A furcation (or furca) is the area of a tooth where the root divides from the common root trunk into a bifurcation or trifurcation. Furcation involvement in posterior teeth is the result of progressive periodontal breakdown due to inflammation. It is important to determine the extent of furcation involvement to a make an appropriate diagnosis and developing a treatment plan. Furcation involvement worsens the prognosis of the tooth because long-term studies indicate that teeth with furcation involvement are the teeth that tend to be lost over time. In a study Hirschfeld and Wasserman (1978) 1, reported that percentage of tooth loss in furcation-involved molars was 31.4% as compared to 4.9% in single-rooted teeth after a mean maintenance period of 22 years. Similarly, McFall (1982) 2 reported that the frequency of tooth loss with furcation-involved teeth was 57% as compared to 7% for single-rooted teeth.
The access to the furcation area is difficult both for the dentist and patient, and their treatment constitutes an enormous challenge. The treatment of teeth with furcation involvement ranges from thorough debridement to regenerative procedures and, if the lesion progresses, to extraction. In the following discussion, we shall discuss in detail the etiology of furcation involvement and its potential treatments.
Figure 73.1 a,b The extension of inflammation into the furcation areas resulting in furcation involvement (arrows)
Anatomy of furcations
Furcations present very unusual challenges for instrumentation due to their anatomical features. It is important to understand………………….
The root trunk height may vary from surface to surface on a molar or premolar (Table 73.1 ). The root cones start at the furcation point from where they may take various shapes diverging from the root trunk. The furcation fornix is referred to as the roof of furcation area and furcation entrance is the transitional area between the divided and undivided roots. Root divergence is the degree of separation of roots and coefficient of separation is the length of root cones in relation to the length of root complex.
The shapes of roots may have different shapes and may be completely or incompletely fused. The incompletely fused roots may be fused in the area of CEJ but are separated in the apical region. The degree of root divergence also varies from tooth to tooth. Let us now discuss the anatomy of various bifurcated and trifurcated teeth in detail.
Table 73.1 Location of furcation of various teeth from CEJ
Approximate distance of furcation from CEJ
|Maxillary arch||First premolar||2||Mesial = 7 mm
Distal = 7 mm
|First molar||3||Buccal= 4 mm
Mesial= 3 mm
Distal= 5 mm
|Second molar||3 (sometimes fused)||Buccal= 4+ mm
Mesial= 3+ mm
Distal= 5+ mm
|Mandibular arch||First molar||2||Buccal = 3 mm
Lingual= 4 mm
|Second molar||2||Buccal= 3+ mm
Lingual= 5+ mm
The root of the maxillary first premolar is usually bifurcated in the apical or middle third making facial and palatal roots. When viewed from the mesial aspect, a longitudinal groove extends from the contact area to the bifurcation. The mean distance of the furcation from CEJ for maxillary first premolar is 8 mm with a furcation width of approximately 0.7 mm.
Maxillary first molar:
The maxillary first molar is the largest tooth in the maxillary dental arch. It has three roots, mesiobuccal, distobuccal and a palatal root. The lingual root is the longest, the mesiobuccal root is not as long, but it is broader buccolingually, the distobuccal root is the smallest of all the three roots. The average root trunk length from the cervical line to the furcation area is around 4 mm. Usually, there is a deep developmental groove which extends on the buccal surface of the root trunk from the furcation area toward the cervical line, where it terminates in a shallow depression or it may extend slightly on the enamel surface at the cervix. The buccal furcation entrance is narrower than the distal and mesial furcation entrances. The distobuccal root is narrower than the other two roots. When seen from the mesial surface, the mesiobuccal root occupies two-thirds of the buccolingual measurement of the tooth and it hides the distobuccal root. The mesiobuccal root of the first maxillary molar is placed more buccally as compared to the distobuccal root and if the thickness of the bone plate is thin, there are more chances for fenestration and /or dehiscence during inflammatory periodontal disease.
