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Cover
Foreword
Preface
Chapter 1: Anatomy of Multi‐rooted Teeth and Aetiopathogenesis of the Furcation Defect
1. 1.1 Introduction: Why Focus on Molars?
2. 1.2 The ‘Special’ Anatomy of Molar Teeth
3. 1.3 Anatomical Factors in Molar Teeth
4. 1.4 Anatomical Aetiological Factors
5. 1.5 Periodontal Aetiological Factors in Molar Teeth
6. References
Chapter 2: Clinical and Radiographic Diagnosis and Epidemiology of Furcation Involvement
1. 2.1 Introduction
2. 2.2 Clinical Furcation Diagnosis
3. 2.3 Radiographic Diagnosis of Furcation Involvement
4. 2.4 Epidemiology of Furcation Involvement
5. References
Chapter 3: How Good are We at Cleaning Furcations? Non‐surgical and Surgical Studies
1. 3.1 Introduction
2. 3.2 Longitudinal Studies on Management of Furcation‐involved Teeth
3. 3.3 Professional Debridement
4. 3.4 Patient Home Care
5. References
Chapter 4: Furcation
1. 4.1 Introduction
2. 4.2 Pathways Between Endodontium and Periodontium: Anatomical Considerations
3. 4.3 Bacteria Involved in Endodontic‐periodontal Disease
4. 4.4 Relationship Between Periodontal Disease and Histological Pulp Changes
5. 4.5 Endodontic‐periodontal Disease
6. 4.6 Relationship Between Pulp and Periodontal Furcation Therapies
7. References
Chapter 5: Why do We Really Care About Furcations? Long‐term Tooth Loss Data
1. 5.1 Introduction
2. 5.2 Measures of Disease Progression
3. 5.3 Tooth Loss
4. 5.4 Tooth Loss for Untreated Furcation‐involved Teeth
5. 5.5 Tooth Loss for Treated Furcation‐involved Teeth
6. 5.6 Conclusions on Risk of Tooth Loss by Furcation Involvement
7. References
Chapter 6: Regenerative Therapy of Furcation Involvements in Preclinical Models
1. 6.1 Introduction
2. 6.2 Available Preclinical Models
3. 6.3 Defect Types
4. 6.4 Regeneration Treatments of Class II Furcation Defects
5. 6.5 Regeneration Treatments of Class III Furcation Defects
6. 6.6 Discussion
7. 6.7 Conclusions
8. References
Chapter 7: Regenerative Therapy of Furcations in Human Clinical Studies
1. 7.1 Introduction
2. 7.2 Outcome Measures for Regenerative Therapy in Furcation Defects
3. 7.3 Clinical Scenarios
4. 7.4 Furcation Regeneration: Step‐by‐step Procedure
5. 7.5 Furcation Regeneration: How to Take the Next Step?
6. References
Chapter 8: Furcation Therapy
1. 8.1 Anatomical Considerations for Treatment Planning
2. 8.2 Pre‐surgical Diagnosis
3. 8.3 Treatment of Furcation Defects
4. 8.4 Resective Procedures and Restorative Approaches
5. 8.5 Conclusions
6. References
Chapter 9: Furcation Tunnelling
1. 9.1 Introduction
2. 9.2 Indication
3. 9.3 Patient Selection
4. 9.4 The Tunnelling Procedure: Surgical Steps
5. 9.5 Postoperative Follow‐Up and Oral Hygiene in the Furcation
6. 9.6 Types of Teeth
7. 9.7 Pulp Reaction
8. 9.8 Caries after Furcation Tunnelling
9. 9.9 Maintenance Phase
10. References
Chapter 10: Innovative and Adjunctive Furcation Therapy:
1. 10.1 Introduction
2. 10.2 Periodontal Endoscope
3. 10.3 Laser Therapy
4. 10.4 Photodynamic Therapy
5. 10.5 Air‐polishing Devices
6. 10.6 Local Antimicrobials
7. 10.7 Systemic Antimicrobials
8. 10.8 Probiotics
9. 10.9 Surgical Innovations
10. 10.10 Furcation ‘Filling’
11. Conclusion
12. References
Chapter 11: Furcation
1. 11.1 Implants vs Periodontal Multi‐rooted Teeth: What is the Clinical Problem?
2. 11.2 Anatomical Considerations for implant Placement in the Posterior Maxilla and Mandible
3. 11.3 Implant Placement in the Mandibular Molar Region
4. 11.4 Bone Augmentation for Implant Placement in the Maxillary Molar Region
5. 11.5 Short Implants
6. 11.6 Implant Biological Complications
7. References
Chapter 12: Is it Worth it? Health Economics of Furcation Involvement
1. 12.1 Health Economic Relevance of Furcation Involvement
2. 12.2 Health Economic Analyses
3. 12.3 The Costs of Furcation Involvement
4. 12.4 Cost‐effectiveness of Retaining Furcation‐involved Molars
5. 12.5 Research Gaps
6. 12.6 Conclusions
7. References
Chapter 13: Deep Gaps between the Roots of the Molars:
1. 13.1 Introduction
2. 13.2 Patient‐reported Outcome Measures in Periodontology
3. 13.3 Patient‐reported Outcome Measures in Furcation Involvement
4. 13.4 Patient Feedback
5. 13.5 Reflections on Patient Feedback
6. 13.6 Implementation of PROMs in Furcation Treatment
7. Acknowledgements
8. References
Chapter 14: Assessment of Two Example Cases Based on a Review of the Literature
1. 14.1 Case 1 (Maxillary)
2. 14.2 Case 2 (Mandibular)
3. References
Chapter 15: Furcations
1. 15.1 Introduction
2. 15.2 First Things First: Proper Diagnosis
3. 15.3 Degree I Furcation Involvement
4. 15.4 Degree II Furcation Involvement
5. 15.5 Degree III Furcation Involvement
6. 15.6 Upper Premolars
7. 15.7 Innovative Treatment
8. 15.8 So, When Should We Extract?
