Skip to main content

Advertisement

SpringerLink
Log in

Periodontal surgery in furcation-involved maxillary molars revisited—an introduction of guidelines for comprehensive treatment

  • Review
  • Published:
Clinical Oral Investigations Aims and scope Submit manuscript

Abstract

Maxillary molars with interradicular loss of periodontal tissue have an increased risk of additional attachment loss with an impaired long-term prognosis. Since accurate clinical analysis of furcation involvement is not feasible due to limited access, morphological variations and measurement errors, additional diagnostics, e.g., with cone-beam computed tomography, may be required. Surgical treatment options have graduated from a less invasive approach, i.e., keeping as much periodontal attachment as possible, to a more invasive approach: (1) open flap debridement with/without gingivectomy or apically repositioned flap and/or tunnelling; (2) root separation; (3) amputation/trisection of a root (with/without root separation or tunnel preparation); (4) amputation/trisection of two roots; and (5) extraction of the entire tooth. Tunnelling is indicated when the degree of root separation allows for opening of the interradicular region. Alternatively, root separation is performed particularly in root-canal treated teeth with reduced coronal tooth substance requiring crown restorations. As soon as the attachment of one or two roots in maxillary molars is severely reduced, root removal is indicated and performed either as amputation or trisection including the corresponding part of the clinical crown. While the indication for regenerative measures in maxillary molars with furcation involvement is very limited, extraction and replacement with implants is restricted, particularly in sites requiring complex alveolar ridge augmentation and sinus elevation. A systematic approach for decision making in furcation-involved maxillary molars is described in this overview, including what constitutes accurate diagnosis and what indications there are for the different surgical periodontal treatment options.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4

Similar content being viewed by others

Abbreviations

FI:

Furcation involvement

PPD:

Probing pocket depth

PAL:

Probing attachment level

Sc&Rp:

Scaling and root planning

RCT:

Root canal treatment

SPT:

Supportive periodontal treatment

FDP:

Fixed dental prosthesis

RDP:

Removable dental prosthesis

CBCT:

Cone-beam computed tomography

GTR:

Guided tissue regeneration

EMD:

Enamel matrix derivative proteins

BoP:

Bleeding on probing

References

  1. Hirschfeld L, Wasserman B (1978) A long-term survey of tooth loss in 600 treated periodontal patients. J Periodontol 49:225–237

    Article  PubMed  Google Scholar 

  2. McGuire MK (1991) Prognosis versus actual outcome: a long-term survey of 100 treated periodontal patients under maintenance care. J Periodontol 62:51–58

    PubMed  Google Scholar 

  3. McGuire MK, Nunn ME (1996) Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol 67:658–665

    PubMed  Google Scholar 

  4. Ducar JP, Tsutsui F, Merin RL (2002) Therapeutic choices in the molar region. J Calif Dent Assoc 30:355–361

    PubMed  Google Scholar 

  5. Al-Shammari KF, Kazor CE, Wang HL (2001) Molar root anatomy and management of furcation defects. J Clin Periodontol 28:730–740

    Article  PubMed  Google Scholar 

  6. Wang HL, Burgett FG, Shyr Y, Ramfjord S (1994) The influence of molar furcation involvement and mobility on future clinical periodontal attachment loss. J Periodontol 65:25–29

    PubMed  Google Scholar 

  7. Zitzmann NU, Berglundh T (2008) Definition and prevalence of peri-implant diseases. J Clin Periodontol 35:286–291

    Article  PubMed  Google Scholar 

  8. Svärdström G, Wennström JL (1996) Prevalence of furcation involvements in patients referred for periodontal treatment. J Clin Periodontol 23:1093–1099

    Article  PubMed  Google Scholar 

  9. Ross IF, Thompson RH Jr (1980) Furcation involvement in maxillary and mandibular molars. J Periodontol 51:450–454

    PubMed  Google Scholar 

  10. Dannewitz B, Krieger JK, Husing J, Eickholz P (2006) Loss of molars in periodontally treated patients: a retrospective analysis five years or more after active periodontal therapy. J Clin Periodontol 33:53–61

    Article  PubMed  Google Scholar 

  11. McFall WT Jr (1982) Tooth loss in 100 treated patients with periodontal disease. A long-term study. J Periodontol 53:539–549

    Article  PubMed  Google Scholar 

  12. Lang NP, Cumming BR, Loe H (1973) Toothbrushing frequency as it relates to plaque development and gingival health. J Periodontol 44:396–405

    Article  PubMed  Google Scholar 

  13. Kalkwarf KL, Kaldahl WB, Patil KD (1988) Evaluation of furcation region response to periodontal therapy. J Periodontol 59:794–804

