Furcation involvement

and treatments
Oleh
: Miftha Lubis, drg
Pembimbing : Krisnamurthy, drg.,
Sp.Perio

Pendahuluan
Furkasi merupakan suatu daerah dengan morfologis
anatomi yang kompleks yang sulit bahkan tidak
mungkin untuk dilakukan debridemen dengan
instrumentasi rutin
Perkembangan inflamasi dari penyakit periodontal
kehilangan perlekatan sampai daerah bifurkasi atu
trifurkasi gigi berakar ganda

periodontitis taraf parah dan prognosis gigi yang

terlibat menjadi kurang menguntungkan

Etiologi
Plak bakteri dan inflamasi yang telah berlangsung
lama
Perluasan kehilangan perlekatan dibutuhkan
untuk menciptakan defek furkasi yang bervariasi
dan berhubungan dengan faktor anatomis lokal
( root trunk length, morfologi akar) dan anomali
perkembangan (cervical enamel projections)
Faktor lokal deposisi plak atau mempersulit
prosedur oral hygiene
Karies dan nekrose

A. Probe Nabers didesain untuk daerah furkasi

B. Defek furkasi Klas II

Diagnosis dan klasifikasi

defek
Probing yang tepat menentukan keterlibatan
dan perluasan furkasi, posisi perlekatan yang
relatif di furkasi, perluasan dan konfigurasi defek
furkasi prob Nabers
Sounding transgingival untuk menggambarkan
anatomi defek furkasi
Tujuan dari pemeriksaan ini adalah untuk
mengidentifkasi
dan
mengklasifikasikan
keterlibatan dan perluasan furkasi dan identifikasi
faktor
yang
berkontribusi
terhadap
perkembangan defek furkasi atau berpengaruh
terhadap hasil perawatan.
Morfologi gigi, posisi gigi terhadap gigi yang

Faktor anatomis lokal

Dimensi dari furkasi entrance bervariasi; 81% furkasi
dengan orifisi < 1mm dan 58% < 0.75mm
pertimbangan klinisi untuk memilih instrumen untuk
probing (keterlibatan dini dibutuhkan prob dengan
dimensi small cross-sectional )
Pemeriksaan klinis pasien memungkinkan terapis
untuk tidak hanya identifikasi ketrlibatan furkasi
tetapi juga anatomi lokal yang dapat mempengaruhi
hasil terapi (prognosis)
Rontgen fotomeskipun tidak menunukkan klasifikasi
pasti ketelibatn furkasi ttp dapat memberikan
informasi vital tambahan untuk rencana perawatan

A, Furkasi derajat I gigi molar pertama mandibula dan derajat III gigi
molar kedua mandibula..The root approximation on the second
molar may be sufficient to impede accurate probing of this defect
B, Defek furkasi multipel pada molar pertama maksila. Derajat I
furkasi bukal dan furkasi derajat II mesiopalatal dan distopalatal.
Deep developmental grooves
molar kedua maksila simulate
keterlibatan furkasi pada molar ini dengan akar yang fused.
C, Furkasi derajat II dan IV pada molar mandibula

Root trunk length

Merupakan hal yang penting dalam perkembangan dan perawatan
keterlibatan furkasi
Jarak antara CEJ- furkasi entrance bervariasi. Gigi dapat
mempunyai root trunks yang sangat pendek, moderate, atau akar
yang fused ke ujung akar (Figure 62-3).
Kombinasi root trunk length dengan jumlah dan konfigurasi akar
mempengaruhi keberhasilan perawatan.
Lebih pendek root trunk, lebih sedikit perlekatan yang terlibat
hingga menebabkan keterlibatan furkasi. Ketika furkasi terekspos,
gigi dengan root trunks yang pendek lebih memudahkan akses
untuk prosedur pemeliharaan, dan memfasilitasi beberapa
prosedur bedah.
Gigi dengan root trunks yang panjang atau akar fused bukanlah
kandidat yang tepat untuk perawatan
ketika sudah ada
keterlibatan furkasi.