9. References
Index
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List of Tables

Chapter 01
1. Table 1.1 Classification of cervical enamel projections.
Chapter 02
1. Table 2.1 Regularly multi‐rooted teeth with location of roots and location of furcation entrances.
2. Table 2.2 Classification of furcation involvement according to Glickman (1953).
3. Table 2.3 Classification of furcation involvement according to Hamp et al. (1975).
4. Table 2.4 Recommended classification of furcation involvement.
Chapter 03
1. Table 3.1 Summary of some longitudinal studies that evaluated multi‐rooted teeth.
2. Table 3.2 Summary of studies that evaluated efficacy of mechanical debridement.
Chapter 04
1. Table 4.1 Effect of periodontal disease on pulp tissue.
2. Table 4.2 Primary endodontic lesions.
3. Table 4.3 Primary periodontal lesions.
4. Table 4.4 Primary endodontic lesions with secondary periodontal involvement.
5. Table 4.5 Primary periodontal lesions with secondary endodontic involvement.
6. Table 4.6 True periodontal‐endodontic combined lesions.
Chapter 05
1. Table 5.1 Summary of study procedures for all included studies.
Chapter 06
1. Table 6.1 Guided tissue regeneration (GTR) in class II furcation defects.
2. Table 6.2 Growth factors in class II furcation defects.
3. Table 6.3 Guided tissue regeneration (GTR) in class III furcation defects.
Chapter 07
1. Table 7.1 Comparison of clinical results after open‐flap debridement and guided tissue regeneration in degree II furcation defects of mandibular molars.
2. Table 7.2 Comparison of clinical results after open‐flap debridement and guided tissue regeneration in degree II furcation defects of maxillary molars.
3. Table 7.3 Comparison of clinical results after open‐flap debridement and guided tissue regeneration in degree II furcation defects of maxillary and mandibular molars.
4. Table 7.4 Comparison of clinical results after guided tissue regeneration using expanded polytetrafluoroethylene and biodegradable barriers in degree II furcation defects of maxillary and/or mandibular molars.
5. Table 7.5 Comparison of clinical results after guided tissue regeneration using a barrier membrane alone and in combination with osseous grafts in degree II furcation defects of mandibular molars (all randomized controlled trials).
6. Table 7.6 Comparison of clinical results after guided tissue regeneration or enamel matrix derivative (Emdogain) application in degree II furcation defects of mandibular molars.
Chapter 08
1. Table 8.1 Clinical studies on the treatment of furcation‐involved molars with root separation/resection.
Chapter 09
1. Table 9.1 Summary of follow‐up studies of multi‐rooted teeth subjected to furcation tunnel preparation.
Chapter 12
1. Table 12.1 Mean (SD) number of treatments provided per year of retention. Differences of number of treatments between groups are indicated in bold (p < 0.05, ANOVA). For more than two groups, different superscript letters indicate a significantly different number of treatments according to the Bonferroni post‐hoc test (p < 0.05).
2. Table 12.2 Mean (SD) periodontal and total treatment costs per retention year. Base case (privately insured patient) and sensitivity (publically insured patient) analyses are shown. Differences of costs between groups are indicated in bold (p < 0.05, ANOVA). For more than two groups, different superscript letters indicate significantly different costs according to the Bonferroni post‐hoc test (p < 0.05).
Chapter 14
1. Table 14.1 Case 1, diagnosis of furcation on 16 based on Muller and Eger (1999).
2. Table 14.2 Case 1, main reasons for treatment choice (tunnelling surgery).
3. Table 14.3 Case 2, evaluation.
4. Table 14.4 Case 2, re‐evaluation.
5. Table 14.5 Case 2, main reasons for treatment choice (regenerative therapy with enamel matrix derivative).
Chapter 15
1. Table 15.1 Main differential diagnostic elements to consider for complex furcation treatment planning.

List of Illustrations

Chapter 01
1. Figure 1.1 Drawing of mandibular molar with furcation involvement, showing the main anatomical features, including root trunk (part of the root from the cemento‐enamel junction [CEJ] to the furcation entrance) and root cones, and pointing at root divergence and degree of separation between roots. The ‘bone loss’ is schematically indicated as the distance between the CEJ and the most apical part of the bone.
2. Figure 1.2 Furcation ridge.
3. Figure 1.3a Cervical enamel projection grade II (>1/3 of root trunk; Masters and Hoskins 1964) on upper right first molar (REM microscope).
4. Figure 1.3b Cervical enamel projection on lower left first molar; grade III (reaching furcation entrance area; Masters and Hoskins 1964).
5. Figure 1.3c Cervical enamel projection on extracted lower right first molar; grade III (reaching furcation entrance area; Masters and Hoskins 1964).
