This distance plays an important role in furcation defects because the deeper the furcation entrance is within the bone, the more bone loss necessary before the furcation becomes exposed. For mandibular first molars, the mean root trunk length is 3 mm on the buccal aspect and 4 mm on the lingual aspect. For maxillary first molars, the mean root trunk length is mm on the buccal aspect, and mm on the mesial aspect and mm on the distal aspect. In , Irving Glickman graded furcation involvement into the following four classes:  Grade I - Incipient furcation involvement, with an associated periodontal pocket remaining coronal to the alveolar bone. The pocket primarily affects the soft tissue.
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Next skip Parihar AS et al. Furcation involvement therefore presents both diagnostic and therapeutic dilemmas. This review explains the vast aspects of furcation involvement in form of etiology, classification, diagnosis and different treatment modalities in detail. Key Words: Furcation, periodontitis, plaque. Corresponding Author: Dr.
The furcation is an area of complex anatomic morphology that may be difficult or impossible to debride by routine periodontal instrumentation. Routine home care methods may not keep the furcation area free of plaque. One of the most compelling challenges faced in management of periodontal disease in multi-rooted teeth is furcation involvement.
Involvement of the furcae in multi-rooted teeth by chronic periodontitis is a common event resulting from loss of bone adjacent to and within the furcae. Extension of the periodontal disease process between the roots of multi-rooted teeth is believed strongly to influence the prognosis of the involved teeth. Nevertheless Conservation of natural dentition has been the aim of periodontics since time immemorial. Some authors recommended extraction of the teeth with furcation invasions rather than trying to retain them.
Nevertheless these same studies showed that in the majority of patients who responded well to treatment, many molar teeth with furcation involvement were retained for periods as long as years. The presence of furcation involvement is one clinical finding that can lead to a diagnosis of advanced periodontitis and potentially to a less favourable prognosis for the affected tooth or teeth. If not detected and treated before plaque and calculus are allowed to form on the root surface adjacent to the endodontic sinus tract, the furcation involvement becomes a combined endoperio defect and prognosis becomes poor.
The pocket is supra bony, involving the soft tissue; there is slight bone loss in the furcation area. Radiographic change is not usual, as bone is minimal. Grade II Involvement: In grade II cases, bone is destroyed on one or more aspects of furcation, but a portion of the alveolar bone and PDL remains intact, permitting only partial penetration of the probe into the furcation.
The lesion is essentially a cul-desac. The depth of the horizontal component of the pocket will determine whether the furcation involvement is early or advanced. The radiograph may or may not reveal the grade II furcation involvement.
Therefore the furcation opening cannot be seen clinically, but is essentially a throughand-through tunnel. There may be a craterlike lesion in the interradicular area, creating an apical or vertical component along with the horizontal loss of bone.
If the radiograph of the mandibular molars is taken as a proper angle and the roots are divergent, these lesions will appear on the radiograph as a radiolucent area between the roots.
The maxillary molars present a diagnostic difficulty owing to roots overlapping each other. Plaque associated inflammation: Extension of inflammatory periodontal disease processes into the furcation area leads to interradicular bone resorption and formation of furcation defect.
Glickman concluded from microscopic features that furcation involvement is a phase in root ward extension of periodontal pocket. Pulpo-periodontal disease The high percentage of molar teeth with patent accessory canals opening into the furcation suggests that pulpal disease could be an initiating cofactor in the development of furcation involvement.
If there is no established periodontal furcaion involvement, these pulpal lesions are initially pure endodontic sinus tracts draining through the periodontal ligament and gingival sulcus. If detected and treated early by endodontic therapy, these furcation defects resolve with regeneration of new interfurcal bone and attachment.
If not detected and treated before plaque and calculus are allowed to form on the root Grade IV Involvement: surface adjacent to the endodontic therapy, The interradicular bone is completely these furcation defects resolves with destroyed.
Therefore these involvements also exhibit tunnels without the orifices being occluded by the gingival. The radiographic picture is essentially the same as that of grade III lesions.
Class III: Through and through involvement: Tissue destruction extends throughout the entire length of furcation. So, that an instrument can be passed between the roots and emerges on the other side of the tooth. Thus the mesial furcation should be probed from the palatal aspect of the tooth. II Bone Sounding or Transgingival probing: Transgingival probing is extremely useful just prior to flap reflection.
It is necessary to anesthetize the tissue locally prior to inserting the probe. The probe may also be passed horizontally through the tissue to provide more threedimensional information regarding bony contours i. Greenburg et al. Diagnosing furcation invasion is therefore best accomplished using a combination of radiographs, periodontal probing with a curved explorer or Nabers probe and bone sounding. Diagnostic procedures must be systematic and organized for specific purposes; merely assembling facts is insufficient.
As a i Probing: general rule, bone loss is always greater than it appears in the radiograph. The radiographic multirooted teeth. In the radiographs, the location closer to the palatal than to the buccal of the interdental bone as well as the bone half of the tooth surface because of level within the root complex should be the larger buccolingual width of the examined.
