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Periodontology 2000, Vol.

22, 2000, 133153 Copyright C Munksgaard 2000

Printed in Denmark All rights reserved
ISSN 0906-6713

The conservative approach in the

treatment of furcation lesions

Molars are the tooth type demonstrating the highest penses of bone and tooth substance within the fur-
rate of periodontal destruction in untreated disease cation area to gain enough space for interdental
(50) and suffer the highest frequency of loss for peri- cleaning devices. Root amputation represents an-
odontal reasons (3, 72). For the purposes of this other form of resective procedure used often for con-
chapter, furcation involvement is defined as bone re- servative purposes.
sorption and attachment loss in the interradicular The conservative approach defined here com-
space that results from plaque-associated peri- prises surgical and nonsurgical treatment employed
odontal disease. Such a condition is reported to con- to debride the furcation area excluding regeneration
siderably increase the risk for tooth loss (24, 32, 57 and root separation procedures. These treatments
59, 80, 99, 102). Therefore, furcation defects repre- are sometimes accompanied by procedures that may
sent a formidable problem in the treatment of peri- change the tooth anatomy and the surrounding peri-
odontal disease, principally related to the complex odontal structures to improve access for plaque con-
and irregular anatomy of furcations. Moreover, the trol, although they do not imply crown restorations.
responsiveness to therapy may be complicated by An array of therapeutic procedures have been sug-
the presence of a greater radicular surface poten- gested by clinicians with the aim of improving the
tially offered to bacterial toxins and calculus build- prognosis of furcated teeth. The scope of this review
up, as compared to defects surrounding single-root- is to discuss the literature on the conservative ap-
ed teeth. Once the lesion has established, the dis- proaches in the treatment of furcation involvements.
crepancy in extent between the root surfaces and the
periodontal soft tissues facing the bacterial insult
may be responsible for a reduced healing response. Epidemiology
Finally, the distal location in the arch and the diffi-
cult access may conceivably impair both self-per- The prevalence of severe periodontitis has been re-
formed and professional plaque control procedures ported to vary from 5% to 20% of the different popu-
in the furcation area, limiting their effectiveness. lations investigated according to the criteria em-
The principles of therapy of furcation involvement ployed to measure extent and amount of periodontal
may be discussed under three major headings: con- destruction (70, 71).
servative, resective and regenerative. It must be Longitudinal studies conducted to describe the
borne in mind, however, that the borderline between progression of untreated periodontitis have shown
conservative and resective terms sometimes does that the majority of sites losing attachment belong
not lend itself to a sharp definition, as it is rather to a small subset of the population (13, 14, 25, 50,
difficult in a clinical setting to completely separate 52). Molars appear to be the most affected teeth (50)
conservative and resective treatments. This is espe- and the tooth type most frequently lost (3, 55, 72).
cially true for furcation involvements. Resective pro- Despite the well-documented evidence that peri-
cedures must sometimes be performed in order to odontal therapy is effective in halting disease pro-
attain a result which can eventually be considered gression (42, 49, 80), tooth loss appears to be an un-
more conservative. For instance, tunnel preparation avoidable event even in some otherwise successfully
is an example of conservative therapy carried out to treated patients, although at a considerably lower
avoid more radical and resective forms of treatment annual rate (0.050.1%) (4, 24, 32, 57, 102) compared
for class II and III furcation involvements. However, with that of untreated populations (0.140.38%) (3,
tunnel preparation is often accomplished at the ex- 11, 52, 72). Molars again represent the tooth type re-

Cattabriga et al.

sponding least favorably to therapy (36, 54, 67) and finding that moderate and severe involvements are
are at greater risk for extraction compared with other predominant in older adults, first molars being more
tooth types (24, 32, 57, 80, 99, 102). affected than second molars.
The greater rate of mortality observed with maxil- Bjorn & Hjort (6) assessed longitudinally the
lary and mandibular molars may partly be explained radiographic prevalence, degree and development of
by the presence of furcations. When the latter are bone destruction in mandibular molar furcations in
initially affected by the destruction of periodontal a sample of 221 factory workers observed over a
support, the peculiar anatomical configuration, to- period of 13 years. The prevalence of furcation in-
gether with the distal location, are likely to acceler- volvement steadily increased from an initial value of
ate the rate of disease progression, whereas the con- 18% to 32% at the end of the observation period.
trol of infection by the patient becomes more Third and second molars had higher frequencies of
troublesome. Indeed, an association between clin- advanced destruction than first molars.
ical or radiographic detection of furcation involve- Additional data are provided by investigations en-
ment, and increased risk of tooth loss has been re- rolling periodontally diseased subjects who either
peatedly demonstrated (24, 32, 5759, 80, 102). were referred for or spontaneously sought peri-
odontal care (24, 32, 57, 88, 102). Therefore, the
findings from these surveys may not be used to de-
Prevalence of furcation involvement
rive conclusions about the general population.
Sparse information is available regarding the preva- Maxillary molars are more frequently affected than
lence of naturally occurring involvement of the mo- mandibular molars, although the prevalence values
lar furcation area in the general population in epide- may greatly differ. The prevalence of involvement in
miological surveys. Most of the available data are de- the furcation area in maxillary and in mandibular
rived from studies based on observations performed molars range from 25% to 52% and from 16% to 35%,
in dry skulls (45, 46, 85, 9092, 96). These results respectively (Table 1). Svardstrom & Wennstrom (88)
must be interpreted cautiously: the number of ob- studied in detail the prevalence of furcation involve-
servations is relatively small and the anatomical ment in a group of 222 patients referred for peri-
specimens belong to populations that are ethnically odontal treatment. They reported that, from the age
and socially quite characterized. Thus, the results of 30 years onward, about 50% of molars in the max-
from these studies may not apply to other ethnic and illa show at least 1 furcation site with deep involve-
social cohorts. ment, while in the mandible a similar prevalence
In the study by Volkansky & Cleaton-Jones (96) on was first observed after the age of 40. Periodontal
43 dry mandibles of South African Bantu people destruction was most frequently observed at the dis-
30.9% of molar teeth present had furcation involve- tal aspect of the first and second maxillary molars
ment. Tal (92) examined 100 dry mandibles from (53% and 35%, respectively). In the mandible the
South African skulls and found that 85.4% of man- buccal and lingual entrances of furcations were
dibular molars presented with osseous resorption in affected with similar frequencies.
the furcation area. He reported also that the degree Furcation involvement is more frequently de-
of furcation involvement, as expressed in terms of tected in smokers (72%) than in nonsmokers (36%);
horizontal depth of the osseous defect, increased the calculated odds ratio for a smoker to have fur-
with increasing age. In a subsequent study on man- cation involvement in one molar is 4.6 (64). It has
dibular molars, Tal & Lemmer (91) confirmed the also been demonstrated that molars with crowns or

Table 1. Frequency of furcation involvement in patients referred for periodontal treatment. Adapted from
original data
Numbers (%) of molars with furcation involvement
Authors Maxillary Mandibular Diagnostic method
Hirschfeld & Wassermann (32) 858/2217 38.7% 597/2054 29.0% Clinical
McFall (57) 95/378 25.1% 60/377 15.9% Clinical
Goldman et al. (24) 454/870 52.2% 169/865 19.5% Radiographic
Wood (102) 87/205 42.4% 77/220 35.0% Radiographic/clinical

The conservative approach in the treatment of furcation lesions

Fig. 1. Influence of ill-fitting restorations in determining ically, an abscess formation in the furcation area was evi-
furcation involvement. A. Radiograph of a second man- dent. C, D. Radiograph and clinical photo showing the
dibular molar presenting with a mesial overhanging same tooth 7 years after a tunnel procedure. Note in D the
crown margin without furcation involvement. B. The overhang of the new crown, probably responsible for the
same tooth 1 year later after a new bridgework was in- furcation involvement.
serted: note the presence of furcation involvement. Clin-

proximal restorations have significantly higher per- Hamp et al. (29) have proposed the same ap-
centages of furcation involvement (5263%) com- proach as Ramfjord & Ash with the exception of
pared with molars without restorations (39%) (98) using 3 mm increments to describe the 3 classes of
(Fig. 1). involvement (Fig. 2), while Tarnow & Fletcher (93)
have proposed a subclassification which takes into
account the vertical extent of the lesion in an
Classification of furcation lesions attempt to better describe its severity.

Different clinical methods for classifying the extent Reproducibility and reliability of
of furcation involvement have been proposed. Glick-
man (23) initially devised a four-degree classification
diagnosis and diagnostic measures
based on the extent of destruction of periodontal
tissues within the furcation. Ramfjord & Ash (79)
have described an index for evaluating the depth of Vertical measurements along the roots adjacent to
involvement using 2 mm increments of periodontal furcation lesions have been shown to be reproduc-
probing measurements. With degree 1 the probe ible in facial sides of maxillary molars and in facial
penetrates horizontally between the roots up to 2 and lingual sides of mandibular molars (62). The in-
mm; with degree 2 more than 2 mm and with degree ter-examiner reproducibility, however, decreases
3 the probe penetrates the furcation all the way with increasing pocket depth and increasing root
through to the opposite entrance. separation because, as the probe penetrates deeper,

Cattabriga et al.