6. Figure 1.4a Macroscopic image of an enamel pearl on an extracted molar.
7. Figure 1.4b Microscopic image of an enamel pearl.
8. Figure 1.4c Orthopantomogram showing enamel pearls on upper right and left second molars.
Chapter 02
1. Figure 2.1 Curved furcation probes: Nabers probes (left: without markings; right: marked in 3 mm steps up to 12 mm).
2. Figure 2.2 Furcation involvement degree I (Eickholz and Staehle 1994; Table 2.4): horizontal loss of periodontal tissue support up to 3 mm: (a) schematic (maxillary molar, buccal furcation entrance): horizontal probing/clinical attachment level 2.5 mm; (b) mesial tooth 24 with neighbouring tooth; (c) buccal tooth 46: the probe does not penetrate more than 3 mm between the two buccal roots; (d) disto‐palatal tooth 16 with neighbouring tooth.
3. Figure 2.3 Furcation involvement degree II (Hamp et al. 1975; Tables 2.3 and 2.4): horizontal loss of support exceeding 3 mm, but not encompassing the total width of the furcation area: (a) schematic (maxillary molar, buccal furcation entrance): horizontal probing/clinical attachment level 5 mm; (b) tooth 47: the 9 mm marking is at the gingival margin. However, the 6 mm marking is at the height of the virtual tangent placed to the roots adjacent to the furcation.
4. Figure 2.4 Furcation involvement degree III (Ammons and Harrington 2006): horizontal ‘through‐and‐through’ destruction of the periodontal tissue in the furcation: (a) schematic (maxillary molar, buccal to interproximal furcation entrance); (b) tooth 46 (occlusal view); (c) lingual view; (d) tooth 14; (e) tooth 16 without neighbouring tooth from mesio‐palatal to disto‐palatal; (f) respective radiograph; (g) tooth 46: 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 (Glickman degree IV); (h) respective radiograph.
5. Figure 2.5 Furcation probing at tooth 16: (a) from mesio‐palatal – probing (PAL‐H)/clinical horizontal attachment loss (CAL‐H) = 9 mm; (b) from disto‐palatal – probing (PAL‐H)/clinical horizontal attachment loss (CAL‐H) = 6 mm. In tooth 16 the PAL‐H/CAL‐H measurements add up to 15 mm. At the furcation entrances tooth 16 has a width less than 15 mm. Thus the furcation is through and through (degree III; Table 2.4).
6. Figure 2.6 Differentiated documentation of furcation scores: (a) periodontal chart from the Department of Periodontology of the Johann Wolfgang Goethe‐Universität, Frankfurt am Main: tooth 17 – buccal degree I furcation; through‐and‐through furcation from mesio‐palatal to disto‐palatal (Grade III); tooth 16 – through‐and‐through furcation at all furcation entrances; tooth 14 – distal degree I furcation. (b) Florida Probe: tooth 17 – buccal degree I furcation; through‐and‐through furcation from mesio‐palatal to disto‐palatal (Grade III); tooth 16 – through‐and‐through furcation at all furcation entrances; tooth 14 – distal degree I furcation.
7. Figure 2.7 Follow‐up of inter‐radicular bone at teeth 46 and 47 using digital subtraction radiography (DSR): (a) standardized radiograph of teeth 46 and 47 prior to regenerative therapy; (b) intrasurgical view – buccal degree II furcation involvement at both teeth; (c) standardized radiograph six months after regenerative therapy; (d) subtraction image – increase of bone density within the furcations of 46 and 47.
8. Figure 2.8 Diagnosis and treatment planning using cone‐beam computed tomography (CBCT). CBCT images with horizontal, sagittal, and transversal sections of first and second left maxillary molars. According to the bone loss around the disto‐buccal root and the remaining periodontal attachment around the mesio‐buccal and palatal root, it was decided to extract the distobuccal root.
9. Figure 2.9 Root resection in a maxillary first molar: (a) pre‐surgical view; (b) tri‐section of the distobuccal root; (c) the flap is fixed with monofil synthetic sutures 5 × 0; (d) four months post‐operation, the wound healing was uneventful; (e) a crown with an extended metal margin is placed and the patient is introduced to meticulous oral hygiene.
Chapter 03
1. Figure 3.1 The upper right maxillary molar (UR6) of a 53‐year‐old female patient affected by generalized advanced chronic periodontitis, extracted as deemed hopeless due to bone loss to the apex and mobility degree III. This tooth had received what was defined as ‘deep cleaning’ by a general dental practitioner. However, the images show very extensive deposits of calculus in the furcation region, testifying to the difficulty of achieving good subgingival debridement in furcation regions.
2. Figure 3.2 (a) Mini Five® Gracey curettes #11/12 and #13/14 with blade width of 0.76 mm; (b) Micro Mini Five® Gracey curettes #11/12 and #13/14 with blade width of 0.6 mm; (c) difference in the blade widths of the Micro Mini Five Gracey curette #11/12 (left) and Mini Five Gracey curette #11/12 (right).
3. Figure 3.3 Traditional piezoelectric ultrasonic scaler tips with a diameter of 0.7–0.8 mm.
4. Figure 3.4 EMS Piezon® Master ultrasonic scaler and tips: (a) PL1 tip with a diameter of 0.5 mm for debridement of hard‐to‐reach interproximal areas; (b) PL5 tip with a ball end of diameter 0.8 mm for debridement of furcations and concavities; (c) PS universal tip with a diameter of 0.6 mm for debridement of deep pockets.
