I guess its time for me to retire

Long term follow-up of periodontal treatment indicates periodontal lesions in the majority of patients will respond well. The one exception to this seem to be lesions in multi-rooted teeth that have advanced into the furcation area between the roots. (Hirschfield 1978, McFall 1982, Goldman 1986)

In teeth with furcation lesions a tooth mortality rate for periodontal reasons of 31% - 57% has been observed over periods averaging about 20 years compared to an overall tooth mortality for all teeth of only 7% - 10%. (Hirschfield 1978, McFall 1982)

Bone loss can occur at any point on the surface of molars so pocket depth must be checked at several points and the deepest measurement recorded. Furcation can be clinically detected by using Nabers probe along with a simultaneous blast of warm air to facilitate visualization and radiographs also help to detect the furcation invasions.

Bone loss in furcations can occur in a horizontal or vertical plane.

Furcation involvements according to Glickman are classified as grade I, grade II, grade III or grade IV.

Grade I furcation involvement shows initial attachment loss with most of the bone still intact in the furcation. No radiographic changes seen.

Grade I furcation on the buccal of first molar.

Radiograph shows intact bone in furcation.

At time of surgery minimal bone loss in furcation. It is basically a soft tissue lesion

GRADE II FURCATION
The bone defect is a cul de sac with a definite horizontal bone loss. Vertical bone loss may also be present. There is an opening into the furca with a bony wall at the deepest portion.

There is some bone present in the inner part of the defect so that in part the furcation is filled to the roof. There may or may not be radiographic changes depending on the amount of furcal bone left unaffected.

Early grade II furcation. Both molars have grade II furcation with 5mm pockets.

Early grade II furcations at time of surgery, beginning bone loss in both molars.

Moderate grade II furcation. More severe horizontal bone loss on the buccal is seen at the time of surgery.

Moderate grade II furcation. Radiographic evidence of bone loss in 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.

GRADE III FURCATION

Radiograph shows a radiolucency in the coronal portion of the furcation bone.

Bone is lost across the whole width of the furcation so no bone is attached to the furcation roof.

GRADE III FURCATION

GRADE III FURCATION

Grade III furcation on mesial of first molar.

Grade III furcation on distal of first molar.

Radiograph shows deep bone loss on mesial and triangular shaped radiolucency in distal furcation.

CAT scan will allow cross section views of interior of furca in 1 mm bucco palatal slices.

CAT scan image shows bone loss with no bone attached to the roof of the furca.

Additional cross section views towards distal show bone loss across the whole width of the furcation.

At time of surgery there is advanced bone loss exposing the mesial furca with bone loss extending all the way to the distal furcation

Grade III furcations extending across both the first and second molars with bone loss allowing passage of probes completely through the furcation.

At the time of surgery there has been bone loss in both a horizontal and vertical dimensions.

GRADE IV FURCATION
Radiographically this shows bone loss similar to Grade III furcation.

Bone loss across the furcation is accompanied with gingival recession at the furcation is clinically visible.

Classification based on the vertical component (Tarnow and Fletcher):

Depending on the distance from the base of the defect to the roof of the furcation, furcations can be classified as
Subgroup A: vertical dimension of bone up to 1/3rd of the interradicular distance.

Subgroup B: vertical dimension of bone up to 2/3rd of the interradicular distance.

Subgroup C: vertical destruction of bone beyond the apical 1/3rd of the interradicular distance.

Classification based on horizontal component (Hamp and Coworkers):

Degree I: horizontal bone loss of less than 3mm.

Degree II: horizontal bone loss of more than 3mm.

Degree III: through and through horizontal lesion.

Furcation involvements have anatomical factors that make it difficult to carry out root planing, calculus removal and degranulation.

Calculus can deposit in the roof of the furcations and in inaccessible regions where the space is too small for hand curettes.

