Carranza 12e - Furcation Involvement and Treatment
Carranza 12e - Furcation Involvement and Treatment
Carranza 12e - Furcation Involvement and Treatment
CHAPTER OUTLINE
Etiologic Factors Anatomy of The Bony Lesions Nonsurgical Therapy
Diagnosis and Classification of Indices of Furcation Involvement Surgical Therapy
Furcation Defects Treatment Prognosis
Local Anatomic Factors
For online-only content on root resection, hemisection, and root resection/hemisection procedure in the surgical therapy section,
please visit the companion website at www.expertconsult.com. Some figures may be out of numeric order in this printed chapter.
Editors Note: An animation (slide show) has been added as a supplement to the chapter by the Editors. This was produced by
My Dental Hub as a patient education tool and covers the basic elements in a conceptual manner. It is not intended to be a
procedural guide for dental professionals.
The progress of inflammatory periodontal disease, if unabated, of the furcation defect.38 The Nabors probe may be helpful to
ultimately results in attachment loss sufficient enough to affect the enter and measure difficult to access furcal areas (Figure 62-1).
bifurcation or trifurcation of multirooted teeth. The furcation is an Transgingival sounding may further define the anatomy of the
area of complex anatomic morphology5,6,11 that may be difficult or furcation defect.29 The goal of this examination is to identify and
impossible to debride by routine periodontal instrumentation.29,36 classify the extent of furcation involvement and to identify factors
Routine home care methods may not keep the furcation area free that may have contributed to the development of the furcation
of plaque17,23 (see Video 62-1: Bone Loss with Furcation). defect or that could affect treatment outcome. These factors include
The presence of furcation involvement is one clinical finding (a) the morphology of the affected tooth, (b) the position of the
that can lead to a diagnosis of advanced periodontitis and poten- tooth relative to adjacent teeth, (c) the local anatomy of the alveolar
tially to a less-favorable prognosis for the affected tooth or teeth. bone, (d) the configuration of any bony defects, and (e) the pres-
Furcation involvement therefore presents both diagnostic and ther- ence and extent of other dental diseases (e.g., caries, pulpal
apeutic dilemmas. necrosis).
The dimension of the furcation entrance is variable but usually
Etiologic Factors quite small; 81% of furcations have an orifice of l mm or less, and
The primary etiologic factor in the development of furcation 58% are 0.75 mm or less.5,6 The clinician should consider these
defects is bacterial plaque and the inflammatory consequences that dimensions, and the local anatomy of the furcation area,11-13 when
result from its long-term presence. The extent of attachment loss selecting instruments for probing. A probe of small cross-sectional
required to produce a furcation defect is variable and related to dimension is required if the clinician is to detect early furcation
local anatomic factors (e.g., root trunk length, root morphology)12,27 involvement.
and local developmental anomalies (e.g., cervical enamel projec-
tions).22,27 Local factors may affect the rate of plaque deposition or Local Anatomic Factors
complicate the performance of oral hygiene procedures, thereby Clinical examination of the patient should allow the therapist to
contributing to the development of periodontitis and attachment identify not only furcation defects but also many of the local ana-
loss. Studies indicate that prevalence and severity of furcation tomic factors that may affect the result of therapy (prognosis).
involvement increase with age.21,22,36 Dental caries and pulpal death Well-made dental radiographs, although not allowing a definitive
may also affect a tooth with furcation involvement or even the area classification of furcation involvement, provide additional informa-
of the furcation. All of these factors should be considered during tion vital for treatment planning (Figure 62-2). Important local
the diagnosis, treatment planning, and therapy of the patient with factors include anatomic features of the affected teeth, as described
furcation defects. next.