Fig. 2. Dry skull specimens depicting class I (A), 2 (B) and

3 (C) furcation involvements

it is more difficult to maintain contact with the root termining the extent and severity of furcation in-
surface. Reproducibility of horizontal measurements volvement shown by some of the former studies is
does not seem to be as satisfactory as with vertical noteworthy, as it has been demonstrated that clini-
recordings (62). cians base treatment options and strategies on the
The reliability of vertical measurements taken at clinical assessment of the degree of interradicular
the deepest interradicular pocket depth is very poor, destruction (65). Errors in diagnosing the extent and
however, as the probe invariably penetrates the fur- severity of furcation involvement may lead to errors
cation connective tissue to an average depth of 2.1 in the choice of treatment.
mm (63), as shown in histological sections. Other
authors have looked for a reliable correlation be-
Radiographic diagnosis
tween the clinical diagnosis of furcation involvement
and the extent of destruction visualized after flap re- Radiographic diagnosis of furcation involvement is
flection. Zappa et al. (106) used both the Ramfjord usually easier to perform in mandibular molars, as
and Hamp indices to compare horizontal clinical as- the superimposition of the palatal root on the radio-
sessments indicated in grades of severity with those graph film may conceal the actual bony morphology
recorded after surgical exposure. Regardless of the in the interradicular area in maxillary molars. Harde-
use of a calibrated or noncalibrated Nabers probe kopf et al. (30) have claimed that the identification
(Fig. 3) the results showed frequent over- and under- of a triangular radiographic shadow (furcation ar-
estimation. On the contrary, Eickholz & Staehle (19) row) on roentgenograms of maxillary molars could
and Eickholz (20) found satisfactory reliability in be a useful indicator for presence of a class 2 or 3
terms of degree of furcation involvement when com- furcation involvement. Although the association of
paring clinical presurgical and intrasurgical meas- the furcation arrow image with class 2 or 3 furcation
urements, except for disto-palatal sites where only involvement was significant mesially and bucally
moderate agreement between the two types of re- when compared with uninvolved furcations, the ab-
cordings was noted. The difficulties in accurately de- sence of the furcation arrow image did not necess-

The conservative approach in the treatment of furcation lesions

Fig. 3. Use of a curved probe (Nabers probe) for clinical margin in order to locate the furcation entrance (A).
assessment of furcation involvement. The probes tip is Subsequently the probe is moved into the interradicular
initially applied on the root trunk just under the gingival space (B).

arily mean absence of a bony furcation involvement. Nevertheless, these studies showed acceptable long-
The presence of a radiolucent interradicular area term functional survival rate for furcated molars, in-
may not always be the result of a true furcation in- dicating that the presence of furcation involvement
volvement due to periodontal reasons, as trauma is not per se a reason for assigning a questionable to
from occlusion and endodontic pathoses due to ac- hopeless prognosis to these teeth.
cessory patent canals (28) communicating with the
interradicular space may be responsible for bone re-
Studies based on tooth mortality (Table 2)
sorption resembling that occurring during peri-
odontitis. Ross & Thompson (83) followed 387 maxillary molars
Ross & Thompson (84) detected furcation involve- with radiographic evidence of furcation involvement
ment more frequently in maxillary molars by radio- in 100 patients with chronic destructive periodontal
graphic examination than clinical inspection, disease for a period ranging between 5 and 24 years.
whereas the opposite was true for mandibular mo- The treatment consisted of a combination of pro-
lars. They also observed that a more accurate fur- cedures including scaling, curettage, occlusal correc-
cation involvement diagnosis was accomplished by tion by coronal reshaping, periodontal surgery of
combining radiographic and clinical examinations. soft tissues and oral hygiene instructions. No oss-
eous surgery was performed; 305 of the 387 (84%)
molars had a questionable to poor prognosis at the
beginning of the study: at least one root with a mini-
The conservative approach mum bone loss of 50%. A total of 341 (88%) were still
in the treatment of furcation functioning efficiently without pain at the end of the
involvement study, whereas the remainder had been extracted at
various time intervals. However, 15 (33%) of the 46
Longitudinal long-term clinical surveys have shown teeth extracted had been in place for 1118 years and
that periodontal therapy is effective in halting the 10 (22%) for at least 6 years.
disease process in nearly every patient and site (18, The retrospective studies by Hirschfeld & Wasser-
27, 40, 97). These results have been achieved inde- man (32), McFall (57), Goldman et al. (24) and Wood
pendent of the type of surgical and nonsurgical ther- et al. (102) are centered on long-term observations
apy performed, provided that supportive periodontal of multiple forms of periodontal therapy. The quality
therapy was administered on a regular basis (100). of response to treatments by an individual patient
However, longitudinal prospective (36, 54, 67) and was evaluated considering the number of teeth lost
retrospective (24, 32, 57, 83, 84, 99, 102) studies during the observation period. This allowed for the
showed that, in molars with furcation involvement, classification of patients into three categories: well-
the results are not as satisfactory as those obtained maintained group (lost 03 teeth), downhill group
for single-rooted teeth or nonfurcated molars. (lost 49 teeth) and extremely downhill group (lost

Cattabriga et al.

Table 2. Molars mortality in long-term surveys on surgical and nonsurgical periodontal treatment
Tooth mortality in molars
Intervals supportive
Number of periodontal therapy/ With furcation Without furcation
Study subjects Mean years (Range) Treatment supportive periodontal care involvement involvement
Ross & Thompson (83) 100 Not available (524) Supragingival scaling, curettage, 3 months 46/387* Not available
occlusal adjustments, oral hygiene 12%
instruction, gingivoplasty,
gingivectomy, apically positioned
flap, no osseous surgery
Hirschfeld & Wasserman (32) 600 22 (1553) Subgingival scaling, gingivectomy, flap Not specified 460/1455 191/3016
surgery, root amputation, 32% 6%
hemisection, occlusal adjustments
McFall (57) 100 19 (1529) Supragingival scaling, subgingival The majority 36 months 88/155 46/600
scaling, occlusal adjustments, oral 57% 8%
hygiene instruction, gingivectomy,
gingivoplasty, ostectomy, osteoplasty
Goldman et al. (24) 211 22.2 (1534) Supragingival scaling, subgingival 36 months 270/630 190/1112
scaling, gingivectomy, gingivoplasty, 43% 17%
apically positioned flap, scaling,
curettage, occlusal adjustments
Wood et al. (102) 63 13.6 (1034) Supragingival scaling, subgingival Not specified 38/164 36/261
scaling, scaling and root planing, 23% 14%
curettage, occlusal adjustments,
gingivectomy, flap surgery, flap
curettage, osseous grafting, root
Wang et al. (99) 24 8 (8) Scaling and root planing, pocket elim- Not specified 20/87 10/78
ination surgery, modified Widman flap, 23% 13%
Surgical procedures in italics. * Only maxillary molars.
The conservative approach in the treatment of furcation lesions

1023 teeth). Such subdivision has been maintained

Without furcation
in this review to construct a table reporting tooth

Not available
mortality rate for furcated molars (Table 3).

52/66 (79)
9/18 (50)
47/80 (59)
Hirschfeld & Wasserman (32) examined retrospec-
tively the periodontal conditions of 600 patients who

had been previously treated in a private practice for

Table 3. Molars mortality rates according to individual response to treatment in long-term surveys on surgical and nonsurgical therapy
15 to 53 years (mean 22 years). A total of 76.5% of

With furcation
the patients had been initially classified as having

75/88 (85)
31/34 (91)
77/82 (94)
5/10 (50)
advanced periodontal disease, whereas 16.5% had

Extremely downhill
disease of intermediate severity and only 7% ex-

hibited early signs of periodontitis. The periodontal
treatment rendered throughout the years consisted


21 (10)
Without furcation No. of
of subgingival scaling, gingivectomy and flap

25 (4)
8 (8)

2 (3)
surgery. Root amputation (17 teeth) or hemisections
were performed as well. Patients were subjected to
periodic maintenance, and subgingival scaling was

Not available
carried out when deemed necessary. Evaluation of

94/303 (31)

98/261 (37)
12/52 (23)
response to therapy was based on the number of
teeth lost during the observation period. The well-

maintained group accounted for 499 (83.2%), the
downhill group 76 (12.6%) and the extremely down-

With furcation

165/235 (70)

137/206 (66)
hill group 25 (4.2%) of the sample investigated. Al-

39/56 (70)

12/28 (43)
though the majority of patients had been initially
classified as having advanced disease, most of them

responded favorably to therapy, leaving a small sub-
group of patients whose periodontal condition con- Downhill


76 (13)
15 (15)
59 (28)
7 (11)
tinued deteriorating despite treatment. These data Without furcation No. of

confirmed epidemiological findings reported from
studies on the natural course of the disease, attesting
that a small subfraction of the population accounts

Not available
for the majority of periodontal destruction recorded

46/2647 (2)
25/530 (5)
45/771 (6)
(13, 14, 50, 52). During the maintenance phase, 7.1%
of all teeth were lost for periodontal causes; 460 of

1455 (31.6%) molars presenting with furcation in-

volvement were lost, the majority belonging to the
With furcation

219/1132 (19)

downhill and extremely downhill groups, whereas


56/335 (17)
21/126 (17)
18/65 (28)

only 19.3% belonged to the well-maintained group.

Overall, the proportion of lost molars with furcation
Well maintained


involvement was about 5-fold that of molars without

furcation involvement.

