Periodontology 2000, Vol.

22, 2000, 154–168 Copyright C Munksgaard 2000

Printed in Denmark ¡ All rights reserved
PERIODONTOLOGY 2000
ISSN 0906-6713

The role of resective periodontal

surgery in the treatment of
furcation defects
M ASSIMO D E S ANCTIS & K EVIN G . M URPHY

Periodontal disease is characterized by the loss of sective treatment of furcations and 3) outline the
connective tissue attachment induced by the pres- step-by-step procedures required for resective treat-
ence of periodontal pathogens within the gingival ment of furcation defects.
sulcus. The destruction of periodontal tissues pro-
gresses in the apical direction affecting all peri-
odontal tissues: cementum, periodontal ligament Predisposition to furcation
and alveolar bone. The degree to which a lesion pro- involvement
gresses is affected by several factors: inflammatory
response, types of bacteria present, organic con- Numerous tooth-specific anatomical variations are
ditions and local factors. In the posterior segments thought to predispose teeth to furcation involve-
of the dentition, numerous factors play a role in in- ment. Recognizing these factors is necessary for the
fluencing the onset and progression of periodontal treatment of the furcation, regardless of the treat-
disease. Attachment loss in the furcation is one of ment modality. Anatomical factors that make molars
the most serious anatomical sequela of peri- particularly susceptible to periodontal disease in-
odontitis. Furcations are frequently not accessible clude: a) accumulation of bacterial plaque as a result
for adequate professional debridement, since their of difficult access for oral hygiene procedures, b) ab-
entrance is very small for the size of periodontal in- errant root morphology, c) enamel projections or
struments, and they present with ridges, convexities pearls, d) presence of accessory canals, e) length of
and concavities that frequently render the defect im- the root trunk and f) location of the root separation
possible to instrument effectively. relative to the root trunk (1).
Resective therapy has been utilized in the treat-
ment of furcation defects for over 100 years. In re-
Accumulation of plaque
cent years it has been demonstrated that guided
tissue regeneration can be effective in the treatment As with all forms of adult periodontitis, apical exten-
and long-term maintenance of some types of fur- sion of attachment loss in the inter-radicular space
cation defects (46). While regeneration of the peri- caused by bacterial plaque pathogens is the com-
odontium is an accepted treatment goal, not all fur- mon cause of furcation involvement. Any restorative
cation defects can be effectively treated using re- or other iatrogenic factor that enhances plaque ac-
generative procedures. For example, mesial and cumulation or prevents the performance of optimal
distal class II and class III maxillary furcation defects oral hygiene procedures results in chronic local in-
cannot be predictably treated using currently avail- flammation, which in turn is associated with attach-
able regenerative treatment (42, 43). Therefore, re- ment loss and ultimately the degree of invasion of
sective therapies including root resection procedures the inter-radicular space.
remain important procedures in periodontal
therapy.
Aberrant root forms
The purposes of this review are 1) to define the
factors believed to predispose teeth to furcation in- The root surface in the furcation has a complex mor-
volvement, 2) to review the literature concerning re- phology. Examining sectioned molar teeth, Bower (8)

154
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

Fig. 2. Class II furcation involvement; an enamel projec-

tion is evident

demonstrated that on mandibular first molar teeth a

concavity was found on the furcation aspect in al-
most all roots. A deeper concavity was present on
the mesial root than in the distal root. On maxillary
first molars, the furcal aspect of the root was concave
in 94% of mesio-buccal roots, 31% of disto-buccal
roots, and 17% of palatal roots. In these locations,
the deepest concavity was in the furcation aspect of
the mesio-buccal root. The complexity in the root
anatomy of multi-rooted teeth implies that, even
after root resection, the resected tooth will likely
have non-flat, and frequently concave, residual root
surface topography (Fig. 1).

