Furkasi merupakan suatu daerah dengan morfologis anatomi yang
kompleks yang sulit bahkan tidak mungkin untuk dilakukan debridemen
dengan instrumentasi rutin
Perkembangan inamasi dari penyakit periodontal kehilangan
perlekatan sampai daerah bifurkasi atu trifurkasi gigi berakar
ganda
• Perluasan kehilangan perlekatan dibutuhkan untuk men"iptakan
defek furkasi yang ber#ariasi 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
(. )efek furkasi Klas **
)iagnosis dan klasi+kasi defek • Probing yang tepat
menentukan keterlibatan
dan perluasan furkasi, posisi perlekatan yang relatif di furkasi,
perluasan dan kon+gurasi defek furkasi prob 'abers
• Sounding transgingi#al untuk menggambarkan anatomi defek
furkasi
• uuan dari pemeriksaan ini adalah untuk mengidentifkasi dan
mengklasi+kasikan keterlibatan dan perluasan furkasi dan
identi+kasi faktor yang berkontribusi terhadap perkembangan defek
furkasi atau berpengaruh terhadap hasil pera-atan.
• Morfologi gigi, posisi gigi terhadap gigi yang
Faktor anatomis lokal
• )imensi dari furkasi entrance ber#ariasi /01 furkasi dengan
ori+si 2 0mm dan 3/1 2 4.53mm pertimbangan klinisi untuk
memilih instrumen untuk probing $keterlibatan dini dibutuhkan prob
dengan dimensi small cross-sectional %
• Pemeriksaan klinis pasien memungkinkan terapis untuk tidak hanya
identi+kasi ketrlibatan furkasi tetapi uga anatomi lokal yang dapat
mempengaruhi hasil terapi $prognosis%
&, Furkasi deraat * gigi molar pertama mandibula dan deraat ***
gigi molar kedua mandibula..he root appro7imation on the se"ond
molar may be su8"ient to impede a""urate probing of this
defe"t
(, )efek furkasi multipel pada molar pertama maksila. )eraat *
furkasi bukal dan furkasi deraat ** mesiopalatal dan distopalatal.
Deep developmental grooves molar kedua maksila simulate
keterlibatan furkasi pada molar ini dengan akar yang fused.
9, Furkasi deraat ** dan * pada molar mandibula
• Merupakan hal yang penting dalam perkembangan dan pera-atan
keterlibatan furkasi
• ;arak antara 9!;< furkasi entran"e ber#ariasi. =igi
dapat mempunyai root trunks yang sangat pendek, moderate, atau akar
yang fused ke uung akar $Figure >?<@%.
• Kombinasi root trunk length dengan umlah dan kon+gurasi akar
mempengaruhi keberhasilan pera-atan.
• 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.
• =igi dengan root trunks yang panang atau akar fused bukanlah
kandidat yang tepat untuk pera-atan ketika sudah ada keterlibatan
furkasi.
• Gambaran berbagai anatomis furkasi yang penting dalam prognosis
dan perawatan keterlibatan furkasi
• &, &kar yang terpisah luas. (, &kar terpisah tetapi
dekat. 9, &kar yang
fused terpisah hanya pada bagian apikal. ), enamel
proe"tion
keterlibatan furkasi dini
Root Length
• 6oot length is dire"tly related to the Auantity of atta"hment
supporting the tooth. eeth -ith long root trunks and short roots
may ha#e lost a maority of their support by the time that the
fur"ation be"omes aBe"ted.0@,?4 eeth -ith long roots and
short<to<moderate root trunk length are more readily treated
be"ause su8"ient atta"hment remains to meet fun"tional
demands
Root Form
• he mesial root of most mandibular +rst and se"ond molars
and the mesiofa"ial root of the ma7illary +rst molar are typi"ally
"ur#ed to the distal side in the api"al third. *n addition, the
distal aspe"t of this root is usually hea#ily uted. he "ur#ature
and uting may in"rease the potential for root perforation during
endodonti" therapy or "ompli"ate post pla"ement during
restoration.0,?3 hese anatomi" features may also result in an
in"reased in"iden"e of #erti"al root fra"ture. he siCe of the
mesial radi"ular pulp may result in remo#al of most of this portion
of the tooth during preparation.
