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Furcation involvement and management

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Furcation involvement is a common sequela of severe chronic periodontal disease. Its effective management has a profound influence on the outcome of periodontal therapy.

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Furcation involvement and management

  1. 1. • Introduction • Terminologies • Classifications • Anatomy of multi rooted teeth • Predisposing preparation • Diagnosis of furcation • Treatment options factors affecting treatment outcome • Conclusion • References
  2. 2. • Waerhaug (1980) ………best chance for success lies in early recognition and treatment. • Multirooted teeth amongst other teeth in dentition offer unique and challenging problems for the periodontist. • FURCATION AREA because of the interrelationships between the size and shape of the teeth, the roots and their alveolar housing, and the varied nature and pattern of periodontal destruction, creates situations in which routine periodontal procedures are somewhat limited and special procedures are generally required.
  3. 3. • FURCATION “the anatomic area of a multi-rooted tooth where the roots diverge’’ (American Academy of Periodontology 1992).
  4. 4. • Carnevale and colleagues (2003) …… Root complex: the portion of the root apical to the cementoenamel junction (CEJ) Root trunk: the undivided portion of the root from the CEJ to the furcation Root cone: that part of the root that Furcation fornix: the roof of the furcation Furcation entrance:the point of union between the root trunk and cones Degree of separation: the angle of separation between the roots Divergence: the distance between two roots.
  5. 5. Coefficient of separation: the length of the root cones in relation to the root complex Flute : Usually concave or grooving of the root trunk, extending from the cervical line and blending into the actual furcation. The surface immediately coronal to the root separation.
  6. 6. • 1. Glickman (1953) • 2. Goldman et al. classification (1958) • 3. Staffileno’s classification (1969) • 4. Easley and Drennan (1969) • 5. Hamp et al. (1975) • 6. Rosenberg (1978) • 7. Ramfjord & Ash (1979) • 8. Goldman and Cohen (1980) • 9. Ricchetti (1982) • 10. Tal and Lemmer (1982) • 11. Tarnow & Fletcher (1984) • 12. Eskow and Kapin (1984) • 13. Fedi (1985) • 14. Grant et al. (1988) • 15. Basaraba (1990) • 16. Carnevale et al. (1997) • 17. Nevins and Capetta (1998) • 18. Hou et al. (1998) • 19. Glossary of periodontal terms (2001) • 20. Walter et al. (2009)
  7. 7. Grade I: incipient involvement into a flute of furcation with suprabony pockets and no interradicular bone loss Grade II: any involvement of the interradicular bone without a through-and-through ability to probe Grade IV: through-and- through loss of interradicular bone, with total exposure of furcation owing to gingival recession Grade III: through-and- through loss of interradicular bone
  8. 8. Glickman's (1958) Grade I, II and III is similar to the class 1, 2 and 3 of Staffileno (1969) and corresponds to Goldman and Cohen's (1980) classifications of Grade I : incipient, Grade II : cul-de-sac and Grade III : through & through furcation involvement.
  9. 9. • Devised a more complex classification based on surface location, number of bony walls & degree of furcal exposure. • information relative to the vertical component of furcation involvement • As this classification does state the number of osseous walls involved in the furcation, it is beneficial when one considers bone grafts or other new attachment procedures, since the extent of osseous involvement at the furcation will, to a greater extent, determine the prognosis or predictability of bone regeneration.
  10. 10. Class I furcation involvement - there is attachment loss that involves the root flutings, but there is no horizontal component to the involvement. SUBTYPE 1 : Horizontal resorption into the furca is SUBTYPE 2 : indicates a significant vertical component to the defect. Class II A : definite horizontal loss of attachment but no bony ledge on buccal on lingual surface Class II B : buccal and lingual bony ledge and definite vertical component Class III A and class III B same as above
  11. 11. DEGREE I / CLASS 1: Represents horizontal attachment loss of less than 3 mm within the furcation involvement. CLASS II: Represents horizontal loss greater than 3 mm but not encompassing the total width of the furcation CLASS III: Denotes horizontal through and through destruction.