Enamel projections

An enamel projection is an extension of the cervical

enamel margin either toward or into the root fur-
cation area (Fig. 2, 3). The presence of a cervical en-
amel projection into the furcation area is an ana-
tomical variation. Masters & Hoskins (34) studied the
prevalence of cervical enamel projections in ex-
tracted molars. Cervical enamel projections were
found on 29% of the buccal surfaces of mandibular
molars and 17% of maxillary molars. The authors
proposed a classification of cervical enamel projec-
tion into three grades according to the extension of
the projections, with a grade III cervical enamel pro-
jection extending directly into the furcation. Al-
though the frequency of enamel projections is very
high, enamel projections are often difficult to detect
in the non-diseased dentition. Atkinson (3) was the

Fig. 1. Root anatomy of a maxillary molar. Please note the

complex root surface morphology with concave and covex
areas.

155
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

first to suggest a possible correlation between en- distal widths at the cementoenamel junction of both
amel projections and furcation lesions. Hou & Tsai maxillary and mandibular first molars had very low
(27) showed a close relationship between the pres- correlation with their furcation entrance diameters.
ence of enamel projections and furcation involve- Likewise, the buccal furcation entrance diameter of
ment by demonstrating that 63% of the 87 furcally the mandibular first molar was smaller than that of
involved molars studied had enamel projections or the lingual first molar. He also demonstrated that the
furcation ridges; these were particularly observed in buccal furcation entrance diameter of the maxillary
first and second molars. They also found significant first molars is smaller than either the mesio-palatal
differences in the mean pocket depth, clinical or disto-palatal. Of clinical relevance is the fact that
attachment loss and Plaque Index scores between the average furcation entrance diameter is smaller
first and second molars with and without enamel than the tips of conventional hand instruments.
projections and furcation ridges. Cervical enamel Therefore, successful treatment of molars with fur-
projections are therefore considered to be a local co- cation involvement depends upon the size and ac-
factor in causing furcation lesions. cessibility of the instrumentation that can remove or
control local causative factors and possibly alter the
morphology of the furcation. Another critical factor
Accessory pulp canals
is the location of the root separation in relation with
Histological studies on extracted human molars have the common root trunk and the cementoenamel
demonstrated the presence of accessory canals, junction.
especially in the furcation region. Bender & Seltzer
(5) found that accessory canals and foramina were
in greater numbers in the furcation regions of pre- Rationale for resective therapy in the
molars and molars. Burch & Hulen (12) demon- treatment of furcations
strated the presence of accessory foramina in 76% of
the furcations examined. Frequently, more that one Furcation lesions are particularly difficult to treat
canal was detected at the trifurcation or bifurcation both by conventional surgical and by nonsurgical
area. It follows that, once the pulp is infected, such means. The anatomical characteristics of the areas
endodontic-periodontal communications may result involved, particularly the size of the furcation en-
in either destruction of the inter-radicular periodon- trance, the presence of root concavities and the un-
tium or interfere with the healing response of either even surface of the roof of the furcation, make ade-
periodontal or endodontic procedures. Likewise, quate instrumentation of the inter-radicular area ex-
chemical root conditioning of the furcation area may tremely difficult even when an open flap technique
induce an alteration in pulpal health (16). is used.
Parashis et al. (41) studied the effectiveness of
manual root planing with both open and closed flaps
Size and location of the furcation
and compared these results with those of planing
Larger teeth do not necessarily have large furcation with a rotating bur. Only 12.5% of the furcation sur-
entrance diameters. Bower (9) found that the mesio- faces with pocket depths of 5–6 mm and treated with
closed root planing were completely free of calculus
deposits, while 25% of those treated with open root
planing were completely free of calculus. The results
improved when a round bur was used (38%). In the
case of pockets 7 mm or deeper, the percentage of
post-treatment calculus-free root surface decreased
significantly. No furcation treated either by closed or
open flap instrumentation was completely free of
calculus. Similar results were demonstrated by Matia
et al. (35) using a surgical approach and examining
the roof of the furcation areas. In fact, only 7 tooth
surfaces of 26 were completely free of calculus.
To overcome the difficulties encountered in scal-
ing and root planing these areas, resective tech-
Fig. 3. Enamel projection niques have been designed to eliminate the morpho-