 Gambaran berbagai anatomis furkasi yang penting dalam

prognosis dan perawatan keterlibatan furkasi
A, Akar yang terpisah luas. B, Akar terpisah tetapi dekat. C, Akar yang
fused terpisah hanya pada bagian apikal. D, enamel projection
keterlibatan furkasi dini

Root Length

Root length is directly related to the

quantity of attachment supporting the
tooth. Teeth with long root trunks and
short roots may have lost a majority of
their support by the time that the
furcation becomes affected.13,20 Teeth
with long roots and short-to-moderate
root trunk length are more readily treated
because sufficient attachment remains to
meet functional demands

Root Form
The mesial root of most mandibular first and second molars and the
mesiofacial root of the maxillary first molar are typically curved to
the distal side in the apical third. In addition, the distal aspect of this
root is usually heavily fluted. The curvature and fluting may increase
the potential for root perforation during endodontic therapy or
complicate post placement during restoration.1,25 These anatomic
features may also result in an increased incidence of vertical root
fracture. The size of the mesial radicular pulp may result in removal
of most of this portion of the tooth during preparation.
Interradicular Dimension
The degree of separation of the roots is also an important factor in
treatment planning. Closely approximated or fused roots can
preclude adequate instrumentation during scaling, root planing, and
surgery. Teeth with widely separated roots present more treatment
options and are more readily treated.

Anatomy of Furcation

The anatomy of the furcation is complex.

The presence of bifurcational ridges, a
concavity in the dome,11 and possible
accessory canals16 complicates not only
scaling, root planing, and surgical
therapy,28 but also periodontal
maintenance. Odontoplasty to reduce or
eliminate these ridges may be required
during surgical therapy for an optimal
result.

Cervical Enamel Projections

Cervical enamel projections (CEPs) are reported

to occur on 8.6% to 28.6% of molars.26,27,35 The
prevalence is highest for mandibular and
maxillary second molars. The extent of CEPs was
classified by Masters and Hoskins27 in 1964 (
Box 62-1). Figure 62-4 provides an example of a
grade III CEP. These projections can affect plaque
removal, can complicate scaling and root
planing, and may be a local factor in the
development of gingivitis and periodontitis. CEPs
should be removed to facilitate maintenance.

Figure 62-4: Furcation

involvement by grade III cervical
enamel projections.

Indikasi keterlibatan furkasi

The extent and configuration of the furcation defect
are factors in both diagnosis and treatment
planning. This has led to the development of a
number of indices to record furcation
involvement. These indices are based on the
horizontal measurement of attachment loss in the
furcation,14,17 on a combination of horizontal and
vertical measurements,37 or a combination of
these findings with the localized configuration of
the bony deformity.10 Glickman14 classified
furcation involvement into four grades (Figure 62

 Figure 62-6: Glickmans classification of furcation involvement.

A, Grade I furcation involvement. Although a space is visible at the entrance to the furcation, no horizontal
component of the furcation is evident on probing. B, Grade II furcation in a dried skull. Note both the horizontal
and the vertical component of this cul-de-sac. C, Grade III furcations on maxillary molars. Probing confirms
that the buccal furcation connects with the distal furcation of both these molars, yet the furcation is filled with
soft tissue. D, Grade IV furcation. The soft tissues have receded sufficiently to allow direct vision into the
furcation of this maxillary molar

 Grade I
A grade I furcation involvement is the incipient or early stage of furcation
involvement (see Figure 62-6, A). The pocket is suprabony and primarily
affects the soft tissues. Early bone loss may have occurred with an
increase in probing depth, but radiographic changes are not usually found.
Grade II
A grade II furcation can affect one or more of the furcations of the same
tooth. The furcation lesion is essentially a cul-de-sac (see Figure 62-6, B)
with a definite horizontal component. If multiple defects are present, they
do not communicate with each other because a portion of the alveolar
bone remains attached to the tooth. The extent of the horizontal probing
of the furcation determines whether the defect is early or advanced.
Vertical bone loss may be present and represents a therapeutic
complication. Radiographs may or may not depict the furcation
involvement, particularly with maxillary molars because of the
radiographic overlap of the roots. In some views, however, the presence of
furcation arrows indicates possible furcation involvement

