Furcations

Furcations

• Furcation is the anatomical area where the roots of a tooth divide.
• A furcation defect involves bone loss at the branching point of the tooth's roots.
• Furcation defects only occur on multi-rooted teeth, not single-rooted teeth.
• The lecture aims to help students recognize the clinical presentation of a furcation-involved tooth, understand its impact on the patient, and identify available treatment options.

Learning Outcomes

• Define the term "furcation."
• Identify the challenges for patients and clinicians in managing furcation.
• Consider anatomical factors impacting furcation assessment and treatment.
• Explain assessment measures and classification for furcations.
• Discuss treatment options for furcation-involved teeth.
• Understand the role of dental hygienists/therapists in furcation treatment.

What is a Furcation?

• A furcation defect is the loss of bone at the point where the roots of a tooth diverge.
• Clinicians should consider which teeth are multi-rooted.

Key Anatomical Features of a Tooth with Furcation Involvement

• Root Complex: The overall structure of the roots.
• Root Trunk Length: The distance from the cementoenamel junction to the entrance of the furcation.
• Root Cones Length: The length of individual root parts.
• Fornix: The space between the roots.
• Inter-radicular Bone Level: The level of bone between the roots.
• Bone Loss: The amount of bone lost due to periodontal disease.
• Divergence: The angle at which the roots spread apart.

Different Types of Multi-Rooted Teeth

• Analyzing different multi-rooted teeth provides various perspectives on assessing the furcation area.
• Understand the variations in root morphology.

Grading According to Clinical Presentation

• The amount of bone loss and gingival recession help determine the severity of furcation involvement and the numerical grading.
• Grading is essential for proper recording and monitoring of clinical findings.

Furcation Index (Glickman 1953)

• A classification system for furcation defects.
• This system categorizes the severity of bone loss in a furcation defect.
• The Grades are I, II, III and IV.

Glickman Classification - Grades I, II, III, IV

• Grade I: Probe curvature can be detected, but the probe tip cannot enter the space between the roots.
• Grade II: Probe penetrates into the furcation, but does not pass completely through to the other side.
• Grade III: Probe passes completely through the furcation; the furcation defect is clinically unobvious.
• Grade IV: Probe passes completely through the furcation, while the furcation entrance is visible due to gingival recession.

Furcation Indices Universally Accepted

• Glickman (1953)
• Hamp, Nyman, and Lindhe (1975)
• Lindhe (1983)
• Tarnow and Fletcher (1984)

Root Trunk Length

• The distance from the cementoenamel junction to the furcation entrance.
• This factor should be considered in the context of tooth morphology.

Root Length

• Overall length of the tooth root influences treatment.
• This factor bears importance in the context of tooth morphology.

Interradicular Dimensions

• The space between the roots.
• The degree of separation of the roots affects treatment.
• Consideration of interradicular dimensions should be made for tooth morphology.

Cervical Enamel Projections/Enamel Pearls

• Enamel projections extending beyond the cementoenamel junction(CEJ).
• These should be considered during furcation assessments.

Challenges for Patients/Clinicians

• Patients with furcation defects may experience unsightly smiles or difficulty cleaning the area.
• Clinicians may face access and treatment challenges due to root morphology or anatomical variations.

Impact on the Patient

• Unsightly smile (for some)
• Food packing
• Difficulty with cleaning
• Exposing dentine/Sensitivity
• Possible root caries
• Impact on prognosis

Examination/Assessment Following Furcation Identification

• Examine/assess gingival tissues for inflammation, probing depths and recession.
• Obtain radiographs
• Gather patient concerns/history
• Evaluate secondary factors.

Instruments for Debridements

• Use of power-driven scaler, and specific instrument types (depending on clinician personal choice).
• The practitioner must be aware that not all furcation areas are the same, meaning instruments must be chosen accordingly to each case.

Initial Treatment Options

• Patient education and motivation is key
• Oral hygiene coaching for optimal plaque control
• Non-surgical periodontal therapy
• Careful monitoring

Restorative Treatment Options

• Endodontic therapy
• Periodontal surgery
• Possible restorative treatment

Further Treatment Options (Referring for Surgery Options)

• Guided Tissue Regeneration(GTR)
• Guided Bone Regeneration(GBR)
• Root Resection
• Root Separation
• Furcation Plasty

Furcation Plasty

• Removal of tooth substance(Odontoplasty)
• Alveloar bone remodeling(osteoplasty) at the furcation defect entrance

Guided Tissue/Bone Regeneration Surgery

• The use of barrier membranes to guide new bone and gingival tissue growth.

Root Separation Surgery

• Sectioning the root complex and maintaining all roots.
• Success depends on root length and shape, root divergence, stability, successful RCT, and thorough plaque control by patient

Root Resection Surgery

• Sectioning and removing one or more roots.
• Success depends on the length, stability and amount of support of root and a successful RCT. Effective plaque control.

Conclusion: Tooth with Furcation Involvement

• Monitoring is essential for managing further furcation progression.

Importance of Monitoring a Tooth with Furcation

• Record and grade furcation.
• Repeat assessments at appropriate recall intervals.
• Reinforce oral hygiene instructions

Prognosis

• Consider general periodontal status, patient age, plaque control, smoking habits, and bruxism when determining prognosis.

Furcation Lecture: Summary

• Carefully examine furcation areas when performing a periodontal examination.
• Inform, educate, and advise the patient.
• Select and implement the correct treatment modality for the furcation.
• Monitor the furcation and refer to a periodontist if furcation progession occurs (progression/worsening of furcation).