Furcation: Involvement and

Treatment

drg. Bambang D. Laksono

021418056306
PENDAHULUAN

 Furcation Involvement adalah berlanjutkan penyakit periodontal yang

melibatkan daerah furkasi (percabangan) akar gigi.

 Daerah furcation mempunyai anatomi yang komplek dan sulit

dibersihkan baik saat perawatan rutin periodontal maupun perawatan
sehari-hari.

 Keterlibatan daerah furcation merupakan penyulit dari sisi diagnosa

maupun terapi penyakit periodontal.
FAKTOR ETIOLOGI

 Etiologi primer: bacterial plaque & proses inflamasi yang lama.

 Faktor-faktor yg mempengaruhi: Anatomi akar gigi, pertumbuhan yg
anomali, karies & kematian pulpa.

DIAGNOSA & KLASIFIKASI FURCATION DEFECTS

 Pemeriksaan klinis yg menyeluruh diperlukan utk mendeteksi kelainan

yg melibatkan daerah furkasi.
 Faktor-faktor yg mempegaruhi pemeriksaan, kontribusi atau hasil
perawatan:
o Morfologi gigi yg terlibat
o Posisi gigi yg berdekatan
o Anatomi tulang alveolar
o Konfigurasi defect tulang
o Adanya kelainan gigi yg lain
DIAGNOSA & KLASIFIKASI FURCATION DEFECTS

 Dimensi furcation entrance sangat kecil membutuhkan alat yg tepat

dan ketelitian dokter gigi.

A, The Nabors probe is designed to probe into the

furcation.

B, The probe placed into a Class II furcation of a

dried skull.
 LOCAL ANATOMIC FACTORS

 Pemeriksaan klinis tidak hanya melihat keterlibatan furkasi tetapi jg

anatomi yg lain.
 Pemeriksaan radiologi diperlukan sebagai pemeriksaan penunjang.

A B C

Different degrees of furcation involvement in radiographs. A, Grade I furcation on the mandibular first molar
and a grade III furcation on the mandibular second molar. The root approximation on the second molar may be
sufficient to impede accurate probing of this defect. B, Multiple furcation defects on a maxillary first molar.
Grade I buccal furcation involvement and grade II mesiopalatal and distopalatal furcations are present. Deep
developmental grooves on the maxillary second molar simulate furcation involvement in this molar with fused
roots. C, Grade III and IV furcations on mandibular molars.
LOCAL ANATOMIC FACTORS

 Root thrunk length

• Jarak CEJ dgn furcation ertrance
• Faktor kunci perkembangan & terapi.
• Variasi root trunk length.
Different anatomic features that may be important in
prognosis and treatment of furcation involvement. A,
Widely separated roots. B, Roots are separated but
close. C, Fused roots separated only in their apical
portion. D, Presence of enamel projection that may
be conducive to early furcation involvement.

Entrance: the transitional area between

the undivided and the divided part of
the root
Fornix: the roof of the furcation
LOCAL ANATOMIC FACTORS

 Root length
• Berhubungan langsung dgn attachment supporting gigi.
• Furcation involvement pd gigi dgn akar yg pendek & gigi dgn long root
trunk kehilangan sebagian besar attacment supporting.

 Root form
• Akar mesial M1 & M2 RB, akar mesiobuccal M1 RA melengkung ke
sisi distal.
• Akar distal biasanya fluted.
• Menyulitkan saat tx endodontik, restorasi dan meningkatkan resiko
fraktur akar.

 Interradicular dimension
• Dimensi interradicular mempengaruhi rencana Tx.
• Jarak yg sempit menyulitkan instrumen saat Tx.
LOCAL ANATOMIC FACTORS

 Anatomy of furcation
• Struktur anatomi yg komplek pada daerah furkasi menyulitkan Tx
periodontal dan Tx bedah.

 Cervical Enamel Projections

• CEP terjadi 8,6% - 28,6% gigi molar. Prevalensi tertinggi pada gigi M2
RA, RB.
• Mempengaruhi kesulitan perawatan periodontal.
• Klasifikasi CEP Masters & Hoskins 1964.
LOCAL ANATOMIC FACTORS

 Cervical Enamel Projections

CEP

Furcation involvement by grade III cervical

enamel projections.

Enamel Pearl
ANATOMY OF THE BONY LESIONS

 Pattern of attachment loss

• Mempengaruhi rencana Tx & hasil perawatan.
• Gigi dengan kehilangan tulang yg komplek dpt dilakukan Tx
regeneratif, namun bila kehilangan attachmentnya pd satu akar dpt
dilakukan Tx resektif.

 Other dental finding

• Kondisi gigi dan jar. perio yg berdekatan menjadi pertimbangan dlm
Tx furcation involvement.
• Gingiva yg adekuat & vestibulum yg cukup dalam menjadi
pertimbangan pd tindakan bedah.

Advanced bone loss, furcation involvement, and root

approximation. Note the buccal furcation, which
communicates with the distal furcation of a maxillary
first molar that also displays advanced attachment
loss on the distal root and approximation with the
mesial root of the maxillary second molar. The
patient with such teeth may benefit from root
resection of the distobuccal root of the first molar or
extraction of the molar
INDICES OF FURCATION INVOLVEMENT

 Luas & konfigurasi furcation defect menjadi faktor yg berpegaruh thd

diagnosa dan rencana Tx.

 Didasarkan pd pengukuran horisontal attachment loss furkasi, atau

kombinasi pengukuran horisontal dan vertikal, atau kombinasi dgn
konfigurasi deformitas tulang.

