Furcation: The Problem and

Its Management
 Definition
 Furcation : an anatomic area of multirooted
teeth, where the root diverges
( area located between individual root cone).

 Furcation invasion : pathologic resorption of

bone within a furcation.
Etiology of furcation involvement

 Extension of inflammatory diseases and bacterial

plaque that result from its long-term presence.

 Isolated furcation lesion: it is the involvement of

furcation without destruction of surrounding
periodontal structure.

 Root fracture-involving furcation

 Terminology
 Root complex
 Furcation entrance
 Furation fornix
 Degree of separation
 Divergence
 Cofficient of separation
 Enamel projections
 Root complex
portion of a tooth that located apical to CEJ ,
normaly cover with cementum , that divided
into two part :-
* Root trunk :-Represents the undivided region of
the root.
The height of the root trunk is the distance
between the CEJ and the separation line
between two root cones
* Root cone :- divided region of the root complex
and may at certain level be connected to or
separation from other root cone .
 Furcation Entrance
Entrance: the transitional area between the
undivided and the divided part of the root

Fornix: the roof of the furcation

Degree of separation: angel of separation

between two root

Divergence : distance between two root , the

distance normally increase in apical direction

Coefficient of separation : is the length of root

cone in relation to length of root complex
 maxillary molar

* Maxillary first molar larger and have short trunk

than second and third molar

* Maxillary first and second molar have three root

1- mesiobuccal root is normally vertical position
2-distobuccal root project distally
3-palatal root in palatal direction
* cross section of the
distobuccal root and palatal
are generally circular

* the distal surface of

misobucal root has a
cocavity (.3 mm deep ) hour
glass configration
 Furcation Entrance
* In maxillary molar have three furcation enterance :
Buccal furcation (3.5mm from CEJ).
Distal furcation (5mm from CEJ).
Mesial furcation (3mm from CEJ)

• Buccal furcation entrance is narrow than distal and mesial

counterparts

• Furcation fornix is inclined mesiodistal plane the fornix is

comparatively close to CEJ at the mesial but closer to apex
at distal surface
 Maxillary premolar

 40% have two root cone one

buccal and one palatal
 Mesiodistal furcation entrance
( .7mm width)
 Furcation is located in apical third
of root complex
 Concavity is often present in
furcation aspect of buccal root )
 Distance from CEJ and furcation
entrance 8mm
 Mandibular molar

* Mandibular first molar larger and shortar

trunk than second and third molar

* Mandibular first and second molar have two

root
1- mesial root (larger )is normally vertical
position
2-distal root project distally
* cross section of the
distal root generally circular

* the distal surface of mesial root

has a cocavity (.3 mm deep )
hour glass configration

* mesial root wider in buccolingual

direction and have large cross
section area
 furcation entrance

* In mandibular molar have two furcation enterance :

Buccal furcation ( <3 to CEJ).
Lingual furcation (4 < more apical to CEJ).

• Furcation fornix is inclined buccolingual plane the fornix

• Wide of furcation entrance

Buccal furcation (>.75mm).
Lingual furcation (< .75mm).
 Cervical Enamel Projections

 13% of molars have

CEPs

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

 Incidence: 1.1% - 9.7%

– Maxillary 2nd molar
found near the CEJ
extending into molar
bifurcations
furcation
 Bone loss can occur at
any point on the buccal
surface of molars so
pocket depth must be
checked at several
points and the deepest
measurement
recorded.
 furcation

Bone loss in furcations

can occur in a
horizontal or vertical
plane.
 Classification

Glickman`s Classification(1953)
 Class I Incipient Furcation
This is an early lesion. The
pocket is suprabony,
involving the soft tissue.
There is slight bone loss in
the furcation area.
Radiographic change is not
usual since bone loss is
minimal. A periodontal
probe will detect root
outline or may sink into a
shallow V-shaped notch into
the crestal area
 Class I Incipient Furcation

The level of bone loss

allows for the insertion
of the periodontal probe
into the concavity of the
root trunk
Class I Incipient Furcation

Grade I furcation on
the buccal of first
molar.
Class I Incipient Furcation

Radiograph shows
intact bone in
furcation.
Class I Incipient Furcation

At time of surgery
minimal bone loss
in furcation.
 Class II Patent Furcation

Early grade II furcation. Early grade II furcations at

Both molars have grade II time of surgery, beginning
furcation with 5mm pockets. bone loss in both molars.
 Class II Patent Furcation
In this, bone is destroyed
in one or more aspects of
the furcation, but a
portion of the alveolar
bone and periodontal
ligament remain intact,
permitting only partial
penetration of the probe
into the furca.
Radiographs may or
may not reveal this type
of furcation.
 Class II Patent Furcation

The level of bone loss allows for the insertion of a

periodontal probe into the furcation area between the
roots.
 Class II Patent Furcation