156
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

logical characteristics and create an area conducive two roots of a multi-rooted tooth (53). For the pur-
to good oral hygiene. pose of this discussion this definition of terms will
Several definitions for root resection and root am- be employed: root separation and resection.
putation have been proposed. The 1986 glossary of
periodontic terms lists the following clinical situ-
ations and definitions:
Efficacy of resective therapy in the
O root resection – the surgical removal of all or a treatment of furcation defects
portion of the root before or after endodontic
treatment; Open or closed flap debridement without
modification of the furcation
O root amputation – the removal of a root from a
multi-rooted tooth; and Schroer et al. (47) studied 25 furcation sites in 15
O hemisection – the surgical separation of the roots patients over a 16-month period. They compared
in a multi-rooted tooth, especially a mandibular scaling and root planing to open flap debridement.
molar, through the furcation area in such a way All sites received initial preparation consisting of
that a root or roots may be surgically removed root instrumentation. One half of the group was
with the associated part of the crown. treated surgically while the remaining teeth received
further root planing. All furcations were class II and
The Guidelines for Periodontal Therapy produced by located on buccal surfaces. Probing depths were re-
the American Academy of Periodontology in 1992 duced equally in both groups at the deepest vertical
(55) list as resective treatment of multi-rooted teeth site in the furcation, with most of this reduction oc-
only root resection and tooth hemisection. curring after the initial root planing treatment. A
In the current literature there is no uniformity in slight loss of attachment was observed in the mid-
the terms used. Root amputation, root resection, furcal area following surgery while a slight gain was
root separation and hemisection are frequently used seen in the root planing areas; this, however, was not
terms. These are generally used as follows (54): statistically significant.
Two years after quadrant treatment with various
O Hemisection is defined as the removal of half of a treatment modalities, Kalkwarf et al. (28) reported a
tooth performed by sectioning the tooth and re- progressive attachment loss in furcations treated
moving one root. It is frequently used with refer- with all tested therapeutic modalities. Tested treat-
ence to lower molars. ments included coronal scaling only, scaling and
O Root amputation is characterized as removal of a root planing, scaling and root planing plus modified
root without removal of the overhanging portion Widman flap, and open flap scaling and root planing
of the crown. with osseous resection.
O Root resection generally indicates the removal of Wang et al. (51) studied the influence of furcation
a root without any information on the crown of involvement and tooth mobility on the outcome of
the tooth. periodontal therapy in molar teeth over an 8-year
O Root separation is indicated as the sectioning of period. The patients were a subset of patients from
the root complex and the maintenance of all the Michigan longitudinal trials. Using a split-mouth
roots. design, pocket elimination osseous surgery, modi-
fied Widman flaps and curettage were performed on
Carnevale et al. more recently (15) have used the 24 patients. It was demonstrated that molars with
term root resection as the sectioning of a mandibu- furcation involvement were 2.5 times more likely to
lar or maxillary molar with the removal of one or two be lost during the maintenance period than molars
roots regardless of how the crown is treated. Con- with intact inter-radicular spaces. If a mobility pat-
versely, the term root separation was used to indi- tern greater than Miller’s class II was present, there
cate the sectioning of a mandibular molar or of the was an even greater tendency for attachment loss
two remaining roots of a maxillary molar after one and tooth loss. There was no difference in outcome
has been removed. The same authors further simpli- between teeth treated with the tested surgical mod-
fied the terms. Root separation was defined as the alities. This study demonstrated a similar success
sectioning of the root complex and the maintenance rate to the other long-term studies that utilized non-
of all roots. Root resection, conversely, was used to surgical and non–root removal resective therapies
indicate the sectioning and the removal of one or (26, 36, 44, 20, 52). Table 1 summarizes these studies.

