furcation grades and treatment

1. FURCATION
By Azkah Qazi

2. DEFFINITION
• The furcation is an area of complex
anatomic morphology, that may be difficult
or impossible to debride by routine
periodontal instrumentation.

3. DEFFINITION
• The furcation is an area of complex
anatomic morphology, that may be difficult
or impossible to debride by routine
periodontal instrumentation.

4. DEFFINITION
• The furcation is an area of complex
anatomic morphology, that may be difficult
or impossible to debride by routine
periodontal instrumentation.

5. Etiologic Factors
• Bacterial plaque
• Local anatomic factors (e.g., root trunk
length, root morphology)
• Local developmental anomalies (e.g.,
cervical enamel projections)

6. Local Anatomic Factors
• Root trunk length
• Root length
• Root form
• Interradicular dimension
• Anatomy of furcation
• Cervical enamel projections

7. Root Trunk Length
• The distance from the cementoenamel
junction to the entrance of the furcation
can vary extensively

8. Root length
• This is directly related to the quantity of
attachment supporting the tooth
• Teeth with long roots and short to medium
root trunks are more readily treated
because sufficient attachments remains to
meet functional demands.

9. Anatomy of furcation
• Presence of bifurcational ridges, a
concavity in the dome and possibly
accesory canals complicates scaling, root
planning and surgical therapy

10. Interradicular Dimension
• Degree of seperation is an imp factor in
Rx planning
• Closely approximated or fused roots can
preclude adequate instrumentation during
scaling,root planning & surgery
• Teeth with widely seperated roots present
more treatment options.

11. Cervical Enamel Projections
• 13% of molars have
CEPs
• These projections may
favor the onset of
periodontal lesions in
the affected furcations

12. Diagnosis
• clinical examination
• Careful probing (Nabors probe)

13. Indices of Furcation Involvement
• Glickman's classification

14. Grade I
• incipient or early stage
• pocket is suprabony
• primarily affects the soft tissues
• Early bone loss
• radiographic changes

15. Grade I
• incipient or early stage
• pocket is suprabony
• primarily affects the soft tissues
• Early bone loss
• radiographic changes

16. Grade II
• essentially a cul-de-sac
• definite horizontal component
• Vertical bone loss may be present
• Radiographs may or may not depict the
furcation involvement

17. Grade II
• essentially a cul-de-sac
• definite horizontal component
• Radiographs may or may not depict the
furcation involvement

18. Grade II
• essentially a cul-de-sac
• definite horizontal component
• Radiographs may or may not depict the
furcation involvement

19. Grade III
• bone is not attached to the dome of the
furcation
• periodontal probe completely through the
furcation
• display the defect as a radiolucent area

20. Grade III
• bone is not attached to the dome of the
furcation
• periodontal probe completely through the
furcation
• display the defect as a radiolucent area

21. Grade III
• bone is not attached to the dome of the
furcation
• periodontal probe completely through the
furcation
• display the defect as a radiolucent area

22. Grade IV
• interdental bone is destroyed
• soft tissues have receded apically
• furcation opening is clinically visible

23. Grade IV
• interdental bone is destroyed
• soft tissues have receded apically
• furcation opening is clinically visible

24. Other Classification Indices
• Hamp et al modified a three-stage
classification system
• Easley and Drennan and Tarnow and
Fletcher
A B C
vertical depth- 1-3mm 4-6mm >7mm
Furcations-IA,IB,IC
IIA,IIB,IIC
IIIA,IIIB,IIIC

25. Treatment
• objectives of furcation therapy
(1) facilitate maintenance
(2) prevent further attachment loss
(3) obliterate the furcation defects as a
periodontal maintenance problem

26. Therapeutic Classes of
Furcation Defects
• Class I: Early Defects
oral hygiene, scaling, and root planing
• Class II
• Localized flap procedures with odontoplasty, osteoplasty, and
ostectomy.
• GTR(Guided tissue regeneration)
• Classes II to IV: Advanced Defects
• Periodontal surgery, endodontic therapy, and restoration of the tooth
may be required to retain the tooth.

27. Nonsurgical Therapy
Oral Hygiene Procedures Scaling and Root Planing

28. Antimicrobials
• Adjunct to scaling and root planning
– Chlorhexidine
– Tetracycline fibers

29. Open Debridement
• Greater calculus removal than closed
• Ultrasonic
– Narrow furcations
– Dome of furcation
• Surgical access and increased operator
experience significantly enhance calculus
removal in molar furcation.

31. Surgical Therapy
• Osseous Resection
• Regeneration(GTR)
• Root Resection
• Hemesection
• Extraction
• Dental Implants

32. Osseous Surgery
• Most effective in grade II furcation
• Osteoplasty and ostectomy
techniques
– Remove the defect to reduce
horizontal depth
– Bone ramps into the furcation to
enhance plaque control
– Reduce probing depths

33. Osseous Grafting
• Autogenous bone
• Allografts
– Freeze dried bone
– Demineralized Freeze dried bone
• Alloplasts
– Hydroxyapatite
• Non-porous
• Porous
– Bioglass

34. Root ResectionProcedure

35. Hemisection
• Mandibular molars
– Grade III furcation
– Need widely separated roots
– Soft tissue positioned below level of pulp
chamber

36. Hemisection Procedure

37. Dental Implants

38. • Grade III furcation
– Permits plaque removal
– Root caries (4% stannous
fluoride)
– 25% failure rate at 5 years
– Recurrent periodontitis

39. Prognosis
• The keys to long time success appear to
be
1. thorough diagnosis
2.Selection of patients with good oral
hygiene
3.Excellence in nonsurgical therapy
4.Careful surgical and restorative
management