Because of its often bizarre anatomy and morphology, the furcation has been called a locus minoris resistentiae (Schroeder and Scherle 1987), a “special case,” and a “freak of nature” (Lindhe).
Once the furcation becomes involved with periodontitis, it is a significant risk factor for the tooth because of its macro- and micromorphology (plaque-retentive niche); also, periodontitis in the furcation area often progresses rapidly. For this reason, furcation involvement must be diagnosed at the earliest possible time. For clinical assessment, color-coded furcation probes are helpful (NP 2C). The two-dimensional radiographic picture provides but meager information about furcation involvement, especially in the maxilla. This situation may be improved in the future through high resolution spiral CT.
The basic principle of furcation treatment is the same as that for single-rooted teeth—cleaning of the root surface. Depending upon the severity of involvement and the complexity of the furcation morphology, supportive topical application of medicaments may be indicated during purely mechanical treatment.
Advanced/severe furcation involvement may demand radical treatment methods (root amputation, resection). The first step is to clarify and decide whether the involved tooth must be maintained at all. Also worthy of consideration is the possibility of a shortened dental arch (premolar occlusion) or the replacement of a molar by a dental implant.
Last but not least, it is important to realize that costly furcation treatment with endodontic and prosthetic care (F3) can be avoided if the furcation involvement is diagnosed early (F1).
This small abridged chapter shows the following:
Therapeutic possibilities for various case types
Furcation involvement—classifications
F2 in the maxilla—furcationplasty (tooth model)
Therapeutic Possibilities for Various Cases
Depending upon the severity of furcation involvement (F1-F3; A-C), as well as the tooth position in either the maxilla or the mandible, various therapeutic methods may be attempted. Even with identical involvement in the same arch or even on the same tooth, diverse treatment methods are possible, depending upon the situation in a dentulous arch (abutment tooth), systemic health of the patient, and his/her oral hygiene compliance.
Depicted below in tables and diagrams are the various possible treatments:
Closed or open scaling, with odontoplasty and possibly osteoplasty
Tunneling procedures
Regenerative methods:
GTR, “fillers,” growth factors, matrix proteins
Resective methods:
Hemisection with maintenance of one root
“Premolarization,” with maintenance of both roots
Root amputation
Trisection in the maxilla, with maintenance of all roots
Tooth extraction, replacement with a dental implant?
685Closed Therapy—ScalingInitial furcation involvement (F1) with a deeply lying furcation (long root trunk): The region can be conservatively treated via scaling and root planing with hand instruments or ultrasonic devices (A). If the furcation is relatively superficial in its location, it can readily be treated radically by pocket elimination (GV/GP). It can then be easily cleaned (B). At the same time, enamel projections or pearls can be removed, also enhancing access to the furcation area for oral hygiene.686Open Treatment in the Mandible—Access FlapsWith deeper furcation invasion (F2), calculus is often present upon the rough cementum surface. In such cases, open treatment is recommended. After reflecting soft tissue flaps, the furcation surfaces are cleaned and planed and the flaps are repositioned coronally to the furcation entrance (C).In the case of through-and-through furcations (F3), one may consider a tunneling procedure with apically repositioned flaps (D).687Furcation Treatment by Means of Regenerative MethodsWith F2 furcation invasions, it is reasonable to attempt regenerative methods using GTR techniques, and also filling the defect with bone or bone replacement materials, and even the incorporation of growth factors or matrix proteins to completely heal the furcation defect. The tooth, itself, remains stable and vital.Such “heroic” measures are generally more successful in the mandible (left) than in the maxilla (only in the buccal furcation!).688Amputation of Individual Roots in the MaxillaIf a class F3 furcation involvement exists on a maxillary molar involving two or three roots, it may be possible to remove a single root (A), with maintenance of the entire tooth crown, or two roots may be removed (B).A Amputation of a buccal root (left)B Amputation of both buccal roots; post build-up upon the palatal root (right)689Trisection in the Maxilla—Maintenance of All Three RootsIf there exists through-and-through furcation involvement between/among all three roots, one should always consider trisection of the tooth. After the separation, it is possible to evaluate the remaining fundament of each individual root and to evaluate its value in terms of any anticipated prosthetic reconstruction.Because the individual roots are usually highly mobile and tend to migrate, stabilization is required.690“Premolarization” in the Mandible—Maintenance of Both RootsIf a class F3 furcation involvement is present in the mandible, and if there are no periapical considerations, the two roots are not in close proximity, are relatively long (remaining support), and the molar has a short root trunk, it should be possible after endodontic therapy to “premolarize” the tooth by means of hemisection. Subsequent definitive prosthetic reconstruction essentially splints the two roots.691Hemisection in the Mandible—Maintenance of One RootExtraction of the poorly supported root is often indicated in class F3 involvement in the mandible and sometimes even in advanced F2 cases, as well as with pronounced, difficult to treat periapical lesions that are often combined with furcation defects. Extraction of one root can be performed after hemisection of the tooth. Definitive prosthetic treatment is subsequently required.Right: Distal root = abutment.
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