    PubMed  Google Scholar 

  14. Hamp SE, Nyman S, Lindhe J (1975) Periodontal treatment of multirooted teeth. Results after 5 years. J Clin Periodontol 2:126–135

    Article  PubMed  Google Scholar 

  15. Ramfjord SP, Ash MM Jr (1979) Periodontology and periodontics. WB Saunders, Philadelphia

    Google Scholar 

  16. Newell DH (1998) The diagnosis and treatment of molar furcation invasions. Dent Clin N Am 42:301–337

    PubMed  Google Scholar 

  17. Walter C, Kaner D, Berndt DC, Weiger R, Zitzmann NU (2009) Three-dimensional imaging as a pre-operative tool in decision making for furcation surgery. J Clin Periodontol 36:250–257

    Article  PubMed  Google Scholar 

  18. Eickholz P (1995) Reproducibility and validity of furcation measurements as related to class of furcation invasion. J Periodontol 66:984–989

    PubMed  Google Scholar 

  19. Eickholz P, Kim TS (1998) Reproducibility and validity of the assessment of clinical furcation parameters as related to different probes. J Periodontol 69:328–336

    PubMed  Google Scholar 

  20. Mealey BL, Neubauer MF, Butzin CA, Waldrop TC (1994) Use of furcal bone sounding to improve accuracy of furcation diagnosis. J Periodontol 65:649–657

    PubMed  Google Scholar 

  21. Zappa U, Grosso L, Simona C, Graf H, Case D (1993) Clinical furcation diagnoses and interradicular bone defects. J Periodontol 64:219–227

    PubMed  Google Scholar 

  22. Hardekopf JD, Dunlap RM, Ahl DR, Pelleu GB Jr (1987) The "furcation arrow". A reliable radiographic image? J Periodontol 58:258–261

    PubMed  Google Scholar 

  23. Burnette EW Jr (1971) Limitations of the roentgenogram in periodontal diagnosis. J Periodontol 42:293–296

    PubMed  Google Scholar 

  24. Topoll HH, Streletz E, Hucke HP, Lange DE (1988) Furcation diagnosis—comparison of orthopantomography, full mouth X-ray series, and intraoperative finding. Dtsch Zahnärztl Z 43:705–708

    PubMed  Google Scholar 

  25. Deas DE, Moritz AJ, Mealey BL, McDonnell HT, Powell CA (2006) Clinical reliability of the "furcation arrow" as a diagnostic marker. J Periodontol 77:1436–1441

    Article  PubMed  Google Scholar 

  26. Fuhrmann RA, Bucker A, Diedrich PR (1997) Furcation involvement: comparison of dental radiographs and HR-CT-slices in human specimens. J Periodontal Res 32:409–418

    Article  PubMed  Google Scholar 

  27. Mozzo P, Procacci C, Tacconi A, Martini PT, Andreis IA (1998) A new volumetric CT machine for dental imaging based on the cone-beam technique: preliminary results. Eur Radiol 8:1558–1564

    Article  PubMed  Google Scholar 

  28. Schulze D, Heiland M, Thurmann H, Adam G (2004) Radiation exposure during midfacial imaging using 4- and 16-slice computed tomography, cone beam computed tomography systems and conventional radiography. Dentomaxillofac Radiol 33:83–86

    Article  PubMed  Google Scholar 

  29. Mengel R, Candir M, Shiratori K, Flores-de-Jacoby L (2005) Digital volume tomography in the diagnosis of periodontal defects: an in vitro study on native pig and human mandibles. J Periodontol 76:665–673

    Article  PubMed  Google Scholar 

  30. Vandenberghe B, Jacobs R, Yang J (2007) Diagnostic validity (or acuity) of 2D CCD versus 3D CBCT-images for assessing periodontal breakdown. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 104:395–401

    Article  PubMed  Google Scholar 

  31. Misch KA, Yi ES, Sarment DP (2006) Accuracy of cone beam computed tomography for periodontal defect measurements. J Periodontol 77:1261–1266

    Article  PubMed  Google Scholar 

  32. Pinsky HM, Dyda S, Pinsky RW, Misch KA, Sarment DP (2006) Accuracy of three-dimensional measurements using cone-beam CT. Dentomaxillofac Radiol 35:410–416

    Article  PubMed  Google Scholar 

  33. Walter C, Weiger R, Zitzmann NU (2010) Accuracy of three-dimensional imaging in assessing maxillary molar furcation involvement. J Clin Periodontol 37:436–441

    Article  PubMed  Google Scholar 

  34. Polson AM (1977) Periodontal considerations for functional utilization of a retained root after furcation management. J Clin Periodontol 4:223–230