157
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

Table 1. Long-term clinical studies of conserva- caries accounted for 70% of this group of failures.
tive non–root removal surgical and nonsurgical Tunneled teeth appear to be at higher risk for the
therapies in molars with furcation involvement development of caries. Nevertheless, the authors
Observation Number % of
suggested that tunnel preparation should be con-
period of teeth teeth sidered a valid treatment modality.
Author(s) (years) evaluated lost
Furcations treated with resective osseous surgery
Hirschfeld & 15–53 1464 31
Wasserman (26)
for tunnel preparation are expected to result in a
Goldman et al. (20) 15–34 636 44
slight loss in attachment as a consequence of the
Ross & Thompson (44) 5–24 387 12
therapy.
Wood et al. (52) 10–34 164 23
McFall (36) 15–29 163 57 Root separation and resection
Wang et al. (51) 8 87 30
There is no consensus of data shown in the literature
concerning the success of root separation and resec-
tion techniques. In the various studies, the need for
root separation and resection was determined by a
variety of factors: periodontal, endodontic, fracture
Tunneling procedures
or caries. Similarly, there is no consensus in the cri-
Irrespective of the considered treatment modality, teria used to evaluate results; in fact, most authors
furcation by itself seems to be a very difficult ana- used tooth survival as the only evaluation criterion
tomical area to be maintained free of bacterial
plaque and thus free of inflammation. Thus resective
therapy, with the aim of eliminating all plaque re-
taining factors, has been utilized in periodontal de-
fects, with advanced horizontal bone loss and class
II or III furcation involvement.
Advanced furcation lesions can be treated by ‘‘tun-
neling’’, i.e. the intentional creation of a class III fur-
cation with its entrance accessible for oral hygiene
procedures (Fig. 4–7). During surgery, bone is re-
shaped to obtain a scalloped morphology and the
soft tissues are apically positioned; care must be
taken that the space obtained under the roof of the
furcation will allow proper plaque removal (9). Sev-
eral studies have reported the medium to long-term
Fig. 4. Class III furca involvement of first lower molar to
outcomes of tunneling procedures.
be treated with tunnel preparation
Hamp et al. (23) reported the results of 7 molars
with degree III furcation defects that had undergone
tunnel preparation. After 5 years they observed evi-
dence of carious lesions in 4 teeth (57%). The
authors emphasized the unfavorable prognosis of
this therapy.
Little et al. (31) followed for 5 years 18 class II or
III molar furcations that underwent tunneling pro-
cedures. Five of the teeth were maxillary molars.
Crestal bone levels and attachment levels in the fur-
cations were maintained for this time period. During
follow-up, 3 of the 18 teeth experienced root caries.
Helldén et al. (25) evaluated 149 teeth which had
received tunnel preparation. The mean observation
time was 37.5 months. Overall, 24% of the teeth de-
veloped caries. Of the 17 teeth that had to be ex- Fig. 5. The bone is recontoured to obtain a scalloped mor-
tracted or further treated by root resection, root phology and the furcation area is reshaped.

158
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

examining root separation and resection treatment

of furcations.
Bergenholtz (6) reported the results of 45 teeth
treated with root resection. Evaluations were made
at different intervals over 5–10 years; only 3 teeth
were extracted: two for periodontal reasons and one
as result of endodontic complications.
Klavan (29) studied 34 maxillary molars having
undergone root separation and resection; the teeth
were periodically checked following surgery for a
period varying from 11 to 81 months. Only one fail-
ure for periodontal reasons was reported. The aver-
Fig. 6. The flap is apically positioned; the space obtained age probing depth of the remaining teeth was 2.6
under the roof of the furcation will leave the entrance of mm. This study also demonstrated that removal of
the furcation exposed and thus allows for proper oral hy- one root of a maxillary molar does not increase the
giene. mobility of a tooth in normal function and that rou-
tine splinting of root resected teeth does not seem
to be indicated. An exception cited by Klavan con-
cerned the use of resected teeth as abutments for
removable partial dentures. Of the only three of 33
resected maxillary molars examined that had meas-
urable mobility during the post-resection evaluation
period, two of these three teeth were removable par-
tial denture abutments.
Hamp et al. (24) carried out a study on 310 multi-
rooted teeth. These underwent different forms of
surgical treatment, including osseous resection, root
resection and tunneling procedures. Eighty-seven of
these underwent root amputation. Probing carried
out at the follow-up 5 years after treatment showed
Fig. 7. Healing of the tunnel preparation allows proper that 78 teeth had pockets equal to or less than 3 mm;
oral hygiene. seven teeth had pockets 4–6 mm deep and only two
teeth had pockets deeper than 6 mm. No teeth were
extracted during the observation period. Total elim-
for long-term results. Only few authors included in ination of plaque retention areas in the furcations
their evaluation periodontal parameters such as the
Plaque Index, the Bleeding Index, pocket depth and
attachment loss. Consequently, it is very difficult to
Table 2. Failure rates following root resection
make a comparison of the data obtained. Further-
therapy
more, most of the studies are retrospective analyses.
Despite these limitations in the literature, some Observation
period Average Failure
trends can be identified. In particular, failure rates, Author(s) (years) (years) rate (%)
as reported by most of the authors, are quite low Blömlof et al. (7) 3–10 5.8 32
after the initial 5 years of observation. Basten et al. (4) 2–23 11.5 8
Most frequently failures seem to be due to endo- Hamp et al. (24) 7 7 7
dontic or restorative reasons. Plaque control in Carnevale et al. (14) 3–11 6.5 6
treated areas has been reported to be equal or even Buhler (11) 10 10 32
better than in nonfurcated areas. Erpenstein (19) 1–7 2.9 21
All authors agree that root separation and resec- Langer et al. (30) 10 10 38
tion procedures have a high degree of complexity Hamp et al. (24) 5 5 0
and to be correctly performed they need a high level Klavan (29) 1–7 3 3
of surgical and reconstructive skills. Bergenholtz (6) 1–7 3.6 7
Table 2 presents a summary of long-term studies

