J Clin Periodontol 2001; 28: 730740 Printed in Denmark .

All rights reserved

Copyright C Munksgaard 2001

ISSN 0303-6979

Molar root anatomy and management of furcation defects

Al-Shammari KF, Kazor CE, Wang H-L: Molar root anatomy and management of furcation defects. J Clin Periodontol 2001; 28: 730740. C Munksgaard, 2001. Abstract Background, aims: Furcally-involved teeth present unique challenges to the success of periodontal therapy. Anatomical and morphological complicating factors dictate modications in treatment approaches used for managing these areas. Method: Various treatment approaches are available for furcally-involved teeth, the choice of which depends on selected interdependent factors. Results: These factors, along with various approaches used in the treatment of furcally compromised teeth are discussed in this review, with particular emphasis on morphology, etiology, classication and diagnosis.

Khalaf F. Al-Shammari, Christopher E. Kazor and Hom-Lay Wang

Department of Periodontics/Prevention/ Geriatrics, School of Dentistry, University of Michigan, Ann Arbor, MI, USA

Key words: root anatomy; morphology; furcations; furcation involvement; incidence; treatment; regeneration Accepted for publication 8 August 2000

Furcation areas present some of the greatest challenges to the success of periodontal therapy. Higher mortality and compromised prognoses for molars with furcal involvement have been reported in several retrospective studies of tooth loss. Additionally, reduced efcacy of periodontal therapy has been consistently found in multirooted teeth with furcal involvement, regardless of the treatment modality employed. For example, Ramfjord et al. (1987) reported that 16 of the 17 teeth lost during the maintenance phase in the latest Michigan longitudinal study had furcal involvement initially. Reasons for compromised results in furcation areas include the lack of proper access for instrumentation due to furcation anatomy and, consequently, a persistence of pathogenic microbial ora (Cobb 1996). This paper will review molar root anatomy and the etiology, diagnosis, and treatment of furcation-involved molars.
Classication of Furcation Involvement

bone within a furcation (American Academy of Periodontology 1992). Several classications of furcation involvement based on the degree of horizontal and/or vertical probe penetration have been developed. The most commonly employed classication systems are listed in Table 1.
Molar Root Anatomy

A furcation is dened as the anatomic area of a multirooted tooth where the roots diverge, and furcation invasion refers to the pathologic resorption of

A thorough understanding of molar root anatomy is essential for proper diagnostic and therapeutic decisions. Factors such as root trunk length, furcation entrance, root separation, and root surface area can affect diagnosis, and consequently, the choice of the appropriate therapy for furcally involved molars. The furcation area can be divided into 3 parts: (1) the roof, (2) the surface immediately coronal to the root separation (ute), and (3) the area of root separation (Grant et al. 1988). Bower (1979a, b), Gher & Dunlap (1985) and Dunlap & Gher (1985), reported the anatomical features of maxillary and mandibular rst molars, respectively. Table 2 summarizes these ndings. Other observations from the aforementioned studies indicate that the mesial-palatal furcation entrance of the maxillary rst molar is located closer to

the palatal third of the tooth, while the distal-palatal furcation is in the middle portion of the tooth (Gher & Dunlap 1985). Therefore, a palatal approach is indicated when probing the mesialpalatal furcation, while the distal-palatal furcation can be probed from either the facial or palatal aspect. Also, the distal-buccal root of the maxillary rst molar and the distal root of the mandibular rst molar have the smallest root surface areas of their respective teeth (Bower 1979b). For this reason, all other factors being equal, these roots are preferentially removed during root resective procedures.
Contributing Anatomical Factors

Several morphological factors related to furcations and roots contribute to the etiology and compromised prognoses of furcation-involved teeth. These factors include: furcation entrance width, root trunk length and the presence of root concavities, cervical enamel projections, bifurcation ridges, and enamel pearls.
Furcation entrance diameter

Bower et al. (1979a, b), reported that 81% of all furcation entrance diameters

Molar root anatomy and furcations

Table 1. Classications of furcation involvement Glickman (1953) Grade Grade Grade Grade

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I. Pocket formation into the ute, but intact interradicular bone (incipient). II. Loss of interradicular bone and pocket formation, but not extending through to the opposite side. III.Through-and-through lesion. IV.Through-and-through lesion with gingival recession, leading to a clearly visible furcation area.

Goldman (1958)

Grade I. Incipient. Grade II. Cul-de-sac. Grade III. Through-and-through. Degree I. Horizontal loss of periodontal tissue support less than 3 mm. Degree II. Horizontal loss of support 3 mm, but not encompassing the total width of the furcation. Degree III. Horizontal through-and-through destruction of the periodontal tissue in the furcation Class I. Beginning involvement. Tissue destruction 2 mm ( 1/3 of tooth width) into the furcation. Class II. Cul-de-sac. 2mm ( 1/3 of tooth width), but not through-and-through. Class III. Through-and-through involvement. Sub-classication based on the degree of vertical involvement Subclass A. 03 mm Subclass B. 46 mm Subclass C. 7 mm same subclasses as Tarnow & Fletcher (1984), but thirds instead of 3-mm units are used. combined the Glickman and Hamp classications; same Glickman grades I through IV, but grade II furcations are subdivided into degree I ( 3 mm) or degree II ( 3 mm) Class Class Class Class Class I. 1 mm of horizontal measurement; the root furrow. Ia. 12 mm of horizontal invasion; earliest damage. II. 24 mm of horizontal invasion. IIa. 46 mm of horizontal invasion. III. 6 mm of horizontal invasion.

