Plaque associated Inflammation Extension of inflammatory periodontal disease in

furcation area leads to inter-radicular bone resorption—reduction of bone height and formation of furcation defect.

Furcation involvement is a phase in root ward extension of periodontal pocket(Glickman, 1950)

Cellular and fluid inflammatory exudation---epithelial proliferation

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Trauma from Occlusion

• Suspected etiologic/contributing factor in isolated furcation defects—crater like or angular deformities in bone---bone destruction is localized to one of the roots--controversial

• Glickman(1950)

• Waerhaug (1980) inflammation +oedema=extrude tooth

Traumatized and sensitive

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Contributing anatomical factors

Cervical Enamel Projections

Root trunk length

Root length

Root form

Interradicular dimension

Anatomy of furcation

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CERVICAL ENAMEL PROJECTIONS

8.6%-28.6% of molars(highest—maxillary and mandibular 2nd molar)

Grade I: extension from CEJ of the tooth to furcation entrance

Grade II: approaches entrance but doesnot enter the furcation(no horizontal component)

Grade IIIExtends horizontally into furcation Masters and Hoskins(1964)--Clinical significance

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.

Interradicular dimension:Degree of separation

Enamel Pearls

Incidence: 1.1% - 9.7% (moskow & canut et al(1990)

In ,Maxillary 2nd molar -found near the CEJ extending into molar bifurcations

Prevent connective tissue attachment.

Diagnosis PROBING Mealy and Beybayer (1994) have investigated the

role of transgingival probing in defining the anatomy of the furcation defect. They found it to be importance in determination of factors such as

Morphology of the tooth The position in relation to adjacent teeth. Local anatomy of the alveolar bone. Configuration of bone defects. Presence and extent of other diseases such

as caries and pulpal necrosis.  

Diagnosis Probing of the furcation.

Instruments. : Nabers probe. Buccal and lingual furcation can be

easily probed. Proximal furcations are difficult for

probing particularly when broad contacts are present n adjacent teeth.

In maxillary molars mesial furcation is located more palatally than to the buccal tooth surface. It should therefore be probed from the palatal aspect.

Diagnosis In contrast the distal furcation is

located midway bucco-lingually and can therefore be probed either from

the buccal or palatal aspect

Furcation probing in maxillary premolar is very difficult due to the presence of anatomic variations such as longitudinal furrows, invaginations opening at varying distances from the CEJ.

Diagnosis Radiographs It should include intra oral periapical and vertical bitewing

radiographs. Inter dental bone as well as that within the root complex

should be examined. Inconsistency in clinical and radiographic findings may

occur.

Differential Diagnosis 1. Endo-Perio lesions A pulpal pathology may involve the furcations via

accessory canals.

Differential Diagnosis 2. Trauma from occlusion Increase occlusal forces may cause tissue destruction or

adaptation within the inter radicular area of multirooted tooth. In such cases a radiolucency may be evident in the root complex

and tooth may exhibit increase mobility. Probing however fails to detect any furcations involvement. In such situations occlusal adjustment should precede periodontal

therapy. If the defect is of occlusal origin the tooth becomes stabilized and

the defect disappears within weeks following occlusal correction.

Management Objectives of furcation therapy

To facilitate maintenance.

To prevent further attachment loss.

Obliterate furcation defects as a periodontal maintenance problem.

Factors to be considered when deciding for mode of therapy Degree of involvement Crown-root ratio Length of root Degree of root separation Strategic value of tooth Root anatomy Residual tooth mobility Ability to eliminate the defect Endodontic therapy & complications Prosthetic requirements Periodontal condition of adjacent teeth.

Can be broadly classified as put forth by Kalkwarf and Reinhardt as follows. (1988)

Maintain the furcation Increase the access to furcation Removal of furcation Closure of furcation with new

attachment.

Maintain the furcation Hirschfeld and Wasserman evaluated 600

patients who had been treated for periodontal disease and followed with maintenance appointments every 4-6 months for at least 15 years.

Many furcations were primarily treated by sub gingival scaling.