159
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

and meticulous oral hygiene in conjunction with recontouring and apically positioned flaps. Only
maintenance therapy was cited as the reason for suc- badly broken down teeth were restored with cast
cess. post and cores; threaded posts were not used. Evalu-
Langer et al. (30) reported a 10-year retrospective ations were carried out between seven and 22 years
study on 100 root resections. The author reported 38 post-operatively, with a mean observation period of
failures; seven of these were endodontic, 18 due to 11.5 years. All the teeth were maintained using a re-
root fractures, three due to cement leakage and ten call interval of 3–6 months. Four teeth were extracted
were due to periodontal reasons. Almost twice as during the study: one for endodontic reasons, two
many mandibular molars fractured as maxillary. Fail- for caries and one for strategic reasons. The failure
ure among the maxillary molars was primarily peri- rate reported by the authors was 8%.
odontally related, while root fracture was the reason Blömlof et al. (7) reported the results of a study
most mandibular molars failed. Almost all teeth were conducted on 146 root-resected molars. The root-re-
restored with post-and-core restorations. sected molars were compared with 100 endodont-
Erpenstein (19) reported the results of 34 sec- ically treated single rooted teeth. The period of ob-
tioned molars clinically examined for a period of 3 servation was between 3 and 10 years, with an aver-
years. The indications for performing a root resec- age time of 5.8 years. After 5 years, root-resected
tion were varied: endodontic (58%), periodontal teeth and single-rooted teeth had the same pro-
(26%), caries (11%) and other (5%). During the study, portion of survival: 82% and 83% respectively. At 10
four sectioned teeth were extracted: one for peri- years, the frequencies were 68% for multi-rooted and
odontal reasons and three as a result of endodontic 77% for endodontically treated single-rooted teeth.
recurrences. The resections resulted in a significant This difference was not statistically significant. The
decrease in probing depth for the treated teeth de- majority of the teeth were extracted because of pro-
spite the fact that no pocket reduction osseous gression of periodontitis. The results of this study are
surgery was done in concert with the root resection. less favorable than those reported by Carnevale et al.
The results were maintained throughout the dur- (14) and by Basten et al. (4). The risk of losing root-
ation of the study. resected molars because of periodontitis progression
Buhler (10) conducted a 10-year study on 34 sec- did not appear to be greater than the risk of losing
tioned molars. Although he reported a 32% failure single-rooted, endodontically treated teeth in a peri-
rate, only one tooth was extracted for periodontal odontitis-prone population. A strong risk factor for
reasons. The primary cause of failure was endodon- tooth survival was smoking.
tic complication. Because of the use of different procedures and
Carnevale et al. (14) carried out a retrospective outcomes, an accurate comparison and summary of
analysis of 194 randomly selected patients to evalu- the results of the discussed root separation and re-
ate the result of root resection over a period of 3 to section studies is difficult to achieve. To improve the
11 years. The experimental sample consisted of 488 possibilities of comparison of the studies, Buhler
molars that underwent root resection or amputation (11) has attempted to reduce the results of various
and prosthetic reconstruction. The observation studies to the common denominators of time of ob-
period was 3–6 years for 303 molars and 7–11 years servation and the criteria for failure as defined by
for 185 molars. They indicated the following criteria Langer et al. (31). This limited meta-analysis using
to assess failures: tooth extraction, pocket depth these assumptions demonstrates that over a 7-year
greater than 5 mm, root and crown fracture, untreat- observation period, the failure rate for teeth treated
able endodontic lesion, cement washout, caries and by root separation and resection was 11% (Table 3).
prosthetic breakage. Of the experimental teeth, 28 Buhler notes that this success rate compares favor-
(6%) were considered failures: four for endodontic ably to the one of endosseous implants in the pos-
reasons, nine for caries, three because of probing terior dentition.
depths greater than 5 mm, three for abutment frac- Nevertheless, significant variations in the success
ture and nine for root fracture. The final assessment rates reported by the different authors are evident. A
revealed that, of the remaining teeth, 90% showed a partial explanation of the observed variability comes
pocket depth of 3 mm or less and absence of from the different inclusion criteria and the presence
bleeding was present in 93% of the teeth. of a significant technical factor: the method of res-
Basten et al. (4) reported data from a retrospective toration of the tooth treated by root separation and
analysis of 49 root-resected molars. Patients were resection. In facts, the above investigations show
treated in a postgraduate clinic and received bone little consistency in terms of indications for the