  12. 12. Grade III (TOTAL) : through-and- through loss of interradicular bone. Grade I (INITIAL) : loss of interradicular bone less than or equal to one-third Grade II (PARTIAL) : loss of interradicular bone greater than one-third but not through and through
  13. 13. subclass A : vertical loss of 1 to 3 mm subclass B : vertical loss of 4 to 6 mm siubclass C : vertical loss of 7+ mm
  14. 14. CLASS I : Incipient involvement : horizontal involvement just into the interradicular area No interradicular bone loss Treatment: Osteoplasty/ Ostectomy Prognosis : Very good CLASS Ia: Cul - de -sac involvement, approximating the first half of the initial one-third of the tooth dimension. Interradicular bone loss Treatment: Osteoplasty/ Ostectomy &/or odontoplasty Prognosis : Good CLASS II: Horizontal involvement beyond Ia, but not into the middle third of the tooth. Interradicular vertical & horizontal bone loss; usually a crater. Treatment: Sectioning & Osteoplasty/ Ostectomy & endodontics, full coverage or new attachment Prognosis : Good CLASS III: Horixontal involvement, beyond one half of the tooth dimension. Interradicular horizontal & vertical bone loss; severe combination type defect Treatment: Sectioning & Osteoplasty/ Ostectomy & endodontics, splinting & full coverage or new attachment or extraction. Prognosis : dependant on crown/root ratios, mobility, bone loss restorability. CLASS IIa: Horixontal involvement, into the middle one- third of the tooth but not beyond one half of the tooth dimension. Interradicular horizontal & vertical bone loss; always a craater Treatment: Sectioning & Osteoplasty/ Ostectomy & endodontics, full coverage or new attachment Prognosis : Good with sectioning; Poor with new attachment
  15. 15. SUBCLASS B: Vertical destruction reaching two thirds of the inter radicular height SUBCLASS A: Vertical destruction to one third of the total inter radicular height SUBCLASS C: Inter radicular osseous destruction into or beyond the apical third
  16. 16. GOLDMEN AND COHEN • Grade I : Incipient lesion • Grade II : Cul de sac • Grade III : Through and through and lesion
  18. 18. FURCATION INVOLVEMENT AND FURCATION INVASION • Furcation invasion : pathologic resorption of bone within a furcation’’ (American Academy of Periodontology 1992) • Furcation involvemnent : causes other than periodontal factors • Endodontic causes • Pulpal pathosis • Restorations • Root resorptions • Trauma from occlusion • Important to diagnose and then formulate treatment plan
  19. 19. ETIOLOGY OF FURCATION INVASIONS PRIMARY FACTOR - BACTERIAL PLAQUE Predisposing factors - Anatomical considerations • Root anatomy and concavities • Enamel pearls and projections • Accessory pulp canals • Bifurcation ridges • Location of furcation relative to CEJ • Location and diameter of furcation entrance
  20. 20. ROOT ANATOMY • Morphology • Divergence • Convergence • Fusion • Degree of separation of the roots: • Wide separation of the roots improves access, thereby facilitating instrumentation
  21. 21. PROXIMAL ROOT CONCAVITY • Mesiobuccal root of maxillary molar and mesial root of mandibular molar. • Instrumentaion and plaque maintainence becomes difficult
  22. 22. BIFURCATION RIDGES • Ridges cross from mesial to distal root at midpoint of bifurcation • Two types of bifurcation ridges have been described. I) Intermediate: connect the mesial and distal roots and are covered with cementum II) Buccal / lingual ridges : composed primarily of dentin with overlying thin layers of cementum
  23. 23. CERVICAL ENAMEL PROJECTIONS • Causative due to lack of connective tissue attachement on enamel surfaces (Carranza & Jolkovsky 1991). MASTER & HOSKINS (1964) Grade I: distinct change in the CEJ contour, enamel projecting toward bifurcation ( less than 1/3rd of the root trunk) Grade II: CEP approached the furcation, but not actually making contact (>1/3rd) Grade III: CEP that extends directly into the furcation proper
  24. 24. ENAMEL PEARL • AAP - Enamel pearl is “a small focal mass of enamel formed apical to the CEJ” • Prevalence :2.69% • More common in 1st max and least in mand 1st molars .