499 (83)
77 (77)
131 (62)
54 (86)

McFall (57) analyzed a sample of 100 patients who

No. of

had been treated and maintained for 15 years or


longer (average duration 19 years, range 15 to 29

years). Severity of periodontal disease was classified
Hirschfeld & Wasserman (32)

according to the criteria of Hirschfeld & Wasserman

(32): 36 of 100 were diagnosed as having advanced
Adapted from original data.

disease, 53 presented with intermediate degree of se-

Goldman et al. (24)
Wood et al. (102)

verity and 11 had early signs of disease. Therefore, this

study population contained fewer advanced cases
McFall (57)

than those monitored by Hirschfeld & Wasserman

(32). All patients were treated similarly during the

period of initial preparation with supragingival and

subgingival scaling, occlusal adjustment and oral hy-

Cattabriga et al.

giene instruction. Treatment consisted primarily of contouring, osseous grafting and root amputation.
gingivectomy and gingivoplasty. Infrabony defects Maintenance intervals differed greatly among pa-
were treated with ostectomy and osteoplasty where tients, from 6 to 9 months. According to response
pocket elimination was deemed feasible. Root ampu- to therapy patients were divided as follows: well-
tation was performed on only 5 teeth. Other molars maintained group 54 (85.7%), downhill group 7
with furcation involvement were treated surgically or (11.1%) and extremely downhill group 2 (3.2%). Dur-
maintained with open or closed curettage. The ma- ing the maintenance period, 5% of teeth initially
jority of the patients had been under a maintenance present were lost due to progressing periodontal de-
regime at 3-, 4- or 6-month intervals. During this struction. Thirty-eight (23.2%) of the initially fur-
period, when indicated, patients were rescheduled for cated teeth were lost. In the well-maintained group,
surgical procedures. The study population, divided on 21 of 126 (16.6%) teeth with furcation involvement
the basis of tooth loss, was distributed in the following were lost. Among the 261 molars without furcation
manner: well-maintained group 77, downhill group involvement, 36 were extracted (13.8%).
15 and extremely downhill group 8. Periodontal dis- In a study on 24 patients treated either with mech-
ease was the cause of 259 teeth (9.8%) lost; 56.7% of anical or surgical procedures, Wang et al. (99) dem-
teeth with furcation involvement were lost during the onstrated that molars with furcation involvement
observation period, and the well-maintained group were 2.54 times more likely to be lost compared with
had only 27% of the furcation involvement teeth ex- teeth without furcation involvement during the 8-
tracted. Of 600 molars without furcation involvement, year maintenance period.
only 46 (7.6%) were lost. Remarkably, molars with fur- The above-mentioned longitudinal studies reveal
cation involvement had functioned before extraction that molars with furcation involvement are definitely
for an average of 14 years, 10.5 years and 9 years in the more prone to loss than nonfurcated molars (Table
well-maintained, downhill and extremely downhill 2). However, the number of molars having furcation
groups, respectively. involvement lost for periodontal reasons may be
Goldman et al. (24) examined the clinical records of lower, as some teeth, mainly third molars, might
211 patients treated and maintained for 15 to 34 years have been extracted for other causes related to the
(average time 22.2 years). Treatment rendered con- accomplishment of comprehensive treatment plans,
sisted of supragingival and subgingival scaling, oral such as extrusion due to absence of the antagonist
hygiene instruction and occlusal adjustment when tooth or poor compatibility with prosthetic recon-
needed. Surgery consisted mainly of gingivectomy or struction. On the other hand, some furcated molars
gingivoplasty, and in few cases a flap or open curet- were extracted in these studies at the commence-
tage was performed. According to their response to ment of treatment and hence were not included in
treatment, patients were classified as follows: well- the computation of survival rates. Moreover, the
maintained group 131 (62%), downhill group 59 presence of furcation involvement might have been
(28%), and extremely downhill group 21 (10%). At no overlooked due to diagnostic misjudgment. There-
time was osseous tissue removed. Furcations were fore the figures reported in the surveys may not cor-
treated by gingivectomy or gingivoplasty or an apic- respond to the actual mortality rates for molars with
ally positioned flap and maintained by scaling and furcation involvement.
curettage. In only five cases was root amputation per- The percentages of initially furcated molars lost
formed. Of the teeth initially present, 13.4% were lost. during the observation periods of the studies varied
Of 630 teeth with initially diagnosed furcation in- from 11.8% to 56.7% (24, 32, 57, 83, 99, 102). However,
volvement, 270 were extracted (43.5%), whereas in the the well-maintained groups, representing the vast
well-maintained group the number of lost teeth majority of the patients enrolled in the surveys (rang-
having furcation involvement was 56 of 335 (16.7%). ing from 62% to 85.7%), had considerably lower rates
Among nonfurcated molars, 190 of 1112 (17.0%) were of molars with furcation involvement extracted
lost during the study. (16.7% to 27.3%) compared with patients in the ill-re-
Wood et al. (102) studied 63 patients who had re- sponding groups (Table 3). This finding is in accord-
ceived periodontal treatment for at least 10 years ance with the assumptions that the majority of pa-
previously (average duration 13.6 years, range 10 tients in these studies, probably because of lower sus-
34). Therapy consisted initially of supragingival and ceptibility to disease or effective plaque control,
subgingival scaling accompanied by oral hygiene in- responded well to periodontal treatment. Thus, mo-
structions. Subsequent surgical therapy included lars with furcation involvement do not seem to be
gingivectomy, flap surgery, flap curettage, osseous necessarily associated with a questionable prognosis,

The conservative approach in the treatment of furcation lesions

because most of them remained in the well-main- mortality. Shorter prospective studies, owing to the
tained groups for many years. Moreover, many of the limited duration of the period of investigation, have
lost furcated molars had been claimed to function focused on the response to treatment based on
well for a considerable length of time before their ex- measurements of clinical parameters such as attach-
traction. However, despite the tenet that furcated ment level and pocket depth rather than tooth mor-
teeth can be successfully treated and maintained in tality. A few studies have also investigated the effects
compliant and less susceptible individuals, the pres- of periodontal therapy on the subgingival microflora
ence of furcation involvement must still be con- and the distribution of calculus deposits.
sidered a true risk factor, as clearly shown by the cal- Two 2-year prospective studies (54, 67) investi-
culation, for each response-to-treatment category, of gated the effects of root debridement and plaque
the odds ratios for extraction between molars with control in adult periodontitis patients. Molar fur-
and without furcation involvement in the long-term cation sites responded less favorably to treatment
studies from which data for such computations are compared with molar flat surfaces and non-molar
available (24, 32, 57). The meta-analysis (Table 4) sites. This was revealed by higher mean bleeding on
clearly indicates that furcated teeth have significantly probing scores, higher mean loss of attachment and
greater chances to be lost than nonfurcated molars, less reduction of probing depth. Among the deepest
regardless of the response to treatment, with the sole sites (initially 7 mm), 2138% of molar furcations
exception of the extremely downhill group in the sur- lost attachment as compared with 1.77% of the mo-
vey by Hirschfeld & Wasserman (32). lar flat surfaces and 611% of the non-molar sites.
Unfortunately, no long-term investigation re- Similar trends have been observed in other indepen-
ported in Table 2 provides data about the frequency dent researches. Kaldahl et al. (36) found that fur-
distributions of furcation involvement according to cations of molar teeth always responded less favor-
the extent and severity of destruction nor do they ably than other site groupings to surgical peri-
report as to the choice of treatment in relation to the odontal therapy in terms of attachment level
degree of involvement. It is therefore impossible to measurements, regardless of the initial probing
draw any conclusion from these articles about the depth. Finally, Wang et al. (99) reported that during 8
efficacy of the various periodontal treatments ap- years of supportive periodontal therapy, molars with
plied in accordance with the initially diagnosed se- furcation involvement lost an average of 1.24 mm
verity of involvement. More recently, other studies in attachment level, while molars without furcation
have been carried out to investigate the effectiveness involvement lost only 0.6 mm.
of specific periodontal treatments on furcations with The comparatively poorer clinical response of mo-
different degrees of destruction. This issue is dis- lar furcated sites is also reflected in the microbiologi-
cussed in another section. cal outcome observed in a study conducted by Loos
et al. (53). These authors monitored for 52 weeks the
clinical and microbiological effects of plaque control
Studies based on clinical measurements, microbial and root debridement with ultrasonics at 24 non-
parameters and efficacy of root instrumentation
molar sites and at 31 grade II molar furcation sites
The above-mentioned retrospective longitudinal with probing depth 5 mm in 11 patients. Through-
studies have all based their conclusions on tooth out the study, numbers and percentages of spiro-

Table 4. Odds ratio for extraction between furcated and nonfurcated molars calculated for each
response-to-treatment category using data from Table 3
Study Well maintained Downhill Extremely downhill
Hirschfeld & Wasserman (32) Odds ratio 13.56 5.24 1.55
95% confidence interval 10.3917.66 3.049.01 1.421.68
z 19.35* 5.98* 1.04
McFall (57) Odds ratio 7.73 7.64 10.33
95% confidence interval 4.2614.01 3.3517.41 2.6340.44
z 6.74* 4.84* 3.35*
Goldman et al. (24) Odds ratio 3.23 3.30 10.81
95% confidence interval 2.164.83 2.264.80 4.4626.15
z 5.73* 6.21* 5.28*
* P0.05.