Then, the localized but extensive attachment loss which may be detected within the root complex of a maxillary molar with the use of a probe will not always appear in the radiograph. This may be due to the superimposition in the radiograph of the palatal root of remaining bone structure. In such a case, additional radiographs with different angles of orientation of the central beam should be used to identify bone loss within the root complex. PROGNOSIS: Clinical research has indicated that furcation problems are not as severe a complication as originally suspected, if one can prevent the development of caries in the furcation.
A variety of methods are available for treatment. Not all of them provide elimination of the furcation of the furcation. Some provide only increased accessibility for plaque removal; some reduce the susceptibility of the tooth to caries. Pocket formation into the flute, but intact interradicular bone incipient. Loss of interradicular bone and pocket formation, but not extending through to the opposite side.
Through-and-through lesion with gingival recession, leading to a clearly visible furcation area. Autografts: Material to be grafted can then plaque alone. Therefore therapy for be obtained from the same individual. Allografts: From a different individual removal of plaque and calculus by scaling of the same species and root planing. These procedures results in 3. Xenografts: From different species. Osteogenesis: Refers to formation or development of new bone by cells Open flap debridement and root contained in the graft.
Osteoinduction: is a chemical process Even though by itself a non surgical by which molecules contained in the approach to therapy is very efficient in graft bone morphogenic proteins decreasing the risk of onset and progression convert the neighbouring cells into of various diseases of the gingival tissues, it osteoblasts, which in turn from bone. Osteoconduction: is a physical effect by Factors that contribute to the decreased which the matrix of the grafts forms a effectiveness of non surgical therapy include; scaffold that favours outside cells to time constraints, difficulty in accessing the penetrate the grafts and form a new area to be treated, operator experience, bone.
For these above mentioned reasons it may be advantageous and indicated to have surgical access to the area in need of decontamination. The possibility to elevate a flap and visualize the roots surfaces allows for an accurate and complete elimination of local etiologic factors. Many different surgical techniques have been described based on the type of case being treated as well as on the objectives of therapy. Among the most relevant clinical problems that can occur after surgery are the unaesthetic outcomes in aesthetic areas lengthening of the clinical crowns.
Some of the incision techniques, that allow us to gain adequate access to the area under treatment, have been designed in such a way as to decrease these undesired outcomes. Autografts in the form of osseous coagulum, bone blend, and marrow have the most promise for bone induction and regeneration of lost tissues. Osseous coagulum and bone utilizing intraoral cancellous bone and marrow grafts exhibit some lack of predictability in restoring furcation lesions.
Illiac autografts have yielded the best potential for osseous regeneration. Despite a promise of high predictability for success, the use of iliac autografts has been reserved, possibly because of the need for additional surgical intervention, expense of procurement, and a significant incidence of root resorption.
Sigurdsson et al. Following application of BMP the flaps were advanced to submerge the teeth and were sutured. Histologic analysis showed significantly more cementum formation and regrowth of alveolar bone on BMP treated sites as compared to the control. Ripamonti et al.
On one side BMP was implanted with a collagenous matrix, while at the control sites only the collagen matrix was used. Considerable regeneration of cementum, periodontal ligament and bone was observed in the BMP treated furcations as compared to the control furcations treated without BMP. Further experimentation is needed to evaluate a possible role of BMP in periodontal regeneration. Root Resection and Hemisection: Hemisection usually denotes removal of half the tooth performed in two procedures: tooth sectioning followed by removal of a root at the furcation or apical to it, without removal of the crown, usually on maxillary molars.
Root sectioning generally is defined as removal of a root without reference to how the crown is treated. Tooth extraction: This therapy is indicated when the destruction of the periodontium has progressed to such a level that no tooth can be preserved. Extraction may also be performed when the maintenance of the affected tooth will not improve the overall treatment or when treatment of the furcation involved tooth will not result in conditions which can be properly maintained by selfperformed plaque control measure.
The extraction of a periodontally involved multirooted tooth will of course predictably eliminate the disease in this particular area. Restorative management: Crowns used to restore root-resected teeth should follow the form created during the amputation procedure described previously. Proximal walls should taper evenly into the remaining root surface. No spurs of overhangs should remain to complicate maintenance.
Interproximal areas should be open to facilitate cleaning. Root concavities in the furcation areas should be reproduced in the restoration. Contours should be flat for access for effective plaque removal. Hemisected teeth should not be cantilevered unless supported by splinting. Endodontic therapy should be conservative with minimal enlargement of the root canal for root strength.
Condensation should not be excessive. Gutta-percha permits the placement of posts without disturbing the apical seal. Badly broken-down teeth may be built up with a post and core before final restoration is attempted.
CONCLUSION: Successful treatment, management and longterm retention of multi-rooted teeth with periodontal destruction of varying degrees into their furcations have long been a challenge to the discerning general dentist or dental specialist. Indeed, some earlier authors have reported that periodontal pockets that involve the domes of furcations of multi-rooted teeth present a hopeless or at best an unfavourable prognosis and should be extracted.
However, long term studies of treated teeth with furcations have shown impressive on retention for period up to 50 years. The decision for a specific treatment mode for furcation involved tooth depends on several factors, with a both general and local perspective.
62: Furcation: Involvement and Treatment