There are three furcation entrances on a maxillary first molar and these are located at varying distances from the CEJ. The distance of the mesial furcation entrance from CEJ is around 3 mm, while that of buccal and distal furcations from CEJ is 3.5 and 5 mm respectively 3, 4. It indicates that the furcation fornix is inclined in the mesiodistal plane and the mesial furcation entrance is closer to CEJ as compared to the distal entrance.
Maxillary second and third molars:
In general, the overall size of maxillary second molar is smaller than the first molar and larger than the third molar. The root trunk length of second maxillary molar is more than the first molar and hence the respective furcation entrances are farther from CEJ as compared to the first molar. The degree of root separation of the second molar is less than the first molar and that of the third molar is less than the second molar. All the depressions found on the root surface of the second molar are usually shallower than the first molar. As the degree of root separation of the second molar is less that the first molar, the furcation entrances are narrower.
Mandibular first molar:
The mandibular first molar has two roots, a mesiodistally flattened mesial root and a mostly straight and more rounded distal root 5. The mesial root is curved mesially from cervical third to middle third portion. Distal root is less curved and its axis is in the distal direction from the root trunk to the apex. Both mesial and distal roots are wider mesiodistally on the buccal aspect as compared to the lingual aspect. The point of bifurcation is present approximately 3 mm below the CEJ on the buccal aspect and 4 mm below the CEJ on lingual aspect. Thus, the furcation fornix is inclined in buccolingual direction. The alveolar bone thickness on the buccal aspect of the first molar is less as compared to the second molar and thus chances of fenestration and dehiscence are more on the buccal aspect of the first mandibular molar.
Mandibular second and third molar:
The root trunk length of mandibular second molar is more than the first molar. Root divergence of mandibular second molar is less than the first molar. The root trunk of both first and second molar has a depression between the bifurcation and cervical line. The shape of mandibular third molar varies considerably from individual to individual. The mesial and distal roots may have a definite bifurcation point or they may be fused for all or part of their length.
Etiology of furcation involvement
The most common etiology of furcation involvement is bacterial plaque causing inflammation in periodontal tissues. Extension of inflammation leads to progressive loss of soft and hard tissue in the bifurcation and trifurcation of posterior teeth. Other predisposing and contributing factors which facilitate furcation involvement include tooth brush trauma causing recession and loss of attachment, trauma from occlusion, endodontic lesions that get an access to furcation area, the thickness of investing alveolar process, root fracture and iatrogenic factors. A tooth may also be predisposed to furcation involvement due to anatomical factors and root fracture involving furcations 6. Following is the detailed description of these factors,
Extension of inflammatory periodontal diseases into furcation:
The plaque-induced inflammation causes the destruction of collagen fiber attachment of gingiva and alveolar bone. Furcation involvement is primarily due to the rootward extension of the periodontal pocket in the region of furcation. The resolution of inflammation prevents further attachment loss and is the primary requirement of all types of furcation treatments. If the patient is not able to keep the furcation areas free from plaque further hard and soft tissue loss results.
Trauma from occlusion (TFO):
TFO is a predisposing factor for a more rapid involvement of furcation in inflammatory periodontal diseases. It has been well established that in the absence of inflammation, TFO causes……………..
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Cervical enamel projection:
The cervical enamel projection (CEP) is an enamel projection, which extends from the CEJ to furcation. Masters and Hoskins (1964) 7 reported the incidence of CEPs in extracted human teeth and suggested their possible implication in isolated furcation involvement. They can be classified on the basis of their proximity to furcation entrance as,
Grade I – The enamel projection extends from the CEJ of the tooth toward the furcation entrance.
Grade II – The enamel projection approaches the entrance to the furcation. It does not enter the furcation, and therefore, no horizontal component is present.
Grade III – The enamel projection extends horizontally into the furcation.
The prevalence of CEP’s varies significantly from study to study, however, overall mean values have a range from 8.6 to 32.6% in molars 7-9. A higher prevalence of CEPs has been found in the mandibular molars than in the maxillary molars. Further, the prevalence is highest for mandibular and maxillary second molars. Grade II enamel projection has a higher prevalence as compared to Grade I and Grade III 10. The clinical significance of CEP is that while attempting regeneration in involved furcation, CEP should be removed because connective tissue does not attach to enamel and a long junctional epithelium shall be formed which is easily susceptible to breakdown.