621
622 PART 2 Clinical Periodontics
62-3). The combination of root trunk length with the number and
configuration of the roots affects the ease and success of therapy. Root Form
The shorter the root trunk, the less attachment needs to be lost The mesial root of most mandibular first and second molars and
before the furcation is involved. Once the furcation is exposed, the mesiofacial root of the maxillary first molar are typically curved
teeth with short root trunks may be more accessible to maintenance to the distal side in the apical third. In addition, the distal aspect
procedures, and the short root trunks may facilitate some surgical of this root is usually heavily fluted. The curvature and fluting may
procedures. Alternatively, teeth with unusually long root trunks or increase the potential for root perforation during endodontic therapy
fused roots may not be appropriate candidates for treatment once or complicate post placement during restoration.1,25 These anatomic
the furcation has been affected. features may also result in an increased incidence of vertical root
fracture. The size of the mesial radicular pulp may result in removal
Root Length of most of this portion of the tooth during preparation.
Root length is directly related to the quantity of attachment sup-
porting the tooth. Teeth with long root trunks and short roots may Interradicular Dimension
have lost a majority of their support by the time that the furcation The degree of separation of the roots is also an important factor in
becomes affected.13,20 Teeth with long roots and short-to-moderate treatment planning. Closely approximated or fused roots can pre-
root trunk length are more readily treated because sufficient attach- clude adequate instrumentation during scaling, root planing, and
ment remains to meet functional demands. surgery. Teeth with widely separated roots present more treatment
options and are more readily treated.
Anatomy of Furcation
The anatomy of the furcation is complex. The presence of bifurca-
tional ridges, a concavity in the dome,11 and possible accessory
canals16 complicates not only scaling, root planing, and surgical
therapy,28 but also periodontal maintenance. Odontoplasty to
reduce or eliminate these ridges may be required during surgical
therapy for an optimal result.
A B C
Figure 62-2 Different degrees of furcation involvement in radiographs. A, Grade I furcation on the mandibular first molar and a grade
III furcation on the mandibular second molar. The root approximation on the second molar may be sufficient to impede accurate probing
of this defect. B, Multiple furcation defects on a maxillary first molar. Grade I buccal furcation involvement and grade II mesiopalatal and
distopalatal furcations are present. Deep developmental grooves on the maxillary second molar simulate furcation involvement in this molar
with fused roots. C, Grades III and IV furcations on mandibular molars.
CHAPTER 62 Furcation: Involvement and Treatment 623
Grade I
A grade I furcation involvement is the incipient or early stage of
furcation involvement (see Figure 62-6, A). The pocket is suprabony
and primarily affects the soft tissues. Early bone loss may have
occurred with an increase in probing depth, but radiographic
changes are not usually found.
Grade II
Figure 62-4 Furcation involvement by grade III cervical enamel A grade II furcation can affect one or more of the furcations of the
projections. same tooth. The furcation lesion is essentially a cul-de-sac (see
Figure 62-6, B) with a definite horizontal component. If multiple
affected tooth and adjacent teeth must also be considered during defects are present, they do not communicate with each other
treatment planning. The treatment response in deep, multiwalled because a portion of the alveolar bone remains attached to the
bony defects is different from that in areas of horizontal bone loss. tooth. The extent of the horizontal probing of the furcation deter-
Complex multiwalled defects with deep, interradicular vertical mines whether the defect is early or advanced. Vertical bone
components may be candidates for regenerative therapies. Alterna- loss may be present and represents a therapeutic complication.
tively, molars with advanced attachment loss on only one root may Radiographs may or may not depict the furcation involvement,
be treated by resective procedures. particularly with maxillary molars because of the radiographic
overlap of the roots. In some views, however, the presence of furca-
Other Dental Findings tion “arrows” indicates possible furcation involvement (see Chapter
The dental and periodontal condition of the adjacent teeth must be 31).
considered during treatment planning for furcation involvement.