During the 22 year span of the study of the 1464 molars involved 460 were lost

Maintain the furcation Waerhaug has noted a close association of 0.91

mm between the sub gingival plaque front and attachment fibers in areas of attachment loss in furcations.

Some amount of plaque was always left behind when it was present in the central area prior to treatment.

He concluded that subgingival plaque removal in the furcation was invariably incomplete.

Maintain the furcation Obliteration of the furcation: Baer et al (1983)

proposed the elimination of anatomic niches by filling advanced furcation defects with biocompatible material.

Furcation areas of 50 maxillary teeth and 20 mandibular molars were surgically exposed and 2 weeks later packed with Intermediate Restorative Material (IRM).

Clinical success was reported for up to 5 years.

They concluded that IRM was physiologically acceptable to gingival tissues, prevented caries and simplified plaque control.

They also advised IRM placement in advancement furcations during flap reflection.

Increasing access to the furcation

Gingivectomy / Apically positioned flap. Increases access for plaque control and allows resolution of periodontal inflammation.

Odontoplasty It is the reshaping of the tooth coronal to the

furcation to improve access for plaque control. It increases entrance to the furca and reduces its

horizontal depth. Mainly advised for Grade I and Grade II furcation

defects. Caution should be exercised with regard to

Hypersensitivity Pulpal irritation leading to permanent damage Pulp exposure Increase risk of root caries.

b. Osteoplasty and Ostectomy: Osteoplasty: Reshaping surfaces of bone without removing

tooth supporting bone 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

gingival 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.

--furcationplasty

Recommended for Grade I and II furcation involvements.

In advanced cases of Grade II and Grade III furcations ostectomy may be extended into create a tunnel to expose the entire furcation area.

Tunnel preperation Grade III furcation

Permits plaque removal

Root caries Recurrent

periodontitis

Such treatment should be restricted to Cases where other surgical procedures are contra indicated. Roots are divergent to allow adequate postoperative plaque

control with inter proximal brushes Patient has demonstrated a high level of plaque control in

the past. Hamp et al 1975—5 year clinical trial(7 teeth)—4/7 caries Helden et al 1989– 149 teeth(mean of 37.5 months)---75%

functional

Grant and Stern advocate that such procedures often result in a reverse architerature, which may encourage further plaque accumulation.

The main advantage of this technique -- avoidance of prosthetic reconstruction and

endodontic therapy

Anatomical consideration--maxillary

III. Elimination of the furcation:

Terminology Tooth sectioning Root resection Hemisection /Root

separation/bicuspidization Root amputation

III. Elimination of the furcation:

Root resection / Hemisection Objectives To resect the open root furcation area and make

possible debridement of the residual root. To eliminate the periodontal pocket by removal of the

furcation. To improve the furcation form for dental hygiene. To preserve maximum periodontal tissue to the

residual root. To control inter dental sparse (embrasure) in the area

adjacent to the root. To treat teeth with severe caries.

Indications for root resection and hemisection.

--Advanced furcation involvement Grade II and Grade III is an absolute indication for root resection or hemisection.

Contra indications Insufficient periodontal support to save the roots Fused roots Extremely long root trunks. In conditions where endodontic treatment of the

resected root is impossible. In patients who are unable to establish

appropriate hygiene or where the strategic value of maintaining dental arch continuity is lacking.

From a prognostic point of view the following factors should be considered.

Periodontal considerations. A long and wide root with a large crown is the ideal

form After root resection / hemisection the crater like

osseous defect around the residual root is removed by osseous resection and the periodontal pocket eliminated.

A form that facilitates plaque control must be achieved. Patient must be capable of following through oral

hygiene and keeping up the professional schedule.

Distobuccal root amputation of a maxillary first molar.

Bicuspidisation

85- 100% predictable results if proper case selection,treatment and restoration done

Guided tissue regeneration

Guided tissue regeneration in the treatment of degree III furcation defects in maxillary molars Pontoriero R, Lindhe T, JCP, 1995; 22:810-812.