160
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

Table 3. Comparison of various root resection The periodontal indications for root separation
studies using normalized data for a 7-year and resection are often based upon diagnosis of the
observation period using failure criteria as furcation involvement. The horizontal component of
defined by Langer et al. [after Buhler (11)] furcation involvement (classes I to III) and its verti-
Observation cal component (subclasses A to C) represent the key
period Failure criteria utilized to assess the extent of disease pro-
Author(s) n (years) rate (%)
gression in the inter-radicular space (see Papapanou
Hamp et al. (24) 24 7 17
and Tonetti, this volume). Several other factors con-
Carnevale et al. (14) 185 ±7 5
cur in determining whether or not root separation
Buhler (10) 28 7 11
and resection is indicated in a specific case: these
Langer et al. (30) 100 7 20
are periodontal, endodontic, reconstructive and stra-
Average 84 7 11
tegic in nature.
Key periodontal anatomical factors include the
lack of fusion between the roots, the length of the
root trunk, the position of the root separation, the
method employed to restore the root-resected teeth. divergence between the roots as well as their shape
This is significant, as the predominant reported and length, the amount of residual attachment, the
mode of failure of a root-resected tooth is related to
either endodontic or technical complications such
as root fracture. It is therefore generally emphasized
Table 4. Indications for root resection and
that successful root resection therapy requires a separation treatment
careful multidisciplinary approach including peri-
Periodontal indications
odontal surgery, conservative endodontic treatment O severe bone loss affecting one or more roots
and prosthetic reconstruction. untreatable with regenerative procedures
O class II or III furcation invasions or involvements
For these reasons, the efficacy and the efficiency O severe recession or dehiscence of a root
of root resection therapy remains controversial: Endodontic or conservative indications
complications seem to be rather common and are O inability to successfully treat and fill a canal
O root fracture or root perforation
mainly of a non-periodontal nature. O severe root resorption
The 1989 World Workshop in Periodontics stated O root decay
that root resection therapy ‘‘is a procedure which Prosthetic indications
O severe root proximity inadequate for a proper
should still remain as part of the periodontal arma- embrasure space
mentarium to treat very specific problems which O root trunk fracture or decay with invasion of the
biological width
cannot be solved by any other therapeutic approach,
and when the tooth in question has a very high stra-
tegic value’’ (13).