Hamp et al. (1975)

Ramfjord & Ash (1979)

Tarnow & Fletcher (1984)

Eskow and Kapin Fedi (1985) Ricchetti (1982)

Table 2. Anatomical features of maxillary and mandibular 1st molars Maxillary 1st molar* furcation entrance M: 3.6 mm B: 4.2 mm D: 4.8 mm MB: 5.0 mm DB: 5.5 mm 4.6 mm M: 0.3 mm (94%) D: 0.1 mm (31%) P: 0.1 mm (17%) DB: 91 mm2 (19%) MB: 118 mm2 (25%) P: 115 mm2 (24%) root trunk: 153 mm2 (32%) Mandibular 1st molar B: 2.4 mm L: 2.5 m B: 3.0 mm L: 4.0 mm 4.6 mm M: 0.7 mm (100%) D: 0.5 mm (99%) M: 162 mm2 (37%) D: 142 mm2 (32%) root trunk: 134 mm2 (31%)

root separation furcation roof root depression

root surface area (% total RSA)

* Bower (1979a, b), Gher & Dunlap (1985).

Bower (1979a, b), Dunlap & Gher (1985).

were 1 mm, and 58% were 0.75 mm (63% of maxillary molars and 50% of mandibular molars were 0.75 mm). Considering that the average width of a curette blade face ranges between 0.75 1.10 mm, the authors conclude that the use of curettes alone might not be suitable for root preparation in the furcal area. They also found no association between the mesio-distal width of 1st molars and furcation entrance diameter. Similar ndings were reported by Chiu et al. (1991), where 49% of fur-

cation entrances were found to be 0.75 mm.

Root trunk length

The root trunk is dened as the area of the tooth extending from the cementoenamel junction to the furcation, otherwise dened as root separation. In a study of mandibular rst and second molars, Mandelaris et al. (1998), reported that the mean root trunk length was 3.14 mm on the buccal aspect, and

4.17 mm on the lingual aspect. The root trunk surface area for mandibular and maxillary molars averages 31% and 32% of the total root surface area respectively (Dunlap & Gher 1985, Gher & Dunlap 1985). Therefore, horizontal attachment loss leading to furcation invasion compromises the root trunk, resulting in the loss of one third of the total periodontal support of the tooth (Hermann et al. 1983, Grant et al. 1988). The signicance of root trunk length relates to both prognosis and

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Al-Shammari et al. They reported the highest incidence of CEPs in the mandibular 2nd molar (14.8%), followed by the maxillary 2nd molar (9.1%), mandibular 1st molar (7.8%), and maxillary 1st molar (3.3%). Swan & Hurt (1976), reported that CEPs occurred on 32.6% of all molars in a study of 200 East Indian skulls. Hou & Tsai (1987), reported a 45.2% incidence of CEPs in 78 Taiwanese patients. Of the teeth with furcation involvement, 82.5% had CEPs, while only 17.5% of teeth without furcation involvement had CEPs. In a more recent morphometric analysis of 134 mandibular rst and second molars, Mandelaris et al. (1998), reported that CEPs were found in 56.4% of all mandibular molars (61.7% of 2nd and 38.3% of 1st molars). CEPs were more commonly found on the buccal (61.9%) than the lingual (50.8%) aspects. Table 4 summarizes studies assessing the prevalence of CEPs.
Bifurcation ridges

treatment of the tooth. A molar with a short root trunk is more vulnerable to furcal involvement, but has a better prognosis after treatment since less periodontal destruction has presumably occurred. Alternatively, a furcation-involved molar with a long root trunk and short roots may not be a candidate for root resection, since these teeth lose more periodontal support with furcal invasion.
Root concavities

having a greater prevalence (67.9%) than mandibular second molars (54.8%). A highly signicant difference in clinical parameters of disease (pocket depth, clinical attachment level, plaque and gingival indices) was also found between mandibular rst and second molars with CEPs and intermediate bifurcation ridges compared to those without.
Enamel pearls

Another complicating factor reducing the efcacy of periodontal therapy in furcations arises from root depressions or concavities. Bower (1979b), reported a 1794% incidence of root depressions in maxillary roots and 99100% in mandibular roots (Table 2). In a study of 50 maxillary rst premolars, Booker & Loughlin (1985), reported the presence of mesial concavities in 100% of examined teeth. In 2-rooted maxillary premolars, they reported a buccal root furcal depression in 100% of the examined teeth at a level of 9.4 mm.
Cervical enamel projections

The prevalence of enamel pearls is less than that of cervical enamel projections. Moskow & Canut (1990), reported an incidence of 2.6% (range 1.1 9.7%). Like CEPs, enamel pearls contribute to the etiology of furcation involvement by preventing connective tissue attachment.
Diagnosis of Furcation Invasion
Incidence

Cervical enamel projections (CEPs) have been implicated as etiologic factors in furcation defects due to the lack of connective tissue attachment on enamel surfaces (Carranza & Jolkovsky 1991). Several studies have assessed the incidence of cervical enamel projections and their correlation with furcation involvement. Leib et al. (1967), was the only study that reported no association between CEPs and furcation involvement. Masters & Hoskins (1964), however, found a CEP incidence of 28.6% for mandibular and 17% for maxillary molars, which correlated more than 90% to mandibular molar furcation involvement. They further classied CEPs into 3 grades (Table 3). Bissada & Abdelmalek (1973), reported a CEP incidence rate of 8.6% in a study of 1138 molars, with mandibular molars having CEPs twice as frequently as maxillary molars. The association between CEPs and furcation involvement was 50%.

