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Furcation
Its Involvement and Rx
Dr Jignesh
Why Furcation is an area of complex anatomic
morphology ?
1. Difficult for routine periodontal instrumentation
2. Difficult to maintain by routine home care
3. clinical finding of furcation indicates advanced
periodontitis and less favourable prognosis
Introduction
Dr Jignesh
BASIC TERMINOLOGIES
Dr Jignesh
 Maxillary Molars & Premolars
Brief about normal anatomy
mesialdistalDr Jignesh
Complexity in Anatomy
Dr Jignesh
 Mandibular Molars and other teeth
Dr Jignesh
Complexity in Anatomy
Dr Jignesh
1. Based on horizontal attachment loss
 Glickman’s classification (1953)
 Hamp’s classification (1975)
2. Based on Horizontal and vertical componenets
 Tarnow and Fletcher’s classification (1984)
3. Based on Combination of these findings and
morphology of bone deformity
 Easley and Drennan’s classification (1969)
Classifications of
Furcation Involvement (FI)
Dr Jignesh
 Four grades
Glickman’s classification (1953)
Dr Jignesh
GR-III
GR-IV
Dr Jignesh
Hamp’s Classification (1975)
Horizontal loss ≤ 3 mm. Horizontal loss of support > 3mm
Horizontal through and through destruction
Class I Class II
Class III
Dr Jignesh
Tarnow and Fletcher (1984)
 Based on vertical component 3 subgroups:
Subgroup A: 1-3mm
Subgroup B: 4-6mm
Subgroup C: >7mm
Dr Jignesh
 Clinical Probing
Diagnosis
• Naber’s Probe
• No. 23 Explorer
• Each furcation
entrance is classified.
Dr Jignesh
• Identification of Local anatomic factors:
• Root trunk length
• Root length
• Interradicular dimension
• Anatomy of furcation
• Cervical Enamel Projections
Dr Jignesh
Radiographically
Dr Jignesh
Different angulation
Dr Jignesh
1. Endodontic involvement
Differential Diagnosis
Dr Jignesh
2. TFO
Dr Jignesh
 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
Treatment Aspect
Dr Jignesh
Treatment modalities
Grade-I Grade-II Grade-III or IV
• SRP
• Furcationplasty
(Combination of
Odontoplasty and
Osteoplasty)
• SRP
• Furcationplasty
• OFD and Grafting
• GTR
• Tunnel preparation
• GTR
• Tunnel preparation
• Root resection
• Extraction and
implant
Dr Jignesh
1. SRP
 Indicated for Grade- I and early grade- II
Non-surgical therapy
Dr Jignesh
 Advancements in non-surgical- DeMarco curettes,
diamond files, Quetin furcation curettes, and mini Five
Gracey Curettes
 Svärdström and Wennström ( J Periodontol 2000)
in the long term, furcations could be maintained
over a 10-year period using NSPT.
Dr Jignesh
2. Oral Hygiene Procedures
 meticulous oral hygiene by the patient
 rubber tips; periodontal aids; proxa toothbrushes.
Non-surgical therapy
Dr Jignesh
1. Furcation plasty
 First described by Hamp and colleagues (1975)
 Early Grade-II
 Result should be firm, well contoured papilla to
cover the furcation defect.
Surgical approach
Dr Jignesh
Furcation plasty
Odontoplasty
Osteoplasty
Dr Jignesh
Tunnel preparation
 Indicated in deep grade- II and grade- III furcation defects
in mandibular molars.
 Long and divergent roots (no possibility of regeneration)
Dr Jignesh
Regenerative procedures
 Gottlow et al. (1986) published first case rep. using GTR
 Most predictable results in grade- II (Pontoriero et al.
1988; Lekovic et al. 1989; Caffesse et al. 1990)
 Less predictable in grade-III and maxillary grade-II
(Pontoriero et al. 1989; Pontoriero & Lindhe 1995,
Metzeler et al. 1991)
Dr Jignesh
1. Horizontal type of furcation defects
2. Complex anatomy- poor debridement
3. Poor blood supply for graft material
4. recession of the flap margin and early exposure of
both the membrane and fornix
Why limited predictability ?
Dr Jignesh
GTR and grafting
Dr Jignesh
Advancement in regeneration
 e-PTFE and DFDBA
 Enamel matrix proteins
 PDGF
 LANAP
 e-PTFE membrane with b- tricalcium phosphate
Dent Clin N Am - (2015)
Dr Jignesh
 Root resection- involves the sectioning and the
removal of one or two roots of a multirooted tooth.