  25. 25. ACCESSORY PULP CANALS 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 Furcation involvement - combined endodontic periodontic defect
  27. 27. • A furcation probe is a type of periodontal probe used to evaluate the bone support in the furcation areas of bifurcated and trifurcated teeth. • Furcation probes have curved, blunt-tipped working-ends that allow easy access to the furcation areas. • Examples of furcation probes are the Nabers 1N and 2N, ZA2, ZA3, HO2, NS2, NP2C and ACE probes. • Tal (1982) described a probe which permits direct measurements of the depth of the furcal defects • Consists of Millimeter scale; Flexible metal spring tube ensheathing a rigid stilleto, 0.3 mm thick Atlas of cosmetic and reconstructive periodontal surgery, 3rd edition
  29. 29. • To determine the bone contours associated with furcation involvement more accurately, TRANSGINGIVAL PROBING OR BONE SOUNDING can be accomplished through anesthetized soft tissues. • This technique has been shown to yield accurate measurements when compared with those made at the time of open flap surgery (Greenberg 1976)
  30. 30. RADIOGRAPHS • As an adjunct to clinical probing • Paralleling periapical and bitewing • Maxillary furcations are not readily seen in radiographs taken at right angles to the teeth and suggested that better visualization of the furcations is possible by varying the angle of the beam. Superimposition of palatal root and other bone structures
  31. 31. SUBTRACTION RADIOGRAPHY • This technique permits visualization of change in image densities at different time intervals and allows detection of mineral changes as little as 5%. • Computer-assisted densitometric image analysis (CADIA), has shown favorable results over digital subtraction radiography when used to study alveolar bone density changes in furcations (Bragger et al., 1988; Bragger et al., 1989).
  32. 32. • CT scans offer more detailed information on furcation involvement than clinical probing. Especially before surgical treatment, three-dimensional radiographic imaging can be a useful tool to assess the degree of furcation involvement and optimize treatment decisions. Laky M, Majdalani S, Kapferer I, Frantal S. Periodontal Probing of Dental Furcations Compared With Diagnosis by Low-Dose Computed Tomography: A Case Series. J Periodontol 2013;84:1740-1746.
  33. 33. CONE BEAM CT (CBCT) • A CBCT image showing a Class III furcation involvement . Various authors (Mengel et al., 2005; Vandenberghe et al., 2007) have reported that furcation involvement can be differentiated into Class I, II and III furcations clearly with both CT and CBCT. • However, in terms of image quality the CBCT scans were superior to the CT scans, with the periodontal ligament space in particular being represented exactly in all three planes, and that CBCT resolution can be as small as 0.2 mm, as compared to 0.5-1 mm for CT
  34. 34. RECENT ADVANCES IN IMAGING • 1. Natural frequency analysis • 2. Ultrasonography • 3. Optical coherence tomography
  35. 35. • The major principle of treatment of furcation involved tooth is • to eliminate the etiologic factor, the furcation per se, and • to create a predictably maintainable environment.
  36. 36. THREE BROAD STRATEGIES OF FURCATION THERAPY (Kalkwarf & Reinhardt R.A 1988) I. Maintenance of the existing Furcation Scaling and root planing Obstruction of Furcation II. Increasing access to the Furcation Gingivectomy/Apical positioned flap Odontoplasty & Furcationplasty Osteoplasty /ostectomy III. Elimination of the Furcation Root amputation/ Tooth resection Bicuspidization
  37. 37.  DEGREE OF INVOLVEMENT  GRADE I  GRADE II  THERAPY  Scaling and root planning  Odontoplasty  Furcation plasty  Furcationplasty  Tunnel preparation  Root resection  Tooth extraction  GTR at mandibular molars Lindhe and Nyman 1998, classified treatment depending on degree of involvement
  38. 38.  DEGREE OF INVOLVEMENT  Grade 3  THERAPY  Tunnel preparation  Root resection  Tooth extraction
  39. 39. • Minor distance (<5 mm; degrees I and I1 involvement) : scaling and root planing with proper oral hygiene program • 5-6 mm (Degree II involvement) : initial cause related treatment is frequently supplemented with surgery involving, osteoplasty, odontoplasty • Deeper into the furcation area, >5 mm; (degree I1 involvement) or a through and through defect (degree I11 involvement) : tunnel preparation or root resection
  40. 40. PROGNOSIS • Prognosis for individual teeth depend on: • 1. Morphology of the bone deformity. • 2. Root anatomy • 3. Tooth morphology • 4.Chronicity of the destructive process. • 5.Clinical crown to clinical root ratio. • 6.Mobility: Tooth mobility caused by inflammation and trauma from occlusion may be correctable, but mobility resulting from loss of alveolar bone alone is not likely to be corrected. • 7.Patients age and general health
  41. 41. I. Non- surgical/Closed scaling and Root Planing: vs Surgical/Open Scaling and Root planing: • Maria et al (1986), Parashis et al (1993) and Fleischer et al in favour and Kalkwarf et al (1988), Schroer et al (1991) and Wang et al (1994) against it. • In conclusion, although scaling and root planing combined with flap surgery is more effective at removing calculus, the clinical evaluations do not indicate a dramatic difference between surgical and nonsurgical treatments irrespective of the degree of furcation involvement.