There is a high percentage of molars with patent accessory canals that open in their furcation area 11-15. It is one of the co-factors contributing to the development of furcation lesion. The presence of accessory canals in the furcation area may easily extend the endodontic infection in the furcation area and may result in bone loss in furcation. In one study, the prevalence of assessor canals in the furcation region of molars has been found to be 28.4%. Out of total samples, accessory canals in the furcation area were demonstrated in 29.4% of mandibular molars, and 27.4% of maxillary molars 16. With no apparent periodontal involvement, the endodontic lesion gets access to the furcation by accessory canals. The endodontic treatment of tooth resolves the periodontal problem also. Regeneration of new intrafurcal bone and attachment can be expected in such cases. If there is an accumulation of plaque in the furcation area adjacent to endodontic sinus tract the lesion becomes endo-perio lesion. If the furcation lesion is detected in a non-vital tooth, the endodontic treatment should be initiated and re-evaluation of furcation should be done after 3-4 weeks. The resolution of clinical inflammation in furcation area can be observed after this time period. However, complete hard and soft tissue formation may take as long as 6 months or more.
Thickness of investing alveolar process:
During the inflammatory process, the thick alveolar process may predispose to the formation of deep horizontal and vertical defects without soft tissue recession, whereas think bone is commonly associated with recession which may result in easier access to the furcation.
A rapid localized bone loss is often seen in association with vertical root fracture. In the case of vertical root fracture involving trunk of the root, frequently its extension to furcation area is found. It may result in rapid formation of isolated furcation lesion. The prognosis of such teeth is poor and frequently, tooth loss results.
The development of furcation lesions has also been demonstrated due to inappropriate treatments. Overhanging restorations result in harboring of plaque resulting in inflammation and thus initiating the development of a furcation lesion. It has been observed that molars with restorations have a higher prevalence of furcation involvement than the non-restored molars.
Prevalence of furcation lesions
The furcation lesions are most commonly seen in maxillary and mandibular first molars 17. This is because their……………………….
Diagnosis of furcation involvement
The diagnosis of furcation involvement is made on the basis of patient’s clinical history, thorough clinical examination, radiographic examination, consultation with other specialists when indicated and if necessary, laboratory tests. A curved explorer or Naber’s probe and bone sounding are used to make a clinical diagnosis of furcation involvement 20.
The prognosis of the tooth is established only after the exact condition of furcation is known. There are various factors which are considered while making a diagnosis of furcation involvement and establishing the prognosis of the involved tooth. These include 21,
- The root trunk length
- Size of the furcation
- Root separation and divergence
- Root fusion
- Root concavity
- Crown root ratio of the tooth
- Occlusal interferences and trauma from occlusion
- Tooth mobility
- Adherence of the gum
- The ease with which hygiene of the affected furcation can be maintained
- The capacity of the patient to maintain optimum hygiene
The extent of furcation disease can be determined by evaluating
- Vertical bone loss
- Horizontal bone loss
- Both vertical and horizontal bone loss
Out of horizontal and vertical bone loss parameters, the horizontal bone loss is more commonly used parameter.
Classification of furcation involvement
Various classifications have been proposed historically to describe the horizontal and/or vertical component of furcation involvement. Following are some of these proposed classifications for furcation involvement,
Classifications on the basis of horizontal component of bone loss in furcation:
Classification by Glickman:
Glickman (1953) 22 proposed classification for furcation involvement were four grades of furcation involvement were described,
Grade I: Incipient or early lesion. The pocket is suprabony, involving the soft tissue and there is a slight bone loss in the furcation area. The bone loss is minimal, so sometimes is not shown on the radiologic image.
