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ISSN 0303-6979
Review article
Furcation diagnosis
Muller H-P, Eger T: Furcation diagnosis. J Clin Periodontol 1999; 26:
485498. C Munksgaard, 1999.
Abstract. One of the most important and at present unsolved problems in clinical
periodontology is the predictable successful treatment of periodontitis-affected
furcations of multirooted teeth. Since several therapeutic approaches are proposed, i.e., conservative, resective or regenerative, a proper diagnosis of these
lesions is demanding. The aim of the present article is to review the current
information on the impact of a proper diagnosis of a furcational lesion as well
as tooth morphology on decision making with regard to different treatment modalities and to emphasize the need for a detailed clinical, radiographical and
intraoperative diagnosis of the furcation lesion beyond the usually performed
diagnosis of the degree of furcation involvement.
486
Furcation diagnosis
at the level of the furcation roof, mean
concavities between 1.2 mm at the distal
aspect and 2.7 mm at the mesial aspect
were observed (Roussa 1998). The root
surface at the buccal and distal furcation entrances is more steeper than at
the mesial entrance. Therefore, the former entrances are more distinctly
marked since there is more or less
abrupt transition from a predominantly
vertical to a mainly horizontal outline
of the root surface (Svardstrom &
Wennstrom 1988).
Many morphological characteristics
of maxillary 1st molars are also found
at the 2nd and 3rd molars. However,
the variation of several components is
even greater. Usually, the 2nd molar has
3 roots, but 2-rooted and 1-rooted variants are more frequent than for 1st molars; and finally, the frequencies of these
variants were even greater for 3rd molars (Carlsen 1987). The only root of
this tooth group, which is usually composed of 3 root cones is the mesiobuccal
of the 1st molar. All other roots consist
of 2 root cones. Sometimes, the mesiobuccal root is separated. Both separation degree and degree of divergence
decrease from the 1st molar to the 2nd
and 3rd molar (Carlsen 1987). Concurrently, root fusions are rarely found at
1st molars but frequencies increase for
2nd and 3rd molars (Hou & Tsai 1994).
Short root trunks have been reported to
be more common buccally, whereas
long root trunks were more commonly
found mesially and distally in both 1st
and 2nd molars (Hou & Tsai 1997a),
however, racial differences may exist
(Gher & Dunlap 1985, Roussa 1998).
Enamel projections may extend from
the cemento-enamel junction into the
furcation. In the upper jaw, they are
most frequently found at buccal furcations of 1st molars (Moskow & Canut
1990a). A classification scheme was
proposed by Masters & Hoskins (1964).
Thus, small extensions of the cementoenamel junction covering only the root
trunk, medium-sized spurs reaching the
furcation entrance and extended lancets
within the furcation area may be distinguished. In general, enamel projections seem to occur on rather rare occasions (Roussa 1998). Further enamel
structures can be found on the root
complex as enamel pearls, islands and
tongues, which originate from activated
parts of Hertwigs epithelial root sheet
(Moskow & Canut 1990b). Within the
furcation area, the root surface is either
regularly covered by cellular mixed
487
488
In conclusion, a careful consideration of the complexity of all combinations of primary structures of the
root complex of a multirooted tooth inevitably gives rise to a more detailed diagnosis of the neighbourhood of periodontitis lesions, which may not be
confined within clearly separated roots
or root cones. Apparently, an appropriate assessment of all possible separation
structures, i.e., root grooves and interradicular projections, is demanding. By
all means, this also includes a recording
of incomplete separations, degree of
separation, degree of divergence and
surrounding infrabony lesions. In the
following chapters the diverse traditional and more recent attempts to
account for this diagnostic challenge
are reviewed in detail.
Clinical Diagnosis
Cardinal symptoms
Redness and swelling of the tissues, increased temperature, pain, and loss of
function, i.e., the cardinal symptoms of
inflammation, may be found with varying expression also in periodontitis. The
unique morphology of the root complex certainly favours the development
of periodontitis lesions in the furcation
area. In advanced cases, the close topography of the roots of a multirooted
tooth may even promote the development of a painful periodontal abscess.
In such a case, the (vital) tooth may be
perceived elongated and mobile
which may result in impaired function.
Some other cardinal symptoms of inflammatory reactions in the gingiva are
regularly found in established gingivitis
and any case of destructive periodontal
disease. Thus, redness and edematous
swelling of the gingival tissue as well as
increased temperature within the periodontal pocket are direct consequences
of an enhanced vascularity as well as increased dilatation and permeability of
vessels in the connective tissue. Although valuable parameters for assessing the degree of inflammation of
the gingival tissues (Armitage 1996),
these symptoms, as well as the resulting
increased bleeding tendency upon
gentle probing, nor occasional suppuration, are by no means specific for interradicular periodontitis.
Attachment loss
Furcation diagnosis
trolled probe set at 0.5 N yielded a
penetration of the probe of about 2 mm
into the inflamed connective tissue, on
average, whereas the probe tip was
located a mean 0.4 mm apical to the alveolar crest (Moriarty et al. 1989). A
plausible explanation may be the difficulty to follow the contour of the tooth
with the probe in the furcation area as
compared to the flat surfaces of singlerooted teeth. Bone sounding, i.e., transgingival probing to the bone crest under
local anaesthesia, has been reported to
permit a relatively accurate assessment
of the osseous topography (Renvert et
al. 1981, Ursell 1989). Mealey et al.