Local anatomic factors in the treatment of furcatons: 1. Root trunk length The combination of root trunk length and the no. and configuration of roots affects both the ease and success of therapy Furcal involvement in teeth with short root trunk length show less bone loss and are easily accessible to instrumentation. Once furcation is exposed teeth with short root trunk length are more accessible to maintenance procedures and facilitate some surgeries. 2. Root length It is directly related to the quantity of the supporting apparatus of the tooth Teeth with short root trunks & long roots have greater amount of attachment to meet functional demands. 3. Root form: The mesial roots of most mandibular 1st and 2nd molars and the mesiobuccal roots of most maxillary molars are curved to the distal in the apical third. Also the distal aspect of this root is heavily fluted. These increase the potential for perforation during endodontics and complicate post placement during restoration and may also result in the increased of vertical root fracture. The size of the mesial radicular pulp may result in the removal of the majority if the tooth structure.

4. Interradicular dimension: Closely approximated roots can preclude adequate instrumentation during scaling, root planing and surgery. Teeth with widely spaced roots present more treatment options and are more readily treated. 5. Anatomy of the furcation: The presence of bifurcational ridges, a concavity in the dome, and possible accessory canals complicates not only scaling, root planing, and surgical therapy, but also periodontal maintenance. Odontoplasty to reduce or eliminate these ridges may be required during surgical therapy for optimum results. 6. Cervical enamel projections: These are reported to occur on 8.6% to 28.6% of molars. The prevalence is highest for mandibular and maxillary 2nd molars. These can affect plaque removal, complicate scaling and root planing and may be a local factor in the development of gingivitis and periodontitis.

Classifications of cervical enamel projections: Grade 1: the enamel projections extends from the CEJ to the tooth towards the furcation entrance. Grade 2: the enamel projections approaches the entrance to the furcation. It does not enter the furcation and therefore has no horizontal componenet. Grade 3: the enamel projections actually enters horizontally into the furcation.

Cervical enamel projections as an etiologic factor in furcation involvement. Swan RH, Hurt WC. Two thousand molars in 200 East Indian skulls were examined for the occurrence, location, and grade of cervical enamel projections. The relationship between the enamel projections and furcation involvements was studied. Several findings resulted. The incidence of cervical enamel projections in molars was 32.6%. The incidence of cervical enamel projections varied between molars. The mandibular second molars showed the highest incidence of enamel projections (51.0%), followed by the maxillary second molars (45.6%). The lowest incidence was seen in the maxillary first molars (13.6%). Grade 1 enamel projections were the most frequently encountered. Cervical enamel projections occurred most frequently on the buccal surfaces of teeth. There was a positive, statistically significant relationship between tooth surfaces with grade 2 and 3 enamel projections and periodontally involved furcations. However, no etiologic relationship was found between grade 1 projections and furcation involvements. There seems to be a physiologic relationship between bone and enamel projections. The alveolar crest has a tendency to follow the outline of the enamel projection, and a channel much wider than a normal periodontal membrane space accommodates the enamel projection as it extends toward the furcation. The results indicate that when cervical enamel projections are severe enough to approach or enter the furcation area (grades 2 and 3), they may be an etiologic factor in the breakdown of these furcations.

Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvements. Hou GL, Tsai CC. Graduate Institute of Dental Sciences, Kaohsiung, Medical College, Kaohsiung City, Taiwan. In this study, the cervical enamel projection (CEP) and intermediate bifurcational ridge (IBR) correlated with localized molar furcation involvement (FI) was investigated. Study samples consisting of 87 hopeless permanent mandibulars (56 first and 31 second molars), which required extraction for periodontal therapy, were randomly collected from the School's Dental Clinic. The furcal defects, CEPs, and IBRs of molars were diagnosed via clinical probing, periapical radiographs, and inspection of ground tooth sections of extracted teeth with a stereomicroscope. Prevalence and distribution of molars with CEPs and/or IBRs were also analyzed. Probing depths (PD), clinical attachment loss (CAL), gingival index (GI), and plaque index (PLI) were measured for the buccal and lingual surfaces of molar furcal areas. Moreover, the relationships between the molar FI with and without CEPs and IBRs and periodontal status were analyzed using Student's paired t-test. Based on those results, we can conclude the following: 1) among 87 molars with FIs examined, 63.2% (55/87) had cervical enamel projections and bifurcational ridges, and the prevalence was greatest in mandibular first (67.9%, 38/56) and second (54.8%, 17/31) molars; and 2) the differences in mean PD, CAL, PLI, and GI between the molars with and without CEPs and IBRs were highly significant (P < 0.001) in the mandibular first and second molars.