    Article  PubMed  Google Scholar 

  35. Badersten A, Nilveus R, Egelberg J (1984) Effect of nonsurgical periodontal therapy. II. Severely advanced periodontitis. J Clin Periodontol 11:63–76

    Article  PubMed  Google Scholar 

  36. Wennström JL, Tomasi C, Bertelle A, Dellasega E (2005) Full-mouth ultrasonic debridement versus quadrant scaling and root planing as an initial approach in the treatment of chronic periodontitis. J Clin Periodontol 32:851–859

    Article  PubMed  Google Scholar 

  37. Matuliene G, Pjetursson BE, Salvi GE, Schmidlin K, Brägger U, Zwahlen M, Lang NP (2008) Influence of residual pockets on progression of periodontitis and tooth loss: results after 11 years of maintenance. J Clin Periodontol 35:685–695

    Article  PubMed  Google Scholar 

  38. Loos B, Nylund K, Claffey N, Egelberg J (1989) Clinical effects of root debridement in molar and non-molar teeth. A 2-year follow-up. J Clin Periodontol 16:498–504

    Article  PubMed  Google Scholar 

  39. Nordland P, Garrett S, Kiger R, Vanooteghem R, Hutchens LH, Egelberg J (1987) The effect of plaque control and root debridement in molar teeth. J Clin Periodontol 14:231–236

    Article  PubMed  Google Scholar 

  40. Bohnenkamp DM, Garcia LT (2004) Fixed restoration of sectioned mandibular molar teeth. Compend Contin Educ Dent 25:920–924

    PubMed  Google Scholar 

  41. Reynolds JM (1968) Abutment selection for fixed prosthodontics. J Prosthet Dent 19:483–488

    Article  PubMed  Google Scholar 

  42. Park SY, Shin SY, Yang SM, Kye SB (2009) Factors influencing the outcome of root-resection therapy in molars: a 10-year retrospective study. J Periodontol 80:32–40

    Article  PubMed  Google Scholar 

  43. Fleischer HC, Mellonig JT, Brayer WK, Gray JL, Barnett JD (1989) Scaling and root planing efficacy in multirooted teeth. J Periodontol 60:402–409

    PubMed  Google Scholar 

  44. Hempton T, Leone C (1997) A review of root resective therapy as a treatment option for maxillary molars. J Am Dent Assoc 128:449–455

    PubMed  Google Scholar 

  45. Huynh-Ba G, Kuonen P, Hofer D, Schmid J, Lang NP, Salvi GE (2009) The effect of periodontal therapy on the survival rate and incidence of complications of multirooted teeth with furcation involvement after an observation period of at least 5 years: a systematic review. J Clin Periodontol 36:164–176

    Article  PubMed  Google Scholar 

  46. Friedman N (1962) Mucogingival surgery: the apically repositioned flap. J Periodontol 33:328–340

    Google Scholar 

  47. Feres M, Araujo MW, Figueiredo LC, Oppermann RV (2006) Clinical evaluation of tunneled molars: a retrospective study. J Int Acad Periodontol 8:96–103

    PubMed  Google Scholar 

  48. Basaraba N (1969) Root amputation and tooth hemisection. Dent Clin N Am 13:121–132

    PubMed  Google Scholar 

  49. Greenstein G, Caton J, Polson A (1984) Trisection of maxillary molars: a clinical technique. Compend Contin Educ Dent 5(624–626):631–622

    Google Scholar 

  50. Bower RC (1979) Furcation morphology relative to periodontal treatment. Furcation entrance architecture. J Periodontol 50:23–27

    PubMed  Google Scholar 

  51. Gher MW Jr, Dunlap RW (1985) Linear variation of the root surface area of the maxillary first molar. J Periodontol 56:39–43

    PubMed  Google Scholar 

  52. Smukler H, Tagger M (1976) Vital root amputation. A clinical and histological study. J Periodontol 47:324–330

    PubMed  Google Scholar 

  53. Türp JC, Heydecke G, Krastl G, Pontius O, Antes G, Zitzmann NU (2007) Restoring the fractured root-canal-treated maxillary lateral incisor: in search of an evidence-based approach. Quintessence Int 38:179–191

    PubMed  Google Scholar 

  54. Pontoriero R, Lindhe J (1995) Guided tissue regeneration in the treatment of degree III furcation defects in maxillary molars. J Clin Periodontol 22:810–812

    Article  PubMed  Google Scholar 

  55. Carranza FA Jr, Jolkovsky DL (1991) Current status of periodontal therapy for furcation involvements. Dent Clin N Am 35:555–570

