Furcation management

Question 1

Define furcation

Answer 1

• The anatomic area of a multi-rooted tooth where the roots (furca) diverge one from another. Can be bifurcated or trifurcated
• Furcation involvement of molar teeth increase the exposed root surface, anatomical irregularities that favour bacterial growth
• Removal of plaque biofilm is difficult for patient and dental professional
• Preventing the progression of furcal lesions requires motivation of the dental professional and patient
• However, several studies conclude that 85% of teeth with furcation involvement which are treated for perio disease can be maintained stable for 7-8 years

Question 2

List causes of furcations (8)

Answer 2

• Inflammation (periodontal disease, pulpal inflammation, oedema)
• Attachment loss
• Due to periodontal surgery
• Orthodontic correction
• Occlusal trauma
• Diseases of the jaw
• Developmental grooves
• Enamel pearls

Question 3

Describe the classification of furcations and demonstrate the ability to differentiate between the grades of furcations

Answer 3

• Class/Grade I: Incipient furcal lesion. Circumferential movement of probe–reveals slight V-shaped depression less than 3mm horizontally
• Class/Grade II: Patent furcal invasion. Bone loss of 3mm or greater horizontally
• Class/Grade III: Furcation is open from facial to lingual aspects (“through & through” covered by gingiva)
• Class/Grade IV: Clinically visible furcation–“Through & through” with furca visible in the mouth (not covered by gingival)

Identify the essential components of furcation debridement:
• Some molar furcation entrances cannot be adequately debrided using curettes that were tested
• Recommendation to use of other hand instruments such as periodontal files and ultrasonic devices

Question 4

Discuss the evidence related to the progression of periodontal disease with furcation involved teeth and possible treatment options

Answer 4

• Long-term survival rates of multi-rooted teeth with furcations were good using several different therapeutic approaches
• Incipient furcations (Class/Grade I) were found to be managed successfully with non-surgical periodontal debridement
• Following tunnelling procedures, caries in furcation areas were most frequent reason for extraction of molars
• Following resection, vertical root fractures and endodontic failure- not progression of perio disease- were most frequent complications
• Guided Tissue Regeneration (GTR) or application of Enamel Matrix Derivatives (EMDs) was not predictably successful to close furcations

Question 5

Discuss the management of furcations, including appropriate periodontal instrumentation techniques (5)

Answer 5

Periodontal instrument techniques
• Optimal blade contour and sharpness
• Instrumentation sequence observed
• Use of specialised instruments; mini curettes, mini-bladed hoes or furcation curettes. Diamond files (with light pressure only)
• Precision-thin ultrasonic tips/inserts
• Definitive assessment following instrumentation

Question 6

Discuss the management of Grade 1 and 2 furcations

Answer 6

Grade 1 and 2 furcations
• Monitor hygiene. Good hygiene to prevent progression of lesion, toothbrushing technique, end-tuft brush and frequent evaluation
• Debridement (non-surgical or surgical) without modifying furcation
• DO may consider additional treatment; Guided tissue regeneration or Tunnel technique

Question 7

Discuss the management of Grade 3 furcations

Answer 7

• Monitor hygiene. Good hygiene to prevent progression of lesion and frequent evaluation
• Debridement (non-surgical or surgical) without modifying furcation
• Due to inability to access furcation, difficult for both dental practitioner and patient to debride, DO may consider additional treatment, guided tissue regeneration, root hemisection (most commonly for mand molars, prior endodontic treatment is necessary), root amputation (also requires endodontic treatment) and lastly, extraction

Question 8

Discuss the management of Grade 4 furcations

Answer 8

Grade 4 furcations
• Monitor hygiene, good hygiene more easily achieved. Patient- interdental brushes, superfloss
• Dental Professional- debride each root as “individual tooth”
• Debridement (non-surgical or surgical) without modifying furcation
• Due to inability to access furcation, difficult for both dental practitioner and patient to debride