The combination of furcation involvement and root approximation Grade III
with an adjacent tooth represents the same problem that exists in In grade III furcations, the bone is not attached to the dome of the
furcations without adequate root separation. Such a finding may furcation. In early grade III involvement, the opening may be filled
dictate the removal of the most severely affected tooth or the with soft tissue and may not be visible. The clinician may not even
removal of a root or roots (Figure 62-5). be able to pass a periodontal probe completely through the furca-
The presence of an adequate band of gingiva and a moderate to tion because of interference with the bifurcational ridges or facial/
deep vestibule will facilitate the performance of a surgical proce- lingual bony margins. However, if the clinician adds the buccal and
dure, if indicated. lingual probing dimensions and obtains a cumulative probing mea-
surement that is equal to or greater than the buccal/lingual dimen-
Indices of Furcation Involvement sion of the tooth at the furcation orifice, the clinician must conclude
The extent and configuration of the furcation defect are factors that a grade III furcation exists (see Figure 62-6, C). Properly
in both diagnosis and treatment planning. This has led to the exposed and angled radiographs of early Class III furcations
624 PART 2 Clinical Periodontics
A B
C D
Figure 62-6 Glickman’s classification of furcation involvement. A, Grade I furcation involvement. Although a space is visible at the
entrance to the furcation, no horizontal component of the furcation is evident on probing. B, Grade II furcation in a dried skull. Note both
the horizontal and the vertical component of this cul-de-sac. C, Grade III furcations on maxillary molars. Probing confirms that the buccal
furcation connects with the distal furcation of both these molars, yet the furcation is filled with soft tissue. D, Grade IV furcation. The soft
tissues have receded sufficiently to allow direct vision into the furcation of this maxillary molar.
display the defect as a radiolucent area in the crotch of the tooth selection of therapeutic mode varies with the class of furcation
(see Chapter 31). involvement, the extent and configuration of bone loss, and other
anatomic factors.
Grade IV
In grade IV furcations, the interdental bone is destroyed, and the Therapeutic Classes of Furcation Defects
soft tissues have receded apically so that the furcation opening is Class I: Early Defects. Incipient or early furcation defects
clinically visible. A tunnel therefore exists between the roots of (Class I) are amenable to conservative periodontal therapy.15
such an affected tooth. Thus the periodontal probe passes readily Because the pocket is suprabony and has not entered the furcation,
from one aspect of the tooth to another (see Figure 62-6, D). oral hygiene, scaling, and root planing are effective.16 Any thick
overhanging margins of restorations, facial grooves, or CEPs
Other Classification Indices should be eliminated by odontoplasty, recontouring, or replace-
Hamp et al17 modified a three-stage classification system by attach- ment. The resolution of inflammation and subsequent repair of the
ing a millimeter measurement to separate the extent of horizontal periodontal ligament and bone are usually sufficient to restore
involvement. Easley and Drennan10 and Tarnow and Fletcher37 periodontal health.
have described classification systems that consider both horizontal
and vertical attachment loss in classifying the extent of furcation Class II. Once a horizontal component to the furcation has devel-
involvement. The Tarnow and Fletcher article utilizes a subclas- oped (Class II), therapy becomes more complicated. Shallow hori-
sification that measures the probeable vertical depth from the roof zontal involvement without significant vertical bone loss usually
of the furca apically. The subclasses being proposed are: A, B, and responds favorably to localized flap procedures with odontoplasty,
C. “A” indicates a probeable vertical depth of 1 to 3 mm, “B” osteoplasty, and ostectomy. Isolated deep Class II furcations may
indicates 4 to 6 mm, and “C” indicates 7 or more mm of probeable respond to flap procedures with osteoplasty and odontoplasty
depth from the roof of the furca apically. Furcations would thus be (Figure 62-7). This reduces the dome of the furcation and alters
classified as IA, IB, and IC; IIA, IIB, and IIC; and IIIA, IIIB, and gingival contours to facilitate the patient’s plaque removal.
IIIC.
Consideration of defect configuration and the vertical compo- Classes II to IV: Advanced Defects. The development of
nent of the defect provides additional information that is useful in a significant horizontal component to one or more furcations of a
planning therapy. multirooted tooth (late Class II, Class III, or Class IV13) or the
development of a deep vertical component to the furca poses addi-
Treatment tional problems. Nonsurgical treatment is usually ineffective
The objectives of furcation therapy are to (a) facilitate mainte- because the ability to instrument the tooth surfaces adequately is
nance, (b) prevent further attachment loss, and (c) obliterate the compromised.31,40 Periodontal surgery, endodontic therapy, and res-
furcation defects as a periodontal maintenance problem. The toration of the tooth may be required to retain the tooth.