Cattabriga et al.

chetes, total anaerobic colony-forming units and mon finding. In a study conducted by Bower (8),
numbers of Porphyromonas gingivalis were always the furcation entrance diameter in a sample of 114
higher in furcations than in non-molar sites. This maxillary and 103 mandibular first molars was
finding may be accounted for by the difficulty in found to be narrower than the width of commonly
achieving complete debridement in furcation sites. used periodontal curettes in 58% of the furcations
Indeed, it has been demonstrated that more residual examined. A later study by Chiu et al. (17) found
calculus is left after debridement in furcation areas in 185 Chinese first maxillary molars that furcation
than on other root surfaces (22, 73, 74, 101). Parashis entrance dimension 0.75 mm were present in
et al. (74) studying 30 mandibular molars scheduled 79% of buccal, 39% of mesial and 43% of distal en-
for extractions with class II and III furcation involve- trances. In 178 mandibular molars, furcation en-
ment and Calculus Index 2 (78) showed that the trances 0.75 mm were detected in 36% and 47%
mean values of residual calculus were statistically of buccal and lingual aspects, respectively. Half of
lower for the external surfaces than for furcation all furcation entrance dimensions of these first
areas when using a closed approach. molars were less than the blade width of a new
Gracey curette. Hou et al. (35) examined the fur-
cation entrance dimension of 89 Chinese maxillary
The influence of furcation anatomy
molars (49 first and 40 second molars) and 93
The reduced rate of success experienced with the mandibular molars (50 first and 43 second). The
conservative approach in the treatment of furcation majority of furcation entrances in second molars
involvement seems to result from the incomplete re- had smaller dimensions than the width of a Gracey
moval of hard and soft debris present in the interrad- curette (0.76 mm), although they were larger than
icular area owing to the peculiar anatomy of the fur- the average dimension of a new standard ultra-
cation space (cervical enamel projections, bifurca- sonic tip. Ultrasonic inserts may then have easier
tion ridges, convexities, concavities and furcation access to furcation areas than curette blades, espe-
entrance dimension) (8, 9, 17, 3335, 87). cially in deep furcation involvements. Such as-
Svardstrom & Wennstrom (87) have described in sumption is in accordance with the clinical and
detail the topography of the furcation area in the microbiological results reported by Leon & Vogel
maxillary and mandibular first molars. By im- (48), who compared hand versus ultrasonic de-
plementing a photogrammetric method, these bridement in class I, II and III furcation involve-
authors plotted the interradicular area to obtain ments by assessing gingival crevicular fluid flow
three-dimensional contour maps. The complexity of and the composition of the subgingival microflora
the internal surfaces of the furcation areas was out- using dark-field microscopy. While in class I both
lined showing an array of small peaks, ridges and treatments were equally effective, ultrasonic instru-
pits. ments proved more effective than hand scaling in
Bower (9) found that, in maxillary first molars, the reducing gingival fluid flow and bacterial pro-
furcal aspect of the root was concave in 94% of portions of spirochetes and other motile organisms
mesiobuccal roots, 31% of distobuccal roots and 17% in class II and III. This finding substantiates the
of palatal roots. Moreover, he observed that the con- results reported by Matia et al. (56), who found
cavity of the furcal aspect was present in 100% and significantly more residual calculus in furcations
99% of mandibular mesial and distal roots, respec- 2.3 mm wide after debridement with curettes
tively. Once the plaque front has reached the fur- than with ultrasonic scalers.
cation area, these configurations render the cleans- Therefore, efforts have been made to construct
ing procedures quite awkward. specially designed ultrasonic tips to improve accessi-
Furcation entrance dimension is of paramount bility to the innermost areas of the interradicular
importance for successful therapy, as it influences space. In vitro studies have tested different sonic and
the feasibility of gaining access to the interradicular ultrasonic tips devised to gain access in the furcation
area with mechanical instruments, as shown by Mat- area, reporting satisfactory results in terms of arti-
ia et al. (56) and Parashis et al. (74), who found that ficial calculus removal (43, 69, 75, 89). Longitudinal
the amount of residual calculus was related to the controlled clinical trials based on the use of these
width of the furcation entrance when open root new instruments are needed to show their ultimate
planing was performed. effectiveness in vivo. However, improvement in cal-
Furcation entrances that are not amenable to culus elimination in furcations with entrance dimen-
access by mechanical instruments are a quite com- sion of 2.4 mm has been also attained by utilizing

The conservative approach in the treatment of furcation lesions

a rotary diamond bur, thus circumventing the com- the dimension of the furcation entrance, open de-
plications related to the presence of narrow furcation bridement with ultrasonics left significantly less cal-
entrances (73, 74). culus than curettes in entrances measuring 2.3
mm. Similarly, Fleischer et al. (22) assessed the post-
extraction amounts of residual calculus after a single
session of scaling and root planing with or without
Methods and techniques of surgical access performed by operators with two dif-
conservative therapy ferent skill levels. Among more experienced oper-
ators, open root planing left more furcations free of
The long-term retrospective clinical studies reviewed calculus than closed debridement (68% versus 44%),
above (Table 2) employed a vast array of surgical and but this difference did not reach statistical signifi-
nonsurgical procedures. Unfortunately, as noted be- cance. When these procedures were performed by
fore, no information is available on the application the less experienced dentists, furcations occurred
and outcome of the various techniques according to significantly more frequently with flap access than
the clinically diagnosed degree of involvement, pre- following closed debridement (43% versus 8%).
cluding the possibility of drawing conclusions about Thus, the level of experience seems to play an ad-
the proficiency of each procedure in the different ditional role in furcation debridement, as the more
types of destruction in furcations. The following sec- skilled periodontists achieved calculus-free furcation
tions will discuss the effect of surgical and nonsurgi- surfaces more often than the less experienced oper-
cal procedures, chemotherapy and the more invasive ators, regardless of the type of approach, although a
tunnel preparation and root amputation. significant difference was noted only for those
lesions treated with closed root planing. No infor-
mation was provided by Fleischer et al. (22) concern-
Surgical and nonsurgical procedures
ing the type and distribution of the furcal defects to
Few short-term studies are available for compari- be treated. Parashis et al. (73, 74) evaluated in detail
sons of different forms of conservative techniques in the efficacy of calculus removal in class II and III
the treatment of selected furcation lesions. The ef- furcations achieved by scaling and root planing with
fectiveness of the various surgical and nonsurgical or without surgical access. A third approach com-
approaches employed has been studied in regard to prised the use of a rotary diamond bur to remove
the residual amount of subgingival calculus (22, 56, calculus deposits in the furcation area after surgical
73, 74, 103, 104), clinical parameters (38, 86, 99), and exposure. This combined treatment was best in re-
interradicular bone density changes (10, 76). Other moving calculus from furcations, especially in the
studies have used mechanical debridement as a flute area and when the furcation entrance meas-
positive control to determine whether any possible ured 2.4 mm. The studies by Matia et al. (56), Wy-
adjunctive effect could be derived from the use of lam et al. (103, 104), Fleischer et al. (22) and Parashis
locally delivered antibiotic therapy beyond that of et al. (73, 74) were conducted on molars proposed
root planing alone (61, 66, 68, 94). for extraction, characterized by the presence of se-
A preliminary report by Wylam et al. (103) demon- vere bone destruction and heavy calculus deposits.
strated the inadequacy of root planing with or with- Whether the results reported in these articles are ap-
out surgical access in grade II and III furcation areas plicable to molars with less dramatic furcation in-
of condemned teeth: residual plaque and calculus volvements and calculus accretions has not yet been
were found in 89% and 95% of surgically and non- established by other investigations.
surgically treated molars. A later article by the same It can be concluded that experienced operators re-
authors (104) reported that residual calculus de- move more calculus than those with less skill. In ad-
posits covered on average 93.2% (range 79.2100%) dition, the open approach proves more efficacious at
and 91.1% (range 77.4100%) of furcal root surfaces removing calculus deposits from the furcation area,
after closed and open instrumentation, respectively. especially when combined with the use of a dia-
In contrast, Matia et al. (56) found significantly mond bur.
more residual calculus after closed than open root However, the seemingly more beneficial results
planing in furcated molars with deep lesions (class achieved with the combination of root planing and
II and III). No difference was observed between the access surgery in terms of calculus removal demon-
use of ultrasonic scalers and curettes in either group. strated by Matia et al. (56), Parashis et al. (73, 74)
However, when the data were stratified according to and Fleischer et al. (22) are not accompanied by a

Cattabriga et al.