2 types of bifurcation ridges have been described: intermediate and buccal/lingual ridges. Intermediate bifurcation ridges connect the mesial and distal roots, and are composed primarily of cementum. Buccal and lingual ridges are composed primarily of dentin with overlying thin layers of cementum. Everett (1958), was the rst to describe the incidence of bifurcation ridges, reporting a 73% incidence of intermediate ridges in mandibular rst molars, of which 60% were considered prominent. Buccal and lingual ridges were found in 63% of the mandibular molars. Burch & Hulen (1974), reported a similar incidence of 76.3%. These bifurcation ridges provide yet another barrier to successful plaque control and root preparation. Hou & Tsai (1997), investigated the correlation of intermediate bifurcation ridges and cervical enamel projections with furcation involvement in 87 furcally involved mandibular molars. Their results indicated that 63.2% of molars with furcation involvement had CEPs and intermediate bifurcation ridges, with mandibular rst molars

Few reports are available in the periodontal literature that examine the prevalence of furcation invasion in adult periodontitis patients. Bissada & Abdelmalek (1973), reported a 30.9% incidence of furcation-involved molars in a study of Egyptian skulls. Nevins & Cappetta (1998), cite a 1980 unpublished thesis by Purisi on 83 cadavers that reports a 26% incidence in the 29 35 year old age group, and a 70% incidence in the 35 year old group. Ross & Thompson (1980), reported a 90% incidence in maxillary molars and a 35% incidence in mandibular molars. Becker et al. (1984), reported a 42.3% incidence of furcation involvement in 560 molars. Different incidence estimates are due, in part, to difculties in properly diagnosing the presence and severity of furcation involvement.
Radiographs

Radiographs may aid in the diagnosis of furcation defects but are of limited value if used as the sole diagnostic tool, especially in early and moderate defects. Ross & Thompson (1980), reported that radiographs were able to

Table 3. Classication of cervical enamel projections* grade I grade II grade III distinct change in CEJ contour, with enamel projecting toward the bifurcation ( 1/3 of the root trunk) CEP approaching the furcation, but not actually making contact with it ( 1/3) CEP extending into the furcation proper

* Masters & Hoskins (1964).

Molar root anatomy and furcations

Table 4. Incidence of cervical enamel projections Study Masters & Hoskins, (1964) Leib et al. (1967) Bissada & Abdelmalek (1973) Hou & Tsai (1987) Mandelaris et al. (1998) * N/A: not applicable. Prevalence 28.6% mandibular; 17% maxillary 25% mandibular; 22% maxillary 8.6% overall (5.9% maxillary; 10.4% mandibular) 45.2% incidence overall 56.4% of mandibular rst and second molars Association with FI 90% correlation with FI in mandibular molars no signicant association 50% association with FI

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82.5% of teeth with FI had CEPs, while only 17.5% of teeth without FI had CEPs. N/A*

detect furcation invasion in 22% of maxillary and 8% of mandibular molars. This discrepancy was attributed to the difference in bone densities of the maxillary and mandibular arches. Hardekopf et al. (1987), reported a signicant association between a radiographic furcation arrow and degree 2 and 3 maxillary interproximal furcation invasion. The association for mesial furcations was 19% for degree 1, 44% for degree 2, and 55% for degree 3. Distal furcations had a furcation arrow incidence of 12% for degree 1, 30% for degree 2, and 52% for degree 3. The authors, however, stressed the importance of correlating the radiographic ndings with clinical evidence to properly diagnose the degree of involvement.

Probing Diagnostic limitations of the periodontal probe become particularly apparent in furcation areas. Ross & Thompson (1980), reported that clinical examination alone detected furcation involvement in only 3% of maxillary and 9% of mandibular molars. The combination of radiographic and clinical examinations improved detection to 65% in maxillary molars, but only 23% in mandibular molars. The reliability of diagnosing the degree of furcation involvement with the periodontal probe has been investigated by Moriarty et al. (1988, 1989), and Zappa et al. (1993). In a histological evaluation of periodontal probe penetration in 12 untreated facial molar furcations using a pressure-sensitive probe, Moriarty et al. (1989), demonstrated that probing the deepest interradicular site does not measure the true pocket depth or attachment level of the furcation area. The probe tip was located an average of 0.4 mm apical to the crest of the interradicular bone and in the inamed connective tissue of the furcation. This indicates that the probing measurement

recorded the depth of probe penetration into the inamed connective tissue, rather than the true pocket depth. Moriarty et al. (1988), evaluated inter-examiner reproducibility of probing pocket depth in 102 grade II or III furcations of 80 untreated molar teeth. A pressuresensitive probe was employed by 3 examiners in recording measurements at 8 sites per furcation. The results indicated high reproducibility in maxillary facial, mandibular facial and lingual furcation sites. The horizontal measurements, however, were the most difcult to assess and were not consistently recordable (only 24/102 furcations were measured by all 3 examiners). Furthermore, the reproducibility of the facial and lingual furcation measurements decreased with increasing pocket depth and root separation. Zappa et al. (1993) questioned the validity of clinical assessments of furcation involvement and the true defect depth. Six dentists evaluated furcation lesions in 12 patients using the Ramfjord and Hamp indices. Measurements at the time of surgery indicated that clinical assessment overestimates the true defect depth. The different indices used in the study were also found to lead to discrepancies in assessing the degree of furcation involvement.