  42. 42. • Quetin furcation curette BL 2 (Larger) & BL1 (Smaller) • • shallow, half-moon radius that fits into roof or floor of furcation & developmental depressions •Shanks are slightly curved for better access • •Tips - 2 widths • •-BL1 & MD1- small fine with 0.9 mm blade width • •-BL2 &MD2- larger and wider 1.3 mm width
  43. 43. • Oda and Ishikawa (1989) designed a new ultrasonic scaler tip made of acid resistant stainless steel. • The end of the tip was spherical (0.8 mm in diameter) to protect the root surfaces and soft tissue injury and improve contact with the root surfaces.
  44. 44. • The difficulties of performing adequate debridement in furcations by mechanical means has prompted experimentation with chemotherapeutic agents in these areas. • Needleman and Watts (1989): 1% metronidazole gel irrigation • Nylund and Egelberg (1990): 50 mg/ml Tetracycline irrigation every 2nd week for 3 months. • Minabe et al (1991): Tetracycline immobilized in a cross-linked collagen film. • Tonetti et al (1998): Tetracycline impregnated fibers • A.R. Pradeep (2013) : 1 % Alendronate Gel
  45. 45. OBLITERATION OF FURCATION - OCCLUSIVE BARRIER Filling of advanced furcation defects with biocompatible material to eliminate anatomic niches for bacteria accumulate. Potential advantages of an occlusive barrier:  Easy to place  Doesn’t require a suture for stability  Elimination of a second stage procedure
  46. 46. Different materials which have been used:  Amalgam  Polymer – reinforced zinc oxide eugenol  Resin ionomer cement  Glass ionomer cement
  47. 47. II. Surgical/Open Scaling and Root planing: • If sufficient subgingival access is not possible with a closed approach, for furcated molars with deep lesions, then open scaling using flap procedure such as Modified Widman flap yields more effective calculus removal with Furcation involvement. • Thus replaced flap results in some pocket reduction by formation of a long junctional epithelial adhesion.
  48. 48. INCREASING ACCESS TO THE FURCATION : 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.
  49. 49. FURCATIONPLASTY : • Odontoplasty i.e. removal of tooth substance in the furcation area in order to widen a narrow entrance of the furca and to reduce the horizontal depth of the involvement. • Osteoplasty - recontouring of bony defects in the furcation area, if indicated. • Repositioning and suturing of the flap
  50. 50. Furcation Plasty—Odontoplasty and Osteoplasty • Hamp and colleagues (1975) described furcation plasty as raising a mucoperiosteal flap to provide access to the furcation area and combining scaling and root planing, osteoplasty odontoplasty to remove local irritants and open the furcation to allow the patient access to clean and maintain the area. • The result should be a firm, well-contoured papilla to cover the interradicular space. This procedure is recommended for grade I and early grade II lesions (Glickman)
  51. 51. • The purpose of the procedure is to establish a condition in the dentogingival region which facilitates self performed plaque control. • It results in the establishment of a soft tissue papilla which covers the entrance to the inter-radicular periodontal tissues.
  52. 52. TUNNEL PROCEDURE • Intentional creation of a Class III furcation – entrance accessible for oral hygiene procedure. • Very conservative approach. • Objective - cleaning the furcation area by the patient using an interdental tooth brush. • Main advantage - avoidance of prosthetic reconstruction and endodontic therapy.
  53. 53. INDICATIONS FOR TUNNEL PRERPARATIONS • Deep grade II or grade III furcation involved teeth • Root anatomy : • Short root trunk (not be longer than 1/3 of the total root length) and a wide diameter of the furcation entrance • long and divergent roots • generally indicated for the mandibular molars Rudiger SG: Mandibular and maxillary furcation tunnel preparations – literature review and a case report. J Clin Periodontol 2001; 28: 1–8.