corresponding superiority when dealing with clinical The more favorable clinical outcome in terms of
parameters, as demonstrated by Kalkwarf et al. (38), clinical attachment level observed by some investi-
Schroer et al. (86) and Wang et al. (99). gators with closed debridement has also been corro-
Kalkwarf et al. (38) evaluated the clinical response borated by studies aiming at assessing the quantitat-
of furcation regions to four types of periodontal ther- ive densitometric changes of alveolar bone within
apy: supragingival scaling, root planing, modified furcation areas either subjected to scaling and root
Widman flap surgery or flap surgery with ostectomy. planing or exposed to flap surgery (10, 76).
Flap surgery with concomitant bone resection was Payot et al. (76) treated class I or II furcation in-
significantly better at reducing pocket depth than volvement with either subgingival curettage or
the other procedures, producing a mean decrease of modified Widman flap or by furcation osteoplasty.
1.65 mm. Conversely, it was the only type of treat- All 3 procedures resulted in an initial loss of density
ment to produce a mean vertical attachment level in the superficial layer of interradicular bone during
loss (0.36 mm) at the end of the 2-year observation the first 2 months following treatment. The loss was
period. Supragingival scaling, root planing and then followed by a statistically significant recovery,
modified Widman flap surgery demonstrated gain in which became a net gain in density 1 year post-oper-
probing attachment of 0.32 mm, 0.44 mm and 0.4 atively only for sites treated by curettage. Likewise,
mm, respectively. All procedures, except root plan- bone loss was initially found in the profound layer
ing, caused a loss of horizontal probing attachment after the two surgical procedures. However, a sig-
in furcations. The loss associated with osseous nificant net gain in density was detected at the end
surgery was significantly greater (0.51 mm) than of the study, 1 year after therapy.
those created by supragingival scaling (0.13 mm) and Equivalent results were reported by Bragger et
modified Widman flap (0.14 mm). The best results al. (10). Loss of bone density occurred readily after
for attachment levels (vertical and horizontal) and surgical exposure, whereas a gain was recognized
pocket depths were recorded within the first year for furcation sites treated by closed root planing,
post-operatively. Despite the limited reduction of denoting a statistically significant difference be-
pocket depths compared with the surgical pro- tween the two treatments. However, bone density
cedures, root planing proved more efficacious in pre- levels were shown to be of comparable magnitude
serving both vertical and horizontal attachment in surgical and nonsurgical sites 1 year post-oper-
levels in furcations, and even produced gains in atively.
some sites. Interestingly, the implementation of oss- In conclusion, although scaling and root planing
eous surgery brought about the extraction of a re- combined with flap surgery is more effective at re-
markable number (n55) of furcated molars com- moving calculus, the clinical evaluations do not indi-
pared to other procedures. On the other hand, the cate a dramatic difference between surgical and
remaining furcations, once treated with bone re- nonsurgical treatments irrespective of the degree of
sective surgery, yielded a lower percentage of sites furcation involvement. Rather, closed scaling and
demonstrating clinically significant breakdown dur- root planing proves more effective at preserving the
ing the 2 years of maintenance. This may derive from existing attachment level, together with producing a
the apical positioning of the gingival margin, where- more expeditious bone remineralization, although
by a facilitated cleansibility of the furcation entrance these phenomena are accompanied by a lesser re-
was attained. duction in pocket depth. The equivalence in clinical
Schroer et al. (86) investigated attachment level efficacy between closed and open procedures may
and probing depth change of closed versus open de- be attributed to the procedure, operator variables,
bridement in facial class II molar furcations. At 16 compliance with professional recommendations, the
months, both procedures had reduced pocket depth initial risk of the patient or, most likely, to a combi-
by 1.21.5 mm. A mean gain in attachment level nation of these factors.
from baseline was observed after closed subgingival A few studies are also available to compare the
scaling (0.6 mm), whereas treated furcations lost effects of conservative treatment (open debride-
attachment (0.46 mm). However, this difference ment) following surgical access used as a positive
did not reach statistical significance. Similarly, Wang control, with those of some selected regenerative
et al. (99) reported no statistically significant differ- procedures (39, 77, 105). Allografts such as porous
ence in attachment levels changes following either hydroxyapatite (39) or tricalcium phosphate in com-
pocket elimination surgery, curettage or modified bination with doxycycline (77) and collagen mem-
Widman flap. branes (105) produced greater pocket reduction and

The conservative approach in the treatment of furcation lesions

defect fill than surgical debridement alone in class II initial counts, although a slight return towards
and III furcation defects. baseline values was noticeable. Very recent data by
Tonetti et al. (94) show that tetracycline-containing
fibers exert a significant adjunctive pocket depth
and bleeding reduction over that produced by scal-
The difficulties of performing adequate debridement ing and root planing alone, although this finding is
in furcations by mechanical means has prompted confined only to the first 3 months following fiber
experimentation with chemotherapeutic agents in insertion. No difference between treatments could
these areas. Needleman & Watts (66) tested the ad- be observed, however, at the 6-month follow-up
junctive effect of 1% metronidazole gel irrigation visit, except for the significant greater number of
into furcation areas with class II and III involve- sites presenting with a pocket depth reduction 2
ments during periodontal maintenance with subgin- mm in the group receiving both scaling and root
gival scaling. Clinically, no further improvement was planing and fiber therapy. In summary, aside from
seen for the furcations treated with metronidazole. a significant short-term anti-inflammatory effect
Likewise, lack of adjunctive effect exerted by the me- mirrored by the increased reduction in bleeding
tronidazole gel was reported for proportions of upon probing, tetracycline in slow-delivery devices
spirochetes, motile rods and cocci observed with does not seem to greatly enhance or prolong the
dark-field microscopy. effectiveness of commonly used subgingival de-
Nylund & Egelberg (68) evaluated the thera- bridement in class II furcations.
peutic effects of subgingival irrigation with tetracy- Overall, the results from the studies above do not
cline as a supplement to mechanical debridement lend clear acceptance to the implementation of ad-
in furcations with class I, II and III involvements. junctive local drug therapy in furcation involve-
The professional irrigation of 50 mg/ml tetracy- ments, regardless of the degree of severity.
cline solution was performed every second week
for 3 months. One-year evaluation of attachment
Tunnel procedure
levels and pocket depths showed similar clinically
negligible (1 mm) variation in both tetracycline- The tunnel preparation of multi-rooted teeth is a
and saline-irrigated furcations. It may be therefore very conservative approach in the treatment of class
concluded from these studies that sporadic, un- II and III furcation involvement (Fig. 4). The objec-
controlled local delivery of antibiotic substances is tive of this treatment is to obtain the possibility of
unlikely to exert any supplemental effect over that cleaning the furcal area by the patient using an inter-
produced by subgingival mechanical treatment. dental toothbrush (29). The main advantage of this
Consequently, Minabe et al. (61) immobilized te- technique is the avoidance of prosthetic reconstruc-
tracycline in a cross-linked collagen film to obtain tion and, for mandibular molars, endodontic ther-
a slow, sustained release of the drug. The film has apy. Unfortunately, tunnel preparation can be util-
been subsequently used alone or in conjunction ized only when the furcation entrance dimension is
with root planing in furcation class II involvements wide enough and coronally located to allow for an
in a controlled randomized clinical trial. A dra- easy utilization of cleaning devices. These anatomi-
matic decrease in frequency of sites bleeding on cal restrictions limit use of this technique mainly to
probing was noted in the group treated with a mandibular first molars, even if it can be im-
combination of tetracycline and mechanical de- plemented sometimes in maxillary molars (31). In
bridement. The magnitude of reduction was sig- this situation, however, one of the three roots may
nificantly greater than that produced by either root have to be resected to improve accessibility to the
planing or tetracycline film alone throughout the furcation area.
study period (8 weeks). Probing attachment levels Very few studies have investigated the possibilities
and pocket depths were similarly reduced by the of tunnel preparations. In a 5-year longitudinal
three treatment regimens. Likewise, comparable study, Hamp et al. (29) found that four of seven teeth
decreases in the three groups were observed for treated with this technique developed root caries,
total microbial counts and proportions of spiro- and three of them had been extracted during the ob-
chetes, which dropped from pre-operative values servation time.
of 1017% to proportions of 23% at the end of ac- Hellden et al. (31) evaluated in a retrospective
tive treatment (4 weeks). At 8 weeks, spirochetes in study the clinical outcome of tunnel preparations in
all three treatment groups were still far below the 102 patients (149 teeth) for a mean observation time

Cattabriga et al.

Fig. 4. A. Pre-operative radiograph of a first mandibular

molar with a class 3 furcation involvement plus a distal
infrabony defect. B. Buccal mirror view of a tunnel prep-
aration following a flap procedure. Note the sutures
placed in the interradicular space to keep the gingival
tissues as far apically as possible from the dome of the
furcation. C. One-year postoperative radiograph showing
healing of the distal infrabony defect and no caries in the
furcation area. D, E. Clinical pictures (mirror view) show-
ing the healing of gingival tissues and the use of an inter-
radicular cleaning aid (SuperflossA).

of 37.5 months (range 10 to 107 months). Sixty-three previously reported by Hamp et al. (29) and could
maxillary and 35 mandibular first molars were the therefore be considered a valid treatment alternative.
most treated teeth. Fluoride prophylaxis was per- However, this is not an evidence-based conclusion
formed after tunneling in the furcation areas. Ten but rather only a proof of principle. To what extent
teeth (7%) were extracted and 7 teeth (5%) were re- the procedure is better or worse than other forms of
treated by hemisection. In 12 of these 17 teeth, the conservative treatment cannot be said until a ran-
extractions and hemisections had been performed domized controlled clinical trial is performed.
because of root caries. Among the remaining 132 It could be argued that the shorter mean obser-
teeth, 23 (15%) showed initial or established caries. vation time could account for the relatively lower
As approximately 75% of the treated teeth were still percentage of new root carious lesions reported by
caries-free and in function at the end of the obser- Hellden et al. (31) when comparing their results to
vation period, the authors opined that tunnel prep- those of Hamp et al. (29). However, the former
arations had a considerably better prognosis than authors observed an increase root carious lesions