 Grade III
In grade III furcations, the bone is not attached to the dome of the furcation. In
early grade III involvement, the opening may be filled with soft tissue and may
not be visible. The clinician may not even be able to pass a periodontal probe
completely through the furcation because of interference with the bifurcational
ridges or facial/lingual bony margins. However, if the clinician adds the buccal
and lingual probing dimensions and obtains a cumulative probing
measurement that is equal to or greater than the buccal/lingual dimension of
the tooth at the furcation orifice, the clinician must conclude that a grade III
furcation exists (see Figure 62-6, C). Properly exposed and angled radiographs
of early Class III furcations display the defect as a radiolucent area in the crotch
of the tooth (see Chapter 31).
Grade IV
In grade IV furcations, the interdental bone is destroyed, and the soft tissues
have receded apically so that the furcation opening is clinically visible. A tunnel
therefore exists between the roots of such an affected tooth. Thus the
periodontal probe passes readily from one aspect of the tooth to another (see
Figure 62-6, D).

 Other Classification Indices

Hamp et al17 modified a three-stage classification system by
attaching a millimeter measurement to separate the extent of
horizontal involvement. Easley and Drennan10 and Tarnow and
Fletcher37 have described classification systems that consider both
horizontal and vertical attachment loss in classifying the extent of
furcation involvement. The Tarnow and Fletcher article utilizes a
subclassification that measures the probeable vertical depth from the
roof of the furca apically. The subclasses being proposed are: A, B,
and C. A indicates a probeable vertical depth of 1 to 3mm, B
indicates 4 to 6mm, and C indicates 7 or more mm of probeable
depth from the roof of the furca apically. Furcations would thus be
classified as IA, IB, and IC; IIA, IIB, and IIC; and IIIA, IIIB, and IIIC.
Consideration of defect configuration and the vertical component of
the defect provides additional information that is useful in planning
therapy

Perawatan
The objectives of furcation therapy are
to (a) facilitate maintenance, (b)
prevent further attachment loss, and
(c) obliterate the furcation defects as
a periodontal maintenance problem.
The selection of therapeutic mode
varies with the class of furcation
involvement, the extent and
configuration of bone loss, and other
anatomic factors.

Therapeutic Classes of Furcation Defects

Class I: Early Defects.
Incipient or early furcation defects (Class I) are amenable to conservative
periodontal therapy.15 Because the pocket is suprabony and has not entered
the furcation, oral hygiene, scaling, and root planing are effective. 16 Any
thick overhanging margins of restorations, facial grooves, or CEPs should be
eliminated by odontoplasty, recontouring, or replacement. The resolution of
inflammation and subsequent repair of the periodontal ligament and bone
are usually sufficient to restore periodontal health.
Class II.
Once a horizontal component to the furcation has developed (Class II),
therapy becomes more complicated. Shallow horizontal involvement without
significant vertical bone loss usually responds favorably to localized flap
procedures with odontoplasty, osteoplasty, and ostectomy. Isolated deep
Class II furcations may respond to flap procedures with osteoplasty and
odontoplasty (Figure 62-7). This reduces the dome of the furcation and
alters gingival contours to facilitate the patients plaque removal.

 Figure 62-7: Treatment of a grade II furcation by osteoplasty and

odontoplasty.
A, This mandibular first molar has been treated endodontically and an area
of caries in the furcation repaired. A Class II furcation is present. B, Results
of flap debridement, osteoplasty, and severe odontoplasty 5 years
postoperatively. Note the adaptation of the gingiva into the furcation area.

 Classes II to IV: Advanced Defects.