Etiology and Contributing Factors

In addition to previously mentioned anatomic factors, etiologic factors associated with the development of furcation defects include plaque-associated inammation, trauma from occlusion, pulpal pathology, vertical root fractures, and iatrogenic factors (Newell 1998).
Plaque-associated inammation

Extension of inammatory periodontal disease processes into the furcation area leads to interradicular bone resorption and formation of furcation defects. No unique histological features were found in the furcation areas, suggesting that they were an extension of existing periodontal pockets (Glickman 1950).
Trauma from occlusion

Bone sounding Bone sounding or transgingival probing with local anesthesia may aid in the diagnosis of furcation defects by more accurately determining the underlying bony contours. Greenberg et al. (1976), reported that bone sounding yielded accurate measurements when compared to surgical entry measurements. Diagnosing furcation invasion is therefore best accomplished using a combination of radiographs, periodontal probing with a curved explorer or Nabers probe, and bone sounding (Kalkwarf & Reinhardt, 1988).

Although some controversy still exists, trauma from occlusion is a suspect etiologic/contributing factor in isolated furcation defects. Since trauma from occlusion coupled with gingival inammation has been implicated in greater alveolar bone loss in experimental animals (Lindhe & Svanberg 1974), the heavy occlusal load on molar teeth may render them susceptible to increased bone loss in the furcation areas if inammation is present. Glickman et al. (1961) reported that furcations are some of the more susceptible areas of the periodontium to excessive occlusal forces, and suggested the periodontal ber orientation in furcation areas facilitated a more rapid spread of inammation and accounted for the increased susceptibility to occlusal forces. Wang et al. (1994), reported that teeth with mobility and furcation involvement were more likely to lose attachment and to be extracted. Waerhaug (1980), however, has suggested that increased mobility is a late symptom,

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Al-Shammari et al. cation involvement than non-restored teeth. While only 39.1% of molars without restorations had furcation involvement, 52.8% of molars with class II restorations and 63.3% of molars with crowns were found to have furcation involvement.
Treatment of Furcation Defects

rather than the cause of furcation defects.

Pulpal pathology

Although the role of pulpal pathology in the etiology of furcation involvement is still unclear, the high incidence of molar teeth with accessory canals supports such an association. Lowman et al. (1973), reported the incidence of accessory canals to be 55% in maxillary molars and 63% in mandibular molars. Burch & Hulen (1974), reported openings in the furcation area in 76% of maxillary and mandibular molars. Vertucci & Williams (1974), reported that 45% of mandibular rst molars in their study had accessory canals extending into the furcation area. Alternatively, Kirkham (1975), found no accessory canals in the furcation areas of 45 maxillary and mandibular molars. Gutman (1978), reported a 29.4% incidence of accessory canals in mandibular molars and 27.4% in maxillary molars.
Vertical root fractures

Lommel et al. (1978), reported that vertical root fractures are associated with rapid, localized alveolar bone loss. Furcation defects can result if the fracture extends into the furcation area. A poor prognosis is often given in these situations.
Iatrogenic factors

Methods for the treatment of furcationinvolved molars have shown varying degrees of success. The goals of therapy in furcation areas are the same as the goals in all of periodontal therapy: arresting the disease process, and ultimately, maintaining the teeth in health and function with appropriate esthetics. However, the differences inherent in furcation morphology pose a serious challenge to the efcacy of most wellestablished therapeutic modalities. As a consequence, specic treatment approaches have been proposed to deal with those unique challenges. The choice of the appropriate treatment approach for a given situation depends on several factors that must be carefully evaluated prior to initiating treatment. Table 5 lists various treatment approaches and factors to consider when managing furcation-involved molars.
Closed and open root preparation

Overhanging restorations present iatrogenic predisposing factors that may lead to furcation involvement. Wang et al. (1993), in a study of 134 maintenance patients reported that molars with a crown or a proximal restoration had a signicantly higher percentage of fur-

Several longitudinal studies have established thorough root debridement as the key to successful periodontal therapy. However, reduced efcacy has been reported in the treatment of multirooted teeth (Ramfjord et al. 1987, Kalkwarf et al. 1988). Studies specically assessing the response of furcation sites to mechanical non-surgical treatment have all reported decreased clinical response over non-furcated counterparts (Nordland et

al. 1987, Loos et al. 1988). Surgical access has been reported to improve the efcacy of calculus removal, although heavy deposits still remain. Matia et al. (1986), compared the efcacy of hand and ultrasonic instrumentation with and without surgical access in 50 hopeless mandibular molars. 20 teeth were instrumented with curettes, 10 with and 10 without surgical exposure. Twenty more teeth were instrumented with ultrasonic scalers, 10 with and 10 without surgical access, with the remaining 10 teeth serving as controls. The teeth were then extracted and the amount of residual calculus was assessed via stereomicroscopy. Results demonstrated that surgical access was more effective than closed instrumentation with ultrasonic scalers being more effective than curettes in narrow furcations treated with surgical access. Even with surgical access, however, only 7/60 surfaces were calculus free. Fleischer et al. (1989), reported similar results. Surgical access and operator experience were found to increase the efcacy of calculus removal in furcation areas, although total calculus removal was rare with any of the examined approaches. However, Wylam et al. (1993), found no statistical difference with respect to the effectiveness of calculus removal in furcations between non-surgical (93.2% residual plaque and calculus) and surgical access (91.1%). The results of the above studies further illustrate the inuence of root morphological factors on treatment outcome. Even when access was not the major issue, the presence of concavities, ridges and cervical enamel projections make adequate instrumentation of the furcation regions difcult if not impossible. Attempts to increase the efcacy of scaling and root planing in deep pockets and furcal areas have included