Extracted upper molar with calculus in roof of furcation.

In lower molars there is often an anatomical groove on the lateral aspect of the roots particularly the mesial root.

This makes it difficult for instrumental access. Fine ultrasonic scalers or ultrafine diamond burs in a slow speed handpiece may be the only accessible instrumentation.

Treatment of furcation defects:

1. Therapy for early furcation defects: Class 1 These are amenable to conservative periodontal therapy. As the pocket is suprabony and has not entered the furcation, oral hygiene, scaling, and root planing are effective. Any thick overhanging margins, facial grooves, or CEPs are removed by odontoplasty, recontouring, or replacement.

2. Therapy for furcation defects: Class 2 Shallow horizontal component with little vertical bone loss responds well to localized flap operation with odontoplasty and osteoplasty. This reduces the dome of the furcation and improves the gingival contours to facilitate periodontal maintenance. 3. Therapy for advanced furcation defects: class2-3 The development of significant horizontal component to one or more furcations of a multirooted tooth &/or a deep vertical component to the furca poses additional problems. Nonsurgical therapy is usually ineffective and periodontal surgery, endodontics, and restoration of the tooth are required.

In this case grade II furcations on the buccal and lingual were treated with initial therapy and then with flap and osseous surgery.

Pre osseous surgery

Post osseous surgery

Pre osseous surgery

Post osseous surgery

Apical positioned flaps

Post surgery

In this Grade two furca the bone defect is less than 4 mm. Below the roof of the furca and so resective osseous surgery is indicated.

Bone has been removed to eliminate the defect and to create a positive architecture

The flap is apically positioned and shaped to follow the bone contours so that minimal post surgical pockets are developed.

In this furca there is deep pockets and advanced bone loss.

The bone loss is such that the deepest part of the defect is more than 4 mm. from the roof of the furca. Regenerative procedures are needed.

Bio oss and Emdogain have been used to fill the defect to the level of the bone crest.

The flap has been sutured at its original level and Emdogain applied to the space under the flap.

More advanced bone loss is treated with regenerative periodontal surgery.

In this case the advanced bone loss precludes osseous surgery so regeneration surgery using a periosteal graft was used.

Periosteal graft from palate

Periosteal graft placed over bony defects and flaps sutured to position

Six months

Six months Re entry

Advanced grade II to IV furcations may be treated with root resections.

In this upper molar the distobuccal root was resected, endodontic therapy done and a specially contoured crown was placed.

Root resection:
It may performed on vital or endodontically treated teeth. It is however preferable to have endodontic therapy done before resection of the root(s). if not possible the pulp should be first removed , the patency of the canals determined, and the pulp chamber medicated before resection. It is distressing to perform a vital root resection and to subsequently have an untoward event such as perforation, fracture of the root, or inability to instrument the canal.

Indications of root resection are :

1. Teeth that are of critical importance to the overall dental treatment plan. Examples are teeth that serve as abutments of fixed and removable prosthesis for which the loss of the tooth would lead loss of the prosthesis and entail major prosthetic retreatment. 2. Teeth that have sufficient attachment remaining for function. Molars with advanced bone loss in the interproximal and interradicular areas, unless the lesions have 3 bony walls, are not candidates for root amputation.

3. Teeth which have no remaining predictable or cost effective method of therapy. Examples are teeth with furcation defects that have been successfully treated with endodontics but now present with vertical root fracture, advanced bone loss or caries on the bone root. 4. Teeth in patients with good oral hygiene and low caries activity are suitable candidates. These therapies can present a sizeable financial investment on part of the patient to save the tooth. Alternative therapies and their impact on the overall treatment plan should always be considered and presented to the patient . Also root resection and hemisection are contraindicated in patients unable or unwilling to perform oral hygiene & preventive measures. Which root to remove and why? 1. Remove the root(s) that will eliminate the furcation and form a maintainable architecture on the remaining roots. 2. Remove the roots with greatest amount of bone and attachment loss. Teeth with uniform advanced horizontal bone loss are not suitable candidates for root resection. 3. Remove the root which best contributes to the elimination of periodontal problems on adjacent teeth. For example a maxillary 1st molar with a classIII buccal to distal furcation is adjacent to a 2nd molar with a 2 walled intrabony defect between the molars and an early classII defect on the 2nd molar. The removal of the distobuccal root of the 1st molar allows the elimination of the furcation and management of the 2 walled bony defect and facilitates access for instrumentation and maintenance of the 2nd molar.