The conservative approach in the treatment of furcation lesions

development mostly during the initial 19 months of Concluding remarks

the follow-up period. This is in agreement with data
reported by Ravald & Hamp (81) and Ravald et al. O The studies reviewed here have shed new light on
(82), who demonstrated that following periodontal the topic, transforming our therapeutic concepts
surgery the development of root caries mostly occurs and prognostic paradigms regarding the manage-
within 2 years after treatment. The results obtained ment of furcation lesions.
by Hellden et al. (31) in relation to root caries devel- O No data are to date available to infer that any of
opment could be due to the fluoride prophylaxis the various approaches advocated for treatment
performed by the patients in the furcations. In a re- of furcation lesions is to be preferred because it
cent study (51), the possibility of a tunnel prepara- produces better long-term results in terms of
tion procedure has been evaluated in 18 subjects, functional survival. Likewise, studies comparing
each having a molar with Glickman class II or III fur- the effects of different approaches within the
cation involvement, who were followed for a mean same subject are lacking.
observation time of 5.8 years. The treated teeth were O Retrospective long-term studies based on tooth
five maxillary and 13 mandibular molars. At the end mortality demonstrated that teeth with initial fur-
of the observation period, root caries was detected cation involvement can have a remarkable sur-
in only three teeth (16.7%) confirming the results ob- vival rate following conservative treatments in pa-
tained by Hellden et al. (31). In addition, no differ- tients responding well to treatment.
ence was found in attachment level and in radio- O However, furcated teeth are lost in higher pro-
graphic bone evaluation in surgically tunneled man- portions as compared with single-rooted teeth or
dibular molars compared with adjacent sites treated with nonfurcated molars. The same trend has
by osseous surgery. been shown in studies based on clinical par-
ameters, comparing the outcome of treatment be-
tween teeth with furcation involvement with mo-
lar flat surfaces and single-rooted teeth (36, 54, 67,
Root amputation
Root amputation is a technique used in maxillary O These results could have been caused by the dif-
molars by removing one of the three roots in order ficulties in obtaining adequate debridement in
to eliminate the furcation problem and to achieve teeth with furcation involvement. The peculiar
good access for proper plaque control. As this tech- anatomy of the area and the dimensions of the
nique can be applied without gross changes in tooth entrance diameter seems to be the reason for the
anatomy and without prosthetic reconstruction, it possible presence in furcations of residual
can be considered a conservative approach to treat amounts of subgingival plaque (53) and calculus
the furcation involvement. This technique was intro- (56, 73, 74). In this regard, more effective debride-
duced by Farrar in 1884 (21) and reintroduced by ment was achieved in class II and III furcation in-
Messinger & Orban in 1954 (60). It has been advo- volvement when surgical access was provided and
cated for use in combined periodontal-endodontic ultrasonic scalers or rotary diamond burs were
lesions (95) as well as bone loss related only to peri- implemented (48, 56, 73, 74).
odontitis (1). Only a few studies have followed the O However, the clinical outcome of surgical and
clinical course following root removal. Green fol- nonsurgical approaches is comparable in long-
lowed 122 cases of molar hemisection or root ampu- term as well as in short-term longitudinal studies.
tation for up to 25 years. In this group, 41 of 101 In some instances closed root planing has been
maxillary molars that received root amputation were shown to better preserve clinical attachment
removed, most before 8 years (26). The cause of loss levels (38, 86) and exert faster remineralization of
in almost every case was continuing breakdown of the interradicular alveolar bone (10, 76).
periodontal bone in spite of good oral hygiene and O The above-mentioned studies show that the in-
careful plaque control on the part of these patients. complete removal of subgingival debris in fur-
Patients in a second study fared better, with 33 of 34 cations using conservative treatments may not af-
maxillary molars surviving for 11 to 84 months after fect the clinical and biological response on an in-
root amputation (41). Clinical experience has shown dividual site and patient basis. On the site level,
that this procedure is often an interim step and that the procedure utilized during the conservative ap-
a large percentage of these teeth fail within a few proach may have enhanced both self-performed
years of root removal. and professionally performed plaque control. On

Cattabriga et al.

the patient level, the favorable response to treat- up. However, the well-maintained groups, repre-
ment of most subjects observed in the long-term senting the vast majority of the patients in long-
retrospective studies (well-maintained groups) to- term retrospective studies based on a conservative
gether with the long functional survival rate of approach, have shown, in a much longer obser-
most furcated molars may be related to adequate vation period, a tooth mortality of furcation in-
plaque control and low susceptibility to disease in volvement molars ranging from 16.7% to 27.7%
the majority of periodontal patients, thus explain- (Table 3). These rates are much lower than those
ing the long-standing acceptable results of treat- reported by the majority of the studies based on
ment. On the other hand, the specific procedures root separation or resection for a considerably
employed and the severity of furcation involve- shorter time. These findings lead to the con-
ments were not taken into account in these sur- clusion that the conservative approach for fur-
veys. This made it impossible to relate the type of cation involvement teeth can be performed in the
treatment applied to the degree of involvement in majority of patients with the expectation of a high
the evaluation of the outcome of therapy. long-term survival rate for the patients demon-
O A very limited number of studies have been per- strating an overall satisfactory response to con-
formed on tunnel preparation, with differing re- ventional periodontal treatment (Fig. 5).
sults. However, the study by Hellden et al. (31),
who enrolled a considerable number of patients,
demonstrated promising results, although the
mean observation time was limited. Moreover, Establishing prognosis
long-term prospective and controlled studies on
this technique are needed to corroborate these The prognosis of furcated teeth treated by conserva-
findings. tive approach lends itself to a moderate degree of
O Very little information is available on root ampu- optimism, bearing in mind, however, that the pres-
tations and odontoplasty. However, root ampu- ence of interradicular alveolar bone destruction may
tation has not been extensively used in clinical still be considered a local risk factor for tooth loss
long-term studies. Therefore, caution must be ex- (58, 59) (Table 4).
ercised when interpreting the limited published Other local factors may accelerate the rate of dis-
data. ease progression, thus increasing the risk for exfoli-
O The use of drugs does not seem to add long-term ation of furcated teeth: restorations (98) and smok-
advantages to the benefits obtainable by root ing habits (64) have been shown to be positively cor-
planing alone. However, the encouraging short- related with the presence of furcation involvement,
term reduction in bleeding on probing and pocket while mobile furcated molars are at greater risk for
depth observed by Tonetti et al. (94) indicates that loss of attachment in the furcation area (99).
high concentrations of an antimicrobial drug A few risk factors have been identified in the
combined with conventional treatment have the literature to play a role in the fate of treated furcated
potential of improving the clinical response at fur- teeth. Advanced periodontal disease (7) and smoking
cation sites, during supportive periodontal care. have generally been shown to influence the outcome
O Even if the management of furcation involvement of therapy in conservative and resective treatments
teeth with a conservative approach does not yield (7, 37). Such factors must be kept in mind by the
the same satisfactory results as with single-rooted clinician in that their suppression or reduction may
teeth or molar flat surfaces, the alternative treat- greatly improve the prognosis of furcated teeth.
ments based on resection or regeneration are not Moreover, genetic testing for inflammatory modifiers
much more promising. Studies on regeneration (44) may be helpful to guide treatment planning and
have shown the unpredictability of complete clo- prognosis for the different approaches according to
sure of furcation involvement (16). Some reports the individual response to treatment.
on root resection or root separation have shown Once the identified risk factors are ameliorated or
remarkably low failure rates (48%) (2, 5, 15), al- eliminated, the clinician may consider the conserva-
though other long-term studies demonstrated tive approach as a first option. Frequent monitoring
definitely less favorable results with such therapy, during supportive periodontal treatment is import-
tooth mortality ranging after 10 years between 32 ant to ensure the stability of the periodontal struc-
38% (12, 26, 47), while Langer et al. (47) reported tures within furcations. If recurrence appears, ad-
a total failure rate of 51% after 20 years of follow- ditional care, including new instrumentation, local

The conservative approach in the treatment of furcation lesions

Fig. 5. A, B. Clinical pictures taken in 1980 from a patient

with generalized periodontal destruction. The patient was
treated by scaling and root planing under local anesthesia
and refused surgical treatment. C, D. Clinical pictures of
the same patient 17 years later. Note the good plaque con-
trol and the generalized recession of the gingival margin.
The patient had been subjected to 3-month supportive
periodontal care since initial scaling and root planing.
E. Initial radiograph of maxillary right molars showing
furcation involvement in the first molar (the tooth was
vital). F. Radiograph of the same area as in Fig. 5e showing
the remineralization of the interradicular osseous lesion
17 years later. The wisdom tooth was extracted. G. Clinical
appearance of the area in 1997.

Cattabriga et al.