(1994) tried to improve the accuracy of
furcation measurements by bone
sounding. These authors identified the
intitial, frequently subgingival, concavity of the furcation entrance as a reference point for measuring vertical and
horizontal furcation dimensions in 67
patients with moderate or advanced
periodontitis. Results of vertical and
horizontal probing the tissues before,
and respective bone sounding after local anaesthesia were compared with intrasurgical measurements. By employing post-anesthesia sounding, both
the vertical and horizontal agreement
with intrasurgical measurements was
significantly improved. For instance,
bone sounding revealed a result within
2 mm of the intrasurgical assessment in
88% of the cases. In general, underestimation of surgical furcation depths
by pre-anaesthesia probing was much
more common than overestimation.
Tooth type and furcation location
seemed not to play a significant role. It
should be critically noted that the
identification of the reference for measurements, an initial fluting of the root
surface, is expected to considerably
contribute to measurement error. If this
concavity is in a subgingival location,
the examiner relies on tactile sensation
alone. Errors in detecting this landmark will certainly result in considerable variation of the measurements
taken before and after flap elevation.
Besides the paramount importance
of the validity of a measurement, clearly
also its reliability has to be considered.
Reliability of a diagnostic measure is its
potential to reproduce the measurement
after a short period of time in a reasonable and satisfactory way. It has been
shown that, in general, the result of
periodontal probing may depend on (i)
the inflammatory status of the respective tissues, (ii) probing force, (iii) form
489
490
Since the furcation entrance lies subgingivally in most cases, the operator has
to search for a concavity at the respective site and then to penetrate into the
area between the roots. Consequently, a
pressure controlled, flexible, plastic
probe (Hunter et al. 1992) was shown to
hamper a correct furcation assessment
especially in case of a through-andthrough involvement (Kim et al. 1996,
Eickholz & Kim 1998). On the other
hand, bleeding on probing, which has
been shown to negatively affect the reproducibility of furcation measurements (Steinbrenner et al. 1997), is expected to be provoked more frequently
with the searching probe trying to
gain access to this area. Since the
pocket has a vertical and horizontal
component, conventional straight probes may also underestimate the severity
of the furcation involvement (Eickholz & Kim 1998). Provided, measurements are normally distributed with a
mean difference of zero and a standard
deviation of differences s, which may
be, at least for vertical measurements,
an erroneous assumption in most instances (Janssen et al. 1987), a standard
deviation of a single measurement s/!2
of 0.50.7 mm, as reported for buccal,
lingual and mesiolingual furcations by
that group of investigators, may correspond to the measurement errors observed with rigid, not pressure-controlled, periodontal probes for vertical
attachment loss, as calculated by several authors (Goodson et al. 1982, Haffajee et al. 1983, Aeppli et al. 1985,
Goodson 1986, Gibbs et al. 1988).
However, when considering the reported sample standard deviation, a
measurement error of 1.1 mm for distolingual furcations (Eickholz & Staehle
1994, Eickholz & Kim 1998) may be
comparable to a standard deviation of
differences being generated by chance.
Especially in case of a further tooth
being present distal to the respective
furcation site, clinical diagnosis of the
distolingual furcation appears to lack
the desired accuracy. Moreover, the
concept of a fictitious landmark, the
tangent applied at the root concavities
at the level of the entrance of the furcation, may not be very convincing. If
the furcation entrance is in a subgingival location, the height of the root
trunk is actually not known. Thus, an
accurate measurement (actually something else than an estimate) to a fictitious tangent is unfortunately not
possible, and identification of an initial
Furcation diagnosis
gree I involvement, 40% in furcations
with degree II involvement and 43%
readings in degree III furcations were
actually overestimations (2 mm or more
discrepancy) as compared to intrasurgical measurements, which were shown
to correspond, by and large, with the
respective analysis of the impression
material applied into the furcation area.
This finding may be in contrast to the
results reported by Mealey et al. (1994)
who performed 2 measurements, a first
from the gingival margin to the concavity in the respective tooth surface,
from where a 2nd was done to estimate
the horizontal attachment loss. As discussed earlier, a constant source for
measurement error is the coronal position of the gingiva relative to the furcation entrance which prevents the desired control of the location of a probes
increments. With regard to the probe
with 3 mm increments, Zappa et al.
(1993) reported that 7% of the measurements in degree I furcations, 24% in degree II, but none in degree III furcations were overestimations as compared to intrasurgical assessments.
Moreover, a surgically proven throughand-through involvement was not detected clinically in 43 and 27% with the
2 mm or 3 mm probes, respectively,
whereas a surgical degree II involvement was diagnosed in 4 and 21% of
cases as degree III. Such false diagnoses
may condemn a molar to premature extraction or at least to unnecessary sur-
491
*At this point of discussion, a first remark is demanding. In a common clinical situation, the periodontist makes a diagnosis and thereafter
plans the necessary treatment. Therefore, for a therapist, his or her reproducibility of scores may be of special interest, i.e., intrarater agreement.
