Furcation diagnosis and management in multirooted teeth **Dr.PRADEEP KOPPOLU** **DR ANNA HUGHES/Dr Tina Choo**  **Dr. Pradeep Koppolu** **Dr. Anna Hughes / Dr. Tina Choo** Clinical intraoral photograph showing the buccal aspect of a multirooted molar. The image demonstrates significant gingival recession exposing the furcation area between the roots. There is visible calculus accumulation on the exposed root surfaces and the adjacent tooth. # The significance of furcation involvement in multirooted teeth * Furcation involvement is a significant risk factor for tooth loss. * Risk of tooth loss increases with increasing bone loss in the furcation area. * Diagnosis of furcation involvement is challenging. * Hence thorough examination and early diagnosis is essential * Multirooted teeth have a significant role in our dentition and have unique anatomical features. * Due to their posterior position, access is challenging for professional and self performed cleaning - Furcation involvement is a significant risk factor for tooth loss. - Risk of tooth loss increases with increasing bone loss in the furcation area. - Diagnosis of furcation involvement is challenging. - Hence thorough examination and early diagnosis is essential. - Multirooted teeth have a significant role in our dentition and have unique anatomical features. - Due to their posterior position, access is challenging for professional and self performed cleaning. Terminology & Anatomy **Root Complex** **Root Trunk** **Root** **Cone** **Divergence** **Degree of separation** **Coefficient of separations A/B**    **Root Complex** **Root Trunk** **Root** **Cone** **Divergence** **Degree of separation** **Coefficient of separations A/B** Clinical photograph of a molar tooth viewed from the mesial aspect. The image displays labels identifying the 'Root Complex' (orange box encompassing both roots), 'Root Trunk', and individual 'Root Cone' sections. Clinical photograph of a tooth demonstrating root morphology. Labels indicate 'Divergence' with arrows showing the separation angle between roots and 'Degree of separation' at the apical level. Clinical photograph of a tooth illustrating the 'Coefficient of separations A/B'. Dotted lines and an orange bracket define measurement zones labeled 'A' and 'B' to quantify root divergence. # Anatomy   Labelled anatomical diagram of a tooth root showing the furcation area. The image displays a model or specimen with four labeled regions: 'Buccal Furcation Entrance', 'Mesial Furcation Entrance', 'Distal Furcation Entrance', and the central 'Furcated Region' outlined in orange. Clinical photograph (endodontic view) of a tooth canal entrance showing the 'Fornix'. A dark instrument is visible entering the canal space beneath the fornix structure.  Clinical photo of a dental specimen showing the occlusal view of a tooth with multiple cusps. The tooth appears to be a molar or premolar, with visible enamel and dentin structures. Anatomy of Multi-rooted Teeth | 3 **Figure 1.1** Drawing of mandibular molar with furcation involvement, showing the main anatomical features, including root trunk (part of the root from the cemento-enamel junction [CEJ] to the furcation entrance) and root cones, and pointing at root divergence and degree of separation between roots. The ‘bone loss’ is schematically indicated as the distance between the CEJ and the most apical part of the bone. *Source:* Courtesy of Dr Aliye Akcali.  **Figure 1.1** Drawing of mandibular molar with furcation involvement, showing the main anatomical features, including root trunk (part of the root from the cemento-enamel junction [CEJ] to the furcation entrance) and root cones, and pointing at root divergence and degree of separation between roots. The 'bone loss' is schematically indicated as the distance between the CEJ and the most apical part of the bone. *Source:* Courtesy of Dr Aliye Akcali. Anatomical diagram of a mandibular molar illustrating key structural features. Labels identify the Crown, Root complex (subdivided into Root trunk and Root cone), Fornix, Degree of separation, Divergence, and Bone loss. The illustration depicts the relationship between the tooth structure and the surrounding alveolar bone. # Anatomy   Clinical photograph showing the distal view of a maxillary molar (likely first or second) with two prominent roots and a V-shaped interradicular groove. Clinical photograph showing the mesial view of a mandibular molar with three distinct roots and deep developmental grooves separating them.    Clinical photo: A close-up view of a human molar tooth (likely mandibular first or second molar) showing two roots and three crowns. The tooth has been sectioned longitudinally to reveal the internal anatomy, including the pulp chamber and root canals. The enamel appears smooth and intact, while the dentin is visible beneath. The roots are divergent, with one being slightly shorter than the other. Clinical photo: Another molar tooth, similar in structure to the first, but with a more pronounced curvature in the roots. The crown is also divided into three cusps, suggesting it might be a premolar or a molar with an additional cusp. The surface texture and coloration are consistent with natural teeth. Clinical photo: A third molar tooth, again showing two roots and three crowns. This tooth appears to have a more symmetrical root structure compared to the previous ones. The overall morphology suggests it could be a maxillary or mandibular molar, depending on the specific dental formula used. Maxillary first PREMOLARS 40 % of maxillary premolars have 2 roots and furcation @ 8mm form CEJ FIGURE 2: Measurement of the buccal root with furcation grooves in maxillary first premolars using micro-CT. (a) Vertical measurement. (b) Horizontal measurement. A1: root furcation position; B1: apical position; C1: the start point of furcation groove; D1: the end point of furcation groove; E1: the middle point of CD connection. A1B1: buccal root length; C1D1: furcation groove length; A1C1: length from root bifurcation to the beginning of furcation groove; B1D1: length from apical position to the end point of furcation groove. AB: buccal root canal wall thickness; CD: palatal root canal wall thickness; DE: furcation groove depth (depth of root invagination).  Maxillary first premolars - 40% of maxillary premolars have 2 roots and furcation @ 8mm from CEJ **FIGURE 2:** Measurement of the buccal root with furcation grooves in maxillary first premolars using micro-CT. (a) Vertical measurement. (b) Horizontal measurement. A1: root furcation position; B1: apical position; C1: the start point of furcation groove; D1: the end point of furcation groove; E1: the middle point of CD connection. A1B1: buccal root length; C1D1: furcation groove length; A1C1: length from root bifurcation to the beginning of furcation groove; B1D1: length from apical position to the end point of furcation groove. AB: buccal root canal wall thickness; CD: palatal root canal wall thickness; DE: furcation groove depth (depth of root invagination). Micro-CT scan visualizations of a maxillary first premolar showing two distinct views labeled (a) and (b). Panel (a) displays a vertical view of the tooth with anatomical labels indicating root positions: A1 (root furcation position), B1 (apical position), C1 (start point of furcation groove), D1 (end point of furcation groove), and E1 (middle point of CD connection). Lines connect these points to illustrate measurements such as buccal root length (A1B1) and furcation groove length (C1D1). Panel (b) presents horizontal cross-sections of the tooth roots, annotated with lines AB, CD, and DE representing buccal root canal wall thickness, palatal root canal wall thickness, and furcation groove depth respectively. # ANATOMY OF MOLARS - Root surface area and shape - Bifurcation ridges - Enamel projections/pearls-connective tissue does NOT adhere to enamel - Horizontal component of furcations = 4.6-6.9 mm wide - Accessory canals - Iatrogenic- overhangs, caries, fractures - Root surface area and shape - Bifurcation ridges - Enamel projections/pearls – connective tissue does NOT adhere to enamel - Horizontal component of furcations = 4.6–6.9 mm wide - Accessory canals - Iatrogenic – overhangs, caries, fractures # ANATOMY OF MOLARS and Premolars * FURCATION ENTRANCE WIDTH * Almost all less than 1mm * 50% less than 0.75mm * Average curette width is 1mm, thin US tip 0.5mm  **Furcation entrance width** - Almost all less than 1 mm - 50% less than 0.75 mm - Average curette width is 1 mm, thin US tip 0.5 mm Clinical photograph showing three dental roots (likely molar or premolar) with visible furcation entrances. The image demonstrates