5. Figure 3.5 Cavitron® Slimline™ insert with a diameter of 0.5 mm.
6. Figure 3.6 (a) The maxillary right first molar presented with a Grade I cervical enamel projection, 6 mm pockets, and a class II furcation. (b) Periapical radiograph showed radiolucency in the furcation area. (c) Cervical enamel projection was evident and seen protruding into the furcation. (d) Furcal area was debrided with After‐5 Gracey curettes (Hu‐Friedy, USA) and Piezo ultrasonic scalers (EMS, Switzerland). (e) Newmeyer’s rotary bur was used to remove the cervical enamel projection and any remaining granulomatous tissue. (f) Clinical photo showed the defect after cleaning. (g) Defect was grafted with human cancellous allograft (LifeNet, USA). (h) The graft was then protected with a well‐trimmed collagen membrane (2–3 mm beyond the defect margin all around). (i) The flap was then coronally advanced and sutured. (j) At the two‐year post‐surgery follow‐up visit, the probing pocket depth at the furcation area was reduced to 3 mm and (k) radiographic bone fill was observed. (l) The furcation area remained stable clinically and (m) radiographically even at the four‐year post‐surgery follow‐up visit. Further details and indications of furcation regenerative therapy are given in Chapter 7.
7. Figure 3.7 The mandibular left second molar presented with a grade III cervical enamel projection, 6–8 mm pockets, and a class III furcation. (a) Residual calculus observed on flap elevation, reflecting the ineffectiveness of non‐surgical debridement. (b) Surgical open‐flap scaling and root planing with fine ultrasonic inserts (Cavitron®, Dentsply, USA) and Gracey curettes (Hu‐Friedy, USA) were performed to achieve a smooth root surface. The flap was repositioned and sutured apically, exposing the class III furcation involvement. (c) At the two‐year post‐surgery follow‐up visit, there was recurrence of the pocket to 5 mm at the midlingual site (d) with bleeding on probing, despite the patient using an interdental brush of the appropriate size and being on a strict three‐monthly periodontal maintenance regimen. This therefore concurs with the literature that plaque removal at the furcation area is unpredictable, even when exposed and visible.
Chapter 04
1. Figure 4.1 Accessory canal located distally to the mesial root on 4.6 (LR6) (a). Interradicular radiolucency on 3.6 (LL6) (b). After root canal therapy, the accessory canal located distally to the mesial root was filled with cement (c). Complete remineralization after four‐year follow‐up (d).
2. Figure 4.2 Vertical root fracture starting from the apex on 2.7 (UL7). The lesion resembled an endodontic infection (a). Complete failure after two years follow‐up (b). Root resection was not possible due to unfavourable anatomy.
3. Figure 4.3 Vertical fracture of the distal root on 3.6 (LL6) (a). Rizectomy of the distal root (b) and after healing (c).
4. Figure 4.4 Disto‐lingual external progressive root resorption on 4.7 (LR7). Initally, the invisible resorption induced pulpitis and root canal therapy was performed.
5. Figure 4.5 Pulp necrosis on 3.6 (LL6) after deep root debridement.
6. Figure 4.6 Pulpitis on 3.6 (LL6). Inter‐radicular and periapical radiolucencies due to bacterial toxins. Five‐year follow‐up after root canal therapy.
7. Figure 4.7 Primary endodontic lesion with inter‐radicular and apical involvement on 4.6 (LR6). No furcation probing after three months and partial healing after one‐year follow‐up.
8. Figure 4.8 Degree III furcation involvement on 4.6 (LR6) with progressive deepening of the defect and secondary pulp necrosis after 14 years. Root canal therapy led to resolution of the endodontic component of the defect. Besides scaling and root planing and oral hygiene instructions, no further periodontal treatment was performed.
9. Figure 4.9 Class 3 inter‐radicular defect and concomitant decay of the furcation roof on 4.7 (LR7). The caries progression led to pulp necrosis. Tunnelling spontaneously occurred after non‐surgical periodontal treatment. One‐year follow‐up after root canal therapy.
10. Figure 4.10 Fistulous sinus track between 1.6 (UR6) and 1.7 (UR7) (a). Fistula tracking revealed the origin of the endodontic infection on 1.7 (b).
11. Figure 4.11 Radiographic radiolucency on 3.6 (LL6) affected by secondary occlusal trauma without furcation involvement (a). Six‐month follow‐up after root debridement and occlusal adjustment (b).
12. Figure 4.12 Degree II furcation defect (lingual) on 3.6 (LL6) affected by secondary occlusal trauma. Being the possible result of jiggling movements, the apical radiolucency present on the mesial root disappeared after the occlusal adjustment. Twenty‐year follow‐up after non‐surgical periodontal therapy and oral hygiene instructions.
13. Figure 4.13 Diagnostic tests for pulp health assessment.
14. Figure 4.14 Pulp necrosis limited to the distal root on 4.6 (LR6) and result after root canal therapy.
15. Figure 4.15 True combined lesion on 3.6 (LL6) with an incongruous root canal therapy. The endodontic infection led to the apical resorption of the distal root. Despite the inter‐radicular radiolucency, furcation probing was negative. A periodontal defect was present on the distal aspect of the tooth. Two‐year follow‐up after non‐surgical periodontal therapy, oral hygiene instructions, and root canal retreatment.
16. Figure 4.16 Inter‐radicular defect on 3.6 (LL6) due to stripping of the mesial root and results after rizectomy.
17. Figure 4.17 Pulp exposure after resective therapy on vital 4.6 (LR6). Root canal treatment was performed one week later.