 Root separation- involves the sectioning of the root
complex and the maintenance of all roots.
 Indicated in deep grade- III and IV.
Root resection and separation
Dr Jignesh
 By Bassarba et al.:
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
Indications
Dr Jignesh
1. Poor C/R ratio on remaining roots
2. Unfavourable anatomy of retained roots
3. Long root trunks/ fused roots
4. Teeth in which Endo-Restorative Rx is not possible
5. Inability to perform oral hygiene
6. Splinting is not possible
7. Prosthetic factors
Contraindications
Dr Jignesh
1. root that will eliminate the furcation
2. with greatest amount of bone/attachment loss
3. Greatest number of anatomic problems:
 Curvature, grooves, accessory canals
4. Least complicate the future periodontal
maintenance
Which root to remove ?
Dr Jignesh
1. Endodontic treatment
2. Provisional restoration
Sequence of treatment (carnevale 1981)
Dr Jignesh
3. Root resection/ Hemisection
Dr Jignesh
• performed as part of the preparation of the
segment for prosthetic rehabilitation, that is prior
to periodontal surgery (Carnevale et al. 1981).
Dr Jignesh
4. Periodontal surgery
• osseous resective techniques are used to eliminate
angular bone defects around the maintained roots.
• The provisional restoration is relined.
• The margins of the provisional restoration must end
≥3 mm coronal of the bone crest
• flaps are secured with sutures at the level of the
bone crest.
Dr Jignesh
5. Final prosthetic restoration
• After complete soft tissue and hard tissue healing
(3months)
Dr Jignesh
Extraction
 Extraction is better in grade- III and IV.
 Inadequte plaque control
 Can’t commit to a maintenance programe
 High caries activity
 Poor socio-economic factor
Dr Jignesh
 In a 5‐year study, Hamp et al. (1975) observed the
outcome of treatment of 175 teeth with various
degrees of furcation involvementOf
 32 (18%) were treated by SRP alone, (12)
 49 (28%) were subjected to furcation plasty (3)
 87 teeth (50%), root resection (5)
 7 teeth (4%) a tunnel had been prepared (4).
Prognosis of Therapy
Dr Jignesh
 Hamp et al. 1992 7‐year study, 182 furcation‐ involved
teeth.
 57 had been treated by SRP alone
 101 were treated by furcation plasty, and
 24 were subjected to root resection or hemisection
 >85% of the furcations treated with SRP alone, or in
conjunction with furcation plasty, maintained stable
conditions
Dr Jignesh
 Carnevale et al. (1998) in a 10‐year prospective
controlled clinical trial, demonstrated a 93% survival
rate of root resected teeth similar to that of success
rates of implants (Fugazzato et al. 2001)
 Greater than 65-70% rate of implants placed in
poorer bone quality (Engquist, Jaffin and Berman
1991)
Dr Jignesh
 Recently, Huynh‐Ba et al. (2009) published a
systematic review (22 publications)
 Reported tooth survival rates
 Non‐surgical furcation therapy: 90.7–100% at the end
of the observation period of 5–12 years.
 Grade- I : 99-100%
 Grade- II: 95%
 Grade- III & IV: 25%
Dr Jignesh
 Surgical furcation therapy (i.e. flap with or without
osseous resection, gingivectomy/gingivoplasty, but
not including furcation odontoplasty): 43.1–96% at the
end of an observation period of 5–53 years.
 Tunnel preparation: 42.9–92.9% after 5–8 years of
observation.
Dr Jignesh
 Surgical resective therapy (i.e. root resection or root
separation): 62–100% after an observation period of
5–13 years. Reported complications were mainly root
fractures and endodontic failures.
 Surgical regenerative therapy (i.e. GTR, bone grafts):
62–100% after a period of 5–12 years.
 horizontal furcation depth reduction in most of the
cases No complete furcation closure, especially in
severely involved mandibular and maxillary molars.
Dr Jignesh
Conclusion
 No clear scientific evidence that any given treatment
modality is superior to the others.
 Treatment modalities are more predictable for grade- I
and grade- II
 4 keys for long term success
Dr Jignesh
Dr Jignesh
Refrences
 Carranza clinical Periodontology 11th edition
 Jan Lindhe, Clinical Periodontology and Implant dentistry:6th ed.
 Periodontal therapy: Clinical approaches and evidence of success:
Nevins and Mellonig.
 Periodontal surgery a clinical atlas: N. Sato.
 Color atlas of cosmetic and reconstructive periodontal surgery: E.
Cohen.