the anatomy of molars and premolars in relation to furcation entrance width, supporting the OCR text stating that almost all are less than 1mm and 50% are less than 0.75mm. **Furcation entrance distances** **from CEJ ( Root trunk length)** **MAXILLARY MOLARS** Buccal-4.3 +/- 1mm Distal- 4.8 +/- 0.8mm MP 3.6 +/- 0.8mm **MANDIBULAR MOLARS** Buccal – average 4.15mm Lingual- average 3.4 mm **HENCE AT 6MM FROM CEJ-ALL FURCATION** **ENTRANCES INVOLVED** **Furcation entrance distances from CEJ (Root trunk length)** **Maxillary molars** - Buccal – 4.3 +/- 1 mm - Distal – 4.8 +/- 0.8 mm - MP – 3.6 +/- 0.8 mm **Mandibular molars** - Buccal – average 4.15 mm - Lingual – average 3.4 mm **Hence at 6 mm from CEJ – all furcation entrances involved** **Enamel projecting to furcation** - Projections/ enamel pearls - Risk factor for furcation involvement   **Enamel projecting to furcation** - Projections / enamel pearls - Risk factor for furcation involvement Clinical photograph of a molar tooth specimen showing enamel projecting towards the furcation area between roots. Macroscopic image of a green-colored dental model or cast demonstrating an enamel pearl located at the furcation. # Diagnosis * History and examination—clinical and radiographic. * Colour coded Nabers probe, Perio probe * Radiographs—parallel periapicals/ vertical bitewings but limitations of overlapping roots etc, esp upper molars and premolars * Consider CBCT if tooth is strategic in treatment planning Grade, Class, Degree - History and examination—clinical and radiographic. - Colour coded Nabers probe, Perio probe. - Radiographs—parallel periapicals/vertical bitewings but limitations of overlapping roots etc, esp upper molars and premolars. - Consider CBCT if tooth is strategic in treatment planning. Grade, Class, Degree Diagnosis & Classification of <b>furcation involvement</b> F0 F1 F2 F3  Diagnosis & Classification of furcation involvement - F0 - F1 - F2 - F3 A composite figure illustrating the diagnosis and classification of furcation involvement. The top-left panel shows a diagrammatic representation of four stages: F0 (no bone loss), F1 (incipient bone loss), F2 (partial bone loss), and F3 (complete bone loss). Below are corresponding clinical photos and radiographs demonstrating each stage using probes and X-rays. <table> <tr> <td>Degree 0</td> <td>No furcation involvement.</td> </tr> <tr> <td>Degree I</td> <td>Horizontal loss of periodontal tissue support up to 3 mm (Eickholz and Staehle 1994).</td> </tr> <tr> <td>Degree II</td> <td>Horizontal loss of support exceeding 3 mm, but not encompassing the total width of the furcation area (Hamp et al. 1975).</td> </tr> <tr> <td>Degree III</td> <td>Horizontal 'through-and-through' destruction of the periodontal tissue in the furcation. In early degree III involvement, the opening may be filled with soft tissue and may not be visible. The clinician may not even be able to pass a periodontal probe completely through the furcation because of interference with the bifurcational ridges or facial/lingual bony margins. However, if the clinician adds the buccal and lingual probing dimensions and obtains a cumulative probing measurement that is equal to or greater than the buccal/lingual dimension of the tooth at the furcation orifice, the clinician must conclude that a degree III furcation exists (Ammons and Harrington 2006).</td> </tr> </table> Sources: Hamp et al. (1975); Eickholz and Staehle (1994); Ammons and Harrington (2006).  - **Degree 0**: No furcation involvement. - **Degree I**: Horizontal loss of periodontal tissue support up to 3 mm (Eickholz and Staehle 1994). - **Degree II**: Horizontal loss of support exceeding 3 mm, but not encompassing the total width of the furcation area (Hamp et al. 1975). - **Degree III**: Horizontal 'through-and-through' destruction of the periodontal tissue in the furcation. In early degree III involvement, the opening may be filled with soft tissue and may not be visible. The clinician may not even be able to pass a periodontal probe completely through the furcation because of interference with the bifurcational ridges or facial/lingual bony margins. However, if the clinician adds the buccal and lingual probing dimensions and obtains a cumulative probing measurement that is equal to or greater than the buccal/lingual dimension of the tooth at the furcation orifice, the clinician must conclude that a degree III furcation exists (Ammons and Harrington 2006). Sources: Hamp et al. (1975); Eickholz and Staehle (1994); Ammons and Harrington (2006). A structured table defining four levels of periodontal furcation involvement. The first column lists 'Degree 0', 'Degree I', 'Degree II', and 'Degree III'. The second column provides detailed definitions: Degree 0 is 'No furcation involvement.'; Degree I involves 'Horizontal loss of periodontal tissue support up to 3 mm'; Degree II is 'Horizontal loss of support exceeding 3 mm, but not encompassing the total width of the furcation area'; and Degree III describes 'Horizontal through-and-through destruction of the periodontal tissue in the furcation' with specific clinical probing criteria. Vertical component-subclasses affecting prognosis Mandibular molar Grade A 1–3 mm Grade B 4–6 mm Grade C 7 mm+ maxillary molar Grade C 7 mm+ Grade B 4–6 mm Grade A 1–3 mm Thus, a subclassification was proposed that measures the probeable vertical depth from the roof of the furcation apically: (1) subclass A indicates a probeable vertical depth of 1–3 mm, (2) subclass B of 4–6 mm, and (3) subclass C of ≥7 mm. Furcations would thus be classified as IA, IB, IC, IIA, IIB, IIC and IIIA, IIIB, IIIC (Tarnow & Fletcher 1984).   #### Vertical component-subclasses affecting prognosis **Mandibular molar** - Grade A: 1–3 mm - Grade B: 4–6 mm - Grade C: 7 mm+ **Maxillary molar** - Grade C: 7 mm+ - Grade B: 4–6 mm - Grade A: 1–3 mm Thus, a subclassification was proposed that measures the probeable vertical depth from the roof of the furcation apically: (1) subclass A indicates a probeable vertical depth of 1–3 mm, (2) subclass B of 4–6 mm, and (3) subclass C of ≥7 mm. Furcations would thus be classified as IA, IB, IC, IIA, IIB, IIC and IIIA, IIIB, IIIC (Tarnow & Fletcher 1984). Diagram showing the vertical component-subclasses affecting prognosis for a mandibular molar. The diagram includes a sketch of a tooth with labels indicating Grade A (1-3 mm), Grade B (4-6 mm), and Grade C (7 mm+). Diagram showing the vertical component-subclasses affecting prognosis for a maxillary molar. The diagram includes a sketch of a tooth with labels indicating Grade C (7 mm+), Grade B (4-6 mm), and Grade A (1-3 mm). Clinical exam: **Nabers** Probe  Clinical exam: **Nabers** Probe Clinical photo showing the use of a Nabers probe during an oral examination. The image displays the gingival margin between two posterior teeth (likely premolars or molars), with the thin metallic tip of the probe inserted into the interproximal space to detect secondary caries or open margins at the interface of adjacent restorations.  Clinical intraoral photograph showing the buccal aspect of two premolars with a gold alloy crown restoration on the distal tooth. A periodontal probe is inserted into the gingival sulcus between the teeth, demonstrating the depth of pocketing or recession at the furcation area. # Accuracy of diagnosis - Clinical assessment alone detects 3% of maxillary molars and 9% of mandibular molars - 2 D radiographs and clinical assessment combined-65% of maxillary molars and 23% of mandibular molars - WHY? Angulation of radiographs, superimposition of roots, high mandibular bone density..... - Clinical assessment alone detects 3% of maxillary molars and 9% of mandibular molars. - 2D radiographs and clinical assessment combined—65% of maxillary molars and 23% of mandibular molars. - WHY? Angulation of radiographs, superimposition of roots, high mandibular bone density... Important diagnostic considerations - Horizontal/ vertical bone loss in furcation area - Length of root trunk - Length/divergence/shape of roots - Fusion of roots - Residual bone support - Endodontic/restorative/caries status #### Important diagnostic considerations - Horizontal/vertical bone loss in furcation area - Length of root trunk - Length/divergence/shape of roots - Fusion of roots - Residual bone support - Endodontic/restorative/caries status # Radiographs: Furcation “Arrows”  Radiographs: Furcation "Arrows" Figure showing two dental radiographs illustrating furcation involvement. The image includes a title banner reading 'Radiographs: Furcation Arrows'. The left panel displays three molar teeth with visible bone loss at the bifurcation area between roots. The right panel shows four teeth with similar findings and large restorations (fillings) present on multiple teeth. **Voltage: 77.0 kV Ampere: 7.0 mA Part: --- Phys. Filter: Conv.Filter: Slice Interval: 0.500 mm Slice Thickness: 1.000 mm Rotation History: Z -69.6 Original Angle: 0.0 deg. **Zoom: 72.19% Slice Position Z -13.234 mm Y -8.594 mm X -4.297 mm Volume Position Z +0.000 mm Y +0.000 mm X +0.000 mm **Figure 2.8 Diagnosis and treatment planning using cone-beam computed tomography (CBCT). CBCT images with horizontal, sagittal, and transversal sections of first and second left maxillary molars. According to the bone loss around the disto-buccal root and the remaining periodontal attachment around the mesio-buccal and palatal root, it was decided to extract the distobuccal root. Source: Walter et al. (2010).