Interradicular Dimension
• he degree of separation of the roots is also an important
fa"tor in
treatment planning. 9losely appro7imated or fused roots "an
pre"lude adeAuate instrumentation during s"aling, root planing, and
surgery. eeth -ith -idely separated roots present more treatment
options and are more readily treated.
Anatomy of Furcation
• he anatomy of the fur"ation is "omple7. he presen"e
of bifur"ational ridges, a "on"a#ity in the dome,00 and
possible a""essory "anals0> "ompli"ates not only s"aling,
root planing, and surgi"al therapy,?/ but also periodontal
maintenan"e. Odontoplasty to redu"e or eliminate these ridges may
be reAuired during surgi"al therapy for an optimal result.
Cervical namel !ro"ections
• 9er#i"al enamel proe"tions $9!Ps% are reported to o""ur on
/.>1 to ?/.>1 of molars.?>,?5,@3 he pre#alen"e is
highest for mandibular and ma7illary se"ond molars. he e7tent of
9!Ps -as "lassi+ed by Masters and Doskins?5 in 0E> $ (o7
>?<0%. Figure >?< pro#ides an e7ample of a grade
*** 9!P. hese proe"tions "an aBe"t plaAue remo#al, "an "ompli"ate
s"aling and root planing, and may be a lo"al fa"tor in the
de#elopment of gingi#itis and periodontitis. 9!Ps should be remo#ed
to fa"ilitate maintenan"e.
*ndikasi keterlibatan furkasi
he e7tent and "on+guration of the fur"ation defe"t are
fa"tors in both diagnosis and treatment planning. his has led to
the de#elopment of a number of indi"es to re"ord fur"ation
in#ol#ement. hese indi"es are based on the horiContal measurement
of atta"hment loss in the fur"ation,0,05 on a "ombination of
horiContal and #erti"al measurements,@5 or a "ombination of
these +ndings -ith the lo"aliCed "on+guration of the bony
deformity.04 =li"kman 0 "lassi+ed fur"ation in#ol#ement
into four grades $Figure >?
• Figure #$%#' Glickman)s classi*cation of furcation
involvement(
• &, =rade * fur"ation in#ol#ement. <hough a spa"e is
#isible at the entran"e to the fur"ation, no horiContal "omponent
of the fur"ation is e#ident on probing. (, =rade ** fur"ation in a
dried skull. 'ote both the horiContal and the #erti"al "omponent of
this "ul<de<sa". 9, =rade *** fur"ations on ma7illary molars.
Probing "on+rms
that the bu""al fur"ation "onne"ts -ith the distal fur"ation of
both these molars, yet the fur"ation is +lled -ith soft tissue. ),
=rade * fur"ation. he soft tissues ha#e re"eded su8"iently to allo-
dire"t #ision into the
fur"ation of this ma7illary molar
• Grade I
• & grade * fur"ation in#ol#ement is the in"ipient or early
stage of fur"ation in#ol#ement $see Figure >?<>, A%.
he po"ket is suprabony and primarily aBe"ts the soft tissues. !arly
bone loss may ha#e o""urred -ith an in"rease in probing depth, but
radiographi" "hanges are not usually found.