It should be emphasized, however, that especially for scientific reason, the question might arise, whether different raters come to different
conclusions. Various k statistics exist, which should be applied specifically in the different situations of reliability assessment. Although
originally developed for the measurement of interrater agreement, the applicability of k statistics extends far beyond this specific problem,
thus, allowing for measuring, on both ordinal and nominal categorical data, similarity, or concordance. Since, in the study by Zappa et
al. (1993), several examiners diagnosed molar furcation sites in the patients with regard to classes or degrees of involvement, interrater reliability
would be of considerable interest, which may be estimated with the k statistic for multiple ratings. Numerous examples for application of the
different k statistics are given by Fleiss (1981).
**Whereas the ordinary k statistic disregards all disagreement in an agreement table, weighted k generalizes unweighted k by employing differential cell weights which reflect differences in the magnitude of disagreement. Thus, weighted k may be appropriate in case of categorical data with
a natural ordering like severity degrees of furcation involvement. Among several possible weighting systems, 2 are mentioned by Fleiss (1981), the
squared error weights and the absolute error weights. Under both weighting schemes, the cells on the leading diagonal (perfect agreement) have
weight equal to 1 and cells representing extreme disagreement are given zero weight. However, for all other cells, squared error and absolute error
weights differ. Thus, the values of weighted k may differ dramatically according to the applied (more or less arbitrary) weighting system, and
likewise their possible interpretations. Fleiss & Cohen (1973) have shown that the intraclass correlation coefficient may be asymptotically equivalent to the weighted k under the squared error system, however investigators did not settle on a certain weighting system. Graham & Jackson (1993)
present an example where relatively high and moderate values of squared and absolute error weighted k are obtained, respectively, even in the case
of no agreement at all. There are several further concerns with regard to the use of weighted k as evidence for reliability, including (i) loss of
information from summarizing the table by a single number, (ii) sensitivity of the value to the form of the marginal distributions, and (iii) subsequent problems in comparing values of k from different tables. Graham & Jackson (1993) recommend weighted k to be interpreted as a measure
of association rather than agreement. Whereas the main focus in agreement studies should be the propensity for pairs to be in agreement, the
presence of off-diagonal association in an agreement table will ususally also be of some interest. When a high level of agreement is observed in a
reproducibility study, the presence of off-diagonal association may further strengthen claims about the underlying quality of the diagnostic instrument. It is not clear how a single index such as weighted k can reflect both differences in exact agreement and differences in off-diagonal association.
Consequently, the possibility of modeling ordinal agreement data in a way outlined in detail, e.g., by Agresti (1988) and others is emphasized, to
get additional information apparently not provided by the weighted k statistic.
492
In this context, differing results obtained in studies dealing with both the
validity and reliability of furcation diagnosis as well as respective interpretations and attitudes of the authors are
remarkable. As compared to intrasurgical measurements, Mealey et al. (1994)
claimed that the common underestimation of the situation by clinically probing the furcational lesion may largely be
corrected by bone sounding under local
anaesthesia. Zappa et al. (1993) reported both under- and overestimations
and concluded that furcation diagnosis
may be of limited value, whereas Eickholz & Kim (1998), based on their calculations of squared error, weighted k,
consider measurements with Nabers
colour-coded, curved probe appropriate for both clinical and scientific purposes. On the other hand, there seems
to be agreement that pressure-controlled probes are not suitable for assessing the furcational lesion (Moriarty
et al. 1988, Kim et al. 1996, Eickholz &
Kim 1998).
Location of assessment
ing tissues are represented as a 2-dimensional image. Mainly for that reason, an
initial furcal lesion, in particular in
maxillary molars (and correspondingly
periapical lesions), may actually be
better uncovered on a panoramic tomogram (Rohlin et al. 1989), which frequently images the central plane of the
alveolar bone including the furcation
area, whereas structures not in the interesting plane are blurred. In contrast,
with the naked eye and without any
special equipment, an eventually present buccal and/or lingual bone plate
may actually obscure an incipient furcal
lesion on periapical or vertical bitewing
radiographs (Gurgan et al. 1994).
Therefore, the actual severity of an advanced furcal lesion as assessed by intrasurgical measurements may be
understimated by periapical radiographs or vertical bitewings, whereas
that of an initial lesion may be overestimated by panoramic tomograms
(Topoll et al. 1988).
Some weak evidence or hint for a
more advanced furcation invasion in
maxillary 1st or 2nd molars may be
provided by a small, triangular radiographic translucency across the mesial
or distal roots of these teeth, the socalled furcation arrow. Hardekopf et
al. (1987) radiographed dry human
skulls with and without proximal furcation involvement in maxillary 1st or
2nd molars and found this furcation arrow in 40 out of 96 furcations diagnosed according to Hamp et al. (1975)
as degree II or III (42% sensitivity). On
the other hand, of 186 furcations with
no or incipient involvement, the arrow
was absent in 159 (85% specificity)*.
Evidently, a radiographic image of a
furcation arrow should induce the periodontist to carefully further assess the
severity of furcation invasions clinically
and, if need be, intra-operatively.