Fig. 6. A. A radiography of the mandibular right posterior

sextant taken in 1981. B. The patient (seen here in 1987)
continued to loose bone in spite of the fact that he im-
proved his compliance with home care and professional
cleanings and had several rounds of closed and open scal-
ing and root planing. C. The teeth were removed in 1997
and dental implants placed. The patient was found to be
genotype-positive for the IL-1 gene.

drug therapy and root separation, may be appro- treatment. Furcation root surface anatomy. J Periodontol
1979: 50: 366374.
10. Bragger U, Pasquali L, Weber H, Kornman KS. Computer-
assisted densitometric image analysis for the assessment
of alveolar bone density changes in furcations. J Clin Peri-
References odontol 1989: 16: 4652.
11. Buckley LA, Crowley MJ. A longitudinal study of untreated
periodontal disease. J Clin Periodontol 1984: 10: 523530.
1. Amen CR. Hemisection and root amputation. Peri-
12. Buhler H. Evaluation of root-resected teeth. Results after
odontics 1966: 4: 19771981.
10 years. J Periodontol 1988: 59: 805.
2. Basten CH-J, Ammons WF, Persson R. Long-term evalu-
13. Blum V, Fejerskov O, Karring T. Oral hygiene, gingivitis
ation of root-resected molars: a retrospective study. Int J
and periodontal breakdown in adult Tanzanians. J Peri-
Periodontics Restorative Dent 1996: 16: 207219. odontal Res 1986: 21: 221232.
3. Becker W, Berg MRL, Becker BE. Untreated periodontal 14. Blum V, Fejerskov O, Manji F. Periodontal disease in
disease: a longitudinal study. J Periodontol 1979: 50: 234 adult Kenyans. J Clin Periodontol 1988: 15: 445452.
244. 15. Carnevale G, Pontoriero R, di Febo G. Long-term effects
4. Becker W, Berg MRL, Becker BE. Untreated periodontal of root-resective therapy in furcation-involved molars. A
disease: a longitudinal study. Int J Periodontics Restora- 10-year longitudinal study. J Clin Periodontol 1998: 25:
tive Dent 1984: 4: 5571. 209214.
5. Bergenholtz A. Radectomy of multirooted teeth. J Am 16. Carnevale GF, Pontoriero R, Markus BH. Management of
Dent Assoc 1972: 85: 870875. furcation involvement. Periodontol 2000 1995: 9: 6989.
6. Bjorn A-L, Hjort P. Bone loss of furcated mandibular mo- 17. Chiu BM, Zee K-Y, Corbet EF, Holmgren CJ. Periodontal
lars. A longitudinal study. J Clin Periodontol 1982: 9: 402 implications of furcation entrance dimensions in Chinese
408. first permanent molars. J Periodontol 1991: 62: 308311.
7. Blomlof L, Jansson L, Appelgren R, Ehnevid H, Lindskog 18. Cobb CM. Non-surgical pocket therapy: mechanical. Ann
S. Prognosis and mortality of root-resected molars. Int J Periodontol 1996: 1: 443490.
Periodontics Restorative Dent 1997: 17: 191201. 19. Eickholz P, Staehle HJ. The reliability of furcation meas-
8. Bower RC. Furcation morphology relative to periodontal urements. J Clin Periodontol 1994: 21: 611612.
treatment. Furcation entrance architecture. J Periodontol 20. Eickholz P. Reproducibility and validity of furcation meas-
1979: 50: 2327. urements as related to class of furcation invasion. J Peri-
9. Bower RC. Furcation morphology relative to periodontal odontol 1995: 66: 984989.

The conservative approach in the treatment of furcation lesions

21. Farrar JM. Radical and heroic treatment of alveolar ab- 42. Knowles JW, Burgett FG, Nissle RR, Shick RA, Morrison
scess by amputation of roots of teeth. Dent Cosmos 1884: EC, Ramfjord SP. Results of periodontal treatment related
26: 7982. to pocket depth and attachment level. 8 years. J Peri-
22. Fleischer HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD. odontol 1979: 50: 225233.
Scaling and root planing in multirooted teeth. J Peri- 43. Kocher T, Ruhling A, Herweg M, Plagman HC. Proof of
odontol 1989: 60: 402409. efficacy of different modified sonic scaler inserts used for
23. Glickman I. Clinical periodontology. 2nd edn. Philadel- debridement in furcations a dummy head trial. J Clin
phia: W.B. Saunders Co., 1958: 694696. Periodontol 1996: 23: 662669.
24. Goldman MJ, Ross IF, Goteiner D. Effect of periodontal 44. Kornman KS, Crane A, Wang H-Y, di Giovine FS, Newman
therapy on patients maintained for 15 years or longer. A MG, Pirk FW, Wilson Jr. TG, Higgingbottom FL, Duff GW.
retrospective study. J Periodontol 1986: 57: 347353. The interleukin-1 genotype as a severity factor in adult
25. Goodson JM, Tanner ACR, Haffajee AD, Sornberger GC, periodontal disease. J Clin Periodontol 1997: 24: 7277.
Socransky SS. Patterns of progression and regression of 45. Larato DC. Furcation involvements: incidence and distri-
advanced destructive periodontal disease. J Clin Peri- bution. J Periodontol 1970: 41: 499506.
odontol 1982: 9: 472481. 46. Larato DC. Some anatomical factors related to furcation
26. Green EN. Hemisection and root amputation. J Am Dent involvements. J Periodontol 1975: 46: 609615.
Assoc 1986: 112: 511518. 47. Langer B, Stein SB, Wagenberg B. An evaluation of root
27. Greenstein G. Periodontal response to mechanical non- resections. A ten-year study. J Periodontol 1981: 52: 719
surgical therapy: a review. J Periodontol 1992: 63: 118130. 722.
28. Gutmann JL. Prevalence, location, and patency of acces- 48. Leon LE, Vogel RI. A comparison of the effectiveness of
sory canals in the furcation region of permanent molars. hand scaling and ultrasonic debridement in furcations as
J Periodontol 1978: 49: 2126. evaluated by differential dark-field microscopy. J Peri-
29. Hamp S-E, Nyman S, Lindhe J. Periodontal treatment of odontol 1987: 58: 8694.
multirooted teeth. Results after 5 years. J Clin Periodontol 49. Lindhe J, Nyman S. Long-term maintenance of patients
1975: 2: 126135. treated for advanced periodontal disease. J Clin Peri-
30. Hardekopf JD, Dunlap RM, Ahl DR, Pelleu GB. The fur- odontol 1984: 11: 504514.
cation arrow. A reliable radiographic image. J Periodontol 50. Lindhe J, Okamoto H., Yoneyama T, Haffajee A, Socransky
1987: 58: 258261. SS. Periodontal loser sites in untreated adult subjects. J
31. Hellden L, Elliot A, Steffensen B, Steffensen JEM. The Clin Periodontol 1989: 16: 671678.
prognosis of tunnel preparations in treatment of class III 51. Little LA, Beck FM, Bagci B, Horton JE. Lack of furcal bone
furcations. A follow-up study. J Periodontol 1989: 60: 182 loss following the tunneling procedure. J Clin Periodontol
187. 1995: 22: 637641.
32. Hirschfeld L, Wasserman B. A long-term survey of tooth 52. Loe H, nerud , Boysen H, Morrison EC. Natural history
loss in 600 treated periodontal patients. J Periodontol of periodontal disease in man. Rapid, moderate and no
1978: 49: 225237. loss of attachment in Sri Lankan laborers 14 to 46 years
33. Hou G-L, Tsai C-C. Relationship between periodontal fur- of age. J Clin Periodontol 1986: 13: 431440.
cation involvement and molar cervical enamel projec- 53. Loos B, Claffey N, Egelberg J. Clinical and microbiological
tions. J Periodontol 1987: 58: 715721. effects of root debridement in periodontal furcation
34. Hou G-L, Tsai C-C. Cervical enamel projections and inter- pockets. J Clin Periodontol 1988: 15: 453463.
mediate bifurcational ridge correlated with molar fur- 54. Loos B, Nylund K, Claffey N, Egelberg J. Clinical effect of
cation involvements. J Periodontol 1997: 68: 687693. root debridement in molar and non-molar teeth. J Clin
35. Hou G-L, Chen S-F, Wu Y-M, Tsai C-C. The topography of Periodontol 1989: 16: 498504.
the furcation entrance in Chinese molars. Furcation en- 55. Marshall-Day CD, Stephens RG, Quigley LF Jr. Periodontal
trance dimensions. J Clin Periodontol 1994: 21: 451456. disease: prevalence and incidence. J Periodontol 1955: 26:
36. Kaldahl WB, Kalkwarf KL, Patil KD, Molvar MP. Responses 185203.
of four tooth and site groupings to periodontal therapy. J 56. Matia J, Bissada N, Maybury J, Ricchetti P. Efficiency of
Periodontol 1990: 61: 173179. scaling the molar furcation area with and without surgical
37. Kaldahl WB, Johnson GK, Patil KD, Kalkwarf KL. Levels of access. Int J Periodontics Restorative Dent 1986: 5: 2535.
cigarette consumption and response to periodontal ther- 57. McFall WT. Tooth loss in 100 treated patients with peri-
apy. J Periodontol 1996: 67: 675681. odontal disease. A long-term study. J Periodontol 1982:
38. Kalkwarf KL, Kaldahl WB, Patil KD. Evaluation of furcation 53: 539549.
region response to periodontal therapy. J Periodontol 58. McGuire MK, Nunn ME. Prognosis versus actual out-
1988: 59: 794804. come. II. The effectiveness of clinical parameters in de-
39. Kenney EB, Lekovic V, Elbaz JJ, Kovacic K, Carranza FA Jr, veloping an accurate prognosis. J Periodontol 1996: 67:
Takei HH. The use of porous hydroxylapatite implant in 658665.
periodontal defects. II. Treatment of class II furcation 59. McGuire MK, Nunn ME. Prognosis versus actual outcome.
lesions in lower molars. J Periodontol 1988: 59: 6772. III. The effectiveness of clinical parameters in accurately
40. Kieser JB. Nonsurgical periodontal therapy. In: Lang NP, predicting tooth survival. J Periodontol 1996: 67: 666674.
Karring T, ed. Proceedings of the 1st European Workshop 60. Messinger TF, Orban B. Elimination of periodontal
in Periodontology. London: Quintessence Publishing Co., pockets by root amputation. J Periodontol 1954: 25: 213
1994: 131158. 219.
41. Klavan B. Clinical observation following root amputation 61. Minabe M, Takeuchi K, Nishimura T, Umemoto TH.
in maxillary teeth. J Periodontol 1975: 46: 15. Therapeutic effects of combined treatment using tetracy-