    PubMed  Google Scholar 

  56. Eickholz P, Pretzl B, Holle R, Kim TS (2006) Long-term results of guided tissue regeneration therapy with non-resorbable and bioabsorbable barriers. III. Class II furcations after 10 years. J Periodontol 77:88–94

    Article  PubMed  Google Scholar 

  57. Jepsen S, Eberhard J, Herrera D, Needleman I (2002) A systematic review of guided tissue regeneration for periodontal furcation defects. What is the effect of guided tissue regeneration compared with surgical debridement in the treatment of furcation defects? J Clin Periodontol 29(Suppl 3):103–116, discussion 160-102

    Article  PubMed  Google Scholar 

  58. Hammarström L, Heijl L, Gestrelius S (1997) Periodontal regeneration in a buccal dehiscence model in monkeys after application of enamel matrix proteins. J Clin Periodontol 24:669–677

    Article  PubMed  Google Scholar 

  59. Bosshardt DD (2008) Biological mediators and periodontal regeneration: a review of enamel matrix proteins at the cellular and molecular levels. J Clin Periodontol 35:87–105

    Article  PubMed  Google Scholar 

  60. Casarin RC, Del Peloso RE, Nociti FH Jr, Sallum AW, Sallum EA, Ambrosano GM, Casati MZ (2008) A double-blind randomized clinical evaluation of enamel matrix derivative proteins for the treatment of proximal class-II furcation involvements. J Clin Periodontol 35:429–437

    Article  PubMed  Google Scholar 

  61. Machtei EE, Zubrey Y, Ben Yehuda A, Soskolne WA (1989) Proximal bone loss adjacent to periodontally "hopeless" teeth with and without extraction. J Periodontol 60:512–515

    PubMed  Google Scholar 

  62. Saxe SR, Carman DK (1969) Removal or retention of molar teeth: the problem of the furcation. Dent Clin N Am 13:783–790

    PubMed  Google Scholar 

  63. Bühler H (1994) Survival rates of hemisected teeth: an attempt to compare them with survival rates of alloplastic implants. Int J Periodontics Restor Dent 14:536–543

    Google Scholar 

  64. Jaffin RA, Berman CL (1991) The excessive loss of Brånemark fixtures in type IV bone: a 5-year analysis. J Periodontol 62:2–4

    Article  PubMed  Google Scholar 

  65. Heitz-Mayfield LJ (2008) Peri-implant diseases: diagnosis and risk factors. J Clin Periodontol 35:292–304

    Article  PubMed  Google Scholar 

  66. Strietzel FP, Reichart PA, Kale A, Kulkarni M, Wegner B, Küchler I (2007) Smoking interferes with the prognosis of dental implant treatment: a systemic review and meta-analysis. J Clin Periodontol 34:523–544

    Article  PubMed  Google Scholar 

  67. Bergenholtz A (1972) Radectomy of multirooted teeth. J Am Dent Assoc 85:870–875

    PubMed  Google Scholar 

  68. Carnevale G, Pontoriero R, di Febo G (1998) Long-term effects of root-resective therapy in furcation-involved molars. A 10-year longitudinal study. J Clin Periodontol 25:209–214

    Article  PubMed  Google Scholar 

  69. Fugazzotto PA (2001) A comparison of the success of root resected molars and molar position implants in function in a private practice: results of up to 15-plus years. J Periodontol 72:1113–1123

    Article  PubMed  Google Scholar 

  70. Minsk L, Polson AM (2006) The role of root resection in the age of dental implants. Compend Contin Educ Dent 27:384–388

    PubMed  Google Scholar 

  71. Farman AG (2005) ALARA still applies. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:395–397

    Article  PubMed  Google Scholar 

Download references

Acknowledgement

The authors would like to thank Dr. Leonard Büttel for performing the reconstructive treatment of the maxillary molars presented in Fig. 4b.

Conflict of interest

The authors declare that they have no conflict of interest.

Author information

Authors and Affiliations

  1. Department of Periodontology, Endodontology and Cariology, University of Basel, Hebelstrasse 3, 4056, Basel, Switzerland

    Clemens Walter, Roland Weiger & Nicola Ursula Zitzmann

Authors
  1. Clemens Walter
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Roland Weiger
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Nicola Ursula Zitzmann
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Nicola Ursula Zitzmann.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Walter, C., Weiger, R. & Zitzmann, N.U. Periodontal surgery in furcation-involved maxillary molars revisited—an introduction of guidelines for comprehensive treatment. Clin Oral Invest 15, 9–20 (2011). https://doi.org/10.1007/s00784-010-0431-9

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00784-010-0431-9

Keywords

Search

Navigation