e137 Management of Furcation-Involved Molars: Recommendation for Treatment and Regeneration Giulio Rasperini, DDS1/Jad Majzoub, BDS2 Periodontitis is a multifactorial Lorenzo Tavelli, DDS, MS2/Enrico Limiroli, DDS1 chronic disease that affects ap- Akihiko Katayama, DDS, PhD3/Shayan Barootchi, DMD2 proximately 42% of the adults in the Roger Hill, DDS, MS2/Hom-Lay Wang, DDS, MS, PhD2 United States.1 Its progression and detrimental results on periodontal tissues have been extensively evalu- Furcation involvement (FI) is one of the most detrimental factors affecting ated.2 When this condition affects tooth survival rate over time. Several authors have used the severity of FI multi-rooted teeth exposing the fur- for assessing the prognosis of the tooth and the complexity of periodontal cation area, the treatment poses ad- disease. While many approaches have been shown to improve the prognosis ditional challenges for the clinician. of furcation-involved teeth, clinical guidelines recommending one treatment or another (based on the horizontal and vertical component of the furcation This is because the unfavorable mor- defects) have not yet been proposed. To this aim, the present article phology and restricted-access area introduces recommendations for the treatment of molars with FI and discusses that characterize furcation defects different treatment options with their potential regenerative approaches. limit not only the efficacy of nonsur- Patient-related factors, together with hard and soft-tissue conditions that gical and surgical therapies but also may affect the outcomes of periodontal regeneration, are discussed. Int J the patient’s self-performed plaque Periodontics Restorative Dent 2020;40:e137–e146. doi: 10.11607/prd.4341 control.3 Due to these limitations, the progression of the disease in the furcation area exhibits horizontal and/or vertical patterns of destruc- tion that may lead to an increased risk for tooth loss.4,5 Therefore, it is not surprising that the severity of furcation involvement (FI) has been used for assessing the prognosis of the tooth6 and the complexity of periodontal disease.7 In a recent meta-analysis, Nibali et al showed 1Department of Biomedical, Surgical and Dental Sciences, University of Milan, that the presence of FI increases the Foundation IRCCS Ca’ Granda Polyclinic, Milan, Italy. risk of tooth loss in molars by two- 2Department of Periodontics & Oral Medicine, University of Michigan School of Dentistry, fold when maintained in supportive Ann Arbor, Michigan, USA. periodontal therapy (SPT).8 3Department of Periodontology, Tokyo Dental College, Tokyo, Japan. Several surgical approaches Correspondence to: Dr Giulio Rasperini, Department of Biomedical, have been proposed for the treat- Surgical and Dental Sciences, Foundation IRCCS Ca’ Granda Polyclinic, ment of molars with FI, including Via della Commenda 12, 20122 Milan, Italy. Email: [email protected] guided tissue regeneration (GTR), bicuspidization, tunneling proce- Submitted February 15, 2019; accepted June 17, 2019. ©2020 by Quintessence Publishing Co Inc. dure, and root amputation. Car- Volume 40, Number 4, 2020 © 2020 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e138 Table 1 Classifications of Horizontal and erticalV Furcation Defects That Were Used in the Present Article Horizontal component of the furcation defect13 Vertical component of the furcation defect15 A B C 1 Horizontal loss of periodontal Horizontal loss of periodontal Horizontal loss of periodontal support < 3 mm of the support < 3 mm of the support < 3 mm of the width of the tooth with width of the tooth with width of the tooth with vertical attachment/bone loss vertical attachment/bone loss vertical attachment/bone loss extending to the coronal extending to the middle extending to the apical third of the root. third of the root. third of the root. 2 Horizontal loss of periodontal Horizontal loss of periodontal Horizontal loss of periodontal support ≥ 3 mm of the support ≥ 3 mm of the support ≥ 3 mm of the width of the tooth, but not width of the tooth, but not width of the tooth, but not “through and through,” “through and through,” “through and through,” with vertical attachment/ with vertical attachment/ with vertical attachment/ bone loss extending to the bone loss extending to the bone loss extending to the coronal third of the root. middle third of the root. apical third of the root. 3 Horizontal “through and Horizontal “through and Horizontal “through and through” destruction of the through” destruction of the through” destruction of the periodontal attachment with periodontal attachment with periodontal attachment with vertical attachment/bone loss vertical