Cattabriga et al.

cline-immobilized collagen film and root planing in peri- 80. Ramfjord SP, Caffesse RJ, Morrison EC, Hill RW, Kerry GJ,
odontal furcation pockets. J Clin Periodontol 1991: 18: Appleberry EA, Nissle RR, Stults DL. 4 modalities of peri-
287290. odontal treatment compared over 5 years. J Clin Peri-
62. Moriarty JD, Scheitler LE, Hutchens LH, Delong ER. Inter- odontol 1987: 14: 445452.
examiner reproducibility of probing pocket depths in mo- 81. Ravald N, Hamp S-E. Prediction of root surface caries in
lar furcation sites. J Clin Periodontol 1988: 15: 6872. patients treated for advanced periodontal disease. J Clin
63. Moriarty JD, Hutchens LH, Scheitler LE. Histological Periodontol 1981: 8: 400405.
evaluation of periodontal probe penetration in untreated 82. Ravald N, Hamp S-E, Birkhed D. Long-term evaluation of
facial molar furcations. J Clin Periodontol 1989: 16: 2126. root surface caries in periodontally treated patients. J Clin
64. Mullally BH, Linden GJ. Molar furcation involvement as- Periodontol 1986: 13: 758767.
sociated with cigarette smoking in periodontal referrals. J 83. Ross IF, Thompson R. A long term study of root retention
Clin Periodontol 1996: 23: 658661. in the treatment of maxillary molars with furcation in-
65. Muller H-P, Eger T, Lange DE. Management of furcation- volvement. J Periodontol 1978: 49: 238244.
involved teeth. A retrospective analysis. J Clin Periodontol 84. Ross IF, Thompson R. Furcation involvement in maxil-
1995: 22: 911917. lary and mandibular molars. J Periodontol 1980: 51:
66. Needleman IG, Watts TL. The effect of 1% metronidazole 450454.
gel in routine maintenance of persistent furcation involve- 85. Saari JT, Hurt WC, Biggs NL. Periodontal bony defects on
ment in human beings. J Periodontol 1989: 60: 699703. the dry skull. J Periodontol 1968: 39: 278283.
67. Nordland P, Garrett S, Kiger R, Vanooteghem R, Hutchens 86. Schroer MS, Kirk WC, Wahl TM, Hutchens LH, Moriarty
LH, Egelberg J. The effect of plaque control and root de- JD, Bergenholtz B. Closed versus open debridement of fa-
bridement in molar teeth. J Clin Periodontol 1987: 14: cial grade II molar furcations. J Clin Periodontol 1991: 18:
231236. 323329.
68. Nylund K, Egelberg J. Antimicrobial irrigation of peri- 87. Svardstrom G, Wennstrom JL. Furcation topography of
odontal furcation lesions to supplement oral hygiene in- the maxillary and mandibular first molars. J Clin Peri-
struction and root debridement. J Clin Periodontol 1990: odontol 1988: 15: 271275.
17: 9095. 88. Svardstrom G, Wennstrom JL. Prevalence of furcation in-
69. Oda S, Ishikawa I. In vitro effectiveness of a newly-de- volvements in patients referred for periodontal treatment.
signed ultrasonic scaler tip for furcation areas. J Peri- J Clin Periodontol 1996: 23: 10931099.
odontol 1989: 60: 634639. 89. Takacs BJ, Lie T, Perala DG, Adams DF. Efficacy of 5 ma-
70. Papapanou PN. Epidemiology and natural history of peri- chining instruments in scaling of molar furcations. J Peri-
odontal disease. In: Lang NP, Karring T, ed. Proceedings odontol 1993: 64: 228236.
of the 1st European Workshop in Periodontology. London: 90. Tal H. Furcal defects in dry mandibles. I. A biometric
Quintessence Publishing Co., 1994: 2341. study. J Periodontol 1982: 53: 360363.
71. Papapanou PN. Periodontal diseases: epidemiology. Ann 91. Tal H, Lemmer J. Furcal defects in dry mandibles. II.
Periodontol 1996: 1: 136. Severity of furcal defects. J Periodontol 1982: 53: 364
72. Papapanou PN, Wennstrom JL, Grondahl K. A 10-year 367.
retrospective study of periodontal disease progression. J 92. Tal H. Relationship between the depths of furcal defects
Clin Periodontol 1989: 16: 403411. and alveolar bone loss. J Periodontol 1982: 53: 631634.
73. Parashis AO, Anagnou-Vareltzides A, Demetriou N. Calcu- 93. Tarnow D, Fletcher P. Classification of the vertical compo-
lus removal from multirooted teeth with and without sur- nent of furcation involvement. J Periodontol 1984: 55:
gical access. I. Efficacy on external and furcation surfaces 283284.
in relation to probing depth. J Clin Periodontol 1993: 20: 94. Tonetti MS, Cortellini P, Carnevale G, Cattabriga M, De
6368. Sanctis M, Pini Prato GP. A controlled multicenter study
74. Parashis AO, Anagnou-Vareltzides A, Demetriou N. Calcu- of adjunctive use of tetracycline periodontal fibers in
lus removal from multirooted teeth with and without sur- mandibular class II furcations with persistent bleeding. J
gical access. II. Comparison between external and fur- Clin Periodontol 1998: 25: 728736.
cation surfaces and effect of furcation entrance width. J 95. Van Swol RL, Whitsell BD. Root amputation as a predict-
Clin Periodontol 1993: 20: 294298. able procedure. Oral Surg Oral Med Oral Pathol Oral
75. Patterson M, Eick JD, Eberhart AB, Gross K, Killoy WJ. The Radiol Endod 1977: 43: 452459.
effectiveness of two sonic and two ultrasonic scaler tips 96. Volkansky A, Cleaton-Jones PE. Bony defects in dried Ban-
in furcations. J Periodontol 1989: 60: 325329. tu mandibles. Oral Surg Oral Med Oral Pathol Oral Radiol
76. Payot P, Bickel M, Cimasoni G. Longitudinal quantitative Endod 1973: 45: 647658.
radiodensitometric study of treated and untreated lower 97. Wachtel HC. Surgical periodontal therapy. In: Lang NP,
molar furcation involvements. J Clin Periodontol 1987: 14: Karring T, ed. Proceedings of the 1st European Workshop
818. in Periodontology. London: Quintessence Publishing Co.
77. Pepelassi EM, Bissada NF, Greenwell H, Farah CF. Doxycy- 1994, 159171.
cline-tricalcium phosphate composite graph facilitates 98. Wang HL, Burgett FG, Shjr Y. The relationship between
osseous healing in advanced periodontal furcation de- restoration and furcation involvement on molar teeth. J
fects. J Periodontol 1991: 62: 106115. Periodontol 1993: 64: 302305.
78. Ramfjord S. Periodontal disease index (PDI). J Periodontol 99. Wang HL, Burgett FG, Shjr Y, Ramfjord S. The influence
1967: 38: 602610. of molar furcation involvement and mobility on future
79. Ramfjord SP, Ash MM. Periodontology and periodontics. clinical periodontal attachment loss. J Periodontol 1994:
Philadelphia: W.B. Saunders Co., 1979. 65: 2529.

The conservative approach in the treatment of furcation lesions

100. Wilson TG Jr, Glover ME, Malik AK, Schoen JA, Dorsett D. 104. Wylam JM, Mealey BL, Mills MP, Waldrop TC, Moskowicz
Tooth loss in maintenance patients in a private peri- DG. The clinical effectiveness of open versus closed scal-
odontal practice. J Periodontol 1987: 58: 231235. ing and root planing on multi-rooted teeth. J Periodontol
101. Wrhaugh J. The furcation problem. Etiology, patho- 1993: 64: 10231028.
genesis, diagnosis, therapy and prognosis. J Clin Peri- 105. Yukna CN, Yukna RA. Multi-center evaluation of bioab-
odontol 1980: 7: 7395. sorbable collagen membrane for guided tissue regenera-
102. Wood WR, Greco GW, Mc Fall WT. Tooth loss in patients tion in human class II furcations. J Periodontol 1996: 67:
with moderate periodontitis after treatment and long- 650657.
term maintenance care. J Periodontol 1989: 60: 516520. 106. Zappa U, Grosso L, Simona C, Graf H, Case D. Clinical
103. Wylam JM, Mills MP, Moskowicz DG. Effectiveness of scal- furcation diagnoses and interradicular bone defects. J
ing on molar teeth surgical vs. non-surgical approach. J Periodontol 1993: 64: 219227.
Dent Res 1986: 65 (spec issue): 270 (abstr 911).