With the aid of high-resolution computed tomography a more detailed, 3dimensional interpretation of bony
lesions and tooth structures especially
in the furcation area seems possible
(Fuhrmann et al. 1997). Unlike to con-
*Data provided in this paper may illustrate the properties of a diagnostic test and its usefulness in practice. For instance, if the prevalence
of advanced furcation involvement of maxillary molars in a given population of older adults is estimated as about 4% (see below), then the
false-positive rate, i.e., the proportion of unaffected molars among those with a radiographic image of a furcation arrow, may be calculated
as about 90%, whereas the false-negative rate, i.e., the proportion of affected molars without a furcation arrow, is 2.8% (Fleiss 1981). Interestingly Hardekopf et al. (1987) stress that absence of a furcation arrow does not mean that there is no bony defect within the furcation area.
However, when calculating false-positive and false-negative rates in case of an estimated prevalence of 4%, a striking argument can be made
that, in spite of a radiographically visible furcation arrow, severe furcation involvement may still be rather exceptional. Especially in case
of a low prevalence of severe furcation involvement in a given population, the test may be considered successful. However, from another point
of view, its large false-positive rate qualifies the test a failure.
Furcation diagnosis
ventional tomography, all structures
not in the plane of interest are removed
from the image, resulting in a clear
visualization of the respective slices.
Direct axial scanning parallel to the
occlusal plane has been recommended
for detection of infrabony pockets, furcation involvements and buccal or lingual bone dehiscences (Fuhrmann et
al. 1997). A serious drawback of computed tomography and other radiographic techniques is the exposure with
ionizing radiation of organs at relatively high risk for the development of
undesired pathology as the thyroid
gland or the eyes lens. To gain all information, numerous exposures are
necessary, which may drastically increase the radiographic burden of the
patient. At present, computed tomography is mainly performed in hospitals due to considerable expenditure
and costs.
Largely standardized radiographs
may allow for comparison of bone
levels, e.g., before and after therapy. It
is of interest that, with the rapid development of a larger spectrum of treatment modalities in clinical periodontology in recent years, this concept has
evolved a main aspect of radiographic
examinations of the periodontal structures. Not infrequently, following successful therapy of inflammatory periodontal disease, both increases in bone
density and gain of bony support may
be observed. Evidence for healing in
furcations may be provided by computer-assisted densitometric image
analysis (Payot et al. 1987a & b, Bragger et al. 1989) as well as qualitative
and quantitative digital subtraction
radiography (Bragger & Pasquali 1989,
Christgau et al. 1996, Eickholz &
Hausmann 1997). Obviously, these
techniques require a highly standardized radiographic technique with minimal vertical or horizontal angulations
of the central beams between consecutive exposures, which may not easily be
achieved by commonly used X-ray
beam aligning systems trying to control for central beam angulations
(Eickholz & Hausmann 1997). Computer programs are available to correct
for different brightness and contrast
(Ruttimann et al. 1986) and image distortion caused by film placement
(Webber et al. 1984). By using reference points (Wenzel 1989) and novel
computer algorithms (Samarabandu et
al. 1994) some problems with misaligning errors due to a manual super-
Comprehensive information with regard to the morphology of a periodontal defect may be further achieved
by intrasurgical inspection. Not infrequently, a definite conclusion for
one or the other treatment modality
can therefore only be drawn intra-operatively. This is especially true for
periodontitis lesions within the furcation area with its bizarre and unforeseeable topography of roots, root cones and bone. After surgically opening
of the defect, removal of the granulation tissue and careful debridement
of the root surfaces within and outside
the interradicular projection, the actual
extent of periodontal destruction may
be visible. Concomitantly, the operator
gains information with regard to access
to all concavities and niches of the furcation as well as a feeling for efficacy
of root debridement. This intraoperative, careful re-assessment of the lesion
within the furcation is by no means
dispensable. Based on intrasurgical
findings, the periodontist may be
forced to thoroughly alter his or her
treatment plan. In certain instances, a
tooth may even be considered hopelessly diseased and condemned for extraction.
For example, in a pioneer, splitmouth, controlled clinical trial to assess
the therapeutic effect of placing a barrier membrane for guided tissue regeneration in mandibular molars with
furcation involvement, Pontoriero et al.
(1989) diagnosed only 1 of 42 furcations clinically as class III involvement. However, all turned out to be
493
through-and-through intrasurgically. 6
months after surgery, clinical re-assessments revealed that 3 of 21 test furcations treated with membranes were
completely open, but 11 of 21 control
furcations treated with conventional
flap surgery were still class III involvements. Interestingly, the intrasurgically
estimated surface area of the furcation
entrance appeared to influence the postsurgical outcome. Thus, whereas the
vast majority of class III test furcations
with a 4.5 mm2 or larger entrance remained open after surgery, the critical
area for regenerative closure was about
3 mm2. Since clinical diagnosis before
surgery was so uncertain as compared
with the intra-operative observations, it
can only be speculated whether the two
treatment modalities actually resulted
in any improvement of the situation.
This study may be a further strong argument for distrusting sole clinical furcation diagnosis. It should be stressed,
however, that the authors used a
straight,
pressure-controlled
periodontal probe for measurements. As
was mentioned earlier in this text, Moriarty et al. (1988) had demonstrated
that a pressure-controlled probe largely
prevented a proper clinical furcation diagnosis.