18. Figure 4.18 Degree II furcation defect (mesial and distal) on 2.6 (UL6). Minimally invasive access to the endodontic space was obtained after isolation with rubber dam. Canals were conservatively shaped and filled with gutta‐percha apical to the furcation floor. Resin composite was used to fill the root canal entrances and to build up the cavity access. The rizotomy (root separation) of the mesio‐buccal and palatal roots and the rizectomy (root amputation) of the disto‐buccal root were performed after endodontic treatment. All the root canals were endodontically treated, since there was no pre‐operative certainty of the extraction of the distal root.
Chapter 05
1. Figure 5.1 The different steps of periodontal therapy.
2. Figure 5.2 Forest plot presenting relative risk (RR) of tooth loss based on follow‐up periods (excluding third molars). Meta‐analysis for the comparison of tooth loss among selected studies presented an overall odds ratio of 2.90 (95% confidence interval [CI] = 2.01–4.18, p < 0.0001). For studies with a follow‐up period of 5–10 years, 10–15 years, and > 15 years, the RR of tooth loss between teeth with and without furcation involvement was 1.46 (95% CI = 0.99–2.15, p = 0.06), 2.21 (95% CI = 1.79–2.74, p < 0.0001), and 4.46 (95% CI = 2.62–7.62, p < 0.0001), respectively.
3. Figure 5.3 Forest plot presenting relative risk (RR) of tooth loss based on degrees of furcation involvement (excluding third molars). Meta‐analysis for the comparison of tooth loss among selected studies presented an RR of 1.67 (95% confidence interval [CI] = 1.14–2.43, p = 0.008), 1.83 (95% CI = 1.37–2.45, p < 0.0001), and 3.13 (95% CI = 2.30–4.24, p < 0.0001) when comparing degree II to I, degree III to II, and degree III to I furcation involvement, respectively.
4. Figure 5.4 (a, b) Clinical photographs of 55‐year‐old male patient affected by chronic periodontitis; (c) periapical radiographs of upper right molars showing triple degree III furcation involvement on UR6 and 7; (d, e) clinical photographs taken 10 years after tunnelling surgery; (f) Periapical photographs at 10‐year follow‐up.
Chapter 06
1. Figure 6.1 Overview photomicrographs of all class III furcation defects in different groups. (a) Furcation treated with ethylenediaminetetraacetic acid (EDTA). Regeneration was observed only at the level of the notch, with connective tissue and granulation tissue plus epithelium covering the rest of the space. (b) Furcation treated with enamel matrix derivative (EMD). The furcation was partially closed and a layer of new cementum with inserting fibres identified coronal to the notch. Regenerated bone filled most of the furcation area. (c) Guided tissue regeneration (GTR)‐treated furcation where the membrane remained covered. The entire circumference of the defect is covered with a layer of new cementum. Regenerated alveolar bone fills the furcation defect completely. (d) Furcation treated with GTR + EMD. The furcation was closed and new cementum can be seen on most of the circumference of the defect. The defect was filled with new bone up to the fornix.
2. Figure 6.2 Clinical appearance of the mandibular buccal aspect of Macaca fascicularis. (a) Induction of chronic inflammation. After fabrication of class III furcation defects, impression materials were placed to encourage growth of oral microflora along the exposed root surfaces. (b) Prior to reconstructive surgery. (c) Immediately after flap reflection. Note the excessive granulation tissue in the chronic defects. (d) Defects were exposed and debrided again at the time of reconstructive surgery. (e) Osteogain/absorbable collagen sponge (ACS) construct before surgical implantation. (f) Left (second molar): ACS alone; right (first molar): placement of Osteogain/ACS. (g) Flaps coronally repositioned and sutured. (h) 16 weeks after reconstructive surgery.
3. Figure 6.3 Overview photomicrographs of all class III furcation defects in different groups (Azan‐Mallory staining). (a) OFD (open‐flap debridement) group overview (scale bar: 1 mm). (b) Higher magnification of framed area (left) in (a) (scale bar: 200 µm). (c) Higher magnification of framed area (right) in (a) (scale bar: 200 µm). (d) Absorbable collagen sponge (ACS) group overview (scale bar: 1 mm). (e) Higher magnification of framed area (left) in (d) (scale bar: 200 µm). (f) Higher magnification of framed area (right) in (d) (scale bar: 200 µm). (g) Emdogain/ACS group overview (scale bar: 1 mm). (h) Higher magnification of apical framed area (left) in (g) (scale bar: 200 µm). (i) Higher magnification of framed area (right) in (g) (scale bar: 200 µm). (j) Osteogain/ACS group overview (scale bar: 1 mm). Arrowhead: notch (apical extent of root planing). (k) Higher magnification of framed area (left) in (j) (scale bar: 200 µm). (l) Higher magnification of framed area (right) in (j) (scale bar: 200 µm).
Chapter 07
1. Figure 7.1 (a) Periodontal measurements at baseline, tooth no. 36 (LL6). Probing depth mesial and distal: 2 mm, furcation degree II buccally, horizontal probing: 4 mm, recession 3 mm. (b) Radiograph of tooth no.36 with visible furcation defect, adjacent bone level at forcation fornix. (c) Flap elevation: intrasulcular incision/horizonal release, mucoperiostal flap, papillae de‐epithelialized, periosteal split in the vestibule. Root surface debridement. (d) Horizontal probing bone level: 4 mm. (e, f) Placement of a bioresorbable matrix barrier (Guidor™ MSL‐configuration, Sunstar Americas, Inc., Schaumburg, IL, USA) to facilitate guided tissue regeneration. Fixation of the barrier with integrated sling sutures. (g, h) Coronally advanced flap secured with sling and interrupted sutures. (i) One day after periodontal regenerative surgery. (j) Clinical view 3 weeks after surgery with matrix exposure. (k, l) Exposed matrix partially removed. (m, n) 5 weeks after surgery. (o, p) 12 months after surgery. Horizontal and vertical probing depths: 2 mm, recession 3 mm. (q) Radiograph taken 12 months after surgery. Almost complete radiographic bone fill in furcation area.