• Grade II
• & grade ** fur"ation "an aBe"t one or more of the fur"ations
of the same tooth. he fur"ation lesion is essentially a
"ul<de<sa" $see Figure >?<>, B% -ith a de+nite
horiContal "omponent. *f multiple defe"ts are present, they do not
"ommuni"ate -ith ea"h other be"ause a portion of the al#eolar bone
remains atta"hed to the tooth. he e7tent of the horiContal probing
of the fur"ation determines -hether the defe"t is early or
ad#an"ed. erti"al bone loss may be present and represents a
therapeuti" "ompli"ation. 6adiographs may or may not depi"t the
fur"ation in#ol#ement, parti"ularly -ith ma7illary molars be"ause
of the radiographi" o#erlap of the roots. *n some #ie-s, ho-e#er,
the presen"e of
fur"ation Garro-sH indi"ates possible fur"ation in#ol#ement
• Grade III
• *n grade *** fur"ations, the bone is not atta"hed to the dome of
the fur"ation. *n early grade *** in#ol#ement, the opening may be
+lled -ith soft tissue and may not be #isible. he "lini"ian may not
e#en be able to pass a periodontal probe "ompletely through the
fur"ation be"ause of interferen"e -ith the bifur"ational ridges or
fa"ialIlingual bony margins. Do-e#er, if the "lini"ian adds the
bu""al and lingual probing dimensions and obtains a "umulati#e
probing measurement that is eAual to or greater than the
bu""alIlingual dimension of the tooth at the fur"ation ori+"e, the
"lini"ian must "on"lude that a grade *** fur"ation e7ists $see
Figure >?<>, C%. Properly e7posed and angled radiographs
of early 9lass *** fur"ations display the defe"t as a radiolu"ent
area in the "rot"h of the tooth $see 9hapter @0%.
• Grade I+
• *n grade * fur"ations, the interdental bone is destroyed, and the
soft tissues ha#e re"eded api"ally so that the fur"ation opening is
"lini"ally #isible. & tunnel therefore e7ists bet-een the roots
of su"h an aBe"ted tooth. hus the periodontal probe passes readily
from one aspe"t of the tooth to another $see Figure >?<>,
D%.
• ,ther Classi*cation Indices
• Damp et al05 modi+ed a three<stage "lassi+"ation system
by atta"hing a millimeter measurement to separate the e7tent of
horiContal in#ol#ement. !asley and )rennan04 and arno- and
Flet"her@5 ha#e des"ribed "lassi+"ation systems that "onsider
both horiContal and #erti"al atta"hment loss in "lassifying the
e7tent of fur"ation in#ol#ement. he arno- and Flet"her arti"le
utiliCes a sub"lassi+"ation that measures the probeable #erti"al
depth from the roof of the fur"a api"ally. he sub"lasses being
proposed are: &, (, and 9. G&H indi"ates a probeable
#erti"al depth of 0 to @ mm, G(H indi"ates to > mm, and G9H
indi"ates 5 or more mm of probeable depth from the roof of the
fur"a api"ally. Fur"ations -ould thus be "lassi+ed as *&, *(,
and *9 **&, **(, and **9 and ***&, ***(, and ***9.
• 9onsideration of defe"t "on+guration and the #erti"al "omponent
of the defe"t pro#ides additional information that is useful in
planning therapy
Pera-atan
• Class I' arly Defects(
• *n"ipient or early fur"ation defe"ts $9lass *% are amenable to
"onser#ati#e periodontal therapy.03 (e"ause the po"ket is
suprabony and has not entered the fur"ation, oral hygiene, s"aling,
and root planing are eBe"ti#e.0> &ny thi"k o#erhanging
margins of restorations, fa"ial groo#es, or 9!Ps should be
eliminated by odontoplasty, re"ontouring, or repla"ement. he
resolution of inammation and subseAuent repair of the periodontal
ligament and bone are usually su8"ient to restore periodontal
health.
• Class II(
• On"e a horiContal "omponent to the fur"ation has de#eloped $9lass
**%, therapy be"omes more "ompli"ated. Shallo- horiContal
in#ol#ement -ithout signi+"ant #erti"al bone loss usually responds
fa#orably to lo"aliCed ap pro"edures -ith odontoplasty,
osteoplasty, and oste"tomy. *solated deep 9lass ** fur"ations may
respond to ap pro"edures -ith osteoplasty and odontoplasty $Figure
>?<5%. his redu"es the dome of the fur"ation and alters
gingi#al "ontours to fa"ilitate the patients plaAue remo#al.