Apart from intrasurgical assessment
of the intraalveolar defect around a
multirooted tooth (Heins & Canter
1968) with its number of bony walls and
relative depth of the 3-, 2- and 1-wall
components (Renvert et al. 1981) and
varying circumference, the actual degree of furcation invasion can now be
judged by inspection and the horizontal
loss of periodontal support be measured more accurately. Distinct vertical
bony defects within the furcation as,
e.g., clinically and radiographically difficult-to-assess hemifurcas and crescentintrafurcal defects (Langer & Wagenberg 1997), i.e., osseous defects that are
usually circumferential in nature and
affect only one half of the furcation or
both roots, can only now properly be
diagnosed.
Some authors suggested to subclassify also the height of the furcation,
i.e., the distance between the roof of the
furcation and the interradicular bone
(Eskow & Kapin 1984, Tarnow &
Fletcher 1984). According to Tarnow &
Fletcher (1984), a subclass A would
correspond to a furcation height of up
to 3 mm, a height of 46 mm would be
a subclass B and subclass C is a furcation with more than 6 mm height.
494
*: 08.10.1971
Date: 23.05.1996
Tooth: 16
mobility (0, 1, 2, 3)
elongation (0, 1)
sensibility testing (1: vital; 2: not vital)
endodontic diagnosis (0: okay; 1: revision necessary)
caries, restorations (0: caries free; 1: small caries or filling; 2: extended
caries, large filling; 3: artificial crown)
Mesial root
Radiographic diagnosis
Distal root
bone loss
0: 1/3 root length
1: 1/3, 2/3 root length
2: >2/3 root length
2
0
1
0
0
Buccal root
m
m/d roots
m/p roots
d/p roots
separation degree
0: 1/3
1: 1/3
degree of divergence
0: 30
1: 30
Clinical measurements
mb
BOP (0, 1)
plaque (0, 1)
PPD
5.0
2.0
vCAL
2.0
2.0
Palatal root
m
b/p roots
db
dl/p
l/p
1.5
4.0
5.5
7.0
2.0
6.0
1.5
4.0
5.0
7.0
2.0
6.0
ml/p
hCAL
0.0
5.0
5.0
degree
II
II
Intraoperative measurements
mb
db
dl/p
l/p
ml/p
furcation height
0.0
4.0
3.0
furcation width
0.0
4.0
3.0
furcation depth
0.0
3.0
3.0
degree corrected
II
II
BD-CEJ
5.0
4.5
2.0
2.5
6.0
7.0
6.5
6.5
BD-LA
0.0
0.5
0.0
0.0
2.0
0.0
0.0
0.0
Furcation diagnosis
tion within the total population*.
Despite this impression of being only a
minor problem in the population, in
affected people after periodontal therapy furcation involvement may increase
the risk for further attachment loss and
recurrent disease (Wang et al. 1994,
Rams et al. 1996). This holds true especially for mobile molars with furcation
involvement (Wang et al. 1994), although it should be noted that there is
some data suggesting the opposite
(Chace & Low 1993). In the past, resective measures as root amputation or
hemisection of the tooth as well tunnel
preparation had been frequently advocated (Carnevale et al. 1995). A proper
diagnosis beyond simply assessing degree of involvement is necessary even
for these traditional treatment modalities. For example, a tunnel preparation
at mandibular 1st and 2nd molars may
only be successful, if the degree of divergence is larger than 30 or so, to enable the daily brushing with, e.g., an
interdental brush. Root amputation
may result in a (prosthetic) failure, if
the tooth morphology is not accurately
acknowledged (Majzoub & Kon 1992).
A separation degree of about 1/3 obviously interferes with root amputation
or hemisection. With the development
of novel, regenerative treatment modalities, a more careful documentation of
the pre- and postsurgical outcome is demanding. Clearly, only closure of a furcational defect should be regarded an
endpoint of therapy. Therefore, a thorough intrasurgical assessment of factors increasing the chances to obtain
this result seems to be necessary. This
should include the recording of, for instance, the height of the root trunk,
presence of infrabony pockets, the
height of the interproximal bone as well
as the position of the gingival margin
in relation to the furcation entrance. In
addition, unfavorable conditions interfering with root debridement or flap
management and therefore proper healing should supplement the clinical and
radiographic furcation diagnosis. For
example, even thickness of the mucoperiosteal flap had been identified as a
factor influencing the postsurgical outcome after regenerative procedures in
furcations (Anderegg et al. 1995). Interestingly, it has recently been demonstrated that the overall significance of
regenerative procedures in the treatment of furcations may be rather
limited if the available information
from the literature is considered, even
in case of a clientele which is mainly
affected
by
periodontal
disease
(Muller & Eger 1997). Postoperative
control of healing of furcational lesions
is a further challenge. Especially in clinical research bone sounding under local
anaesthesia may be a valuable surrogate
if, after healing of the lesion, a re-entry
operation is not allowed by the patient
(Mealey et al. 1994). Self-evidently, assessment of a contingent furcation closure has to be supplemented by sensitive, largely standardized, radiographical techniques.