Table 5. Treatment approaches and factors to consider in furcation-involved molars Treatment approaches 1. 2. 3. 4. 5. open and closed root preparation odontoplasty open debridement (pocket elimination) tunneling procedures root resection: (a) Root amputation (b) Hemisection 6. bicuspidization (root separation) 7. regenerative approaches (GTR, bone grafts, BMPs) 8. extraction/implant placement Factors to consider 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. degree of involvement crown/root ratio; length of roots root anatomy/morphology degree of root separation strategic value of the tooth residual tooth mobility need for endodontic treatment prosthetic requirements periodontal condition of adjacent teeth ability to maintain oral hygiene quality of bone/ability to place implants nancial considerations long-term prognosis

Molar root anatomy and furcations

Table 6. Long-term prognosis of furcation-involved molars % tooth loss Study Hirschfeld & Wasserman (1978) McFall (1982) Goldman et al. (1986) Ross & Thompson (1978) Wood et al. (1989) Wang et al. (1994)

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Duration 1553 1529 1534 524 1034 8 years years years years years years

. teeth 1464 163 636 387 164 87

WM 19.3% 27.3% 16.9% N/A* N/A N/A

overall 31.4% 56.9% 43.5% 12% 23% 30%

WM: well maintained. * N/A: not applicable.

the use of ber optic illumination with papillary reection (Reinhardt et al. 1985). Improved efcacy was noted with this method, but calculus deposits still remained on many surfaces. Parashis et al. (1993), have therefore suggested that the use of a rotary diamond in combination with surgical access is the most effective method for cleaning furcal areas. Most studies evaluating the response of furcation-involved molars to traditional surgical and non-surgical therapy have reported compromised prognoses. Results from some of these studies are summarized in Table 6. Ross & Thompson (1978), was the only study with relatively low tooth mortality. Utilizing conservative treatment methods (no root resection or osseous surgery), they reported 88% of 387 maxillary molars with furcation involvement were maintained for 524 years. Criticisms of this study, however, include obscurity in classifying the degree of furcal involvement, and the use of instruments that would limit severity estimates (.17 explorer and periodontal probe). According to Newell (1998), many defects in this study were likely incipient or shallow grade II furcal involvements.
Odontoplasty

ation procedures. The furcation operation utilizes osseous recontouring and/or reduction to create physiologic bony contours and apically positioned aps to reduce the pocket depth (Hamp et al. 1975).
Tunneling procedures

Odontoplasty may aid in the treatment of grade I and shallow grade II furcation defects through reducing postoperative plaque and debris accumulation and improving patient access for oral hygiene measures (Goldman 1958, Fleischer et al. 1989). Hypersensitivity and root caries may result, however, if excessive amounts of tooth structure are removed.
Open debridement

Tunnel preparations are used to convert grade III and deep grade II furcations into grade IV furcations to improve access for oral hygiene. Hamp et al. (1975), reported unfavorable results after 5 years in 7 molars with grade III furcation involvement treated with tunnel preparations. 3 of the 7 teeth had a greater than 3 mm probing depth, and 4 of 7 (57%) developed root caries that led to the extraction of 3 teeth (43%). More favorable results were reported by Hellden et al. (1989). In an evaluation of 149 ` molars with grade III furcation involvement treated by tunneling, they reported that the majority of probing depths were 3 mm, after an average of 37.5 months. Ten molars (7%) were extracted, and 7 (5%) had subsequent root resection. The incidence of root caries in the remaining teeth was 17% (23.5% overall incidence). Despite the decreased incidence of caries reported in this study, tunneled teeth appear to be at a higher risk for developing root caries compared with other surgical procedures. For instance, the incidence of caries on exposed root surfaces following routine surgical treatment was reported to be less than 5% (Ravald & Hamp 1981).
Regenerative techniques

Shallow grade II defects may respond to open debridement/pocket elimin-

Several studies have evaluated the use of guided tissue regeneration (GTR) techniques in the treatment of furcation defects. Most studies reported favorable results in class II mandibular furcations (Pontoriero et al. 1987, Caffesse et al. 1990), while less favorable results were found in mandibular class III defects

(Becker et al. 1988, Pontoriero & Lindhe 1995), and maxillary class II defects (Metzler et al. 1991). Pontoriero et al. (1987), compared ePTFE membranes to surgical debridement in 21 class II and 16 class III furcation defects. Complete defect closure was reported in 67% of class II defects and 25% of class III defects in the group receiving ePTFE membrane treatment. The results for class III defects, however, have not been reproduced in other studies. Indeed, in a later publication, Pontoriero & Lindhe (1995), reported that none of the studied maxillary class III defects achieved complete closure. Metzler et al. (1991), reported the results of a study comparing ePTFE membranes to surgical debridement in 17 paired maxillary class II furcation defects. No statistically signicant differences were found in recession, probing depth, or clinical attachment gain between the two groups, with unpredictable hard tissue changes for the ePTFE group. The results of these and other studies have limited the use of GTR to mandibular and some maxillary buccal class II furcation defects. Evans et al. (1996), reviewed 50 papers involving some 1016 furcations to determine the closure frequency of grade II furcation defects with various regenerative techniques: bone replacement grafts, coronally positioned aps, guided tissue regeneration barriers and open ap debridement. General improvement in clinical furcation status was reported only about 50% of the time, with complete furcation closure in only 20% of furcation defects, and partial defect ll (a change from grade II to grade I) in an additional 33% of cases. The most favorable results were reported using a combination of guided tissue regeneration and bone replacement grafts (91% overall improvement), while the least favorable results were found with open ap debridement (15% overall improvement). The authors con-

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Al-Shammari et al. regenerative potential of growth factors and BMPs in furcation areas, but additional studies are needed to fully establish the value of these biologic modiers in the treatment of human furcal defects.
Root resection

cluded that if furcation closure is the primary goal of therapy, regenerative techniques do not appear to commonly meet that goal.
Growth Factors