Table 5. Contraindications to root resection and

separation treatment
Indications and contraindications General contraindications to periodontal surgery
O systemic factors
for treatment of furcation defects O poor oral hygiene
by root separation and resection Factors associated with local anatomy
O fused roots
O unfavorable tissue architecture
Commonly cited indications and contraindications
Endodontic factors
of root separation and resection treatment are dis- O retained roots endodontically untreatable
played in Tables 4 and 5, respectively. It is clear that O excessive endodontic instrumentation of retained
roots
root separation and resection treatment represents O excessive deepening of pulp chamber floor
a possible solution to a variety of conditions; these Restorative factors
include advanced inter-radicular periodontitis, O internal root decay
O presence of a cemented post in the remaining root
caries, fractures, and endodontic problems. The fol-
Strategic considerations
lowing discussion will be focused upon root separ- O consider adjacent teeth available for conventional
ation and resection performed to eliminate the prosthetic restoration
O consider removable prosthesis
plaque-retentive areas resulting from inter-radicular O consider implants
periodontitis.

161
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

Fig. 8. Class III disto-buccal furcation involvement of an the residuate distal surface has been flattened with a dif-
upper molar. Initial incisions and flap elevation (A). The ferential preparation technique (C). Suture and flap clo-
disto-buccal root is separated and extracted (B). Note that sure (D).

anticipated stability of the individual roots, and the The possibility of successfully performing root
access for oral hygiene procedures (54). Pre-surgical separation and resection therapy also requires a
evaluation of these anatomical characteristics repre- comprehensive evaluation of the endodontic and re-
sents a major challenge, especially at maxillary mul- constructive components of the treatment. The
ti-rooted teeth. Case selection based on these ana- prognosis of the endodontic treatment or re-treat-
tomical factors is, nevertheless, considered to be key ment as well as the need for and the eventual limi-
in the success of root separation and resection ther- tations of restorative treatment need to be carefully
apy; the final evaluation of the indication of root evaluated before making a decision to proceed with
separation and resection and pertaining to how root separation and resection therapy.
many and which roots shall be retained is frequently As usual, the most critical of all diagnostic aspects,
left to the time of surgery. once the technical feasibility of root separation and

162
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

Fig. 9. Sequence of treatment for a class III furcation in- pared with a differential technique to obtain convex sur-
volvement of teeth 1.7 and 1.6 (A). A full-thickness flap is faces (C). The flap is apically positioned following bone
elevated (B). The disto-buccal roots are extracted, the recontouring (D).
palatal and mesio-buccal roots are separated and pre-

resection therapy has been established according to out correctly. Carnevale et al. (15) describe an eight-
all involved parameters, is the comparison of the ex- step procedure that emphasizes pre-operative endo-
pected efficacy and cost-benefit ratio of root separ- dontics and removal and/or separation of the root
ation and resection with respect to the existing treat- during the first tooth preparation and temporization
ment alternatives. These include maintenance (see phase. After initial healing has been established, oss-
Cattabriga et al. in this volume), regeneration (see eous surgery is performed in order to establish posi-
Sanz & Giovannoli in this volume) and extraction tive osseous architecture and to reshape the remain-
with or without replacement of the tooth by conven- ing tooth structure. The teeth are then re-prepared
tional or implant-borne reconstructions (see P- and temporized. Final restorations are placed after 3
 2000 Volumes 4 and 17). months of healing (Fig. 8–10).