495
Addendum
Resume
Diagnostic dans les furcations
Un des proble`mes les plus importants en parodontologie clinique, et jusqu a` present non
resolu, consiste a` trouver pour les furcations
atteintes de parodontite dans les dents multiradiculees un traitement dont le succe`s soit
previsible. Puisqu on dispose de plusieurs
approches therapeutiques, par conservation,
par resection ou par regeneration, un diagnostic adequat de ces lesions est tre`s exigeant. Le but du present article est de passer
en revue linformation actuelle sur limpact
dun diagnostic adequat de la lesion de furcation ainsi que de la morphologie dentaire sur
la decision a` prendre en ce qui concerne les
differentes modalites de traitement, et de
souligner la necessite detablir un diagnostic
clinique, radiographique et intra-operatoire
detaille de la lesion de furcation en plus du
*Assume, for example, the height of the root trunk of a molar of about 4 mm, on average (Dunlap & Gher 1985, Gehr & Dunlap 1985,
Roussa 1998). Then, a 5-mm attachment loss should lead to definite furcation involvement. Of 192 possible periodontal sites (mesiobuccal,
buccal, distobuccal, distolingual, lingual and mesiolingual sites at 32 teeth), only 30 are associated with furcation entrances of molars. Since
the root trunks of premolars are about twice as high (Booker & Loughlin 1985) these teeth are not considered in the following calculation. In
a representative sample of the employed adult U.S. population from the 19851986 survey of the NIDR (Brown et al. 1990) a 5 mm or more
(vertical) attachment loss was observed in 25% of 45 to 54 years old individuals and 35% of 55 to 64 years old people. However, only 1.4 and
2% sites were affected, respectively. These estimates are probably lower than the actual prevalence and extent due to partial recording. However,
even if the extent is underestimated by, say 100%, advanced periodontal disease with an attachment loss of 5 mm or more is expected at only
4% of tooth surfaces in the oldest age group (Brown & Le 1990). Thus, 1.2 furcations (4% of 30) may be involved, on average. This is a little
bit higher than the figure for about 60-years-old subjects reported by Larato (1970), who studied dry Mexican skulls. Even in case of a rather
realistic assumption of a twofold increased risk for periodontitis at molar teeth, only 2 or 3 furcations may be affected in the 55 to 64 years
age group.
496
References
Abbas, F., Hart, A. A. M., Ossing, J. & van
der Velden, U. (1982) Effect of training
and probing force on the reproducibility
of pocket depth measurements. Journal of
Periodontal Research 17, 226234.
Albandar, J. M., Brunelle, J. A. & Kingman,
A. (1999) Destructive periodontal disease
in adults 30 years of age and older in the
United States, 19881994. Journal of Periodontology 70, 1329.
Aeppli, D. M., Boen, J. R. & Bandt, C. L.
(1985) Measuring and interpreting increases in probing depth and attachment
loss. Journal of Periodontology 56, 262
264.
Agresti, A. (1988) A model for agreement between ratings on an ordinal scale. Biometrics 44, 539548.
Anderegg, C. R., Metzler, D. G. & Nicoll, B.
K. (1995) Gingiva thickness in guided
tissue regeneration and associated recession at facial furcation defects. Journal
of Periodontology 66, 397402.
Anderson, R., McGarrah, H., Lamb, R. &
Eick, J. (1983) Root surface measurements
of mandibular molars using stereophotogrammetry. Journal of the American Dental Association 107, 613615.
Armitage, G. C. (1996) Periodontal diseases:
diagnosis. Annals of Periodontology 1, 37
215.
Basaraba, N. (1990) Furcation invasions. In:
Periodontal diseases, 2nd edition, eds.
Schluger, S., Yuodelis, R., Page, R. C. &
Johnson, R. H., pp. 541559. Philadelphia:
Lea & Febinger.
Benn, D. K. (1990) Limitations of the digital
image subtraction technique in assessing
alveolar bone crest changes due to misalignment errors during image capture.
Dentomaxillofacial Radiology 19, 97104.
Booker, B. W. III. & Loughlin, D. M. (1985) A
morphologic study of the mesial root surface of adolescent maxillary first bicuspids.
Journal of Periodontology 56, 666670.
Bower, R. C. (1979a) Furcation morphology
relative to periodontal treatment: furcation entrance architecture. Journal of
Periodontology 50, 2327.
Bower, R. C. (1979b) Furcation morphology
relative to periodontal treatment: furcation root surface anatomy. Journal of
Periodontology 50, 366374.
Bragger, U. & Pasquali, L. (1989) Color conversion of alveolar bone density changes in
digital subtraction images. Journal of Clinical Periodontology 16, 209214.
Bragger, U., Pasquali, L., Weber, H. & Kornman, K. S. (1989) Computer-assisted
densitometric image analysis (CADIA) for
the assessment of alveolar bone density
changes in furcations. Journal of Clinical
Periodontology 16, 4652.
Brown, L. J. & Loe, H. (1990) Prevalence,
extent, severity and progression of peri-
odontal disease. In: Classification and epidemiology of periodontal diseases, eds. Loe,
H. & Brown, L. J., Periodontology 2000 2,
5771.