 Ponteriero and Lindhe. GTR in the treatment of degree III
furcation defects in maxillary molars: JCP 1995, 22: 810-812.
 J zambon, Unanswered Questions Can Bone Lost from Furcations
Be Regenerated?. dental clinics of north america. 2015.Dr Jignesh

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Furcation Involvement: Treatment and Prognosis

  • 2. Why Furcation is an area of complex anatomic morphology ? 1. Difficult for routine periodontal instrumentation 2. Difficult to maintain by routine home care 3. clinical finding of furcation indicates advanced periodontitis and less favourable prognosis Introduction Dr Jignesh
  • 4.  Maxillary Molars & Premolars Brief about normal anatomy mesialdistalDr Jignesh
  • 6.  Mandibular Molars and other teeth Dr Jignesh
  • 8. 1. Based on horizontal attachment loss  Glickman’s classification (1953)  Hamp’s classification (1975) 2. Based on Horizontal and vertical componenets  Tarnow and Fletcher’s classification (1984) 3. Based on Combination of these findings and morphology of bone deformity  Easley and Drennan’s classification (1969) Classifications of Furcation Involvement (FI) Dr Jignesh
  • 9.  Four grades Glickman’s classification (1953) Dr Jignesh
  • 11. Hamp’s Classification (1975) Horizontal loss ≤ 3 mm. Horizontal loss of support > 3mm Horizontal through and through destruction Class I Class II Class III Dr Jignesh
  • 12. Tarnow and Fletcher (1984)  Based on vertical component 3 subgroups: Subgroup A: 1-3mm Subgroup B: 4-6mm Subgroup C: >7mm Dr Jignesh
  • 13.  Clinical Probing Diagnosis • Naber’s Probe • No. 23 Explorer • Each furcation entrance is classified. Dr Jignesh
  • 14. • Identification of Local anatomic factors: • Root trunk length • Root length • Interradicular dimension • Anatomy of furcation • Cervical Enamel Projections Dr Jignesh
  • 19.  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 Treatment Aspect Dr Jignesh
  • 20. Treatment modalities Grade-I Grade-II Grade-III or IV • SRP • Furcationplasty (Combination of Odontoplasty and Osteoplasty) • SRP • Furcationplasty • OFD and Grafting • GTR • Tunnel preparation • GTR • Tunnel preparation • Root resection • Extraction and implant Dr Jignesh
  • 21. 1. SRP  Indicated for Grade- I and early grade- II Non-surgical therapy Dr Jignesh
  • 22.  Advancements in non-surgical- DeMarco curettes, diamond files, Quetin furcation curettes, and mini Five Gracey Curettes  Svärdström and Wennström ( J Periodontol 2000) in the long term, furcations could be maintained over a 10-year period using NSPT. Dr Jignesh
  • 23. 2. Oral Hygiene Procedures  meticulous oral hygiene by the patient  rubber tips; periodontal aids; proxa toothbrushes. Non-surgical therapy Dr Jignesh
  • 24. 1. Furcation plasty  First described by Hamp and colleagues (1975)  Early Grade-II  Result should be firm, well contoured papilla to cover the furcation defect. Surgical approach Dr Jignesh
  • 26. Tunnel preparation  Indicated in deep grade- II and grade- III furcation defects in mandibular molars.  Long and divergent roots (no possibility of regeneration) Dr Jignesh
  • 27. Regenerative procedures  Gottlow et al. (1986) published first case rep. using GTR  Most predictable results in grade- II (Pontoriero et al. 1988; Lekovic et al. 1989; Caffesse et al. 1990)  Less predictable in grade-III and maxillary grade-II (Pontoriero et al. 1989; Pontoriero & Lindhe 1995, Metzeler et al. 1991) Dr Jignesh
  • 28. 1. Horizontal type of furcation defects 2. Complex anatomy- poor debridement 3. Poor blood supply for graft material 4. recession of the flap margin and early exposure of both the membrane and fornix Why limited predictability ? Dr Jignesh
  • 30. Advancement in regeneration  e-PTFE and DFDBA  Enamel matrix proteins  PDGF  LANAP  e-PTFE membrane with b- tricalcium phosphate Dent Clin N Am - (2015) Dr Jignesh
  • 31.  Root resection- involves the sectioning and the removal of one or two roots of a multirooted tooth.  Root separation- involves the sectioning of the root complex and the maintenance of all roots.  Indicated in deep grade- III and IV. Root resection and separation Dr Jignesh
  • 32.  By Bassarba et al.: 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 Indications Dr Jignesh