2. Figure 7.2 (a, b) Periodontal measurements at baseline, tooth no. 46 (LR6). Probing depth mesial and distal: 3 mm, furcation degree II. Situation 2 months after an acute abscess and mobility grade 2 treated with debridement of the accessible root surfaces and local antimicrobials. (c) Radiograph of tooth no. 46 with visible furcation defect, proximal bone loss to the level of the furcation, and a very short distal root. (d) Horizontal probing bone level: 7 mm, crown margin reduced and polished. (e, f) Debrided root surfaces. Flap design: intrasulcular incision/vertical release mesial, mucoperiostal flap, papilla mesial de‐epithelialized, periosteal split in the vestibule. The distal papilla was left intact, but mobilized and slightly elevated by a tunnelling procedure. (g) Placement of a bioresorbable matrix barrier (Guidor™ MSL‐configuration, Sunstar Americas, Inc., Schaumburg, IL, USA) after application of a xenogeneic bone mineral into the furcation defect (Bio‐oss collagen™, Geistlich Biomaterials, Wollhusen, Switzerland) to facilitate guided tissue regeneration. (h) Coronally advanced minimally rotated flap secured with sling and interrupted sutures. (i) Clinical view one day after periodontal regenerative surgery. (j, k) Clinical view 2 weeks after surgery. (l) Clinical view 3 months after surgery. (m) 9 months, vertical and horizontal probing depths: 2 mm. (n) 9 months, radiographic fill of the furcation defect.
Chapter 08
1. Figure 8.1 Root separation (rizotomy: sectioning of the multi‐rooted tooth with the maintenance of all the roots) of a mandibular first molar affected by degree III furcation involvement (a–d), followed by an apical positioned flap (e) and final restoration (f), allowing self‐performed oral hygiene.
2. Figure 8.2 Root resection (rizectomy) of the mesio‐buccal root of an upper maxillary molar, without separation of the other two roots, performed due to the severe loss of bone support caused by an endodontic‐periodontal lesion. Degree III furcation involvement on the mesial and buccal furcations was present, with no distal furcation involvement. This procedure was carried out after appropriate endodontic therapy. Three months after the root resection, an apically positioned flap was performed and a provisional prosthetic crown was positioned. Three months later, a final metal‐ceramic crown was cemented, with a good long‐term (five years) clinical result (last image).
3. Figure 8.3 Root separation of all three roots of a maxillary upper second molar and extraction (rizectomy) of the disto‐buccal root.
4. Figure 8.4 Root separation in a mandibular first molar affected by degree III furcation involvement associated with periodontal‐endodontic pathology on the distal root. Distal root resection (rizectomy) was carried out, maintaining the mesial root in situ. A prosthetic metal‐ceramic crown was carried out after the three‐month healing period.
Chapter 09
1. Figure 9.1 Example of a well‐functioning tunnel at a maintenance visit. The tunnel has been in function for seven years. Healthy periodontal tissues are noted around the two roots from the buccal (a) and lingual (b) aspects. On the intraoral radiograph (c), the inter‐radicular alveolar bone is dense, which can be taken as a sign of stable conditions.
2. Figure 9.2 Root anatomy guides the interdental brush from the buccal to the mesio‐palatal furcation entrance. When an interdental brush is inserted into the buccal furcation entrance, root anatomy will usually lead the brush to the mesial furcation entrance.
3. Figure 9.3 Tunnel preparation by gingivectomy. If the interdental brush – coming from the buccal furcation entrance – cannot pass a through‐and‐through furcation involvement at the lingual aspect due to soft‐tissue obstruction, gingivectomy at the lingual aspect will create accessibility through the whole furcation.
4. Figure 9.4 Different approaches for tunnelling surgery needed according to the amount of keratinized gingiva (KG). In a case of an adequate amount of KG (a), scalloped incisions can be performed to expose the furcation area for self‐performed cleaning (b). In a case of a reduced amount of KG (c), an apically repositioned flap is performed in order to preserve the KG while still exposing the furcation area for self‐performed cleaning (d).
5. Figure 9.5 Osteoplasty during tunnel operation and suturing through the furcation. A furcation entrance can be obstructed by soft tissue (a) and bone ridges (b). A positive bone architecture has to be created by intrasurgical osteoplasty (see arrows) to secure easy insertion of the interdental brush through the furcation. Good soft‐tissue adaptation can be achieved in the furcation entrances by placing a suture through the furcation (c), ensuring good healing (d).
6. Figure 9.6 At upper molars, root anatomy does often not form a straight pathway from the buccal to the mesial furcation entrance (in contrast to the furcation at lower molars). In such a case, it is more advisable to open the furcation by trimming the flaps, to leave the furcation entrances to heal openly (a), and not to place sutures, which after healing ensures good accessibility for the patient (b).