More recently, the use of growth factors and bone morphogenic proteins (BMPs) has shown promising results in the treatment of furcation defects. Animal studies have reported signicant regeneration in class III mandibular furcation defects in beagle dogs using platelet-derived growth factor-BB (Park et al. 1995), and osteogenic protein-1 (Giannobile et al. 1998). Park et al. (1995), reported signicant new bone and periodontal ligament formation in class III furcation lesions at 8 and 11 weeks using PDGF-BB. At 11 weeks, the newly formed bone lled 87% of the defects compared to 60% bone ll with GTR alone. Giannobile et al. (1998), reported that human osteogenic protein1 (OP-1, 7.5mg/g) in a collagen vehicle led to signicantly greater new bone, cementum, and periodontal ligament formation in surgically created class III furcation defects compared to surgical debridement with the collagen vehicle or surgical debridement alone. In the rst human study of growth factors, Howell et al. (1997), reported that furcation lesions responded most favorably to the application of both plateletderived growth factor and insulin-like growth factor-I. These and other studies have established the promising

The surgical removal of all or a part of a tooth root can be classied into either root amputation or hemisection, depending on crown management. Root amputation is the removal of a root from a multirooted tooth, while hemisection refers to the surgical separation of a multirooted tooth in such a way that a root and the associated portion of the crown may be removed (American Academy of Periodontology 1992). Although the advent of dental implants has led to a decline in the use of root resective procedures, they can provide an effective alternative in some situations. Table 7 lists the indications and contraindications of root resection techniques. Various studies have evaluated the effectiveness of root resection in treating molars with furcation involvement. Bergenholtz (1972), reported long term results of 45 teeth treated with root resection (21 teeth after 25 years, and 17 teeth after 510 years). Only 3 teeth (6%) were extracted, two for periodontal and one for endodontic reasons. Hamp et al. (1975), evaluated 310 multirooted teeth with varying degrees of furcation involvement, of which 135

were extracted during initial therapy. Of the remaining teeth, 32 received scaling and root planing, 49 had furcation operations, 7 tunnel preparations, and 87 root resection. None of the resected teeth were lost, and carious lesions were detected on only 5 tooth surfaces. The authors attributed their success to the elimination of plaque retentive areas in the furcations, meticulous patient oral hygiene, and regular maintenance care. Klavan (1975), reported that only one of 34 root-resected maxillary molars were extracted after 3 years, and that was due to a periodontal abscess. Erpenstein (1983), reported only 3 of 34 root-resected teeth (9%) followed for 4 7 years were lost for periodontal reasons (2 due to pocketing and 1 due to excessive mobility). In contrast, less favorable results were reported in other studies. Langer et al. (1981), retrospectively evaluated the success rate of 100 root-resected molars (50 maxillary and 50 mandibular). Only 6% of the teeth failed after 4 years, which increased to 15.8% in the rst 5 years and to 38% after 10 years, indicating that 84% of the failures occurred after 5 years. Progressive periodontal breakdown accounted for 26.3% (10 teeth) of the failures. Other causes of failure were root fractures (47.4%; 25 teeth), endodontic failures (18.4%; 7 teeth), and cement washout (7.9%; 3 teeth). There were almost twice as many mandibular failures as maxillary failures (25 versus 13), with root fractures being the primary cause of

Table 7. Indications and contraindications for root resection Indications 1. 2. 3. 4. 5. class II or III FI severe bone loss involving one or more roots root fracture, perforation, resorption, or deep root caries root proximity with adjacent teeth failed endodontic treatment or inoperable/calcied canals. Contraindications 1. inadequate bone support on the remaining roots or unfavorable anatomical factors (long root trunk, fused roots) 2. signicant discrepancies in adjacent interproximal bone height 3. remaining roots cannot be restored/endontically treated

Table 8. Study results evaluating root resection in furcally-involved molars Study Bergenholtz (1972) Klavan (1975) Hamp et al. (1975) Langer et al. (1981) Erpenstein (1983) Bhler (1988) Carnevale et al. (1991) Carnevale et al. (1998) * Tooth loss was 18 teeth (4%). . cases 45 34 87 100 34 28 488 175 Duration (years) 210 3 5 10 47 10 311 10 Total failures 3 (6%) 1 (3%) 0 38 (38%) 7 (20.6%) 9 (32%) 28 (5.7%)* 12 (7%) Perio 2 1 10 1 2 3 3 Endo 1 7 6 5 4 4 Root fx 18 1 12 2 Caries 3 1 9 3

Molar root anatomy and furcations

Table 9. Studies evaluating single-tooth implants in molar regions* Study Becker & Becker (1995) Balshi et al. (1996) Bahat & Handelsman (1996) Levine et al. (1997) * Only studies of 20 or more molar implants are presented. Duration 2 years 3 years 16 months (mean) 12 months (mean) . molar implants 24 22 54 94 Failures 1 1 2 3