  54. 54.  PULP REACTIONS • The tunneling procedure might provoke a pulp reaction as it exposes a large root surface area relative to the root length. • Accessory root canals on the exposed root surface can connect periodontal and endodontic tissues.  CARIES RISK Rudiger SG: Mandibular and maxillary furcation tunnel preparations – literature review and a case report. J Clin Periodontol 2001; 28: 1–8.
  56. 56. Root amputation / Root resection : involves the removal of one or more roots of a multirooted tooth, at the same time permitting retention of the remaining tooth portion. Hemisection is defined as removal or separation of the root with its accompanying crown portion. Radisection is a newer terminology for removal of roots of maxillary molars. Bisection / Bicuspidization is the separation of mesial and distal roots of mandibular molars along with its crown portion, where both segments are then retained individually.
  58. 58. ROOT RESECTION A round bur is used for bone removal over the affected root. B and B', A 701L bur is used for the second cut. C and C', A flame-shaped enamel finishing bur is used for the oblique horizontal third cut. D and D', Oblique cut completed and final internal contouring established with round and oval enamel finishing burs.
  59. 59. INDICATIONS FOR ROOT RESECTION AND SEPARATION TREATMENT: Periodontal Indications : Severe bone loss affecting one or more roots untreatable with regenerative procedures. Class II or Class III furcation invasions or involvements. Severe recession or dehiscence of a root. Endodontic or Conservative Indications : Inability to successfully treat and fill a canal Root fracture or root perforation Severe root resorption Root decay Prosthetic Indications Severe root proximity inadequate for a proper embrasure space. Root trunk fracture or decay with invasion of the biological width.
  60. 60. CONTRAINDICATIONS TO ROOT RESECTION AND SEPARATION TREATMENT: • General contraindications to periodontal surgery - Systemic factors - Poor oral hygiene • Factors associated with local anatomy - Fused roots - Unfavorable tissue architecture
  61. 61. • Endodontic factors : - Retained roots endodontically untreatable - Excessive endodontic instrumentation of retained roots - Excessive deepening of pulp chamber floor • Restorative factors : - Internal root decay - Presence of a cemented post in the remaining root
  62. 62. BICUSPIDIZATION Separation of a two-rooted tooth (mandibular molar) & restoration of the crown portion of each section has been described to enhance plaque control & to convert the part of the tooth most susceptible to caries attack (dentin & cementum in the furcation) into metal. Indication : Grade III furcation involvement & divergent well supported roots. Disadvantages : Time, expense & attention to detail required for successful completion of the case.
  64. 64. 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. •Contain bone forming cells (osteogenesis) •Serve as a scaffold for bone formation (Osteoinduction). •Matrix of the grafting material contains bone inductive substances (Osteoinduction), which would stimulate both the regrowth of alveolar bone and the formation of new attachment.
  65. 65. •Schallhorn O (1967) observed probing depth reduction and bone fill of degree II furcation following transplantation of iliac grafts. •Gantes et al (1988): dFDBA •Kenny et al (1988): Porous hydroxyapatite •Pepelassi et al (1991): Composite graft of tricalcium phosphate, plaster of Paris and doxycycline •Yukna et al (1994): HTR bioplant
  66. 66. • Bone replacement grafts alone have had limited success in managing Class II and III furcation defects. • Problems Containment of graft, Epithelial exclusion, and Variable inductivity of the graft.
  67. 67. GUIDED TISSUE REGENERATION •Guided Tissue Regeneration is defined as procedure attempting to regenerate lost periodontal structures through differential tissue responses. •Using GTR, Gottlow et al (1986) demonstrated clinical and histological resolution of angular as well as furcation defects in humans. •These barriers can be absorbable/non-absorbable natural/synthetic. Degree I1 and degree I11 furcation involvements
  68. 68. • It was found that root resorption rather than new attachment occurred if the detached root surface was repopulated by cells derived from bone or gingival connective tissue. • A new connective tissue attachment with cementum and inserting collagen fibers was formed only when periodontal ligament cells were allowed to repopulate the root surface.