CHAPTER 62 Furcation: Involvement and Treatment 625
A B
Figure 62-7 Treatment of a grade II furcation by osteoplasty and odontoplasty. A, This mandibular first molar has been treated
endodontically and an area of caries in the furcation repaired. A Class II furcation is present. B, Results of flap debridement, osteoplasty,
and severe odontoplasty 5 years postoperatively. Note the adaptation of the gingiva into the furcation area. (Courtesy Dr. Ronald Rott,
Sacramento, CA.)
Nonsurgical Therapy
Oral Hygiene Procedures
Furcal management is difficult at best. Therapeutic modalities for
the treatment and maintenance of furcations have long been a
dilemma amongst periodontists and restorative dentists. Nonsurgi-
cal therapy is a very effective way of producing a satisfactory
stable result. Ideal results with furcations are impossible to obtain.
Once furcation breakdown has begun, there is always a somewhat
compromised result clinically. Both surgical and nonsurgical thera-
pies have been shown to work effectively over time. Nonsurgical
therapy, a combination of oral hygiene instruction and scaling and
root planing, has provided excellent results in some patients. The
earlier the furcation is detected and treated the more likely a good A
long-term result can be obtained. Nonetheless, even advanced fur-
cation lesions can have successful long-term treatment.34 Several
oral hygiene procedures have been used over time. All include
access to the furcation. Obtaining access to the furcation requires
a combination of the awareness of the furcation by the patient and
an oral hygiene tool that facilitates that access. Many tools, includ-
ing rubber tips; periodontal aids; toothbrushes, both specific and
general; and other aids have been used over time for access to the
patient (Figure 62-8).
A B
C D
E F
Figure 62-9 Resection of a root with advanced bone loss. A, Facial osseous contours. There is an early grade II furcation on the facial
aspect of the mandibular first molar and a Class III furcation on the mandibular second molar. B, Resection of the mesial root. The mesial
portion of the crown was retained to prevent mesial drift of the distal root during healing. The grade II furcations were treated by osteoplasty.
C, Buccal flaps adapted and sutured. D, Lingual flaps adapted and sutured. E, Three-month postoperative view of the buccal aspect of this
resection. New restorations were subsequently placed. F, Three-month postoperative view of the lingual aspect of this resection.
A B C
Figure 62-10 A, Grade III furcation lesion. B, Hemisection to divide the tooth into mesial and distal portions. C, Postoperative view of a
hemisected mandibular with new crowns for both roots.
CHAPTER 62 Furcation: Involvement and Treatment 626.e3
A B
C D
Figure 62-11 Hemisection and interradicular dimension. A, Buccal preoperative view of a mandibular right second molar with a deep
grade II buccal furcation and root approximation. B, Buccal view of bony lesions with flaps. Note the mesial and distal one-wall bony
defects. The lingual furcation was similarly affected. C, The molar has been hemisected and partially prepared for temporary crowns.
Observe the minimal dimension between the two roots. D, Buccal view 3 weeks postoperatively. Because the embrasure space is minimal,
these roots will be separated with orthodontic therapy to facilitate restoration. (Courtesy Dr. Louis Cuccia, Roseville, CA.)
faciolingually through the buccal and lingual developmental remove portions of the developmental ridges and prepare a furca-
grooves of the tooth, through the pulp chamber, and through the tion that is free of any deformity that would enhance plaque reten-
furcation. If the sectioning cut passes through a metallic restora- tion or adversely affect plaque removal (see Figure 62-12, F).
tion, the metallic portion of the cut should be made before flap Patients with advanced periodontitis often have root resection
elevation. This prevents contamination of the surgical field with performed in conjunction with other surgical procedures. Figure
metallic particles. 68-13 provides an example of combining root resection and peri-
If a vital root resection is to be performed, a more horizontal odontal osseous surgery. The bony lesions that may be present on
cut through the root is advisable (see Figure 62-12, D). An oblique adjacent teeth are then treated using resective or regenerative thera-
cut exposes a large surface area of the radicular pulp and/or dental pies. After resection, the flaps are then approximated to cover any
pulp chamber. This can lead to postoperative pain and can compli- grafted tissues or slightly cover the bony margins around the tooth.