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mandibular failures (15/25) and periodontal breakdown accounting for most maxillary failures (7/13). Bhler (1988), reported the failure rate of 28 root-resected teeth after 10 years. The results showed that no failures occurred during the rst 4 years, 10.7% (3 teeth) failed in 57 years, and a total of 32.1% (9 teeth) failed after 10 years. Carnevale et al. (1991), reported the results of a retrospective analysis of 488 root-resected teeth. 62% of the teeth were followed for 36 years (303 teeth), and 38% (185 teeth) for 711 years. 28 failures (5.7%) were reported, of which 18 (4%) were lost. The most common cause of failure was root fracture, followed by caries. Periodontal breakdown was responsible for failure in only 3 teeth. In contrast to Langer et al. (1981) and Bhler (1998) most failures occurred early (36 year group) rather than later (711 year group). The authors attributed the high success rate to an optimal hygiene regimen and frequent maintenance recall. A more recent investigation by Carnevale et al. (1998), reported the success rate of root resective therapy 10 years after treatment to be 93%. Only 12/175 teeth (7%) were extracted, 4 for endodontic reasons, 3 for root caries, 3 for periodontal reasons, and 2 for root fracture. Results of the studies evaluating the long-term effectiveness of root resection have indicated a success rate ranging from 62100%. Most reported failures were non-periodontal in nature, with periodontal failures accounting for only 010% of the total failures. Since endodontic complications and root fractures were common causes of failure, factors that may inuence the outcome of root resection procedures include: 1) the patency of the root canal system 2) occlusal forces 3) the length of the edentulous span and 4) the length, width, and shape of the root (Nevins & Cappetta 1998). Table 8 summarizes the results of root resective therapy studies.

Restorative considerations

Several factors need to be considered in the restoration of root resected molars due to the unique anatomical features that result after the procedure. Since molar roots are narrower mesiodistally and wider buccolingually than most single rooted teeth (Gher & Vernino 1980), modications of the preparation design are required. A at emergence prole from the preparation margin is essential for the establishment of an environment conducive to the maintenance of adequate plaque control, although complete removal of residual ledges when performing the resection is often difcult to accomplish. Newell (1991) reported that 30% of root resected molars had residual roots and ledges subgingivally. Incomplete removal of furcation utes and root concavities creates plaque-retentive factors that may lead to the recurrence of periodontal defects (Nevins & Cappetta 1998). In addition, the use of posts and cores should be avoided if possible to reduce the risks of root fracture (AbouRass et al. 1982), and an occlusal scheme with a narrow occlusal table and reduced cuspal inclines should be established to minimize excessive occlusal loads (Newell 1998). Endosseous implants Given the predictability and high success rates reported for endosseous dental implants (Adell et al. 1981, Buser et al. 1991, Enquist et al. 1995), and the variable success rates reported for root resection procedures presented in the previous section, the question may arise whether the use of single tooth implants after extraction may provide a more predictable alternative than root resective therapy for periodontally involved molars. Direct comparisons between the two treatment approaches, however, are difcult to perform due to variations in study designs. Studies re-

porting the success rates of single tooth implants are limited, and those addressing molar teeth only are even fewer in number (Table 9). Becker & Becker (1995) retrospectively reported a 95.7% success rate for 24 molar implants placed in 22 patients and followed up for an average of two years. Balshi et al. (1996) reported a 98.6% success rate in a study of 47 patients, 22 of whom received one implant and 25 received two implants in the molar regions. Bahat & Handelsman (1996) reported a 96.3% success rate in their study of 59 implants placed in the posterior areas of the jaws (54 molar implants) of 45 patients followed up for an average of 16 months. Levine et al. (1997) reported on 94 molar implants followed up for an average of one year having a 96.8% success rate. These studies yielded high success rates of single tooth molar implants over their short-term follow up periods. However, additional controlled prospective trials of longer duration are needed to fully establish their long-term predictability in periodontal patients.

Table 10. Treatment approaches for furcation-involved molars based on the degree of involvement class I class II O scaling and root planing O odontoplasty O scaling and root planing O odontoplasty O open debridement/furcation operation O GTR (mandibular molars) O root resection O tunnel preparation O extraction/implant placement O open debridement/furcation operation O GTR (questionable success) O root resection O tunnel preparation O extraction/implant placement