Grade II: This is named as a Cul-de-sac which means a dead end street. Bone loss is present on one or more aspects of the furcation, but a portion of the alveolar bone and periodontal ligament remains intact, allowing only a partial penetration of the probe into the furcation. In mandibular molars, bone loss is evident on radiograph but in maxillary molars, the palatal root overlaps furcation defect making it less visible.
Grade III: Interradicular bone is completely absent. The facial and/or lingual orifices of the furcation are occluded by gingival tissue. The furcation defect is clearly visible on radiographs. The crater-like lesion may be present in the furcation area, creating an apical or vertical component along with the horizontal component of bone loss.
Grade IV: The interradicular bone is completely destroyed similar to grade III lesions, in addition, there is gingival tissue recession making furcation opening clinically visible.
Classification by Goldman:
Goldman (1958) 23, gave the following classification to describe the degree of furcation involvement,
Grade I: incipient
Grade II: cul de sac
Grade III: through-and-through
Classification by Hamp et al:
Hamp et al. (1975) 24 proposed the following classification system to describe furcation involvement in multi-rooted teeth,
Degree I: Early involvement with the horizontal loss of supporting periodontal tissues not exceeding 1/3 of the tooth width. The probe penetration is less than 3 mm into the furcation.
Degree II: Moderate involvement with the horizontal loss of supporting periodontal tissues achieving more than 1/3 of tooth width but no encompassing the total furcation width. The probe penetrates more than 3 mm without transpierce to the opposed side of the furcation.
Degree III: Buccal-lingual involvement with the complete horizontal loss of supporting periodontal tissues with probe transpiercing both sides of the furcation.
Classification by Ricchetti:
Ricchetti (1982) 25, proposed the following classification depending upon the horizontal component of bone loss,
Class I: 1 mm of horizontal measurement; the root furrow
Class la: 1-2 mm of horizontal invasion; earliest damage
Class II: 2-4 mm of horizontal invasion
Class Ila: 4-6 mm of horizontal invasion
Class III: >6 mm of horizontal invasion
Classification by Easley and Drennan:
The classification proposed by Easley and Drennan (1969) 26 was based upon the involvement of the horizontal component of furcation.
Class I: incipient involvement, the entrance of the furcation detectable with no horizontal bone loss.
Class II, Type 1: horizontal bone loss, but no vertical component.
Class II, Type 2: horizontal bone loss and vertical bone loss.
Class III, Type 1: through-and-through bone loss with no vertical component.
Class III, Type 2: through-and-through bone loss with a vertical component.
Classifications on the basis of vertical component of bone loss in furcation:
Classification by Tarnow and Fletcher:
Tarnow and Fletcher (1984) 27 proposed a classification used Grades I, II, III proposed previously by Glickman (1953) 22 with an additional sub-classification based on vertical invasion from the furcation fornix:
Degree I: Vertical destruction up to one-third of the total inter-radicular height (0-3 mm).
Degree II: Vertical destruction reaching two-thirds of the inter-radicular height (4-6 mm).
Degree III: Inter-radicular osseous destruction into or beyond the apical third (>7mm).
Classification by Eskow and Kapin:
The classification given by Eskow and Kapin (1984) 28 has same subclasses as the Tarnow and Fletcher, but thirds instead of 3 mm units are used.
Management of furcation involvement
As already mentioned furcations are areas of complex anatomic morphology 29 and are difficult to debride by routine periodontal instrumentation 30. Presently, there is no uniformity in the terms used to describe various treatments for teeth with furcation involvement. Various terms have been used to describe treatment procedures for furcation involvement in the literature viz; furcationplasty, root amputation, hemisection, root resection, root separation and tunnel preparation. Before we discuss the treatment of furcation defects, let us discuss these terminologies first.
The reshaping of alveolar bone in the furcation area is known as furcationplasty. Furcationplasty can be applied to the buccal and lingual furcation areas. If the same procedure is carried out on the tooth structure, it is called as odontoplasty.
Root amputation is characterized as removal of a root without removal of the overhanging portion of the crown 31.
Root resection generally indicates the removal of a root without any information on the crown of the tooth 31.
