TREATMENT OF FURCATION

DR.AMITHBABU.C.B

M.Sc.D-ENDO

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.

Area of complex anatomic morphology that may be difficult or impossible to debride.

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

FurcationsManagement of teeth with furcation has always been a periodontal challenge

However teeth with furcation involvement can be maintained for many years if appropriately treated

Possible etiologyPrimary: Inflammatory periodontal diseaseOther possible etiologiesEndodontic involvementEnamel extensions and pearlsOcclusal traumaRoot fracture

Anatomical ConsiderationsRoot trunk length Root lengthRoot formInter radicular dimensionAnatomy of furcation

Root trunk lengthPortion of the root between cemento-enamel junction and the separation of the roots.

Teeth may have very short root trunks moderate root trunk length or roots that may be fused to a point near the apex

When the root trunk is short the furcation will become involved early in the disease process.

When the root trunk is long the furcation will be invaded later but will be more difficult for instrumentation.

Root TrunkRepresents 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

ROOT LENGTHIt is directly related to quantity of attachment supporting the tooth

Teeth with long root trunks and short roots may have lost a majority of their support by the time the furcation becomes affected.

Teeth with long roots and short to moderate root trunk are more readily treated because sufficient attachment remains to meet functional demands

Root formAll root surfaces facing the furcation exhibit some degree of concavity or depression in an occluso-apical direction.

This may make instrumentation for plaque removal and root planing almost impossible but these concavity increases the attachment area of the tooth and produce a root shape that is resistant to torque.

It is common in mesiobuccal root of maxillary first molar and mesial root of mandibular first and second molar

INTERRADICULAR DIMENSIONClosely approximated or fused roots can preclude adequate instrumentation during scaling, root planing and surgery.

Teeth with widely separated roots present more treatment options and are more readily treated.

Furcation Entrance Entrance: the transitional area between the undivided and the divided part of the root

Fornix: the roof of the furcation

Furcation Entrance DiameterHow 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 < 0.75 mm

Mandibular molars: buccal wider than lingual maxillary molars:

mesial > distal > buccal

ANATOMY OF FURCATIONThe presence of bifurcational ridges, a concavity in the

dome and accessory canals complicate the treatment and periodontal maintenance.

Root ConcavitiesMandibular Molars100% mesial roots99% distal roots

Maxillary Molars94% mesiobuccal roots

31% distobuccal roots17% palatal roots

Root Convergence and Divergence

Divergence, Convergence, Fusion

Cervical Enamel Projections13% of molars have CEPs

These projections may favor the onset of periodontal lesions in the affected furcations

Classification

Classified by Masters and Hoskins in 1964 as

Grade I: the enamel projection extends from the cemento-enamel junction of the tooth towards the furcation entrance.

Grade II: the enamel projection approaches the entrance to the furcation . It does enter the furcation , and therefore no horizontal component is present.

Grade III : the enamel projection extends horizontally into the furcation

Glickman`s Classification(1953CLASS 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

Class I Incipient FurcationThe level of bone loss allows for the insertion of the periodontal probe into the concavity of the root trunk

Class II FurcationIn 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

Class II FurcationThe level of bone loss allows for the insertion of a periodontal probe into the furcation area between the roots

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.

Class IV A tunnel therefore exists between the roots of such an affected tooth.

Thus the periodontal probe passes readily from one aspect of tooth to the other.

In grade IV furcation the interdental bone is destroyed, and the soft tissues have receded apically so that the furcation opening is clinically visible.

Easely and Drennan’s classification

This provides information relative to vertical component of furcation involvement.

Class I: incipient involvement in which the fluting coronal to the furcation involvement is affected but there is no definite horizontal component to the furca.

Class II: Type 1- a definite horizontal loss of attachment into the furcation, but the pattern of bone loss is essentially horizontal.

There is no definite buccal or lingual ledge of the bone.Type2- there is a buccal or lingual bony ledge and a

definite vertical component to attachment loss

Class III: A through and through loss of attachment in the furcation .

As with class II furcation defects , the pattern of attachment loss may be:

1. horizontal 2. vertical

Hamp, Lindhe and Nyman classification

• Based on the probing depthClass I - Furcation defect is less than 3 mm is depth.Class II - Furcation defect is at least 3 mm in depth (and

thus, in general, surpassing half of the buccolingual thickness of the tooth) but not through-and-through (i.e. there is still some interradicular bone attached to the angle of the furcation. The furcation defect is thus a cul-de-sac.

Class III - Furcation defect encompassing the entire width of the tooth so that no bone is attached to the angle of the furcation

Tarnow & Fletcher`s Classification (1984)

• Vertical bone loss is measured in mm from the roof of the furcation

MICROSCOPICALLYIn its early stages, there is a widening of periodontal space with cellular and inflammatory fluid exudation, followed by epithelial proliferation into the furcation area from the adjoining pocket.

Extension of inflammation into the bone leads to the resorption and reduction in bone height.

The bone destructive pattern may produce horizontal loss, or there may be angular osseous defects associated with infrabony pockets

DIAGNOSISEarlier the recognition – simpler the treatment

Thorough clinical examination

Careful probing To determine the presence and extent of furcation involvement ,

The position of attachment relative to the furca,

The extent and configuration of the furcation defect.

Furcation Probing

Mandibular MolarsBuccal Furcation

Place the probe between the two buccal roots from the buccal aspect

Furcation ProbingMandibular MolarsLingual Furcation

Place the probe between the two lingual roots from the lingual aspect

Furcation RadiographyShould include both periapical and bitewing

Location of the interdental bone and bone level within the root complex should be examined

Factors contributing to the development of furcation defect and affecting the treatment outcome include:

The morphology of the affected toothThe position of the tooth relative to the adjacent teeth.

The local anatomy of the alveolar bone.The configuration of any bony defects.The presence and extent of other dental diseases

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