  • 33. 1. Poor C/R ratio on remaining roots 2. Unfavourable anatomy of retained roots 3. Long root trunks/ fused roots 4. Teeth in which Endo-Restorative Rx is not possible 5. Inability to perform oral hygiene 6. Splinting is not possible 7. Prosthetic factors Contraindications Dr Jignesh
  • 34. 1. root that will eliminate the furcation 2. with greatest amount of bone/attachment loss 3. Greatest number of anatomic problems:  Curvature, grooves, accessory canals 4. Least complicate the future periodontal maintenance Which root to remove ? Dr Jignesh
  • 35. 1. Endodontic treatment 2. Provisional restoration Sequence of treatment (carnevale 1981) Dr Jignesh
  • 36. 3. Root resection/ Hemisection Dr Jignesh
  • 37. • performed as part of the preparation of the segment for prosthetic rehabilitation, that is prior to periodontal surgery (Carnevale et al. 1981). Dr Jignesh
  • 38. 4. Periodontal surgery • osseous resective techniques are used to eliminate angular bone defects around the maintained roots. • The provisional restoration is relined. • The margins of the provisional restoration must end ≥3 mm coronal of the bone crest • flaps are secured with sutures at the level of the bone crest. Dr Jignesh
  • 39. 5. Final prosthetic restoration • After complete soft tissue and hard tissue healing (3months) Dr Jignesh
  • 40. Extraction  Extraction is better in grade- III and IV.  Inadequte plaque control  Can’t commit to a maintenance programe  High caries activity  Poor socio-economic factor Dr Jignesh
  • 41.  In a 5‐year study, Hamp et al. (1975) observed the outcome of treatment of 175 teeth with various degrees of furcation involvementOf  32 (18%) were treated by SRP alone, (12)  49 (28%) were subjected to furcation plasty (3)  87 teeth (50%), root resection (5)  7 teeth (4%) a tunnel had been prepared (4). Prognosis of Therapy Dr Jignesh
  • 42.  Hamp et al. 1992 7‐year study, 182 furcation‐ involved teeth.  57 had been treated by SRP alone  101 were treated by furcation plasty, and  24 were subjected to root resection or hemisection  >85% of the furcations treated with SRP alone, or in conjunction with furcation plasty, maintained stable conditions Dr Jignesh
  • 43.  Carnevale et al. (1998) in a 10‐year prospective controlled clinical trial, demonstrated a 93% survival rate of root resected teeth similar to that of success rates of implants (Fugazzato et al. 2001)  Greater than 65-70% rate of implants placed in poorer bone quality (Engquist, Jaffin and Berman 1991) Dr Jignesh
  • 44.  Recently, Huynh‐Ba et al. (2009) published a systematic review (22 publications)  Reported tooth survival rates  Non‐surgical furcation therapy: 90.7–100% at the end of the observation period of 5–12 years.  Grade- I : 99-100%  Grade- II: 95%  Grade- III & IV: 25% Dr Jignesh
  • 45.  Surgical furcation therapy (i.e. flap with or without osseous resection, gingivectomy/gingivoplasty, but not including furcation odontoplasty): 43.1–96% at the end of an observation period of 5–53 years.  Tunnel preparation: 42.9–92.9% after 5–8 years of observation. Dr Jignesh
  • 46.  Surgical resective therapy (i.e. root resection or root separation): 62–100% after an observation period of 5–13 years. Reported complications were mainly root fractures and endodontic failures.  Surgical regenerative therapy (i.e. GTR, bone grafts): 62–100% after a period of 5–12 years.  horizontal furcation depth reduction in most of the cases No complete furcation closure, especially in severely involved mandibular and maxillary molars. Dr Jignesh
  • 47. Conclusion  No clear scientific evidence that any given treatment modality is superior to the others.  Treatment modalities are more predictable for grade- I and grade- II  4 keys for long term success Dr Jignesh
  • 49. Refrences  Carranza clinical Periodontology 11th edition  Jan Lindhe, Clinical Periodontology and Implant dentistry:6th ed.  Periodontal therapy: Clinical approaches and evidence of success: Nevins and Mellonig.  Periodontal surgery a clinical atlas: N. Sato.  Color atlas of cosmetic and reconstructive periodontal surgery: E. Cohen.  Ponteriero and Lindhe. GTR in the treatment of degree III furcation defects in maxillary molars: JCP 1995, 22: 810-812.  J zambon, Unanswered Questions Can Bone Lost from Furcations Be Regenerated?. dental clinics of north america. 2015.Dr Jignesh