class III

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Al-Shammari et al.
Journal of the American Dental Association 104, 834837. Adell, R., Leckholm, U., Rockler, B. & Brnemark, P-I. (1981) A 15-year study of osseointegrated implants in the treatment of the edentulous jaw. International Journal of Oral Surgery 10, 387416. American Academy of Periodontology (1992) Glossary of periodontal terms, 3rd edition. Chicago, Illinois. Bahat, O. & Handelsman, M. (1996) Use of wide implants and double implants in the posterior jaw: A clinical report. International Journal of Oral and Maxillofacial Implants 11, 379386. Balshi, T. J., Hernandez, R. E., Pryszlak, M. C. & Rangert, B. (1996) A comparative study of one implant versus two replacing a single molar. International Journal of Oral and Maxillofacial Implants 11, 372 378. Becker, W., Berg, L. & Becker, B. E. (1984) The long term evaluation of periodontal treatment and maintenance in 95 patients. International Journal of Periodontics and Restorative Dentistry 4, 5471. Becker, W., Becker, B. E., Berg, L., Prichard, J., Caffesse, R. & Rosenberg, E. (1988) New attachment after treatment with root isolation procedures: report for treated class III and class II furcations and vertical osseous defects. International Journal of Periodontics and Restorative Dentistry 8, 923. Becker, W. & Becker, B. E (1995) Replacement of maxillary and mandibular molars with single endosseous implant restorations: A retrospective study. Journal of Prosthetic Dentistry 74, 5155. Bergenholtz, A. (1972) Radectomy of multirooted teeth. Journal of the American Dental Association 85, 870875. Bissada, N. F. & Abdelmalek, R. G. (1973) Incidence of cervical enamel projections and its relationship to furcation involvement in Egyptian skulls. Journal of Periodontology 44, 583585. Booker, B. W. & Loughlin, D. M. (1985) A morphologic study of the mesial root surface of the adolescent maxillary rst bicuspid. Journal of Periodontology 56, 666 670. Bower, R. C. (1979a) Furcation morphology relative to periodontal treatment. Furcation entrance architecture. Journal of Periodontology 50, 2327. Bower, R. C. (1979b) Furcation morphology relative to periodontal treatment. Furcation root surface anatomy. Journal of Periodontology 50, 366374. Bhler, H. (1988) Evaluation of root-resected teeth. Results after 10 years. Journal of Periodontology 59, 805810. Burch, J. G. & Hulen, S. (1974) A study of the presence of accessory foramina and the topography of molar furcations. Oral Surgery, Oral Medicine, Oral Pathology 38, 451454. Buser, D., Webber, H. P., Brgger, U. & Balsiger, C. (1991) Tissue integration of onestage ITI implants: 3-year results of a longitudinal study with Hollow-Cylinder and Hollow Screw implants. International Journal of Oral and Maxillofacial Implants 6, 405412. Caffesse, R. G., Smith, B. A., Duff, B., Morrison, E. C., Merril, D. & Becker, W. (1990) Class II furcations treated by guided tissue regeneration in humans: case reports. Journal of Periodontology 61, 510 514. Carnevale, G., Gianfranco, D., Tonelli, M., Martin, C. & Massimo F. (1991) A retrospective analysis of the periodontal prosthetic treatment of molars with interradicular lesions. International Journal of Periodontics and Restorative Dentistry 11, 189205. Carnevale, G., Pontoriero, R. & Febo, G. (1998) Long-term effects of root-resective therapy in furcation-involved molars. A 10-year longitudinal study. Journal of Clinical Periodontology 25, 209214. Carranza, F. A. Jr. & Jolkovski, D. L. (1991) Current status of periodontal therapy for furcation involvements. Dental Clinics of North America 35, 555570. Chiu, B. M., Zee, K. Y., Corbet, E. F. & Holmgren, C.J. (1991) Periodontal implications of furcation entrance dimensions in Chinese rst permanent molars. Journal of Periodontology 62, 308311. Cobb, C. M. (1996) Non-surgical pocket therapy. Mechanical. Annals of Periodontology 1, 443 490. Dunlap, R. & Gher, M. E. (1985) Root surface measurements of the mandibular rst molar. Journal of Periodontology 56, 234 238. Enquist, B., Nilson, H. & strand, P. (1995) Single-tooth replacement by osseointegratedBrnemark implants. A retrospective study of 82 implants. Clinical Oral Implants Research 6, 238245. Erpenstein, H. (1983) A 3-year study of hemisectioned molars. Journal of Clinical Periodontology 10, 110. Evans, G. H., Yukna, R. A., Gardiner, D. L. & Cambre, K. M. (1996) Frequency of furcation closure with regenerative periodontal therapy. Journal of the Western Society of Periodontology Periodontal Abstracts 44, 101109. Everett, F. G., Jump, E. B., Holder, T. D. & Williams, G. C. (1958) The intermediate bifurcational ridge: A study of the morphology of the bifurcation of the lower rst molar. Journal of Dental Research 17, 62. Fedi, P. F. Jr. (1985) The periodontal syllabus. 2nd edition. Philadelphia, Lea & Febiger: pp. 169170. Fleicher, H. C., Mellonig, J. T., Brayer, W. K., Gray, J. L & Barnett, J. D. (1989) Scaling and root planing efcacy in multirooted teeth. Journal of Periodontology 60, 402409. Gher, M. E. & Vernino, A. R. (1980) Root morphology clinical signicance in pathogenesis and treatment of periodontal

Conclusion

The various approaches available for the treatment of furcally-involved teeth have resulted in different degrees of success, indicating that the choice of therapy depends on several interdependent factors. An understanding of the special anatomical and morphological features of root furcations and the limitations those features present is essential for successful treatment outcomes. A summary of treatment strategies based on the degree of furcal involvement is presented in Table 10.
Zusammenfassung
Wurzelanatomie von Molaren und Management von Furkationsdefekten Hintergrund, Ziel: Furkationsinvolvierte Zahne prasentieren eine einzigartige Heraus forderung fur den Erfolg der parodontalen Therapie. Anatomische und morphologische komplizierende Faktoren diktieren Modikationen im Behandlungsvorgehen, was fur diese Region genutzt wird. Methoden: Verschiedene Behandlungsmethoden sind fur furkationsinvolvierte Zahne ver fugbar, die Wahl hangt von ausgewahlten voneinander abhangigen Faktoren ab. Ergebnisse: Diese Faktoren werden zusammen mit verschiedenen Methoden, die in der Behandlung von furkationsinvolvierten Zah nen genutzt werden, in diesem Reviewartikel diskutiert. Besondere Betonung gilt der Mor phologie, Atiologie, Klassikation und Diagnose.

Resume
Anatomie radiculaire molaire et gestion des le sions de furcations Origine, but: Les dents dont la furcation est atteinte presentent un de unique en ce qui concerne le succes dun traitement parodon` tal. Des facteurs de complications anatomiques et morphologiques entrainent des modications des approaches therapeutiques utili ses dans la gestion de ces zones. Methode: Divers approches therapeutiques sont disponibles pour les dents dont la furcation est atteinte, leur choix dependent de fac teurs selectionnes interdependants. Resultats: Ces facteurs, ainsi que les differen tes approches utilisees dans le traitement de ces dents, sont discutes dans cette revue criti que, en insistant particulierement sur la mor` phologie, letiologie, la classication et le dia gnostic.

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Molar root anatomy and furcations

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Address: Hom-Lay Wang University of Michigan School of Dentistry 1011 N. University Ave. Ann Arbor, Michigan 481091078 USA Fax: 734 763 5503 e-mail: homlay/umich.edu