Brown, L. J., Oliver, R. C. & Loe, H. (1990)
Evaluating periodontal status of US employed adults. Journal of the American
Dental Association 121, 226232.
Carlsen, O. (1987) Dental morphology. Copenhagen: Munksgaard.
Carnevale, G., Pontoriero, R. & Hurzeler, M.
B. (1995) Management of furcation involvement. In: Surgical, nonsurgical, occlusal and furcation therapies, eds. Caffesse, R. G. & Quinones, C. R. Periodontology 2000 9, 6989.
Carranza, F. A., Jr. & Takei, H. H. (1990)
Treatment of furcation involvement and
combined periodontal-endodontic therapy.
In: Glickmans clinical periodontology, 7th
edition, ed. Carranza, F. A., Jr., pp. 860
874. Philadelphia: W. B. Saunders.
Chace, R., Sr. & Low, S. B. (1993) Survival
characteristics of periodontally-involved
teeth: a 40-year study. Journal of Periodontology 64, 701705.
Christgau, M., Wenzel, A.Hiller, K.-A. &
Schmalz, G. (1996) Quantitative digital
subtraction radiography for assessment of
bone density changes following periodontal guided tissue regeneration. Dentomaxillofacial Radiology 25, 2533.
Cutress, T. W. (1976) Histopathology of periodontal disease in sheep. Journal of Periodontology 47, 643650.
Dunlap, R. M. & Gher, M. E. (1985) Root
surface measurements of the mandibular
first molar. Journal of Periodontology 56,
234238.
Eickholz, P. (1995) Reproducibility and validity of furcation measurements as related to
class of furcation invasion. Journal of Periodontology 66, 984989.
Eickholz, P. & Hausmann, E. (1997) Evidence for healing of class II and III furcations after GTR therapy: digital subtraction and clinical measurements.
Journal of Periodontology 68, 636644.
Eickholz, P. & Kim, T.-S. (1998) Reproducibility and validity of the assessment of clinical furcation parameters as related to different probes. Journal of Periodontology
69, 328336.
Eickholz, P. & Staehle, H. J. (1994) The reliability of furcation measurements. Journal
of Clinical Periodontology 21, 611614.
Eskow, R. N. & Kapin, S. H. (1984) Furcation invasions: correlating a classification system with therapeutic considerations. Part I. Examination, diagnosis and
classification. Compendium of Continuing
Education in Dentistry 5, 527532.
Everett, F. G., Jump, E. B., Holder, T. D. &
Williams, G. G. (1958) The intermediate
bifurcational ridge. A study of the morphology of the bifurcation of the lower
first molar. Journal of Dental Research 34,
162169.
Farrar, J. N. (1884) Radical and heroic treat-
Furcation diagnosis
J. M. (1983) Comparison of different data
analyses for detecting changes in attachment level. Journal of Clinical Periodontology 10, 298310.
Hamp, S.-E. & Nyman, S. (1989) Treatment
of furcation-involved teeth. In: Textbook
of clinical periodontology, 2nd edition, ed.
Lindhe, J., pp. 515533. Copenhagen:
Munksgaard.
Hamp, S.-E., Nyman, S. & Lindhe, J. (1975)
Periodontal treatment of multirooted
teeth. Results after 5 years. Journal of Clinical Periodontology 2, 126135.
Hardekopf, J. D., Dunlap, R. M., Ahl, D.
R. & Pelleu, G. B., Jr. (1987) The furcation arrow. A reliable radiographic image? Journal of Periodontology 58, 258
261.
Heins, P. J. & Canter, S. R. (1968) Furca involvement: a classification of bony deformities. Periodontics 6, 8488.
Hirschfeld, L. & Wasserman, B. A. (1978) A
long-term survey of tooth loss in 600
treated periodontal patients. Journal of
Periodontology 49, 225237.
Hou, G.-L. & Tsai, C.-C. (1993) Relationship
between palatoradicular grooves and localized periodontitis. Journal of Clinical
Periodontology 20, 678682.
Hou, G.-L. & Tsai, C.-C. (1994) The morphology of root fusion in Chinese adults
(I). Grades, types, location and distribution. Journal of Clinical Periodontology
21, 260264.
Hou, G.-L. & Tsai, C.-C. (1997a) Types and
dimensions of root trunk correlating with
diagnosis of molar furcation involvements.
Journal of Clinical Periodontology 24, 129
135.
Hou, G.-L. & Tsai, C.-C. (1997b) Cervical
enamel projections and intermediate bifurcational ridge correlated with molar
furcation involvements. Journal of Periodontology 68, 687693.
Hou, G.-L., Chen, S. F., Wu, Y.-M. & Tsai,
C. C. (1994) The topography of the furcation entrance in Chinese molars. Furcation entrance dimensions. Journal of
Clinical Periodontology 21, 451456.
Hou, G.-L., Tsai, C.-C. & Huang, J.-S.
(1997) Relationship between molar root
fusion and localized periodontitis. Journal
of Periodontology 68, 313319.