attachment/bone loss vertical attachment/bone loss extending to the coronal extending to the middle extending to the apical third of the root. third of the root. third of the root. When presenting their clinical recommendation, the present authors combined the horizontal and the vertical components for describing the furcation defects (eg, A1, B3, C2). nevale et al reported a 93% survival mending one treatment or another (until January 2019) was performed rate for molars with FI following root- have mostly been based upon the across the National Library of resective therapy,9 while Bowers horizontal extension of the furca- Medicine (MEDLINE by PubMed), et al achieved complete furcation tion defect and the morphology of EMBASE, the Cochrane Library, and closure in 74% of mandibular molar the tooth12 alone, while guidelines the Grey Literature, using the fol- sites with facial Class II furcations, based on the vertical component lowing keywords: “furcation involve- reporting that 68% of furcation de- of the defect and the surrounding ment,” “furcation defects,” and fects were reduced to Class I. These soft tissue components have not “guided tissue regeneration.” In results demonstrated the positive yet been proposed. Therefore, the addition, a manual search of related effect of GTR and bone graft in aim of this article is to propose rec- articles, including complete search- furcation-involved molars.10 In line ommendations for the treatment of es of The International Journal of with these results, the American molars with FI and discuss different Periodontics & Restorative Dentistry, Academy of Periodontology (AAP) treatment options with their poten- Journal of Clinical Periodontology, Regeneration Workshop on furca- tial regenerative approaches. and Journal of Periodontology were tion defects concluded that regen- performed. A decision tree for fur- eration is a viable treatment option cation management and regenera- for molars with Class II FI and that Materials and Methods tion was formulated, mainly aimed this approach should be consid- at treating the buccal furcations of ered before performing resec- To support the proposal of treat- maxillary or mandibular molars, as tive therapy or other treatments.11 ment and regeneration in FI molars, they show the most realistic and However, clinical guidelines recom- a review of all available literature promising treatment outcomes.11 The International Journal of Periodontics & Restorative Dentistry © 2020 BY QUINTESSENCE PUBLISHING CO, INC. PRINTING OF THIS DOCUMENT IS RESTRICTED TO PERSONAL USE ONLY. NO PART MAY BE REPRODUCED OR TRANSMITTED IN ANY FORM WITHOUT WRITTEN PERMISSION FROM THE PUBLISHER. e139 Fig 1 Decision tree for the management of a furcation-involved molar. Please see Table 1 for explanation of furcation defect classifica- tions. NSPT = nonsurgical periodontal therapy; OFD = open-flap debridement. Management of Furcation- tal13 or vertical attachment loss,14,15 considered the combination of the Involved Molars several classifications for furcation horizontal (grades 1, 2, and 3)13 and involvement have been proposed. vertical (subclasses A, B, and C)14,15 Based upon the evidence available While FI has been often classi- furcation components in this newly in the literature and the clinical expe- fied based on the horizontal attach- formulated decision tree (Table 1 and rience of the authors, the following ment loss, a 10-year retrospective Fig 1). The goal for treatment of FI is factors were considered for formu- study by Tonetti et al recently dem- to clean the furcation and to facilitate lating the presented decision tree: (1) onstrated that the residual periodon- patients’ oral hygiene.13 Bearing in furcation defects considering both tal attachment, evaluated as the loss mind that nonsurgical periodontal horizontal and vertical attachment of vertical component, is a reliable therapy (NSPT) constantly presents loss; (2) level of the interproximal predictor of survival of molars with the first step following the diagnosis bone; (3) accessibility of the area for Class II horizontal FI.15 Nibali et al of a furcation defect, the diagnosis patient oral hygiene; (4) residual at- showed that after surgical treatment of FI has to be confirmed after at tachment of the roots; and (5) tooth and SPT for at least 5 years, both the least 6 weeks following NSPT. In- anatomy (eg, root trunk length, root horizontal and vertical FI were associ- deed, a correct diagnosis is vital for length, divergence of the roots). ated with an increased risk for tooth establishing an adequate treatment Based on the severity of the horizon- loss.16 Therefore, the present authors plan.17 If the area is accessible for