Root separation is indicated as the sectioning of the root complex and the maintenance of all roots 31.
This is the procedure done for mandibular molars where a single molar tooth can be converted into two bicuspids by retaining both mesial and the distal root.
Hemisection is defined as the removal of half of a tooth performed by sectioning the tooth and removing one root. It is frequently used with reference to lower molars 31.
The tunneling procedure is the intentional creation of a class III furcation with its entrance accessible for oral hygiene procedures.
Treatment of grade I furcation involvement
Maintenance of adequate oral hygiene is required for preventing furcation lesion from progression. The patient should be educated about maintenance of good oral hygiene and should be re-evaluated at a frequent interval. For Grade I furcation involvement, following treatment modalities are usually employed,
- The furcation can be debrided with or without open flap debridement but with no modification of the furcation.
- Furcationplasty and/or odontoplasty……………….
- Another treatment is covering the furcation with periodontal plastic surgery. Connective tissue grafts and coronally positioned flaps can be employed to cover the furcation. Some authors have suggested coronally advanced flap with or without root conditioning and placement of bone graft 32. The major disadvantage of the procedure is disease progression in the furcation hidden by the covering and therapeutic failure.
Treatment of grade II furcation involvement
Grade II or Cul-de-sac like furcation defect can be treated by both regenerative and resective procedures.
Open or closed flap debridement without modification of the furcation has been shown to be not very effective in the management of Grade II furcation defects. Schroer et al. (1991) 33 in their study on 25 furcation sites with grade II defect in 15 patients compared scaling and root planing to open flap debridement. The results of the study demonstrated a reduction in probing depth in both groups at the deepest vertical site in the furcation. On the other hand, Kalkwarf et al. (1988) 34 reported a progressive attachment loss in furcations treated with all tested therapeutic modalities 2 years following the treatment. The treatment performed included coronal scaling only, scaling and root planing, scaling and root planing plus modified Widman flap, and open flap scaling and root planing with osseous resection.
Guided tissue regeneration has been shown to be……………………….
Tunneling procedure is recommended mainly to treat advanced Grade II and Grade III lesions 17, 37. In this procedure, bone is reshaped to obtain a scalloped morphology and the soft tissues are apically positioned. The procedure results in exposure of tooth furcation to the oral environment which can be easily cleaned by the patient. It must be made sure that space obtained under the roof of furcation should be adequate enough to allow proper plaque removal 29. Both short term and long term results of this therapy have reported variable results with this therapy. Hamp et al. (1975) 24 carried out tunneling procedure on 7 molars with degree III furcation involvement. Five years follow-up results demonstrated that 4 out of 7 teeth had evidence of carious lesions. The authors suggested unfavorable results of this therapy. In another study, Little et al. (1995) 38 followed 18 teeth with class II or III molar furcations that underwent tunneling procedures. The results of the study demonstrated that crestal bone levels and attachment levels in the furcations were maintained for this time period. However, 3 of the 18 teeth experienced root caries. Other authors have also reported an increased root caries risk in teeth were tunnel preparation has been done 39. Slight attachment loss has been observed in cases where resective osseous surgery for tunnel preparation is done.
Treatment of grade III furcation involvement
There are many factors which determine the clinician’s decision to choose one treatment plan over another when confronted with a Class III furcation invasion. These factors may be classified into three categories,
- Tooth anatomy
- Tooth mobility
- Crown-root ratio
- Severity of attachment loss
- Inter-arch and intra-arch occlusal relationship
- Cost-benefit ratio for retaining a portion of the root
- Health of a patient
- Importance of the tooth to the patient
- Costs and time factor
- Selection of the case
- Diagnostic and treatment planning skills,
- Awareness of therapeutic options
- Skill of the clinician
Tooth anatomy is the primary determinant in establishing treatment planning for grade III furcation involvement. The divergence of root cones, their length and remaining bone support should be considered to establish the treatment plan. The crown root ratio affects the long-term stability of the preserved portion of the tooth. As already stated, the severity of attachment loss determines the portion of the tooth, which can be saved and the portion which should be removed. The root cone with adequate bone support should be saved so that it can withstand occlusal forces. Along with this, the saved root cone should be placed in the occlusal plane so that after placement of fixed prosthesis, adequate inter-arch, and intra-arch occlusal relationship can be maintained. The patient should be well motivated to keep the involved area free of plaque and inflammation. Following are the treatment procedure which are considered while making a treatment plan for maxillary and mandibular molars with grade III furcation involvement,
- Tunneling procedure
- Root separation
- Root amputation
- Root amputation
As described earlier in the management of grade II furcations, the procedure allows “through and through” cleansing of the furcation where root anatomy allows and is indicated in highly motivated patients.