7. Figure 9.7 Meticulous oral hygiene instruction. It is necessary to thoroughly explain to the patient the technique of brushing a furcation tunnel. One crucial piece of information is to point out that the interdental brush has to be inserted through the whole furcation tunnel. The patient should feel the tip of the brush with the tongue.
8. Figure 9.8 Gingival topography reveals the patient’s capability to brush the tunnel. Excellent oral hygiene after furcation tunnelling is often revealed by the inter‐radicular gingiva showing the path of the interdental brush through the tunnel furcation. Good adaption of the gingiva to the root surface is seen.
9. Figure 9.9 In rare cases, double tunnels can be created. In this case, the distal furcation entrance was reached through the buccal entrance (a). The patient had learned to access both the mesial and the distal entrance through the buccal entrance (b).
10. Figure 9.10 Upper left first premolar with mesial bone loss reaching the apical third of the root was chosen for furcation tunnelling. Clinically, at the mesial aspect over the furcation entrance, there was a pronounced swelling corresponding to the radio‐juxtaradicular translucency. Though good compliance with interdental brushing was achieved, the progression of periodontitis could not be arrested. The tooth lost stability only a few months later and had to be extracted.
11. Figures 9.11 and 9.12 Development of caries in furcation tunnels. In these two cases, caries developed within the furcation area – before caries developed (a) and (c); with the established lesions (b) and (d). Caries development was associated with inadequate oral hygiene during supportive periodontal therapy. The lesions may be easily missed by mere clinical examination. Radiographs should therefore be taken during supportive periodontal therapy to detect caries development at an early stage.
Chapter 10
1. Figure 10.1 Upper left first molar (UL6) of patient with chronic periodontitis, affected by degree II FI and treated with photodynamic therapy, following non‐surgical furcation debridement with ultrasonic devices. (a) Application of dye (methylene blue) inside the furcation area; (b) activation of the dye by photodynamic therapy light.
2. Figure 10.2 Application of local antibiotic after non‐surgical debridement in degree II mesial furcation lesion of a maxillary second molar, associated with mesial intrabony defect (10 mm probing pocket depth) and extensive presence of subgingival deposits. (a) Periapical radiograph; (b) clinical photograph; (c) antibiotic application from the mesio‐buccal aspect of the pocket associated with the furcation defect; (d) antibiotic overflowing from the pocket; (e) radiographic re‐evaluation six months after treatment, showing bone fill with reduction in the intrabony defect depth (now 6 mm probing pocket depth and degree I furcation involvement).
Chapter 11
1. Figure 11.1 (a) Left maxillary first molar affected by endodontic‐periodontal pathology. (b) Computed tomography (CT) scan taken after extraction, showing reduction of vertical height, as well as root residuals.
2. Figure 11.2 (a) Left maxillary first molar affected by root fracture. (b) Implant placement was carried out three months after extraction, with the use of osteotome‐mediated sinus elevation associated with bone grafts. (c) An implant‐supported crown was placed three months later.
3. Figure 11.3 Sinus membrane perforation occurred during lateral window sinus elevation approach and repaired with the use of a resorbable membrane.
Chapter 12
1. Figure 12.1 Man, aged 42 years and non‐smoker, diagnosed with chronic periodontitis and horizontal bone loss in both jaws with furcation involvement degree II up to III (Hamp et al. 1975) on all first and second molars (a: initial status). He received scaling and root planing and open‐flap debridement of all posterior teeth. After 22 years of regular supportive periodontal therapy (b), endodontic treatment was required, with trisection of the upper right molars and prosthetic reconstruction being performed. Afterwards, furcation cleaning with interdental brushes (c) was possible. The situation remained stable for a further seven years (d, last observation).
2. Figure 12.2 Woman, aged 36 years and non‐smoker, diagnosed with aggressive periodontitis and horizontal bone loss in both jaws and furcation involvement degree III (Hamp et al. 1975) of all upper molars and tooth 14 (UR4), as well as degree II (Hamp et al. 1975) of all lower molars (a: initial status). Initial periodontal therapy with scaling and root planing was followed by open‐flap debridement of all premolars and molars. After re‐evaluation, supportive periodontal therapy was commenced and after 1.5 years the buccal roots of all upper molars were resected and fixed dental prostheses provided (b). Two (c) and 17 years later (d), no further attachment loss was noted. Tooth 46 (LR6) had to be extracted due to a fracture.
3. Figure 12.3 Man, aged 47 years and smoker; chronic periodontitis and horizontal bone loss in both jaws with furcation involvement degree II (Hamp et al. 1975) on all upper molars and right lower molars, as well as degree III (Hamp et al. 1975) on all left lower molars (a: initial status). Open‐flap debridement of all molars, including tunnelling of the left lower molars, was provided. The patient stopped smoking after the 8th year during SPT. After 28 years of regular supportive periodontal therapy (b), the periodontal situation remained stable.
4. Figure 12.4 First lower molar with furcation involvement degree III (Hamp et al. 1975) after treatment with tunnelling for cleaning at home (a). The situation remained stable for over 9 years (b), while after 13 years (c) a carious lesion in the furcation developed, leading to endodontic involvement and, eventually, extraction.
5. Figure 12.5 Man, aged 59 years and non‐smoker, diagnosed with generalized chronic periodontitis and horizontal bone loss up to one‐quarter of the root length in both jaws and furcation involvement degree I (lower molars) and II (upper molars) (Hamp et al. 1975) (a and b). Initial periodontal therapy using scaling and root planing followed by open‐flap debridement of all pre/molars with extraction of tooth 17 (UR7) (as a result of a root carious lesion) was provided. After re‐evaluation, a regular supportive periodontal therapy was started and after one year a fixed dental prosthesis was fitted. Seven years later, tooth 11 fractured (c) and a fixed dental prosthesis was provided in the front (d). This situation remained stable for 29 years (e, last observation).