**  Voltage: 77.0 kV Ampere: 7.0 mA Part: --- Phys. Filter: Conv.Filter: Slice Interval: 0.500 mm Slice Thickness: 1.000 mm Rotation History: Z -69.6 Original Angle: 0.0 deg. Zoom: 72.19% Slice Position Z -13.234 mm Y -8.594 mm X -4.297 mm Volume Position Z +0.000 mm Y +0.000 mm X +0.000 mm Figure 2.8 Diagnosis and treatment planning using cone-beam computed tomography (CBCT). CBCT images with horizontal, sagittal, and transversal sections of first and second left maxillary molars. According to the bone loss around the disto-buccal root and the remaining periodontal attachment around the mesio-buccal and palatal root, it was decided to extract the distobuccal root. Source: Walter et al. (2010). Composite medical figure showing four panels of a Cone-Beam Computed Tomography (CBCT) scan of maxillary teeth. The top-left panel displays an axial cross-section with technical metadata including Voltage: 77.0 kV, Ampere: 7.0 mA, Slice Interval: 0.500 mm, and Rotation History: Z -69.6. The bottom two panels show vertical cross-sections (likely coronal and sagittal views), revealing dental anatomy with visible roots and surrounding bone structures. A red line indicates the slice position across the lower images. The caption explains that diagnosis revealed bone loss around the disto-buccal root, leading to its extraction decision. | Authors | | Numbers (%) of molars with furcation involvement | | | Diagnostic method | | :--- | :--- | :--- | :--- | :--- | :--- | | **Maxillary** | **Mandibular** | | | | | | Hirschfeld & Wassermann (32) | 858/2217 | 38.7% | 597/2054 | 29.0% | Clinical | | McFall (57) | 95/378 | 25.1% | 60/377 | 15.9% | Clinical | | Goldman et al. (24) | 454/870 | 52.2% | 169/865 | 19.5% | Radiographic | | Wood (102) | 87/205 | 42.4% | 77/220 | 35.0% | Radiographic/clinical |  | Authors | Numbers (%) of molars with furcation involvement | Diagnostic method | | :--- | :--- | :--- | | | **Maxillary** | **Mandibular** | | | Hirschfeld & Wassermann (32) | 858/2217 (38.7%) | 597/2054 (29.0%) | Clinical | | McFall (57) | 95/378 (25.1%) | 60/377 (15.9%) | Clinical | | Goldman et al. (24) | 454/870 (52.2%) | 169/865 (19.5%) | Radiographic | | Wood (102) | 87/205 (42.4%) | 77/220 (35.0%) | Radiographic/clinical | A table summarizing the frequency of furcation involvement in molars across four studies (Hirschfeld & Wassermann, McFall, Goldman et al., and Wood). The table is divided into columns for Authors, Numbers (%) of molars with furcation involvement (subdivided into Maxillary and Mandibular), and Diagnostic method. Data includes raw counts and percentages for each category. **Fig. 38.24** Periodontal abscess associated with a furcation-involved mandibular molar.  Fig. 38.24 Periodontal abscess associated with a furcation-involved mandibular molar. Clinical photo showing an intraoral view of the lower jaw (mandible). The image highlights a periodontal abscess on the gingiva adjacent to a molar tooth with a large metallic restoration. The gum tissue appears swollen and inflamed, consistent with the caption describing a furcation-involved mandibular molar. **Fig. 39.24** Early furcation involvement suggested by fuzziness in the furcation of the mandibular first molar, particularly when associated with bone loss on the roots. **Fig. 39.25** Furcation involvement of mandibular first and second molars indicated by thickening of the periodontal space in the furcation area. The furcation of the third molar is also involved, but the thickening of the periodontal space is partially obscured by the external oblique line. **Fig. 39.26** Furcation involvement of the first molar partially obscured by the radiopaque lingual root. The horizontal line across the distobuccal root demarcates the apical portion (*arrow*), which is covered by bone, from the remainder of the root, where the bone has been destroyed.    Fig. 39.24 Early furcation involvement suggested by fuzziness in the furcation of the mandibular first molar, particularly when associated with bone loss on the roots. Fig. 39.25 Furcation involvement of mandibular first and second molars indicated by thickening of the periodontal space in the furcation area. The furcation of the third molar is also involved, but the thickening of the periodontal space is partially obscured by the external oblique line. Fig. 39.26 Furcation involvement of the first molar partially obscured by the radiopaque lingual root. The horizontal line across the distobuccal root demarcates the apical portion (*arrow*), which is covered by bone, from the remainder of the root, where the bone has been destroyed. Clinical radiograph (X-ray) showing a mandibular molar. The image demonstrates early furcation involvement characterized by 'fuzziness' or loss of definition in the area where the tooth roots divide. This is associated with visible bone loss around the root structures. Clinical radiograph displaying multiple mandibular molars. It shows furcation involvement in the first and second molars, identified by the thickening of the periodontal space at the root division areas. The third molar's furcation involvement is noted as being partially obscured by anatomical lines. Clinical radiograph focusing on a first molar. A black arrow points to a specific region on the distobuccal root. The caption explains that this marks the boundary between the apical portion (which retains bone cover) and the remaining root section where bone destruction has occurred. The lingual root appears radiopaque. DIFFERENTIAL DIAGNOSIS - Endodontic infection - Trauma from occlusion - Iatrogenic damage   - Endodontic infection - Trauma from occlusion - Iatrogenic damage Radiograph showing a molar with endodontic treatment. The root canal filling material appears to extend beyond the apex of the tooth, indicating overfilling or extrusion into the periapical tissues. Radiograph showing two adjacent molars with root canal fillings. One tooth exhibits a radiolucent area at the apex, suggesting possible periapical pathology or incomplete healing post-treatment. **Endodontic infection-may take up to 5 years of radiographic healing**  **Endodontic infection** – may take up to 5 years of radiographic healing A composite figure demonstrating the progression of a primary endodontic lesion on tooth 4.6 (LR6) over time. The figure includes clinical photos and radiographs showing initial inter-radicular and apical involvement, followed by images documenting no furcation probing at three months and partial healing after one year. **Endodontic considerations for FI teeth** * Pulp changes can be induced by periodontal disease- can be reparative or degenerative changes. Pulp necrosis can occur if apical NV bundle involved . * Endodontic infections eg through accessory canals can mimic FI Class III- pulp testing important . * If both periodontal disease and necrotic pulp present- medicate canals first. **Endodontic considerations for FI teeth** - Pulp changes can be induced by periodontal disease – can be reparative or degenerative changes. Pulp necrosis can occur if apical NV bundle involved. - Endodontic infections (e.g., through accessory canals) can mimic FI Class III – pulp testing important. - If both periodontal disease and necrotic pulp present – medicate canals first. **Bold** Endodontic considerations for FI teeth - A vital pulp appears to hinder bacterial migration from the pocket to the pulp chamber- immune cells and fluid flow in tubules - If tooth is vital and root resection is performed- RCT must be done within 2 weeks of resection. - Preventative RCT not recommended for surgical and regenerative therapy unless pulp necrosis /infection is present **Endodontic considerations for FI teeth** - A vital pulp appears to hinder bacterial migration from the pocket to the pulp chamber – immune cells and fluid flow in tubules. - If tooth is vital and root resection is performed – RCT must be done within 2 weeks of resection. - Preventative RCT not recommended for surgical and regenerative therapy unless pulp necrosis/infection is present. # Management of furcation involved teeth Essentially 3 objectives: (I) eliminate microbial plaque from the exposed surfaces of the root complex (II) establish an anatomy of the affected surfaces that facilitates proper self performed plaque control eg tunnelling (III) Eliminate the furcation ( resection or regeneration) Essentially 3 objectives: 1. Eliminate microbial plaque from the exposed surfaces of the root complex 2. Establish an anatomy of the affected surfaces that facilitates proper self performed plaque control (e.g., tunnelling) 3. Eliminate the furcation (resection or regeneration) Terminology Odontoplasty – reshaping of the tooth to aid cleansability Osteoplasty – reshaping of the bone to aid cleansability Flap procedures - OFD (open flap debridement) +/- reshaping, resection or repositioning the soft tissues Regeneration- aims to restore the original architecture (and close the furcation) with new bone, cementum and PDL  **Odontoplasty** – reshaping of the tooth to aid cleansability **Osteoplasty** – reshaping of the bone to aid cleansability **Flap procedures** – OFD (open flap debridement) +/- reshaping, resection or repositioning the soft tissues **Regeneration** – aims to restore the original architecture (and close the furcation) with new bone, cementum and PDL A list of dental terminology defining four specific procedures. The terms are: Odontoplasty (reshaping of the tooth to aid cleansability), Osteoplasty (reshaping of the bone to aid cleansability), Flap procedures - OFD (open flap debridement) +/- reshaping, resection or repositioning the soft tissues, and Regeneration (aims to restore the original architecture and close the furcation with new bone, cementum and PDL). Management: Non-surgical Non-surgical treatment: * Standard Curette width 0.8-1.06mm * Standard Ultrasonic tip 0.88mm measured 1mm from the tip and 1.06mm measured 2mm from the tip * Furcation opening <1mm * Difficult to access furcation * Standard Ultrasonic slightly better than standard curettes in narrow furcation areas * Gr I furcation relatively stable with SRP * Gr II and III furcation relapse or deteriorated over 2 years  #### Non-surgical treatment - Standard Curette width: 0.8–1.06 mm - Standard Ultrasonic tip: 0.88 mm measured 1 mm from the tip and 1.06 mm measured 2 mm from the tip - Furcation opening < 1 mm - Difficult to access furcation - Standard Ultrasonic slightly better than standard curettes in narrow furcation areas - Grade I furcation relatively stable with SRP - Grade II and III furcation relapse or deteriorated over 2 years Clinical photograph demonstrating non-surgical instrumentation. The image shows a dental model of a molar tooth with a visible furcation defect against a blue background. Two curved metal curettes are inserted into the buccal and lingual aspects of the furcation opening to demonstrate access. The photo serves as a visual aid for the text stating 'Difficult to access furcation' and 'Standard Ultrasonic slightly better than standard curettes in narrow furcation areas'. **How good are we at cleaning furcations-** **Success rates of calculus removal from** **furcations** * **Experienced vs** **inexperience** * **Less experienced / closed** **approach only 8 %** of surfaces **were calculus free** * **Closed vs open access-** * **Experienced periodontists** **open** approach-68% calculus **free furcation surfaces** **achieved** * **Experienced** 44% calculus **free with a closed** approach #### Success rates of calculus removal from furcations - **Experienced vs inexperienced** - Less experienced / closed approach: only 8% of surfaces were calculus free - **Closed vs open access** - Experienced periodontists, open approach: 68% calculus free furcation surfaces achieved - Experienced, closed approach: 44% calculus free PL1=0.5, PS=0.6, PL5 & 6=0.8 How Good Are We at Cleaning Furcations? 47 **Figure 3.4 EMS Piezon® Master ultrasonic scaler and tips: (a) PL1 tip with a diameter of 0.5 mm for debridement of hard-to-reach interproximal areas; (b) PL5 tip with a ball end of diameter 0.8 mm for debridement of furcations and concavities; (c) PS universal tip with a diameter of 0.6 mm for debridement of deep pockets.**  PL1 = 0.5, PS = 0.6, PL5 & 6 = 0.8 **Figure 3.4** EMS Piezon® Master ultrasonic scaler and tips: (a) PL1 tip with a diameter of 0.5 mm for debridement of hard-to-reach interproximal areas; (b) PL5 tip with a ball end of diameter 0.8 mm for debridement of furcations and concavities; (c) PS universal tip with a diameter of 0.6 mm for debridement of deep pockets. Clinical photograph showing an EMS Piezon® Master ultrasonic scaler unit alongside three labeled tips. The image includes the main handpiece, a transparent water reservoir, and close-up views of the tips. Tip (a) is a curved, thin PL1 tip (0.5 mm diameter) designed for interproximal cleaning. Tip (b) is a straighter PL5 tip with a ball end (0.8 mm diameter) for furcation and concavity access. Tip (c) is a PS universal tip (0.6 mm diameter) for deep pocket debridement. All components are clearly labeled with letters (a), (b), (c) to correspond with the caption's descriptions. # Many different US tips * Straight and thin eg PS1 * Curved and thin eg PL1/PL2 * Ball ended- for furcation roof and grooves PL5/PL4 * Diamond coated – very fast and efficient but removes cementum and dentine too * Some systems eg Kavo- inbuild light ( LED) to improve visibility #### Many different US tips - Straight and thin (e.g., PS1) - Curved and thin (e.g., PL1/PL2) - Ball ended – for furcation roof and grooves (PL5/PL4) - Diamond coated – very fast and efficient but removes cementum and dentine too - Some systems (e.g., Kavo) have inbuilt light (LED) to improve visibility **Fig. 41.8** The furcation entrance is narrower than a standard curette in 58% of first molars. (Redrawn from Bower RC. Furcation morphology relative to periodontal treatment. Furcation root surface anatomy. J Periodontol. 1979;50:366.) **Fig. 51.27** Micro Mini Five Gracey curettes. Left to right, #1-2, #7-8, #11-12, #13-14. (Copyright A. Pattison.) **Fig. 51.28** Comparison of Gracey curette designs. Left to right, Standard #1-2, After Five #1-2, Mini Five #1-2, Micro Mini Five #1-2. (Courtesy Hu-Friedy, Chicago, IL.)    **Fig. 41.8** The furcation entrance is narrower than a standard curette in 58% of first molars. (Redrawn from Bower RC. Furcation morphology relative to periodontal treatment. Furcation root surface anatomy. J Periodontol. 1979;50:366.) **Fig. 51.27** Micro Mini Five Gracey curettes. Left to right, #1-2, #7-8, #11-12, #13-14. (Copyright A. Pattison.) **Fig. 51.28** Comparison of Gracey curette designs. Left to right, Standard #1-2, After Five #1-2, Mini Five #1-2, Micro Mini Five #1-2. (Courtesy Hu-Friedy, Chicago, IL.) Anatomical diagram illustrating the cross-section of a molar tooth with a furcation entrance. A magnified circular inset highlights the narrowness of the furcation opening, labeled '58%', demonstrating that it is significantly smaller than the width of a standard curette tip. A clinical photograph displaying four dental instruments known as Micro Mini Five Gracey curettes arranged vertically against a blue background. Each instrument features a curved working end and a colored handle grip corresponding to its specific type. A comparative figure showing four different designs of Gracey curettes side-by-side. From left to right, they are labeled 'Standard', 'After Five', 'Mini Five', and 'Micro Mini Five'. Arrows above each instrument indicate the direction of movement or adaptation for use.  Clinical photograph showing three labeled panels of dental instruments: (a) Mini Five Gracey curettes with wider blades, (b) Micro Mini Five Gracey curettes with narrower blades, and (c) a close-up comparison of the blade widths between the two types. # Self performed biofilm control for management of furcations ## CURRENT EVIDENCE SUGGESTS * **Oscillating rotating electric toothbrush** * **End or compact tufted brush** * **Cylindrical interdental brushes** * **WaterPik?** #### Current evidence suggests - Oscillating rotating electric toothbrush - End or compact tufted brush - Cylindrical interdental brushes - WaterPik? # **TEPE COMPACT TUFT TOOTHBRUSH** **$4.00** This special toothbrush has a small, dome-shaped tuft and short, extra soft filaments. The stable handle and dense, firm tuft make this brush ideal for precision cleaning of difficult to reach areas. The toothbrush is suitable for cleaning around fixed orthodontic appliances, attachments for overdentures or along the gum line. It is also ideal for brushing children’s erupting molars. Colours may vary.  **TePe Compact Tuft Toothbrush** – $4.00 This special toothbrush has a small, dome-shaped tuft and short, extra soft filaments. The stable handle and dense, firm tuft make this brush ideal for precision cleaning of difficult to reach areas. The toothbrush is suitable for cleaning around fixed orthodontic appliances, attachments for overdentures or along the gum line. It is also ideal for brushing children’s erupting molars. Colours may vary. Product photograph of the TEPE COMPACT TUFT TOOTHBRUSH. The image shows a single, light blue toothbrush with a long handle and a small, angled head featuring a dome-shaped tuft of bristles. The text 'TEPE' is visible on the handle. **ROOT RESECTION** - The surgical removal of all or a portion of the root. - Can eliminate an involved furcation    - The surgical removal of all or a portion of the root. - Can eliminate an involved furcation Title banner for the procedure section. Pre-operative dental radiograph showing a multi-rooted molar with severe bone loss and furcation involvement. Post-operative dental radiograph showing the same tooth after root resection, where one of the roots has been surgically removed to eliminate the involved furcation defect. ROOT RESECTION The ‘ideal’ candidate: * Class II or III furcation involved molar * Severe bone loss around just 1 root ideally or occasionally 2 roots * If there is a localised root fracture, perforation or resorption * Remaining roots should have adequate bony support - favourable crown-root ratio * Sound endodontic & restorative prognosis * Tooth has minimal mobility (Gr 1 mobile or nil) * Good oral hygiene The ‘ideal’ candidate: - Class II or III furcation involved molar - Severe bone loss around just 1 root ideally or occasionally 2 roots - If there is a localised root fracture, perforation or resorption - Remaining roots should have adequate bony support - favourable crown-root ratio - Sound endodontic & restorative prognosis - Tooth has minimal mobility (Gr 1 mobile or nil) - Good oral hygiene ROOT RESECTION **Contraindications:** * Teeth with a poor crown-root ratio on remaining roots * Inadequate bone support on roots to be retained * Long root trunks * Fused roots * Teeth where endodontic & restorative treatment not feasible on remaining roots * Poor surgical access & inability to perform oral hygiene procedures **Contraindications:** - Teeth with a poor crown-root ratio on remaining roots - Inadequate bone support on roots to be retained - Long root trunks - Fused roots - Teeth where endodontic & restorative treatment not feasible on remaining roots - Poor surgical access & inability to perform oral hygiene procedures Figure 2.9 Root resection in a maxillary first molar: (a) pre-surgical view; (b) tri-section of the distobuccal root; (c) the flap is fixed with monofil synthetic sutures 5 × 0; (d) four months post-operation, the wound healing was uneventful; (e) a crown with an extended metal margin is placed and the patient is introduced to meticulous oral hygiene.      Figure 2.9 Root resection in a maxillary first molar: (a) pre-surgical view; (b) tri-section of the distobuccal root; (c) the flap is fixed with monofil synthetic sutures 5 × 0; (d) four months post-operation, the wound healing was uneventful; (e) a crown with an extended metal margin is placed and the patient is introduced to meticulous oral hygiene. Clinical photo showing the pre-surgical view of a maxillary first molar with significant carious destruction and gingival inflammation. Clinical photo showing the tri-section (root resection) of the distobuccal root, exposing the tooth structure during surgery. Clinical photo showing the surgical site where the flap is fixed with monofil synthetic sutures (5 × 0). The exposed root surface has blue marking material applied. Clinical photo taken four months post-operation showing uneventful wound healing. A temporary restoration or crown with a blue margin is visible on the treated tooth. Clinical photo showing the final outcome: a crown with an extended metal margin is placed on the restored tooth. **Are these cases suitable for ROOT RESECTION?**      Are these cases suitable for ROOT RESECTION? Title slide or header figure containing the question 'Are these cases suitable for ROOT RESECTION?' in white text on a yellow-orange background with blue graphical elements. Dental radiograph showing multiple posterior teeth with restored crowns and visible root structures; likely part of a case comparison set regarding suitability for root resection. Dental radiograph showing two adjacent molars with endodontic treatment (root canals) and restorations; possibly illustrating a candidate for or contraindication to root resection. Dental radiograph showing a molar with a large radiolucent lesion below the root apex, suggesting periapical pathology that may be relevant to evaluating need for root resection. Dental radiograph showing two mandibular molars with root canal fillings and coronal restorations; potentially demonstrating anatomical features influencing decision-making for root resection. ## Success of Root Resection<p>outcomes of root resection therapy up to 16.8 years: A retrospective study in an academic setting</p> Madi Alassadi | Musa Qazi | Andrea Ravidà Rafael Siqueira | Carlos Garaicoa-Pazmiño | Hom-Lay Wang ```html <table border="1" class="dataframe"> <thead> <tr style="text-align: right;"> <th>Follow-up</th> <th>Sample size</th> <th>Failures</th> <th>Percentage of failure per interval</th> <th>Cumulative survival rate</th> </tr> </thead> <tbody> <tr> <td><12 months</td> <td>85</td> <td>1</td> <td>1.2%</td> <td>98%</td> </tr> <tr> <td>12 to 24 months</td> <td>81<sup>1</sup></td> <td>15</td> <td>18.5%</td> <td>79.6%</td> </tr> <tr> <td>>24 to 36 months</td> <td>61</td> <td>7</td> <td>11.5%</td> <td>69.7%</td> </tr> <tr> <td>>36 to 48 months</td> <td>46</td> <td>8</td> <td>16.7%</td> <td>56.8%</td> </tr> <tr> <td>>48 to 96 months</td> <td>31</td> <td>2</td> <td>6.5%</td> <td>52.9%</td> </tr> <tr> <td>>96 to 144 months</td> <td>19</td> <td>3</td> <td>15.8%</td> <td>42.1%</td> </tr> <tr> <td>>144 months</td> <td>8</td> <td>2</td> <td>25%</td> <td>18.4%</td> </tr> </tbody> </table> ``` <sup>1</sup>Values adjusted per observation period ```text Received: 21 January 2019 | Revised: 6 May 2019 | Accepted: 13 May 2019 DOI: 10.1002/JPER.19-0033 JOURNAL OF PERIODONTOLOGY CALL SEPRIE Methods: Patient-related demographic data, medical history information, and relevant data pertaining to the root-resected teeth performed from **January 1990** to **September 2017** were reviewed through electronic and paper chart Conclusions: Root resection therapy **remains a treatment solution for molars** with furcation defects. In an academic setting, >50% of teeth remained functional after 9 years of root resection therapy ```  #### Success of Root Resection outcomes of root resection therapy up to 16.8 years: A retrospective study in an academic setting Madi Alassadi | Musa Qazi | Andrea Ravidà Rafael Siqueira | Carlos Garaicoa-Pazmiño | Hom-Lay Wang | Follow-up | Sample size | Failures | Percentage of failure per interval | Cumulative survival rate | | --- | --- | --- | --- | --- | | <12 months | 85 | 1 | 1.2% | 98% | | 12 to 24 months | 81<sup>1</sup> | 15 | 18.5% | 79.6% | | >24 to 36 months | 61 | 7 | 11.5% | 69.7% | | >36 to 48 months | 46 | 8 | 16.7% | 56.8% | | >48 to 96 months | 31 | 2 | 6.5% | 52.9% | | >96 to 144 months | 19 | 3 | 15.8% | 42.1% | | >144 months | 8 | 2 | 25% | 18.4% | Received: 21 January 2019 | Revised: 6 May 2019 | Accepted: 13 May 2019 DOI: 10.1002/JPER.19-0033 Methods: Patient-related demographic data, medical history information, and relevant data pertaining to the root-resected teeth performed from **January 1990** to **September 2017** were reviewed through electronic and paper chart. Conclusions: Root resection therapy **remains a treatment solution for molars** with furcation defects. In an academic setting, >50% of teeth remained functional after 9 years of root resection therapy. Table showing cumulative survival rate of root resection therapy at different follow-up intervals. Columns include Follow-up (time intervals), Sample size, Failures, Percentage of failure per interval, and Cumulative survival rate. Data ranges from <12 months to >144 months, with sample sizes decreasing over time and cumulative survival rates dropping from 98% to 18.4%. # Root Separation * All roots retained * Indications- eg caries /perforations of root trunk, deep Class II or III, usually mandibular molars where it is termed premolarization * Rarely , can be used on maxillary molars +/- root resection as well - All roots retained - Indications: caries/perforations of root trunk, deep Class II or III, usually mandibular molars where it is termed premolarization - Rarely, can be used on maxillary molars +/- root resection as well  Clinical procedure sequence showing root separation (rizotomy) of a mandibular first molar with degree III furcation involvement. Panels (a-d) show the tooth before surgery and during sectioning to separate roots while maintaining them. Panel (e) shows the apical positioned flap after surgery. Panel (f) shows the final restored tooth, enabling proper oral hygiene.  