Root separation involves sectioning of the root complex and maintenance of all the roots. In teeth with short root trunk length,……………………….
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While planning for root separation it must be made sure that the root cones are not fused. It can be determined by clinical and radiographic examination. It may be difficult to determine the separation line between mesiobuccal-palatal and distobuccal-palatal roots in maxillary molars and maxillary first premolars where the root complex is narrow. In such a situation soft tissue flap can be raised to get access to the root surface. The mesial/distal furcation of maxillary molars should be probed to a depth of 3-5 mm to ascertain that the roots to be separated are not fused.
It must be made sure by clinical and radiographic examination that following root separation each root cone has an adequate amount of bone support following the procedure.
Bicuspidization is one of the procedures for management of furcation involvement in mandibular molars. This procedure is done in lower molars with well defined and well separated mesial-distal roots. The procedure involves root canal treatment of the involved tooth and dividing the molar into two parts each having an individual crown (Figure 73.2 a, b). Another indication for this procedure is root fracture involving the furcation. It should be noted that both the roots must have adequate bone support. Contraindications for the procedure involve poor oral hygiene, fused roots, unfavorable tissue architecture and roots which are endodontically untreatable.
Figure 73.2 The bicuspidization (a) and hemisectioning (b) procedure
As already stated, hemisection involves removing significantly compromised root structure and the associated coronal structure through deliberate excision 40. The term hemisection has been used interchangeably with root resection 41. The procedure is done where only one root of a multi-rooted tooth is affected and the surviving root is structurally capable of supporting a dowel and core restoration. In addition to this, the surviving root should be aligned so as to provide a proper draw for the resulting fixed prosthetic restoration. The root morphology of the surviving root should allow for surgical access and proper periodontal maintenance of the final restoration 3, 42-47.
This procedure can be done on…………….
The surgical site is allowed to heal with no occlusal stress placed on the root for four weeks 3, 42, 45, 46. After the healing is over, the retained root is rehabilitated with fixed prosthesis (Figure 73.3 a,b). Occlusal adjustments are done to facilitate balanced distribution of occlusal forces.
The procedure involves removal of a root without removal of the overhanging portion of the crown (Figure 73.4 a,b). The procedure is indicated in patients who are capable of maintaining a good oral hygiene and the tooth is also prosthetically maintainable for a relatively long period. In maxillary molars with furcation involvement, this procedure is done when one root is untreatable, two roots have adequate bone support and the crown does not require a prosthetic restoration. In mandibular molars, the procedure involves removal of one root with retaining the complete crown of the tooth. The area under the crown from where the root has been removed should be made self-cleansable by the patient and should allow adequate plaque removal.
Trisection 50 is done in cases………………
Post-treatment maintenance of furcation
Home care by the patient plays a vital role in the overall prognosis of the treated tooth. The interproximal furcation is best maintained by an interdental brush whereas facial and lingual furcations are better maintained by end tuft brush, rubber tip stimulator, or toothpick-in-holder. The patient should be trained regarding the appropriate usage of these plaque control measures. In case of tunnel preparation, the interdental brush of appropriate size should be passed through the furcation to keep it plaque free. The recall interval in patients with furcation involvement is comparatively shorter than the patients with no furcation involvement. Usually, the patients with severe bone loss and furcation involvement are recalled at 1-3 month interval.