• Figure #$%.' -reatment of a grade II furcation by osteoplasty and
odontoplasty(
• Classes II to I+' Advanced Defects(
• he de#elopment of a signi+"ant horiContal "omponent to one
or more fur"ations of a multirooted tooth $late 9lass **, 9lass
***, or 9lass * 0@% or the de#elopment of a deep #erti"al "omponent
to the fur"a poses additional problems. 'onsurgi"al treatment is
usually ineBe"ti#e be"ause the ability to instrument the tooth
surfa"es adeAuately is "ompromised.@0,4 Periodontal surgery,
endodonti" therapy, and restoration of the tooth may be reAuired to
retain the tooth.
erapi non bedah
Obtaining a""ess to the fur"ation reAuires a "ombination of the
a-areness of the fur"ation by the patient and an oral hygiene tool
that fa"ilitates that a""ess. Many tools, in"luding rubber tips
periodontal aids toothbrushes, both spe"i+" and general and other
aids ha#e been used o#er time for a""ess to the patient $Figure
>?</%.
• Figure #$%/
erapi bedah
,sseous Resection
• Regeneration
• *n fur"al lesions, bone regeneration is often thought to be
relati#ely futile. he periodontal literature has -ell<do"umented
therapeuti" eBorts designed to indu"e ne- atta"hment and
re"onstru"tion on molars -ith fur"ation defe"ts. Many surgi"al
pro"edures using a #ariety of grafting materials ha#e been tested
on teeth -ith diBerent "lasses of fur"ation in#ol#ement. Some
in#estigators ha#e reported "lini"al su""ess,? -hereas others
ha#e suggested that the use of
these materials in 9lass **, ***, or * fur"ations oBers little
ad#antage "ompared -ith surgi"al "ontrols.@,E,@4
• Fur"ation defe"ts -ith deep t-o<-alled or three<-alled
"omponents may be suitable for re"onstru"tion pro"edures. hese
#erti"al bony deformities respond fa#orably to a #ariety of
surgi"al pro"edures, in"luding debridement -ith or -ithout
membranes and bone grafts. 9hapter >0 addresses therapies
designed to indu"e ne- atta"hment or reatta"hment.
• sao et al@E ha#e sho-n that the fur"ation defe"t is a
graftable lesion. hey found that lesions that -ere grafted had
greater #erti"al +ll than areas treated -ith open ap debridement
alone. (o-ers et al5 ha#e sho-n fur"ation bone grafting using
#arious membranes "an impro#e the "lini"al status
of these lesions. 'onetheless, bone grafting remains an elusi#e
goal -ith #ariable results in fur"ation lesions. ¬her area
of interest has been barrier membrane te"hnology. &nalysis of
published studies demonstrated a great #ariability in the "lini"al
out"omes in mandibular grade ** fur"ations treated -ith diBerent
types of nonbioabsorbable and bioabsorbable barrier
membranes.
• <hough many barrier membrane studies sho- a slight "lini"al
impro#ement after treatment in both ma7illary and mandibular
fur"ations, the results are generally in"onsistent.
Prognosis
For many years the presen"e of signi+"ant fur"ation in#ol#ement
meant a hopeless long<term prognosis for the tooth. 9lini"al
resear"h, ho-e#er, has indi"ated that fur"ation problems are not as
se#ere a "ompli"ation as originally suspe"ted if one "an pre#ent
the de#elopment of "aries in the fur"ation. 6elati#ely simple
periodontal therapy is su8"ient to maintain these teeth in fun"tion
for long periods.?0,@@ Other in#estigators ha#e de+ned the
reasons for "lini"al failure of root<rese"ted or hemise"ted
teeth.?,?3 heir data indi"ate that re"urrent periodontal
disease is not a maor "ause of the failure of these teeth.
*n#estigations of root<rese"ted or hemise"ted teeth ha#e sho-n
that su"h teeth "an fun"tion su""essfully for long
periods.?,/,?3 he keys to long< term su""ess appear to be
$a% thorough diagnosis, $b% sele"tion of patients -ith good oral
hygiene, $"% e7"ellen"e in nonsurgi"al therapy, and $d% "areful
surgi"al and restorati#e management.