6. Figure 12.6 State transition diagram. Molars with furcation involvement (FI) degrees I and II/III were analysed separately, with different treatments being compared. All periodontal treatments were compared with implant‐supported crowns (ISC). For all teeth, periodontal, endodontic, and restorative complications were modelled, with fatal (leading to tooth loss) and non‐fatal (mendable) complications being simulated separately. For implants, we modelled technical (loss of crowns, abutment fracture, implant fracture) and biological complications (peri‐implantitis), again with separate simulation of fatal and non‐fatal failures. If complications were mendable, teeth and implants were allocated to follow‐up treatments, which generated costs. In case these treatments were not final, i.e. another retreatment was possible (for example re‐restoration after repair), this was modelled as well. Eventually, lost teeth or implants were assumed to be replaced using implant‐supported crowns. Note that within base case analysis, all failed teeth or implants were assumed to be (re‐)replaced. To explore the effects of this assumption, sensitivity analyses were performed.
7. Figure 12.7 Cost‐effectiveness of different strategies to treat molars with furcation involvement (FI). For FI degree I, we compared conservative scaling and root planing (SRP) and flap debridement and SRP (FD) with implant‐supported crowns (ISC). For molars with FI degrees II or III, root resection (RR), guided tissue regeneration (GTR), and tunnelling (TU, for lower molars) were compared with ISC. The presented cost‐effectiveness planes (a, b, c) demonstrate the discounted lifetime costs (y‐axis) per effectiveness (in years of tooth or implant retention). In the case of FI degree I (a), SRP was more effective and less costly than ISC, while FD was both less effective and less costly than ISC. For upper (b) or lower (c) molars with FI degree II or III, ISC was dominated by all tooth‐retaining strategies.
8. Figure 12.8 Man, aged 46 years, with generalized chronic periodontitis after extraction with immediately re‐fixation of tooth 31 (LL1) (a, b: before extraction) and long‐term stability of the situation during supportive periodontal therapy over 10 years (c, d).
9. Figure 12.9 Woman, aged 47 years, with generalized chronic periodontitis and root resorption of the mesial root of tooth 46 (LR6) (a). After successful endodontic treatment and resection of the mesial root (b), a fibre‐enforced pontic was directly placed (c), allowing splinting of teeth 46 and 45 (LR5). Long‐term stability was achieved during supportive periodontal therapy over 11 years (d–f).
Chapter 14
1. Figure 14.1 Case 1, clinical photograph of frontal (a) and upper right palatal (b), followed by baseline periapical radiographs of upper molars (c and d), the only teeth with probing pocket depth > 4 mm at first visit.
2. Figure 14.2 Case 2, clinical photograph (a) of left mandibular first molar, followed by baseline periapical radiograph (b).
Chapter 15
1. Figure 15.1 Proposed algorithm for furcation diagnosis.
2. Figure 15.2 Proposed algorithm for furcation treatment (degree I furcation involvement).
3. Figure 15.3 (a) Periapical radiographs of molars of a female 32‐year‐old aggressive periodontitis patient at periodontal diagnosis. Radiolucency inside the furcation areas is visible, particularly for UR6 and 7 (both degree II clinical furcation involvement [FI] diagnosis), UL6 and 7 (degree I FI), LL6 (degree I FI), and LR6 (degree II FI), often associated with intrabony defects. (b) Periapical radiographs of the same molars one year after initial periodontal therapy (oral hygiene instructions and supra‐ and subgingival debridement with adjunctive systemic antibiotics and extraction of UL8), showing radiographic bone fill in furcation defects and intrabony defects, associated with clinical reduction of FI degrees (now only degree I for UR6 and 7, UL6 and 7, and LR6).
4. Figure 15.4 Proposed algorithm for furcation treatment (degree II mandibular furcation involvement).
5. Figure 15.5 Clinical photograph (a) and periapical radiograph (b) of 47‐year‐old patient diagnosed with chronic periodontitis and affected by double degree II furcation involvement and distal intrabony defect (disto‐buccal and disto‐lingual probing pocket depth [PPD] 12 mm) on tooth 36 (LL6). Following non‐surgical periodontal therapy, regenerative surgery with enamel matrix derivative was carried out (c and d, buccal and lingual intra‐operative views after full‐thickness flaps elevation), with favourable outcomes at five years after surgery, with reduction of PPD to 4 mm and only degree I furcation lingual (e) and fill of intrabony and furcation defect (f).
6. Figure 15.6 Proposed algorithm for furcation treatment (degree II maxillary furcation involvement).
7. Figure 15.7 Proposed algorithm for furcation treatment (degree III furcation involvement).
8. Figure 15.8 Clinical photograph (a) and periapical radiographs (b and c) of 50‐year‐old patient diagnosed with chronic periodontitis and affected by triple degree III furcation involvement on 17 (UR7), 16 (UR6), and 27 (UL7). Following non‐surgical periodontal therapy, tunnelling surgery was carried out (d, intra‐operative view after full‐thickness flaps elevation and osteoplasty), with favourable outcomes at 12 years after surgery with probing pocket depths < 5 mm (e), continued good oral hygiene access to furcations (f, g, and h), and stable radiographic bone levels (i and j).