4. Remove the root with the maximum no. of anatomic problems such as severe curvature, developmental grooves, root flutings, or accessory or multiple root canals. 5. Remove the root that least complicates future periodontal maintenance.

In lower molars hemisection is used and one or both roots are retained.

This involves endodontic treatment and new crowns.

Hemisection:
Hemisection is the splitting of a two-rooted tooth into two separate portions. This procedure has been called bicuspidization as it changes the molar into 2 separtate roots. It is most likely to be performed on mandibular molars with buccal or lingual class II or III furcation involvements. As with root resection molars with severe interradicular and interproximal bone loss are not good candidates for hemisection. As mentioned earlier one or both of the roots may be retained . This decision is based on the extent and pattern of bone loss, root trunk and root length, ability to eliminate the osseous defect, and endodontic and restorative considerations. The anatomy of the mesial roots of the manbdibular molars often leads to their extraction and retention of the distal root to facilitate both endodontics and restorative dentistry.

Importance of the interradicular separation:

Narrow interradicular zones can complicate the surgical procedure. The retention of both the molar roots can complicate the surgical procedure. The retention of both roots can complicate the restoration of the tooth, since it can complicate the placement of finish lines or to provide an adequate an adequate embrasure between the two roots for effective oral hygiene and maintenance.

Therefore orthodontic separation of the two roots may be required to allow restoration with adequate embrasure form.
This can result in the need for multiple procedures and an interdisciplinary therapy.

In such cases GTR or replacement by osseointegrated implants should be considered.

The root resection/hemisection procedure:

The most commonly performed root resection is the distobuccal root of the maxillary first molar. after adequate anesthesia, a full thickness periosteal flap is raised. Root resection in teeth with advanced bone loss reqires opening of both facial & lingual/palatal flaps. The flap should provide for adequate access for proper visualization and instrumentation & to minimize trauma during surgery. After debridement the resection of the root begins with the exposure of the furcation on the root to be removed. Endodontic therapy is typically performed either before or after root resection. Endodontic complications (root fractures) have been cited as a reason for eventual failure of teeth treated with root resective therapy. A root from a maxillary molar and the associated portion of the crown supported by that root can be removed, rather than amputating just the root as it emanates apically from the crown. Greenstein called this treatment of maxillary molars a trisection of the tooth. Keough reviewed the technique of removing a root and its accompanying crown portion while concurrently modifying the emergence profile of the tooth as it emanates from the osseous crest. He advocated recontouring adjacent osseous structures to reestablish positive osseous architecture.

Modifying tooth structure in this fashion eliminates undercuts and has been described as a "barreling in" of the root form. Crown preparation of the altered tooth and prosthetic contours to allow increased access by the patient has been demonstrated by Kastenbaum. Carnevale and others"2 reported a success rate of 95 percent for root resective therapy using the surgical and prosthetic procedures similar to those advocated by Keough and Kastenbaum". Proper selection of teeth, conservative endodontic access and the design of the prosthetic treatment may have lead to the low failure rate. Determining whether the morphology of the tooth is amenable to root resective therapy is critical. An important factor is the length of the root trunk. This length can be defined as the distance between the cementoenamel junction and the opening of the furcation. A tooth with a long root trunk is less likely to have furcation involvement, as the junctional epithelium must traverse a longer distance before the roots separate. When furcation involvement occurs on this tooth, however, successful resective therapy is not as predictable because the length of the remaining roots may not be long enough for support. In addition, removing one root followed by osseous resection to establish positive osseous contours would involve excessive osseous removal on the adjacent teeth. Teeth with short root trunks are more likely to have furcation involvement as the junctional epithelium migrates apically. With less distance for the junctional epithelium to traverse, furcation involvement is more likely. But when these teeth are treated with root resection, the prognosis is greatly improved. Radiographs can help determine the root trunk morphology.