Clinical procedure image showing the step-by-step surgical process for root separation and rizectomy of a maxillary upper second molar. The composite image displays six panels: initial exposure of the tooth, use of surgical instruments to separate the roots, final separation of the disto-buccal root, and suturing of the surgical site post-extraction. <html><body><table><tbody><tr><td colspan="2"><b>TUNNELING PROCEDURES</b></td></tr><tr><td></td></tr></tbody></table></body></html> <html><body><table><tbody><tr><td colspan="2"><b>TUNNELING PROCEDURES</b></td></tr><tr><td></td></tr></tbody></table></body></html>  Clinical dental radiograph (periapical X-ray) showing a segment of the mandibular posterior dentition. The image displays at least three teeth with evidence of endodontic treatment: two molar-like teeth show multiple root canals that have been filled with radiopaque material (root canal obturation), and one premolar-like tooth also shows signs of prior endodontic therapy. A bright, radiopaque restoration or filling material is visible in the occlusal aspect of the rightmost tooth. The surrounding alveolar bone structure is visible, though details are somewhat obscured by image quality. This figure serves to demonstrate the outcome of endodontic procedures and the internal anatomy of treated teeth. Fig. 39-20 Tunnel preparation of a degree III-involved mandibular molar. Radiograph (a) and photograph (b) showing a wide inter-radicular space where self-performed plaque control can be obtained by the use of an interproximal brush.   Fig. 39-20 Tunnel preparation of a degree III-involved mandibular molar. Radiograph (a) and photograph (b) showing a wide inter-radicular space where self-performed plaque control can be obtained by the use of an interproximal brush. Radiograph (a) showing the dental anatomy of a mandibular molar with a visible tunnel preparation between the roots. Clinical photograph (b) displaying a wide inter-radicular space where self-performed plaque control can be obtained by the use of an interproximal brush. # TUNNELING PROCEDURES **Beware – caries risk & tooth sensitivity** **Hamp et al** - 7 molars with degree III furcation defects undergone tunnel preparation. After 5 years, caries in 4 teeth (57%). **Little et al** over 5 years - 18 class II or III molar furcations that underwent tunneling procedures. Crestal bone levels and attachment levels in the furcations were maintained for this time period. During follow-up, 3 of the 18 teeth experienced root caries (17%). **Hellden et al** - 149 teeth received tunnel preparation, over avg 3 years. 24% of the teeth - caries. Of the 17 teeth that had to be extracted or further treated by root resection, root caries in 70%. TUNNELING PROCEDURES **Beware – caries risk & tooth sensitivity** **Hamp et al** - 7 molars with degree III furcation defects undergone tunnel preparation. After 5 years, caries in 4 teeth (57%). **Little et al** over 5 years - 18 class II or III molar furcations that underwent tunneling procedures. Crestal bone levels and attachment levels in the furcations were maintained for this time period. During follow-up, 3 of the 18 teeth experienced root caries (17%). **Hellden et al** - 149 teeth received tunnel preparation, over avg 3 years. 24% of the teeth - caries. Of the 17 teeth that had to be extracted or further treated by root resection, root caries in 70%. # Management: Surgery **Surgical treatment:** * Open Flap debridement **Regenerative treatment:** * GTR ( Guided Tissue Regeneration) +/- bone grafts * And/ or EMD ( Enamel Matrix Derivative) * Not for class III furcations * Most suited for lower molars class II buccal ( and lingual) & upper buccal furcation class II but complete closure NOT PREDICTABLE #### Management: Surgery **Surgical treatment:** - Open flap debridement **Regenerative treatment:** - GTR (Guided Tissue Regeneration) +/- bone grafts - And/or EMD (Enamel Matrix Derivative) - Not for class III furcations - Most suited for lower molars class II buccal (and lingual) & upper buccal furcation class II but complete closure NOT PREDICTABLE # Important factors for success of regeneration * Controlled systemic factors * good OH * thicker phenotype / wide band of keratinized tissue / no recession * good interproximal bone height * good access * complete coverage of defect and membrane - more important than defect size. #### Important Factors for Success of Regeneration - Controlled systemic factors - Good OH - Thicker phenotype / wide band of keratinized tissue / no recession - Good interproximal bone height - Good access - Complete coverage of defect and membrane - more important than defect size **a** **b** **c** **d**  a b c d Clinical procedure photograph showing four sequential stages of a periodontal regenerative surgery on a mandibular first molar. Panel 'a' displays an intraoral view of the tooth with a visible deep infrabony defect at the gingival margin. Panel 'b' shows the surgical site covered by a white Teflon membrane secured with sutures. Panel 'c' depicts the soft tissue flap sutured over the membrane. Panel 'd' presents the final healed result six months later, demonstrating successful closure of the defect. **Which treatment is best?**  Depend on tooth-related factors- degree of furcation involvement, root length & amount of bony support, access, phenotype  Patient-related factors- smoking, level of diabetic control, other systemic factors, caries risk  **Which treatment is best?** - Depend on tooth-related factors: degree of furcation involvement, root length & amount of bony support, access, phenotype - Patient-related factors: smoking, level of diabetic control, other systemic factors, caries risk Table listing factors for determining the best treatment. It is divided into two sections: 'Tooth-related factors' (degree of furcation involvement, amount of remaining periodontal support, probing depth, tooth mobility, endodontic conditions and root/root-canal anatomy, available sound tooth substance, tooth position and occlusal antagonisms) and 'Patient-related factors' (strategic value of the tooth in relation to the overall plan, patient's functional and esthetic demands, patient's age and health conditions, oral hygiene capacity). # Which treatment is best? Degree of furcation involvement: - Class I – NST, odontoplasty - Class II – NST, odontoplasty, OFD, osteoplasty, regeneration eg GTR /EMD, Tunnel Preparation, root resection - Class III – SRD, OFD, Tunnel Preparation, Root resection, extraction Non-surgical treatment depends on patient compliance to attend regular maintenance visits Maintenance is important Less furcation-involved molars were lost in well maintained group (difference >10%) across all studies **Which treatment is best?