  69. 69. Grade II furcation have most predictable outcome of regenerative therapy • Options starts with SRP • Open flap debridement • LDD • Root conditioning • Root resection, Hemisection • Extraction • With advent of regenerative therapy was attempted in furaction defects also with use of biomimetic agents like enamel matrix derivatives, platelet-rich plasma, platelet- derived growth factor, and bone morphogenic proteins
  70. 70. Meta analysis of re entry results was done to give an idea of best regenerative treatment for molar grade II furcation. • Parameters assessed were VPD, VCAL, HBL, and VBL • Treatments employed were • Resorbable membrane • Non resorbable membrane • Open flap debridement • Allograft / xenograft + resorbable or Allograft / xenograft + non resorbable membrane
  71. 71. 1)The use of resorbable membranes was significantly better compared to non- resorbable membranes 2)Guided tissue regeneration by using resorbable or non-resorbable membranes produced better results compared to open flap debridement for all four parameters 3)The addition of allograft/xenograft to a resorbable membrane enhanced VPD reduction, attachment level gain, and HBL increase compared to resorbable membranes alone 4)Guided tissue regeneration by using a nonresorbable membrane and an allograft resulted in improved bone level gains compared to a non-resorbable membrane alone 5)Tooth and patient factors influenced the outcome of regeneration and these factors should be addressed presurgically Kinaia BM, Steiger J, Anthony L. Neely, Shah M, Bhola M. Treatment of Class II Molar Furcation Involvement: Meta-Analyses of Reentry Results. J Periodontol 2011;82:413-428.
  72. 72. TOOTH EXTRACTION Earlier Saxe and Carmen (1969) had stated that the indications for removal of a tooth with a Grade III furcal defects are: 1) The existence of an unopposed molar which is the terminal tooth in the arch. 2) A first molar with adjacent second premolar and second molar each with adequate bone support. 3) A solitary distal abutment tooth which exhibits mobility.
  73. 73. CONCLUSION The decision to retain and treat teeth with furcations has been recognized as feasible and predictable when appropriate parameters are addressed.
  74. 74. REFERENCES • Clinical periodontology and implant dentistry jan lindhe 5th edition • Carranza 10th edition. • Robert C. Bower. Furcation Morphology Relative to Periodontal Treatment Furcation Root Surface Anatomy. J Perioodntol 1979;50 (7):366-374. • Lopez R. Root Resorption in the Furcation Area: A Differential Diagnostic Consideration. J Periodontol 2010;81:1698-1702. • Hou GL, Tsai CC. Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvements. J Periodontol. 1997 Jul;68(7):687-93. • Atlas of cosmetic and reconstructive periodontal surgery, 3rd edition • Eickholz P, Kim ST. Reproducibility and Validity of the Assessment of Clinical Furcation Parameters as Related to Different Probes. J Periodontol 1998;69:328-336. • Hardekopf J D, Dunlap R M, Ahl D R, George B. Pelleu G B. The "Furcation Arrow"* A Reliable Radiographie Image?. J Periodontol 1986;58(4):258-261 • Deas D E et al. Clinical Reliability of the ‘‘Furcation Arrow’’ as a Diagnostic Marker. J Periodontol 2006;77:1436-1441.
  75. 75. • Karting T, Cortellini P. regenerative therapy in furcation defects. Perio2000 1000;19:115- 137. • Gupta D et al. Salvage periodontally compromised teeth through bicuspidization – a case report. IJRID 2011;1(2):35-45. • SANZ M et al. Clinical concepts for regenerative therapy in furcations. Periodontology 2000 2015;68: 308-332. • Laky M, Majdalani S, Kapferer I, Frantal S. Periodontal Probing of Dental Furcations Compared With Diagnosis by Low-Dose Computed Tomography: A Case Series. J Periodontol 2013;84:1740-1746. • Kinaia BM, Steiger J, Anthony L. Neely, Shah M, Bhola M. Treatment of Class II Molar Furcation Involvement: Meta-Analyses of Reentry Results. J Periodontol 2011;82:413- 428. • Rudiger SG: Mandibular and maxillary furcation tunnel preparations – literature review and a case report. J Clin Periodontol 2001; 28: 1–8. • Desanctis M, Murphy K. The role of respective periodontal surgery in the treatment of furcation defects. Periodontology 2000 2000;22:154–168