The development of a significant horizontal
component to one or more furcations of a
multirooted tooth (late Class II, Class III, or Class IV
13) or the development of a deep vertical
component to the furca poses additional problems.
Nonsurgical treatment is usually ineffective
because the ability to instrument the tooth
surfaces adequately is compromised.31,40
Periodontal surgery, endodontic therapy, and
restoration of the tooth may be required to retain
the tooth.

Terapi non bedah

Nonsurgical therapy, a combination of
oral hygiene instruction and scaling
and root planing, has provided
excellent results in some patients.
The earlier the furcation is detected
and treated the more likely a good
long-term result can be obtained

Obtaining access to the furcation

requires a combination of the
awareness of the furcation by the
patient and an oral hygiene tool that
facilitates that access. Many tools,
including rubber tips; periodontal
aids; toothbrushes, both specific and
general; and other aids have been
used over time for access to the
patient (Figure 62-8).

 Figure 62-8
A, The utilization of a Perio-Aid into the furcation for plaque removal.
B, Proxy brush is used for plaque removal into the furcation lesio

Terapi bedah
Osseous Resection
Osseous surgical therapy can be divided into resective and
regenerative therapy. This also applies to the furcation areas
when surgical therapy is contemplated. For many years,
osteoplasty and ostectomy have been used to make the
furcation areas cleansable. In the advanced cases, techniques
were used to open the furcation into a Class IV from a severe
Class II or III case. This would allow easier hygiene into the
furcation area for the patient. These techniques have limited
usefulness today, but in the compromised individual in whom
teeth cannot be extracted or in whom conservative therapy
has failed, these surgical techniques have been used. The
immediate goal with these surgical approaches is to create
access for the patient to maintain good hygiene.

 Regeneration
In furcal lesions, bone regeneration is often thought to be relatively futile. The periodontal
literature has well-documented therapeutic efforts designed to induce new attachment and
reconstruction on molars with furcation defects. Many surgical procedures using a variety of
grafting materials have been tested on teeth with different classes of furcation involvement. Some
investigators have reported clinical success,24 whereas others have suggested that the use of
these materials in Class II, III, or IV furcations offers little advantage compared with surgical
controls.3,9,30
Furcation defects with deep two-walled or three-walled components may be suitable for
reconstruction procedures. These vertical bony deformities respond favorably to a variety of
surgical procedures, including debridement with or without membranes and bone grafts.
Chapter 61 addresses therapies designed to induce new attachment or reattachment.
Tsao et al39 have shown that the furcation defect is a graftable lesion. They found that lesions that
were grafted had greater vertical fill than areas treated with open flap debridement alone. Bowers
et al7 have shown furcation bone grafting using various membranes can improve the clinical status
of these lesions. Nonetheless, bone grafting remains an elusive goal with variable results in
furcation lesions. Another area of interest has been barrier membrane technology. Analysis of
published studies demonstrated a great variability in the clinical outcomes in mandibular grade II
furcations treated with different types of nonbioabsorbable and bioabsorbable barrier membranes.
Although many barrier membrane studies show a slight clinical improvement after treatment in
both maxillary and mandibular furcations, the results are generally inconsistent.

Prognosis
For many years the presence of significant furcation involvement
meant a hopeless long-term prognosis for the tooth. Clinical
research, however, has indicated that furcation problems are not
as severe a complication as originally suspected if one can
prevent the development of caries in the furcation. Relatively
simple periodontal therapy is sufficient to maintain these teeth
in function for long periods.21,33 Other investigators have defined
the reasons for clinical failure of root-resected or hemisected
teeth.2,25 Their data indicate that recurrent periodontal disease is
not a major cause of the failure of these teeth. Investigations of
root-resected or hemisected teeth have shown that such teeth
can function successfully for long periods. 2,8,25 The keys to longterm success appear to be (a) thorough diagnosis, (b) selection
of patients with good oral hygiene, (c) excellence in nonsurgical
therapy, and (d) careful surgical and restorative management.

TERIMA KASIH