It is a well-accepted fact that furcation involvement is associated with early tooth loss. Studies have compared changes in clinical attachment levels in areas with furcation involvement following open flap debridement and guided tissue regeneration (GTR) procedures. Many systemic reviews have concluded that GTR procedure results in significant attachment gain as compared to open flap debridement 51-56. Further, it has been stated that probing depth reduction was more with all barrier types in GTR procedure as compared to open flap debridement. A retrospective study 57 was done to analyze the factors influencing treatment decisions for periodontitis-affected teeth and the long-term outcome of these treatment decisions. The authors stated that various treatment modalities for molars with furcation involvement are selected based on the depth of furcation involvement. The shallow defects can be treated with non-surgical/surgical scaling and root planing with or without furcationplasty whereas deeper defects may require treatments like tunnel preparation, root resection, regenerative procedure or tooth extraction. Factors affecting decision-making for treatment of molars with furcation involvement include tooth mobility, tooth position, lack of antagonist tooth, the degree of furcation involvement and remaining bone support. The results of the study showed that 96% of molars subjected to non-resective periodontal therapy were in function at 8-12 years follow-up examination. The corresponding figure for root separated/resected molars was 89%. The mean radiographic bone loss during 10 years follow-up period was 0.1-0.6 mm for various molars with highest values for maxillary second molars.
Chen et al. (2013) 58 in a systematic review assessed the evidence on the efficacy of GTR with or without osseous grafting for the treatment of Class II furcation defects. The studies included in this systematic review were analyzed for furcation closure rate, horizontal attachment level gain (HAL), vertical attachment level gain (VAL), horizontal bone fill (HBF), and vertical bone fill (VBF). The results indicated that GTR + bone graft was the most effective therapeutic approach in the treatment of Class II defects furcation defects. The mean difference between VAL gain in mandibular molars defects between GTR and open flap debridement (OFD) was 1.02 mm (in favor of GTR). The VAL gain for GTR + bone graft and OFD was 1.53 mm (in favor of GTR + bone graft). Hence, it was concluded that in grade II furcation defects GTR and bone grafting results in better outcomes as compared to OFD.
Another recent systematic review by Avila-Ortiz et al. (2015) 59 analyzed results of various studies on the outcome of surgical periodontal therapy on furcation defects. The review included 150 articles, of which six were systematic reviews, 109 were clinical trials, 27 were case series, and eight were case reports. The authors concluded that regenerative therapy is predictable in situations such as in maxillary facial or interproximal and mandibular facial or lingual Class II furcation defects. The outcome of regenerative therapy in Class III defects has been supported only by case reports and is not predictable based on currently available evidence.
A retrospective study 60 investigated factors affecting treatment decisions and outcome of root resected molars using a nationwide population-based dataset in Taiwan. The results of the study demonstrated 91.1% overall survival rate of root-resected molars. Patients with advanced age (>74 yrs) had 3.33 times higher rates of molar extraction as compared to younger patients. The authors suggested that patient-related factors such as living district, urbanization level, availability of medical institution, and monthly income should be considered while making the decision for root resection.
The presently available evidence suggests that multi-rooted teeth with furcation involvement can be maintained in the oral cavity for a reasonably long duration of time with appropriate nonsurgical or surgical periodontal therapy, provided they are free of plaque and are kept under regular observation.
Similar to all periodontal therapies, the primary aim of non-surgical or surgical periodontal therapy in the furcation areas is arresting the disease process (inflammation & infection), restoring the lost tissues and ultimately, maintaining the teeth in health and function with appropriate esthetics 61 There are multiple factors which should be taken into consideration while making a decision regarding the treatment of teeth with furcation involvement. These factors include local factors related to the involved tooth, patient related factors and clinician-related factors. Initial furcation involvement can be effectively treated with effective plaque control and scaling and root planning, while grade II and III furcations require surgical management. Presently available regenerative therapies have demonstrated good prognosis when used in grade II and III furcation involvement 62. However, more clinical data is required for determination of prognosis for teeth with advanced furcation involvement.
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