Furcation: The Problem and Its Management

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Furcation The Problem and Its Management
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Definition

• It can be defined as an area of complex anatomic
  morphology that may be difficult or impossible to
  be debrided by routine periodontal
  instrumentation.

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Anatomical Considerations

• Root trunk
• Furcation entrance
• Root surface anatomy
• Enamel projections
• Accessory canals

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Root Trunk

• Represents the undivided region of the root.
• The height of the root trunk is the distance
  between the CEJ and the separation line between
  two root cones

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Furcation Entrance

• Entrance the transitional area between the
  undivided and the divided part of the root
• Fornix the roof of the furcation

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Furcation Entrance Diameter

• How does the furcation entrance diameter relate
  to the blade width of a new curette?
• Blade width of new Gracey curette 0.75mm
• 60 of molar furcation entrances lt 0.75 mm
• Mandibular molars buccal wider than lingual
  maxillary molars
• mesial gt distal gt buccal

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Root Concavities

• Mandibular Molars
• 100 mesial roots
• 99 distal roots
• Maxillary Molars
• 94 mesiobuccal roots
• 31 distobuccal roots
• 17 palatal roots

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Cervical Enamel Projections

• 13 of molars have CEPs
• These projections may favor the onset of
  periodontal lesions in the affected furcations

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Enamel Pearls

• Incidence 1.1 - 9.7
• Maxillary 2nd molar found near the CEJ extending
  into molar bifurcations

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Classification

• Glickmans Classification(1953)

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Class I Incipient Furcation

• This is an early lesion. The pocket is
  suprabony, involving the soft tissue. There is
  slight bone loss in the furcation area.
  Radiographic change is not usual since bone loss
  is minimal. A periodontal probe will detect root
  outline or may sink into a shallow V-shaped notch
  into the crestal area

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Class I Incipient Furcation

• The level of bone loss allows for the insertion
  of the periodontal probe into the concavity of
  the root trunk

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Class II Patent Furcation

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

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Class II Patent Furcation

• The level of bone loss allows for the insertion
  of a periodontal probe into the furcation area
  between the roots.

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Class III Communicating or Through and Through
Furcation

• This type of probe penetrates completely from
  one side to the other side characterized by
  severe bone destruction in the furcation area. It
  is clearly shown in the radiographs as a
  radiolucent area in between the roots, especially
  in the lower molars.

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Class IV

• As in Class III, but the gingival tissues recede
  apically so that furcation is clearly visible.

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Hamp, Nyman Lindhes Classification (1975)
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Tarnow Fletchers Classification (1984)
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• Vertical bone loss is measured in mm from the
  roof of the furcation

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Furcation Probing
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Furcation Probing

• Mandibular Molars
• Buccal Furcation
• Place the probe between the two buccal roots
  from the buccal aspect

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Furcation Probing

• Mandibular Molars
• Lingual Furcation
• Place the probe between the two lingual roots
  from the lingual aspect

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Furcation Radiography

• Should include both periapical and bitewing
• Location of the interdental bone and bone level
  within the root complex should be examined

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Differential Diagnosis

• Pulpal pathosis may some times cause a lesion in
  the periodontal tissues of the furcation
• Trauma from occlusion may cause inflammation and
  tissue destruction within the interradicular area
  of a multirooted tooth

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Therapy
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Objective of Treatment

• The elimination of the microbial plaque from the
  exposed surfaces of the root complex.
• The establishment of an anatomy of the affected
  surfaces that facilitates proper self-performed
  plaque control.

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Non-Surgical Root Preparation

• Scaling root planing
• Most effective in grade I and shallow grade II.
• Deeper sites respond less favorably

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Scaling and root planing

• In most situations, it results in the resolution
  of the inflammatory lesion in the gingiva.

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Antimicrobials

• Adjunct to scaling and root planning
• Chlorhexidine
• Tetracycline fibers
• No clinically significant difference in clinical
  parameters after irrigation

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Open Debridement

• Greater calculus removal than closed
• Ultrasonic
• Narrow furcations
• Dome of furcation
• Surgical access and increased operator experience
  significantly enhance calculus removal in molar
  furcation.

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Osseous Surgery

• Most effective in grade II furcation
• Osteoplasty and ostectomy techniques
• Remove the lip of defect to reduce horizontal
  depth
• Bone ramps into the furcation to enhance plaque
  control
• Reduce probing depths

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Root Resection

• Grade II or grade III

• Contraindications
• Inadequate bone support
• Fused roots
• Inoperable endodontically
• Patient considerations

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Sequence of treatment at RSR

• Endodontic treatment
• Provisional restoration
• RSR
• Periodontal surgery
• Final prosthetic restoration

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Factors to be Considered

• The length of the root trunk
• The divergence between the root cones
• The length and the shape of the root cones
• Fusion between root cones
• Amount of remaining support around individual
  roots
• Stability of individual roots
• Access for oral hygiene devices

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Hemisection

• Mandibular molars
• Grade III furcation
• Need widely separated roots
• Soft tissue positioned below level of pulp chamber

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Hemisection
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Root Separation

• Root separation involves the sectioning of the
  root complex and the maintenance of all roots

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Tunnel Preparation

• Grade III furcation
• Permits plaque removal
• Root caries (4 stannous fluoride)
• 25 failure rate at 5 years
• Recurrent periodontitis

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Regeneration of Furcation Defects

• Guided tissue regeneration
• Predictable outcome of GTR therapy was
  demonstrated only in degree II furcation involved
  mandibular molars
• less favorable results have been reported in
  other types of furcation defects
• GTR could be considered in areas with isolated
  degree II furcation defects

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Furcation Defects

• Most predictable Mandibular or
  Buccal Maxillary Class II Furcations
• Mesial or Distal Maxillary Class II
  Furcations
• Class III Furcations
• Least predictable

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Osseous Grafting

• Autogenous bone
• Allografts
• Freeze dried bone
• Demineralized Freeze dried bone
• Alloplasts
• Hydroxyapatite
• Non-porous
• Porous
• Bioglass

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Extraction

• Attachment loss is so extensive that no root can
  be maintained
• If tooth/gingival anatomy will not allow proper
  plaque control
• For endodontic or restorative reason
• Osseointegrated implant substitute

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Prognosis

• Hirshfeld and Wasserman. A long term survey of
  tooth loss in 600 treated periodontal patients.
  J Perio 1978
• 600 patients followed an average of 22 years with
  recall every 4-6 months
• 1464 molars initially diagnosed with furcation
  invasion
• 70 survival of furcated molars

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Patients Factors

• Determine patients goals and expectations
• Screen for local, behavioral and systemic
  factors
• Oral hygiene
• Compliance
• Stress
• Intraoral Accessibility
• Uncontrolled Diabetes
• Smoking
• Healing response to Previous Therapy

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Successful Patient Outcomes

• Function
• Ease of Care
• Esthetics
• Confort
• Health
• Value