Moderate grade II furcation. Moderate grade II

More severe horizontal furcation. Radiographic
bone loss on the buccal is evidence of bone loss in
seen at the time of surgery. furcation.
Class II Patent Furcation
Advanced grade II
furcation. Severe bone
loss in buccal furcation
while the lingual furcation
has normal bone.
Advanced grade II
furcation. The probe can
not pass completely
through the furcation as
there is still intact bone in
the lingual half of the
furcation.
Class III Communicating or Through
and Through Furcation
This type of probe
penetrates completely
from one side to the other
side characterized by
severe bone destruction in
the furcation area. It is
clearly shown in the
radiographs as a
radiolucent area in
between the roots,
especially in the lower
molars.
Class III furcation
 Grade III furcation
Grade III furcation on
mesial of first molar.
Grade III furcation on distal of first molar.
 Grade III furcation
 In cases with
advanced grade III
involvement it may
be necessary to
extract the tooth
due to its very
poor hopeless
prognosis.
 Class IV

As in Class III, but the

gingival tissues recede
apically so that furcation
is clearly visible.
 Hamp, Nyman & Lindhe`s
Classification (1975)
The classification described of the involved furcation is based on the
amount of periodontal tissue destruction that occurred in the interadicular
area (degree horizontal root exposure )or attachment loss that exist within
root complex
* Degree1 horizontal loss of periodontal support not exceed one third of the
width of the tooth
*Degree 2 horizontal loss of periodontal support exceed one third of the
width of the tooth but not encompassing the total width of the furcation area
* Degree 3 horizontal destruction of periodontal tissue in the furcation area
(through and through)
Hamp Classification
 Tarnow &Fletcher’s
classification
Vertical bone loss is measured in mm from the
roof of the furcation
 Furcation probing
 In maxillary molar the mesial furcation entrance much
closer to palatal (probed in palatal aspect of teeth )

 Distal furcation entrance general located in midway

between buccal an palatal surface(probe from either
buccal or palatal aspect of the teeth )

 Maxillary premolar first be identified after the elevation

o soft tissue flap (open at varying distance from CEJ )
Furcation Probing
 Furcation Probing

Mandibular Molars
Buccal Furcation

Place the probe between

the two buccal roots
from the buccal aspect
 Furcation Probing

Mandibular Molars
Lingual Furcation

Place the probe between

the two lingual roots
from the lingual aspect
 Furcation Radiography
 Should include both
periapical and bitewing
 Location of the
interdental bone and
bone level within the
root complex should be
examined
 Differential Diagnosis

 Pulpal pathosis may some times cause a lesion

in the periodontal tissues of the furcation
 Trauma from occlusion may cause
inflammation and tissue destruction within the
interradicular area of a multirooted tooth
 Objective of Treatment

 The elimination of the microbial plaque from

the exposed surfaces of the root complex.
 The establishment of an anatomy of the
affected surfaces that facilitates proper self-
performed plaque control.
 Degree 1: scaling and root planning & furcation plasty

 Degree2 :furcation plasty &tunnel preparation & RSR &

extraction
 Degree 3: tunnel preparation & RSR & extraction .
Scaling and root planning

In most situations, it results in

the resolution of the
inflammatory lesion in the
gingiva.
 Furcation plasty
 Resective treatment modality which should lead elimination
interadicular defect (buccal and lingual furcation, approximal
surface limited )

 Dissection and reflective of soft tissue flap to obtain access to the

interadicular area and the surrounding bone structure
 Scaling and root planning of exposed root surface , removable of
inflammatory soft tissue
 Odontoplasty (reduce horizontal component defect , wider
furcation entrance )
 Ostoplasty (reduce buccolingual dimension of bone defect)
 Position mucosal flap at level of alvelor crest
 Healing (papilla like tissue should close the entrance of furcation )
 Tunnel preparation
 Resective therapy can be offer a mandibular molar (short root
trunk ,long divergence , wide separation angel )

 Scaling and root planning ,remove granulation tissue defect&

some of interadicular bone

 Enough space has been establish in furcation region to allow

access for cleaning device (self perform plaque control
measurement )

 Flap in apical position to surgical establish interadicular

 Exposed root surface should by treatment by chlorohexidine &

fluoride varnish
 Hemisection
 Mandibular molars
– Grade III furcation
– Need widely separated roots
– Soft tissue positioned below level of pulp
chamber
Hemisection
Hemisection
 Root Separation

 Root separation involves the sectioning of the

root complex and the maintenance of all roots
 Regeneration of Furcation Defects

 Guided tissue regeneration

 Predictable outcome of GTR
therapy was demonstrated
only in degree II furcation
involved mandibular molars
 less favorable results have been
reported in other types of
furcation defects
 GTR could be considered in
areas with isolated degree II
furcation defects
 Furcation Defects
Most predictable Mandibular or
Buccal Maxillary
Class II Furcations

Mesial or Distal
Maxillary Class II
Furcations

Class III Furcations

Least predictable