Majzoub and Kon described tooth morphology after distobuccal root resection in maxillary first molars. Root removal was accomplished by using the technique described by Keough. The root was sectioned through the coronal aspect of the tooth. The distobuccal root and its accompanying crown portion were removed simultaneously, resulting in an elimination of all undercuts (a trisection procedure). One of the parameters that the authors looked at was the distance between the distal aspect of the pulp chamber floor and the most coronal aspect of the root separation. They determined that the average value for this distance was 2.7 millimeters. But only 6 percent of the teeth consistently had a distance of 3 to 4 mm. It is necessary to consider the advantage of surgical access and trisection through the crown, which provides proper visualization of the location of the floor of the pulp chamber, and the most coronal aspect of root separation. This information enables the practitioner to determine the feasibility of retaining the remaining portion of the tooth and providing a cast restoration. Backman described four cases in which incomplete root resections were performed. Continued osseous loss was observed after root amputation. The author commented that the initial surgical access may have been inadequate. In addition, he recommended a postoperative radiograph to determine the accuracy of root removal. Newell examined 70 root-resected teeth and described faulty root resections in 30 percent of the teeth examined. Practitioners using the root amputation technique had left subgingival, residual roots, furcal tips and/or ledges.

Current thinking is that a confluence of the root to prosthetic crown contours is more beneficial; axial contours of restored teeth must be physiologically developed and emerge from the root with a zero-degree emergence profile. Flat contours that follow the root morphology are less plaque-retentive than the contours of restored teeth with a cervical bulge at the apical portion of the crown.

Root removal:
There are two ways to remove the affected root: with or without the associated crown portion. Removal of a root only, without its accompanying portion of the crown, is referred to as a root amputation. This can be done with a long fissure bur or diamond, with copious irrigation, and by amputating the root at the CEJ. This leaves the crown portion intact except for the aperture associated with the entrance of the root canal of the involved root into the pulp chamber. This area can be widened, and a restorative material such as amalgam can be placed. The reflection of a gingival flap often enhances access in root amputation procedures. "Trisection" is the term applied specifically to surgical excision of a maxillary molar root and its accompanying crown portion; the same procedure is called a "hemisection" when performed on a mandibular molar. Similar to the root amputation procedure, elevation of buccal and palatal mucoperiosteal flaps enhances access to the involved teeth as well as to the adjacent osseous structures.

A long fissure bur on a highspeed handpiece is placed along the long axis of the tooth in the area of the buccal furcation and a cut is made. This cut is channeled toward the center of the tooth and then directed toward the interproximal furcation opening of the affected root. The cuts are made essentially over the portion of the crown that is supported by the root to be removed. When viewed occlusally, a C-shape typically appears as the cut is made. The bur is moved from the interproximal opening toward the buccal area in a back-andforth motion, and concurrently moved apically toward the furcation area. Once the bur severs the floor of the pulp chamber, the root is separated from the remaining portion of the tooth. The bur must not be extended apically to the floor of the pulp chamber to resect the underlying osseous structures. These structures are recontoured as needed after the root is removed and direct visualization is possible. The severed portion of the root can be removed with a periosteal elevator and/or a small extraction forceps. The remaining portion of the root is barreled in to remove any ledges or undercuts, as these structures are potentially detrimental to periodontal maintenance.

Osseous recontouring.
When odontoplasty is completed, osseous therapy can begin. The practitioner should establish adequate soft tissue width between the restorative margin and the osseous crest and create positive osseous architecture on the tooth undergoing root resection and on the adjacent teeth. Positive osseous architecture can be described as the topographic arrangement of hard tissues where the crest of the interdental tissue (interproximal bone) is coronal to the level of the radicular osseous tissue, facially or lingually. High-speed rotary instrumentation with copious amounts of water can eliminate any osseous defects while establishing moderate parabolic contours on the proximal surfaces and flat contours in the interproximal areas. When this has been completed, the osseous crest on the proximal surfaces will be apical to the osseous crest in the interproximal areas. There will be a minimum of 3 mm from the floor of the pulp chamber to the osseous crest. Two of those millimeters allow for establishment of the supracrestal attachment apparatus, the so-called biological width, and 1 mm for placement of the crown margin. If the remaining root trunk-the distance from the floor of the pulp chamber to the fornix of the furcation is wide enough, additional tooth structure will be obtained through osseous resection to allow for more distance between the junctional epithelial attachment and the crown margin. A minimum of at least 0.5 mm is desirable. Clearly, reflection of flaps and surgical access provide not only for proper osseous recontouring and odontoplasty but also visualization of the distance between the floor of the pulp chamber and the separation of the two remaining roots. This also allows the dentist to eliminate undercuts.