** Degree of furcation involvement: - Class I – NST, odontoplasty - Class II – NST, odontoplasty, OFD, osteoplasty, regeneration e.g. GTR /EMD, Tunnel Preparation, root resection - Class III – SRD, OFD, Tunnel Preparation, Root resection, extraction Non-surgical treatment depends on patient compliance to attend regular maintenance visits. Maintenance is important. Less furcation-involved molars were lost in well maintained group (difference >10%) across all studies. # The importance of Maintenance - Perio treatment and maintenance reduced tooth loss rate of FI molars in all studies vs no treatment ( not many studies on no treatment !) - Tooth loss rate is approx. double for FI molars ( Class II) vs non- FI molars over a 15 year period. - Degree of FI involvement influences tooth loss- x3 risk of tooth loss for Class III. **The importance of Maintenance** - Perio treatment and maintenance reduced tooth loss rate of FI molars in all studies vs no treatment (not many studies on no treatment!) - Tooth loss rate is approx. double for FI molars (Class II) vs non-FI molars over a 15 year period. - Degree of FI involvement influences tooth loss – x3 risk of tooth loss for Class III. ### Classification of Furcation Involvement and Treatment options **Class I** - NST, odontoplasty **Class II** - NST, odontoplasty - OFD, regeneration, Tunnel Preparation **Class III** - SRD, OFD, Tunnel Preparation, Root resection, extraction **Treatment options depend on patient compliance to attend regular maintenance visits** **Classification of Furcation Involvement and Treatment options** **Class I** - NST, odontoplasty **Class II** - NST, odontoplasty - OFD, regeneration, Tunnel Preparation **Class III** - SRD, OFD, Tunnel Preparation, Root resection, extraction **Treatment options depend on patient compliance to attend regular maintenance visits** # Important issues to be discussed-cost , time ,consent * Extraction * Implant * Long term maintenance and unpredictability of treating periimplantitis * OFD * Emdogain * GTR +Bone * Root resection/ tunnelling * +/-RCT * +/-Crown * long term maintenance **Important issues to be discussed – cost, time, consent** - Extraction - Implant - Long term maintenance and unpredictability of treating periimplantitis - OFD - Emdogain - GTR + Bone - Root resection / tunnelling - +/- RCT - +/- Crown - Long term maintenance # Summary of Evidence * Teeth with FI can be retained in the longterm but at higher cost then teeth without FI * The higher degrees of FI, bone loss and mobility, higher cost of maintaining the tooth * However removing and replacing teeth with implant supported crowns does not seem to cost less in the long term **Summary of Evidence** - Teeth with FI can be retained in the long term but at higher cost than teeth without FI - The higher degrees of FI, bone loss and mobility, higher cost of maintaining the tooth - However removing and replacing teeth with implant supported crowns does not seem to cost less in the long term # Conclusions * Furcations can be very difficult to manage * Class I – non-surgical approach with ultrasonics/ mini curettes * Class II and III – more effective debridement with a surgical approach * Regenerative approach more successful with mandibular Class II buccal & lingual furcations; maxillary Class II buccal molars * GTR is more effective than OFD in managing furcation defects, but results can be variable due to operator skill, patient & tooth selection * Tunnel procedures & Root resection both effective & successful treatment modalities long-term for Gr II +III furcation involvements * Regular maintenance is crucial to success of treatment ( only 30% of degree III FI lost after 15years of regular maintenance Nibali et al, 2019) **Conclusions** - Furcations can be very difficult to manage - Class I – non-surgical approach with ultrasonics / mini curettes - Class II and III – more effective debridement with a surgical approach - Regenerative approach more successful with mandibular Class II buccal & lingual furcations; maxillary Class II buccal molars - GTR is more effective than OFD in managing furcation defects, but results can be variable due to operator skill, patient & tooth selection - Tunnel procedures & Root resection both effective & successful treatment modalities long-term for Gr II + III furcation involvements - Regular maintenance is crucial to success of treatment (only 30% of degree III FI lost after 15 years of regular maintenance – Nibali et al, 2019) Diagnosis and Treatment of Fucation-Involved Teeth **Edited by Luigi Nibali** **Senior Clinical Lecturer** **Centre for Immunobiology and Regenerative Medicine** **Centre for Oral Clinical Research, Institute of Dentistry** **Barts and the London School of Medicine and Dentistry** **Queen Mary University of London (QMUL), London, UK** **Honorary Associate Professor, University of Hong Kong** Diagnosis and Treatment of Furcation-Involved Teeth **Edited by Luigi Nibali** **Senior Clinical Lecturer** **Centre for Immunobiology and Regenerative Medicine** **Centre for Oral Clinical Research, Institute of Dentistry** **Barts and the London School of Medicine and Dentistry** **Queen Mary University of London (QMUL), London, UK** **Honorary Associate Professor, University of Hong Kong** **References for those interested** Review > J Periodontol. 2015 Feb;86(2 Suppl):S108-30. doi: 10.1902/jop.2015.130677. # Periodontal regeneration – furcation defects: a systematic review from the AAP Regeneration Workshop Gustavo Avila-Ortiz, Juan G De Buitrago, Michael S Reddy **Conclusions:** On the basis of the reviewed evidence, the following conclusions can be drawn. 1) Periodontal regeneration has been demonstrated histologically and clinically for the treatment of maxillary facial or interproximal and mandibular facial or lingual Class II furcation defects. 2) Although periodontal regeneration has been demonstrated histologically for the treatment of mandibular Class III defects, the evidence is limited to one case report. 3) Evidence supporting regenerative therapy in maxillary Class III furcation defects in maxillary molars is limited to clinical case reports. 4) In Class I furcation defects, regenerative therapy may be beneficial in certain clinical scenarios, although most Class I furcation defects may be successfully treated with non-regenerative therapy. 5) Future research efforts should be primarily directed toward the conduct of clinical trials to test novel regenerative approaches that place emphasis primarily on patient-reported outcomes and also on histologic demonstration of periodontal regeneration. Investigators should also focus on understanding the influence that local, systemic, and technical factors may have on the outcomes of regenerative therapy in furcation defects. **References for those interested** Review > J Periodontol. 2015 Feb;86(2 Suppl):S108-30. doi: 10.1902/jop.2015.130677. Periodontal regeneration – furcation defects: a systematic review from the AAP Regeneration Workshop Gustavo Avila-Ortiz, Juan G De Buitrago, Michael S Reddy **Conclusions:** On the basis of the reviewed evidence, the following conclusions can be drawn. 1. Periodontal regeneration has been demonstrated histologically and clinically for the treatment of maxillary facial or interproximal and mandibular facial or lingual Class II furcation defects. 2. Although periodontal regeneration has been demonstrated histologically for the treatment of mandibular Class III defects, the evidence is limited to one case report. 3. Evidence supporting regenerative therapy in maxillary Class III furcation defects in maxillary molars is limited to clinical case reports. 4. In Class I furcation defects, regenerative therapy may be beneficial in certain clinical scenarios, although most Class I furcation defects may be successfully treated with non-regenerative therapy. 5. Future research efforts should be primarily directed toward the conduct of clinical trials to test novel regenerative approaches that place emphasis primarily on patient-reported outcomes and also on histologic demonstration of periodontal regeneration. Investigators should also focus on understanding the influence that local, systemic, and technical factors may have on the outcomes of regenerative therapy in furcation defects. # References for those interested ## Review > J Clin Periodontol. 2009 Feb;36(2):164-76. doi: 10.1111/j.1600-051X.2008.01358.x. **The effect of periodontal therapy on the survival rate and incidence of complications of multirooted teeth with furcation involvement after an observation period of at least 5 years: a systematic review** Guy Huynh-Ba <sup>1</sup>, Patrick Kuonen, Dominik Hofer, Jürg Schmid, Niklaus P Lang, Giovanni E Salvi **Conclusions:** Good long-term survival rates (up to 100%) of multirooted teeth with furcation involvement were obtained following various therapeutic approaches. Initial furcation involvement (Degree I) could be successfully managed by non-surgical mechanical debridement. Vertical root fractures and endodontic failures were the most frequent complications observed following resective procedures. <sup>1</sup> — Department of Periodontology, University of Zurich **References for those interested** Review > J Clin Periodontol. 