Hunter, F. M., Martin, N. D. & Stevenson,
A. R. L. (1992) Evaluation of a pressure
sensitive periodontal probe tip by measuring its histologic relation to periodontal
attachments. Journal of Dental Research
72 (special issue), abstract . 528, 581.
Janssen, P. T. M., Faber, J. A. J. & van Palenstein Helderman, W. H. (1987) NonGaussian distribution of differences between duplicate probing depth measurements. Journal of Clinical Periodontology
14, 345349.
Joseph, I., Varma, B. R. R. & Bhat, K. M.
(1996) Clinical significance of furcation
anatomy of the maxillary first premolar: a
biometric study on extracted teeth.
Journal of Periodontology 67, 386389.
Karayiannis, A., Lang, N. P., Joss, A. & Nyman, S. (1992) Bleeding on probing as ist
relates to probing pressure and gingival
health in patients with a reduced but
healthy periodontitis. A clinical study.
Journal of Clinical Periodontology 19, 471
475.
Kawasaki, K., Hasegawa, M. & Hara, K.
(1976) Cervical enamel projections in human molars: frequency, location, extent,
with associated furcation involvement. Japanese Journal of Conservative Dentistry
19, 139148.
Kim, T.-S., Knittel, M., Staehle, H. J. &
Eickholz, P. (1996) Reproducibility and
validity of furcation measurements using a
pressure-calibrated probe. Journal of Clinical Periodontology 23, 826831.
Kuhner, M. & Raetzke, P. (1991) Sensitivitat
der Taschendiagnostik in Abhangigkeit
von der Anzahl der Sondierungen. Deutsche Zahnarztliche Zeitschrift 46, 533
535.
Lang, N. P., Nyman, S., Senn, C. & Joss, A.
(1991) Bleeding on probing as it relates to
probing pressure and gingival health.
Journal of Clinical Periodontology 18, 257
261.
Langer, B. S. & Wagenberg, B. D. (1997) The
diagnosis and management of vertical defects within the furcation. Compendium of
Continuing Education in Dentistry 18, 111
120.
Larato, D. C. (1970) Furcation involvements:
incidence and distribution. Journal of Periodontology 46, 499501.
Larato, D. C. (1975) Some anatomical factors related to furcation involvements.
Journal of Periodontology 46, 608609.
Leib, A. M., Berdon, J. K. & Sabes, W. R.
(1967) Furcation involvements correlated
with enamel projections from the cementoenamel junction. Journal of Periodontology
38, 330334.
Lindhe, J. & Nyman, S. (1975) The effect of
plaque control and surgical pocket elimination on the establishment and maintenance of periodontal health. A longitudinal
study of periodontal therapy in cases of
advanced disease. Journal of Clinical Periodontology 2, 6779.
Majzoub, Z. & Kon, S. (1992) Tooth morphology following root resection procedures in maxillary first molars. Journal
of Periodontology 63, 290296.
Masters, D. H. & Hoskins, S. W. (1964) Projection of cervical enamel into molar furcations. Journal of Periodontology 35, 49
53.
McFall, W. T. (1982) Tooth loss in 100
treated patients with periodontal disease.
Journal of Periodontology 53, 539549.
Mealey, B. L., Neubauer, M. F., Butzin, C.
A. & Waldrop, T. C. (1994) Use of furcal
bone sounding to improve accuracy of furcation diagnosis. Journal of Periodontology 65, 649657.
Moriarty, J. D., Scheitler, L. E., Hutchens, L.
H., Jr. & Delong, E. R. (1988) Inter-examiner reproducibility of probing pocket
497
498
Renvert, S., Badersten, A., Nilveus, R. & Egelberg, J. (1981) Healing after treatment of
periodontal intraosseous defects (I). Comparative study of clinical methods. Journal
of Clinical Periodontology 8, 387399.
Risnes, S. (1978) The prevalence and distribution of cervical enamel projections
reaching into the bifurcation of human
molars. Scandinavian Journal of Dental
Research 82, 413419.
Rohlin, M., kesson, L., Hkansson, J.,
Hkansson, H. & Nasstrom, K. (1989)
Comparison between panoramic and periapical radiography in the diagnosis of
periodontal bone loss. Dentomaxillofacial
Radiology 18, 7276.
Ross, I. F. & Evanchik, P. A. (1981) Root
fusion in molars: incidence and sex linkage. Journal of Periodontology 52, 663
667.
Roussa, E. (1998) Anatomic characteristics
of the furcation and root surfaces of molar
teeth and their significance in the clinical
management of marginal periodontitis.
Clinical Anatomy 11, 177186.
Ruttimann, U. E. & Webber, R. (1987) Volumetry of localized bone lesions by subtraction radiography. Journal of Periodontal Research 22, 215216.
Ruttimann, U. E., Webber, R. L. & Schmidt,
E. (1986) A robust digital method for film
contrast correction in subtraction radiography. Journal of Periodontal Research
21, 486495.
Samarabandu, J., Allen, K. M., Hausmann,
E. & Acharya, R. (1994) Algorithm for the
automated alignment of radiographs for
image subtraction. Oral Surgery Oral
Medicine Oral Pathology 77, 7579.
Schroeder, H.-E. & Scherle, W. F. (1987) Warum die Furkation menschlicher Zahne so