Repositioning of gingival flaps

The aforementioned measurements are of great concern if prosthetic treatment is to be done using the concept of the biological width. If this concept is used, a minimum distance of about 2 mm is needed between the osseous crest and the proposed restorative margin. One millimeter would account for the supracrestal fibrous insertion into the cementum and the second millimeter would account for attachment of the junctional epithelium according to the average measurements reported by Gargiulo and colleagues. Even though these average measurements might allow establishment of the supracrestal attachment apparatus, the restorative margin would still be in close proximity to the junctional epithelial attachment. In theory, however, this attachment would not be violated. Certainly, an increased tooth structure would be beneficial so the restorative margin could be placed coronally to the base of the sulcus-the most coronal aspect of the junctional epithelium. No definitive scientific study, however, has documented the need to establish these dimensions for periodontal health. Dello Russo, in a letter to the editor of The Journal of Periodontology,27 pointed out that the range of values for the epithelial attachment was 0.08 to 3.72 mm, and the range for the connective tissue attachment was 0.00 to 6.52 mm in Gargiulo and colleagues' 1961 paper. Dello Russo27 questioned the extrapolations made from that article which are utilized as guidelines for performing crown lengthening procedures. If the epithelial attachment and the connective tissue attachment measurements could be as low as 0.08 mm and 0.00 mm respectively, then it is possible that "an individual patient might have a perfectly healthy periodontium with very little biologic width."

If the cut passes through a metallic restoration it is cut before raising the flap to prevent contamination of the soft tissues with metal particles. If a vital resection is to be performed a more horizontal cut is preferred as it exposes less surface area of the pulp, failing which There is increased incidence of post operative pain. Though a horizontal cut may complicate root removal it is associated with less incidence of post operative pain. The root stump can be removed by odontoplasty after the completion of the endodontic therapy or at the time of tooth preparation. After resection the root is done care should be taken not to traumatize the bone on remaining roots and the adjacent tooth. Removal of the root facilitates the debridement with hand, rotary or ultrasonic instruments on the furcation aspects of the remaining roots. If necessary odontoplasty is performed to remove any developmental grooves or any other anomaly which would cause plaque retention or impede its removal. Patients with advanced bone loss commonly have other procedures combined with root resection. The bone lesions on the adjacent teeth may be treated with resective or regenerative surgeries. After resection the flaps are re-approximated and made to cover any grafted tissues or to slightly cover the bone margins over the tooth. Sutures are then given to maintain the flaps in their position and the area may or may not be covered with a surgical dressing.

The removal of a root alters the occlusal forces on the remaining roots & therefore it is wise to evaluate the occlusion and make adjustments is required. Centric holds may be maintained but eccentric forces are eliminated. Patients with bone loss may benefit from temporary stabilization of the resected root to prevent movement.

Prognosis for root resection and hemisection:

Earlier it was believed that a significant furcal defect deemed to give a tooth a hopeless long term prognosis. However recent clinical trials have shown that it is not as severe a complication as originally thought if one prevent the development of caries in the furcation. Relatively simple periodontal procedures are enough to maintain these teeth in function for relatively long periods of time. Recent data indicates that recurrent periodontal disease is not a majpr cause of failure of these teeth. The key to long term success appear to be thorough diagnosis, selection of patients with good oral hygiene, and careful surgical and restorative treatment.