11 subjects with generalized periodontitis and advanced lesions in the maxillary molar regions, bilateral mesial distal, but not buccal degree III furcation defects in 1st and 2nd molars

--some reduction in PD and some gain in CAL had occurred at both test and control sites

--none of the furcation defects had closed, but retained the characteristics of degree III furcation defects.

Guided Tissue Regeneration in the treatment of degree II furcations in maxillary molars

Pontoriero R, Lindhe J JCP 1995; 22:756-763.

18 inter proximal (10M, 8 D) and 10 buccal pairs Re-entry after 6 months. The addition of GTR enhanced the result by

promoting probing attachment and bone gain and decreases soft tissue recession on buccal furcation only

None seen on mesial / distal furcation.

GTR in degree II furcation involved mandibular molars.

Pontoriero R, Lindhe J JCP 1988: 15:247-254.

21 subjects

--more than 90% of the sites treated with GTR complete resolution of the defect occurred.

--Conventional therapy attained the same result in < 20% cases.

EXTRACTION OF FURCATION INVOLVED TEETH

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.

when no improvement of the overall treatment plan is expected or carious lesions or endodontic problems may cause the preserved tooth to be a future risk with regard to long-term prognosis.

I. Patient factors Adequate plaque control is a must for successful

outcome. Cigarette smokingRosenberg (1994), Tonetti et al (1995) showed less

attachment gains in intra bony defects following GTR in smokers than non smokers.

FACTORS AFFECTING CLINICAL OUTCOME

II. Defect factors Degree 1 and 2 buccal and lingual furcations of 1st and

2nd mandibular molars respond well to GTR therapy. However in maxillary molars location of the defect plays

a critical role as no improvement beyond that of debridement as obtained in interproximal degree II defects compared to buccal defect (Ponteriero et al 1995)

Direct correlation between initial depth of the defect and gain in attachment of GTR is observed.

Based on present evidence successful outcome of GTR treatment can be expected only in mandibular and maxillary buccal degree II furcations.

III. Technical factors A flap management technique that places wound margins

away from the entrance to the healing defects is essential for +ve outcome of regenerative therapy of furcation defects.

Sander and Karring (1995) studied significance of bacterial contamination in monkeys. The findings of this study showed that new attachments and bone formation was favored considerably if bacterial contamination of the membrane was prevented during wound healing.

IV. Antibiotic therapy.

Nyland & Egelberg (1990) studied effect of tetracycline irrigation of the site as compared to saline

One-year evaluation of attachmentlevels and pocket depths showed similar clinically negligible (<1 mm) variation

Prognosis In a 5-year study of Hamp et al (1975) 175 teeth with various

degree of furcation involvement in 100 patients were noted. Of the 175 teeth.

32 (18%) - SRP49 (28%) - SRP + Furcationplasty 87 (50%) - Root resection. 7 (4%) – Tunnel preparation.

Patients were enrolled in a maintenance program of periodic recall of 3-6 months.

Plaque and gingivitis scores measured ensured that oral hygiene maintenance was of the highest quality.

None of the teeth were lost during 5 years of the study.

Prognosis Key to long term success--thorough diagnosis--selection of patients with good oral hygiene--careful surgical and restorative management

Conclusion The presence of furcation involvement is one

clinical finding that can lead to a diagnosis of advanced periodontitis and potentially to a less favorable prognosis for the affected tooth or teeth.

Furcation involvement therefore presents both diagnostic and therapeutic dilemmas.

References Carranza’s clinical periodontology. 10th edition.

Clinical periodontology and implant dentistry. Jan Lindhe. 5th edition.

Diagnosis and epidemiology of periodontal osseous lesions. Periodontology 2000, vol 22, 2000.

The conservative approach in the treatment of furcation lesions

Periodontology 2000, vol 22, 2000.

References Management of furcation involvementPeriodontology 2000, vol. 9, 1995, 69-89

Current status for furcation involvements – dcna 35, no 3, 1991.

Molar root anatomy & management of furcation defects – jcp 2001; 28;730.

Atlas ofcosmetic and reconstructive periodontal surgery

3rd edition, Edward Cohen

Thank you!!!