2009 Feb;36(2):164-76. doi: 10.1111/j.1600-051X.2008.01358.x. **The effect of periodontal therapy on the survival rate and incidence of complications of multirooted teeth with furcation involvement after an observation period of at least 5 years: a systematic review** Guy Huynh-Ba, Patrick Kuonen, Dominik Hofer, Jürg Schmid, Niklaus P Lang, Giovanni E Salvi **Conclusions:** Good long-term survival rates (up to 100%) of multirooted teeth with furcation involvement were obtained following various therapeutic approaches. Initial furcation involvement (Degree I) could be successfully managed by non-surgical mechanical debridement. Vertical root fractures and endodontic failures were the most frequent complications observed following resective procedures. — Department of Periodontology, University of Zurich Received: 20 June 2021 | Revised: 16 August 2021 | Accepted: 8 September 2021 DOI: 10.1111/jcpe.13551 ORIGINAL ARTICLE | Journal of Clinical Periodontology | WILEY **Long-term prognosis of teeth with class III furcation involvement** Peter Eickholz¹ ** | Maren Runschke¹ | Bettina Dannewitz¹ | Katrin Nickles¹ ** | Hari Petsos¹ ** | Dorothea Kronsteiner² | Bernadette Pretzl³ ** Objective: Evaluation of survival of teeth with class III furcation involvement (FI) ≥5 years after active periodontal treatment (APT) and identification of prognostic factors Conclusions: Subgingival instrumentation with adjunctive systemic antibiotics favours retention of class III furcation-involved teeth. Baseline RBL and PPD at T1 deteriorate long-term prognosis. Received: 20 June 2021 | Revised: 16 August 2021 | Accepted: 8 September 2021 DOI: 10.1111/jcpe.13551 ORIGINAL ARTICLE | Journal of Clinical Periodontology | WILEY **Long-term prognosis of teeth with class III furcation involvement** Peter Eickholz, Maren Runschke, Bettina Dannewitz, Katrin Nickles, Hari Petsos, Dorothea Kronsteiner, Bernadette Pretzl **Objective:** Evaluation of survival of teeth with class III furcation involvement (FI) ≥5 years after active periodontal treatment (APT) and identification of prognostic factors. **Conclusions:** Subgingival instrumentation with adjunctive systemic antibiotics favours retention of class III furcation-involved teeth. Baseline RBL and PPD at T1 deteriorate long-term prognosis. References **Lindhe (7th Ed):** Chapter 33  References **Lindhe (7th Ed):** Chapter 33 Photograph of the front cover of the book 'Clinical Periodontology and Implant Dentistry, Fifth Edition'. The cover features a microscopic image of dental tissue. The editors listed are Jan Lindhe, Niklaus P. Lang, and Thorkild Karring. The publisher logo for Blackwell Munksgaard is visible in the bottom right corner. [^1]: Original PDF page 1: [[L11 Furcation diagnosis.pdf#page=1|L11 Furcation diagnosis, p.1]] [^2]: Original PDF page 2: [[L11 Furcation diagnosis.pdf#page=2|L11 Furcation diagnosis, p.2]] [^3]: Original PDF page 3: [[L11 Furcation diagnosis.pdf#page=3|L11 Furcation diagnosis, p.3]] [^4]: Original PDF page 4: [[L11 Furcation diagnosis.pdf#page=4|L11 Furcation diagnosis, p.4]] [^5]: Original PDF page 5: [[L11 Furcation diagnosis.pdf#page=5|L11 Furcation diagnosis, p.5]] [^6]: Original PDF page 6: [[L11 Furcation diagnosis.pdf#page=6|L11 Furcation diagnosis, p.6]] [^7]: Original PDF page 7: [[L11 Furcation diagnosis.pdf#page=7|L11 Furcation diagnosis, p.7]] [^8]: Original PDF page 8: [[L11 Furcation diagnosis.pdf#page=8|L11 Furcation diagnosis, p.8]] [^9]: Original PDF page 9: [[L11 Furcation diagnosis.pdf#page=9|L11 Furcation diagnosis, p.9]] [^10]: Original PDF page 10: [[L11 Furcation diagnosis.pdf#page=10|L11 Furcation diagnosis, p.10]] [^11]: Original PDF page 11: [[L11 Furcation diagnosis.pdf#page=11|L11 Furcation diagnosis, p.11]] [^12]: Original PDF page 12: [[L11 Furcation diagnosis.pdf#page=12|L11 Furcation diagnosis, p.12]] [^13]: Original PDF page 13: [[L11 Furcation diagnosis.pdf#page=13|L11 Furcation diagnosis, p.13]] [^14]: Original PDF page 14: [[L11 Furcation diagnosis.pdf#page=14|L11 Furcation diagnosis, p.14]] [^15]: Original PDF page 15: [[L11 Furcation diagnosis.pdf#page=15|L11 Furcation diagnosis, p.15]] [^16]: Original PDF page 16: [[L11 Furcation diagnosis.pdf#page=16|L11 Furcation diagnosis, p.16]] [^17]: Original PDF page 17: [[L11 Furcation diagnosis.pdf#page=17|L11 Furcation diagnosis, p.17]] [^18]: Original PDF page 18: [[L11 Furcation diagnosis.pdf#page=18|L11 Furcation diagnosis, p.18]] [^19]: Original PDF page 19: [[L11 Furcation diagnosis.pdf#page=19|L11 Furcation diagnosis, p.19]] [^20]: Original PDF page 20: [[L11 Furcation diagnosis.pdf#page=20|L11 Furcation diagnosis, p.20]] [^21]: Original PDF page 21: [[L11 Furcation diagnosis.pdf#page=21|L11 Furcation diagnosis, p.21]] [^22]: Original PDF page 22: [[L11 Furcation diagnosis.pdf#page=22|L11 Furcation diagnosis, p.22]] [^23]: Original PDF page 23: [[L11 Furcation diagnosis.pdf#page=23|L11 Furcation diagnosis, p.23]] [^24]: Original PDF page 24: [[L11 Furcation diagnosis.pdf#page=24|L11 Furcation diagnosis, p.24]] [^25]: Original PDF page 25: [[L11 Furcation diagnosis.pdf#page=25|L11 Furcation diagnosis, p.25]] [^26]: Original PDF page 26: [[L11 Furcation diagnosis.pdf#page=26|L11 Furcation diagnosis, p.26]] [^27]: Original PDF page 27: [[L11 Furcation diagnosis.pdf#page=27|L11 Furcation diagnosis, p.27]] [^28]: Original PDF page 28: [[L11 Furcation diagnosis.pdf#page=28|L11 Furcation diagnosis, p.28]] [^29]: Original PDF page 29: [[L11 Furcation diagnosis.pdf#page=29|L11 Furcation diagnosis, p.29]] [^30]: Original PDF page 30: [[L11 Furcation diagnosis.pdf#page=30|L11 Furcation diagnosis, p.30]] [^31]: Original PDF page 31: [[L11 Furcation diagnosis.pdf#page=31|L11 Furcation diagnosis, p.31]] [^32]: Original PDF page 32: [[L11 Furcation diagnosis.pdf#page=32|L11 Furcation diagnosis, p.32]] [^33]: Original PDF page 33: [[L11 Furcation diagnosis.pdf#page=33|L11 Furcation diagnosis, p.33]] [^34]: Original PDF page 34: [[L11 Furcation diagnosis.pdf#page=34|L11 Furcation diagnosis, p.34]] [^35]: Original PDF page 35: [[L11 Furcation diagnosis.pdf#page=35|L11 Furcation diagnosis, p.35]] [^36]: Original PDF page 36: [[L11 Furcation diagnosis.pdf#page=36|L11 Furcation diagnosis, p.36]] [^37]: Original PDF page 37: [[L11 Furcation diagnosis.pdf#page=37|L11 Furcation diagnosis, p.37]] [^38]: Original PDF page 38: [[L11 Furcation diagnosis.pdf#page=38|L11 Furcation diagnosis, p.38]] [^39]: Original PDF page 39: [[L11 Furcation diagnosis.pdf#page=39|L11 Furcation diagnosis, p.39]] [^40]: Original PDF page 40: [[L11 Furcation diagnosis.pdf#page=40|L11 Furcation diagnosis, p.40]] [^41]: Original PDF page 41: [[L11 Furcation diagnosis.pdf#page=41|L11 Furcation diagnosis, p.41]] [^42]: Original PDF page 42: [[L11 Furcation diagnosis.pdf#page=42|L11 Furcation diagnosis, p.42]] [^43]: Original PDF page 43: [[L11 Furcation diagnosis.pdf#page=43|L11 Furcation diagnosis, p.43]] [^44]: Original PDF page 44: [[L11 Furcation diagnosis.pdf#page=44|L11 Furcation diagnosis, p.44]] [^45]: Original PDF page 45: [[L11 Furcation diagnosis.pdf#page=45|L11 Furcation diagnosis, p.45]] [^46]: Original PDF page 46: [[L11 Furcation diagnosis.pdf#page=46|L11 Furcation diagnosis, p.46]] [^47]: Original PDF page 47: [[L11 Furcation diagnosis.pdf#page=47|L11 Furcation diagnosis, p.47]] [^48]: Original PDF page 48: [[L11 Furcation diagnosis.pdf#page=48|L11 Furcation diagnosis, p.48]] [^49]: Original PDF page 49: [[L11 Furcation diagnosis.pdf#page=49|L11 Furcation diagnosis, p.49]] [^50]: Original PDF page 50: [[L11 Furcation diagnosis.pdf#page=50|L11 Furcation diagnosis, p.50]] [^51]: Original PDF page 51: [[L11 Furcation diagnosis.pdf#page=51|L11 Furcation diagnosis, p.51]] [^52]: Original PDF page 52: [[L11 Furcation diagnosis.pdf#page=52|L11 Furcation diagnosis, p.52]] [^53]: Original PDF page 53: [[L11 Furcation diagnosis.pdf#page=53|L11 Furcation diagnosis, p.53]] [^54]: Original PDF page 54: [[L11 Furcation diagnosis.pdf#page=54|L11 Furcation diagnosis, p.54]] [^55]: Original PDF page 55: [[L11 Furcation diagnosis.pdf#page=55|L11 Furcation diagnosis, p.55]] [^56]: Original PDF page 56: [[L11 Furcation diagnosis.pdf#page=56|L11 Furcation diagnosis, p.56]] [^57]: Original PDF page 57: [[L11 Furcation diagnosis.pdf#page=57|L11 Furcation diagnosis, p.57]] [^58]: Original PDF page 58: [[L11 Furcation diagnosis.pdf#page=58|L11 Furcation diagnosis, p.58]] [^59]: Original PDF page 59: [[L11 Furcation diagnosis.pdf#page=59|L11 Furcation diagnosis, p.59]] [^60]: Original PDF page 60: [[L11 Furcation diagnosis.pdf#page=60|L11 Furcation diagnosis, p.60]] [^61]: Original PDF page 61: [[L11 Furcation diagnosis.pdf#page=61|L11 Furcation diagnosis, p.61]] [^62]: Original PDF page 62: [[L11 Furcation diagnosis.pdf#page=62|L11 Furcation diagnosis, p.62]] [^63]: Original PDF page 63: [[L11 Furcation diagnosis.pdf#page=63|L11 Furcation diagnosis, p.63]] [^64]: Original PDF page 64: [[L11 Furcation diagnosis.pdf#page=64|L11 Furcation diagnosis, p.64]] [^65]: Original PDF page 65: [[L11 Furcation diagnosis.pdf#page=65|L11 Furcation diagnosis, p.65]] [^66]: Original PDF page 66: [[L11 Furcation diagnosis.pdf#page=66|L11 Furcation diagnosis, p.66]] [^67]: Original PDF page 67: [[L11 Furcation diagnosis.pdf#page=67|L11 Furcation diagnosis, p.67]] [^68]: Original PDF page 68: [[L11 Furcation diagnosis.pdf#page=68|L11 Furcation diagnosis, p.68]]