 1958 Glickman
 Grade I: soft tissue lesion extending to the entrance of the furcation but
no furcal bone loss
 Grade II: loss of furcal bone to varying degrees but not through
and through
 Grade III: through and through but not clinically visible
(presence of granulomatous tissue)
 Grade IV: through and through visible clinically (tunnel)
 1975 Hamp et al.
Degree/Class I: horizontal loss of periodontal tissue support <3 mm
Degree/Class II: horizontal loss of periodontal tissue support >3 mm but not
through and through
Degree/Class III: through-and-through defect
 1984 Tarnow and Fletcher
Uses Grades I, II, III proposed previously by Glickman with an additional sub
classification based on vertical invasion from the furcation fornix:
A: VPD, 1 to 3 mm
B: VPD, 4 to 6 mm
C: VPD, >7 mm

 1979 Ramfjord
Degree 1: horizontal penetration <2 mm
Degree 2: horizontal penetration >2 mm but not through and through
Degree 3: through and through
 Differential Diagnosis

 Pulpal pathosis kadang2 menyebabkan kelainan pada

jaringan periodontal daerah furcation

 Trauma oklusi dapat menyebabkan inflamasi &

kerusakan jaringan sampai daerah interradicular area
gigi yg berakar ganda.
TREATMENT

 Therapeutic classes of furcation defects

Tujuan: -. Memfasilitasi pemeliharaan.
-. Mencegah berlanjutnya attachment loss
-. Menghilangkan furcation defect sbg masalah perawatan perio.
Pemilihan Tx mempertimbangkan klasifikasi defect, luas & konfigurasi
kerusakan tulang dan faktor anatomi yg lain.

 Therapy for Early Furcation Defects: Class I

-. Konservatif periodontal terapi: peningkatan OH, SRP,
menghilangkan kelainan anatomi, tumpatan yg overhangging dll

 Therapy for Furcation Involvement: Class II

-. Kerusakan tulang horisontal tanpa kerusakan vertikal pd furcation.
-. Tx lebih komplek odontoplasty/osteoplasty.
Treatment of a grade II furcation by osteoplasty and odontoplasty. A, This mandibular
first molar has been treated by endodontics and an area of caries in the furcation
repaired. A class II furcation is present. B, Five year postoperative picture of the
results of flap debridement, osteoplasty, and severe odontoplasty. Note the adaptation
of the gingiva into the furcation area.

 Therapy for Advanced Furcation Defects: Class II-IV

-. Tx periodontal non bedah tdk efektif lg.
-. Memerlukan Tx bedah perio, endodontik & restorasi gigi
utk mempertahankan gigi.
Objective of Treatment

 Mengeliminasi bakterial plak dari seluruh permukaan akar yg kompleks.

 Pembentukan anatomi daerah furcation agar dpt dilakukan perawatan

secara mandiri.

NON SURGICAL THERAPY

 Oral hygiene procedures

Tx non bedah atau bedah periodontal instruksi peningkatan OH.

 Scaling and root planning

Dilakukan secara teratur dan rutin utk kontrol plak. Tx obat2 an tdk
memberikan hasil yg signifikan.
SURGICAL THERAPY

 Osseous resection
• Efektif pd grade II furcation
• Teknik Osteoplasty & osteotomy
– Ratakan daerah defect utk mengurangi kedalaman
horisontal
– Membuat lantai tulang utk memudahkan kontrol
plak
– Mengurangi kedalaman probing.

 Regenerative
Tx regeneratif banyak dilakukan utk memperbaiki
grade II-IV furcation. Bahan2 yg dipergunakan sangat
bervariasi dari autograft, allograft, xenograft & alloplast.
SURGICAL THERAPY

 Root resection
 Indikasi pd furcation Grade
II – IV.
 Kontra indikasi
-. Dukungan tulang yg
Inadequate.
-. Akar gigi yg menyatu.
-. Perawatan endodontik
tdk bisa dilaksanakan.
-. Pertimbangan pasien.

 Hemisection

 Indikasi pd furcation Grade

II-III
 Jarak akar yg cukup lebar
SURGICAL THERAPY

 Root resection/Hemisection Procedure

 Anesthesia Full thicknes mucoperiosteal flap Debridement
Root resection/hemisection Grafting Reposisi flap
Koreksi oklusi.

 Extraction
Pd furcation grade III-IV. Tx dipilih jk kontrol plak kurang baik, tingkat
karies tinggi, komitmen pasien yg kurang, tk sosek yg kurang
menguntungkan dll.

 Dental Implants
Tx setelah dilakukan ekstraksi gigi utk mempertahankan fungsi serta
estetik yg baik
Diagram of a distobuccal root resection of a maxillary first molar. A, Pre-operative bony contours
with grade II buccal furcation and a crater between the first and second molar. B, Removal of bone
from the facial of the distobuccal root and exposure of the furcation for instrumentation. C, Oblique
section that separates the distal root from the mesial and palatal roots of the molar. D, More
horizontal section that may be used on a vital root amputation as it exposes less of the pulp of the
tooth. E, Areas of application of instruments to elevate the sectioned root. F, Final contours of the
resection.
PROGNOSIS

 Keberhasilan perawatan bergantung pada:

 Diagonsa yg tepat & menyeluruh
 OH yg baik
 Nonsurgical therapy yg exellence
 Tindakan bedah yg tepat & hati2 serta manajemen restoratif

SCIENCE TRANSFER

 Furcation involment diklasifikasikan grade I-IV.

 Tx non bedah atau tx bedah memberikan hasil yg cukup baik utk
furcation grade I-II.
 Sedangkan grade III-IV mempunyai prognosa yg kurang
menguntungkan. Umumnya dilakukan pencabutan & implant