Regeneration:
Furcation defects with deep 2-walled and 3-walled defects are candidates for regenerative procedures. These vertical bony deformities are respond favorably to a variety of other surgical procedures such as debridement with or without membrane and bone grafts. Various regenerative procedures include: a. Autogenous bone grafts, e.g. osseous coagulum, bone blend. b. Allogratfs, e.g. FDBA, DFDBA. c. Alloplasts, e.g. hydroxyapatite, tricalcium phosphate. d. Citric acid root conditioning with coronally placed flap. e. Guided tissue regeneration and combination techniques. For grade III and IV furcation involvements the success is limited.

In cases with advanced grade III involvement it may be necessary to extract the tooth due to its very poor hopeless prognosis.

Extraction:
The extraction of a tooth with through and through defects and advanced attachment loss may be appropriate therapy for some patients. This is particularly true for patients who cannot or will not perform adequate oral hygiene measures, have ahigh caries index, or have socioeconomic factors or other factors that preclude more complex therapies. Some patients are reluctant to accept periodontal surgery or even extraction for a tooth with advanced furcation involvement even though the long term prognosis is poor. The patient may elect to forego therapy and opt to treat the area with scaling and root planing or site specific antibacterial therapies until the tooth becomes symptomatic. Although additional bone loss may occur but it is not uncommon for these teeth to last a significant number of years. The advent of osseointegrated implants as an alternative abutment source has had a major impact on the retention of teeth with advanced furcation defects.

Tunnel preparation:
It is by transforming grade II furcation to a grade III & IV for better access, but it is not performed any more because of increased chances of root caries.

Supportive periodontal care for teeth with furcation defects:

Scaling, root planing and other conventional periodontal therapy can be combined with subgingival application of doxycycline (ATRIDOX - doxycycline hyclate 10%) has been shown to show a short term increase in the clinical attachment level.

Supportive periodontal therapy of furcation sites: non-surgical instrumentation with or without topical doxycycline. Dannewitz B, Lippert K, Lang NP, Tonetti MS, Eickholz P. Section of Periodontology, Department of Conservative Dentistry, Clinic for Oral, Dental and Maxillofacial Diseases, University Hospital Heidelberg, Heidelberg, Germany. OBJECTIVES: Evaluation of the clinical effect of topical subgingival application of doxycycline gel adjunctively to scaling and root planing (SRP) at furcation sites during supportive periodontal therapy (SPT). MATERIAL AND METHODS: In 39 SPT patients exhibiting at least four pockets > or m with bleeding on probing, SRP was rendered in all pockets > or m. Additionally, 14% doxycycline gel was applied subgingivally in 20 patients after random assignment (SRP&DOXY). Clinical parameters were assessed at baseline, 3, 6, and 12 months after therapy. Additional benefit of topical doxycycline was evaluated as a short-term (3 months) improvement of furcation involvement and influence on the frequency of re-instrumentation up to 12 months. RESULTS: A total of 323 furcation sites (class 0: 160; class I: 101; class II: 18; and class III: 44) were treated (SRP: 165, SRP&DOXY: 158). SRP&DOXY resulted in better improvement of furcation involvement than SRP alone 3 months after treatment (p=0.041). However, SRP&DOXY failed to show a significant difference between both groups in the number of re-instrumentations. CONCLUSION: Single subgingival application of doxycycline in addition to SRP had a short-term effect on furcation involvement. However, it failed to reduce the frequency of re-instrumentation up to 12 months at furcation sites.

REFERENCES: 1. Clinical Periodontology- Newman, Takei, Carranza 2. Essentials of Clinical Periodontology and Periodontics- Shantipriya 3. J Am Dent Assoc 1997;128;449-455 : A review of root resective therapy as a treatment option for maxillary molars by T Hempton and C Leone 4. J Am Dent Assoc. 1976 Aug;93(2):342-5 Cervical enamel projections as an etiologic factor in furcation involvement. by Swan RH, Hurt HC 5. J Periodontol. 1997 Jul;68(7):687-93. Cervical enamel projection and intermediate bifurcational ridge correlated with molar furcation involvements by Hou GL, Tsai CC 6. J Clin Periodontol. 2009 Jun;36(6):514-22. Supportive periodontal therapy of furcation sites: non-surgical instrumentation with or without topical doxycycline by Dannevitz B, Lippert K