cate endodontic therapy. A horizontal cut, although it may compli- Sutures are then placed to maintain the position of the flaps. The
cate root removal, has fewer postoperative complications. This root area may or may not be covered with a surgical dressing.
stump can be removed by odontoplasty after the completion of The removal of a root alters the distribution of occlusal forces
endodontic therapy or at the time of tooth preparation. on the remaining roots. Therefore, it is wise to evaluate the occlu-
After sectioning, the root is elevated from its socket (see Figure sion of teeth from which roots have been resected and, if necessary,
62-12, E). Care should be taken not to traumatize bone on the adjust the occlusion. Centric holds should be maintained, but
remaining roots or to damage an adjacent tooth. Removal of the root eccentric forces should be eliminated from the area over the root
provides visibility to the furcation aspects of the remaining roots that was removed. Patients with advanced attachment loss may
and simplifies the debridement of the furcation with hand, rotary, or benefit from temporary stabilization of the resected tooth to prevent
ultrasonic instruments. If necessary, odontoplasty is performed to movement (Figure 62-14).
626.e4 PART 2 Clinical Periodontics
A B
C D
E F
Figure 62-12 Diagrams of distobuccal root resection of maxillary first molar. A, Preoperative bony contours with grade II buccal furca-
tion and a crater between the first and second molar. B, Removal of bone from the facial side of the distobuccal root and exposure of the
furcation for instrumentation. C, Oblique section that separates the distal root from the mesial and palatal roots of the molar. D, More hori-
zontal section that may be used on a vital root amputation because it exposes less of the pulp of the tooth. E, Areas of application of instru-
ments to elevate the sectioned root. F, Final contours of the resection.
CHAPTER 62 Furcation: Involvement and Treatment 626.e5
A B C
D E F
G H I
Figure 62-13 Hemisection combined with osseous surgery to treat furcation defects. A, Buccal preoperative view with provisional
bridge. B, Lingual view with provisional bridge in place. C, Radiograph of bony defects. Note the deep mesial bony defect, largely of one
wall, and the radiolucent area in the furcation of the first molar, indicating a grade II defect. D, Buccal view before osseous surgery. In
addition to the furcation involvement, a root separation problem exists between the two roots of the first molar. Class II furcations are
present on the second molar. E, Buccal view after osseous surgery. Mesial root hemisected and removed. The other defects were treated by
osteoplasty and ostectomy. F, Lingual preoperative view. Note the heavy bony ledging at the lingual surface of these first and second molars.
G, Lingual postoperative view. The mesial root has been resected, the bony ledging recontoured, and the grade II furcations treated by
osteoplasty. H, Buccal view 10 years after treatment. I, Lingual view 10 years after treatment. (Courtesy Dr. Louis Cuccia, Roseville, CA.)
626.e6 PART 2 Clinical Periodontics
A B C
D E F
G H I
Figure 62-14 Mesial root resection in the presence of advanced bone loss. A and B, Buccal and lingual preoperative views. Note the
soft-tissue contours that are predictive of the bony defects. C, Radiograph of extent of furcation involvement of the first and second molars.
D and E, Buccal preoperative and postoperative views. The mesial root of the second molar was resected and the interproximal craters
treated by osteoplasty and minor ostectomy. F and G, Lingual preresection and postresection views. The heavy ledges and horizontal
bone loss on the lingual surface were managed by osteoplasty. H and I, Buccal and lingual views 6 weeks postoperatively. A temporary
wire splint has been bonded to the molars to prevent tipping of the distal root of the mandibular second molar. (Courtesy Dr. Louis Cucci,
Roseville, CA.)
CHAPTER 62 Furcation: Involvement and Treatment 627
0 B
11.7
6.3
C
Figure 62-15 A, Clinical picture of a Class III furcation involvement. B, Radiographic appearance is far more grave than the clinical appear-
ance. C, After the tooth is removed, a computed tomography (CT) radiograph is taken to plan treatment for implant replacement. D, The
implant restored. (Courtesy Dr. Sarvenaz Angha, Los Angeles.)