Suggested clinical protocol for root separation and Endodontic phase

resection
If possible, endodontic therapy and root resection
Newell (38) describes the importance of clinical skill should be performed prior to surgery, during the
in the correct execution the root resection and sep- prosthetic phase leading to construction of tempor-
aration techniques. All phases of the treatment are aries. Sectioning of the root prior to surgery, in fact,
equally important to the success of the procedure. will allow better bone recontouring during surgery
Three disciplines of dentistry are involved. They and allow for more precise flap closure and easier
have been described as endodontic, surgical and re- adaptation of the temporary prosthesis.
storative. Treatment planning for endodontic ther- Only when the pre-surgical identification of the
apy, crown build-up, construction of a provisional root to be resected or separated is impossible should
restoration, tooth preparation during surgery and root sectioning be performed during surgery; in such
final prosthetic reconstruction must all be carried circumstances, removal of the involved root(s) dur-

163
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

Fig. 10. A prosthetic manufact is prepared for teeth 17 and prosthetic reconstruction (C, D).
16 (A, B). Clinical appearence following insertion of the

ing surgery is acceptable even in a vital tooth. In Restorative phase

these cases the subsequent endodontic treatment
should be performed as soon as possible (48). In this Great care should be taken in properly restoring mo-
respect, it should be noted that root resection before lars that have undergone root resection surgery.
endodontic treatment and reconstruction with an Problems that can arise when reconstructive treat-
adhesive material may increase the technical com- ment is not correctly carried out comprise faulty re-
plexity of restoring the remaining portion of the tention, excessive weakening of root structure, in-
tooth. complete marginal seal.
During endodontic treatment, it is suggested that A foundation restoration is the part of the recon-
the access opening be kept as small as possible. struction the replaces the missing coronal and rad-
Since root fracture and restorative material failure is icular tooth structure before placement of a crown.
an important factor in the long-term success of re- The purpose of this restoration is to provide proper
sected teeth, any operative procedure that removes retention and resistance for the subsequent full
intact coronal tooth structure or places excessive coverage restoration. Marin et al. (33) have suggested
pressure within the canal is to be avoided, if poss- that restoration be performed prior to root separ-
ible. Excessive preparation of the radicular canals ation, taking care that the build-up is retentive in
and lateral condensation during the endodontic each single root. This goal is accomplished by modi-
treatment should also be avoided. fying the morphology of the access cavity and the
If the root canal therapy can be completed before coronal third of the canal, and creating lateral slots
the resective treatment is initiated and significant to obtain undercuts in the apico-coronal or mesio-
coronal tooth structure remains, then the chamber distal directions. It is generally suggested to ac-
should be filled with a restorative material whose re- complish crown build up with a chemically cured
tention should also rely upon some form of dentin composite, by using a dentine adhesive to improve
bonding adhesion (18). the retention of the material. In fact, an amalgam

164
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

restoration may detach more easily after root separ- sidual roots, tooth structure–saving knife-edge fin-
ation; furthermore, when the tooth section is carried ishing lines are frequently required to avoid excess-
out with an open flap, amalgam tattoos may occur. ive removal of residual root structure. This finish line
In the past it has been advocated that incorpor- is of particular significance in the cervical extension
ation of a post will reinforce the root. However, re- area whenever the clinician wishes to obtain a fer-
cent evidence suggests that fracture resistance is not rule effect. Such a finish line will require metal mar-
improved and may actually be decreased with the gins of the full coverage restoration.
placement of a post (21). Since root fracture is a sig- A restorative dilemma presents when a residual
nificant cause of failure, any restorative procedure pulp chamber is located less than 3 mm above the
that enhances the chance of root fracture should be root separation. Assuming a distance of 2 mm for
avoided. Therefore, the use of a post in the fabri- ‘‘biological width’’ and 1.5 mm for the solid tooth
cation of the foundation restoration should be structure necessary for the ferrule effect of the
limited to situations where there is insufficient co- crown, a minimum of 3.5 mm of available tooth
ronal tooth structure to provide adequate retention structure between the pulp chamber and above the
and resistance for the full-coverage restorations. En- residual root separation is required. Majzooub & Kon
dodontic posts, therefore, should be incorporated in (32) have demonstrated on extracted teeth that a
the foundation restoration only when adequate re- root resection on a maxillary molar will leave less
tention will not be provided by the residual tooth than 3 mm of available root structure in this area
structures. Whenever it is deemed necessary to place 86% of the time. It can be inferred from these data
a post, recent clinical studies indicated that a pre- that restorations placed in this area frequently ex-
fabricated parallel sided post was less likely to result tend further subgingivally than ideal. This is of par-
in root or restoration fracture compared with a cus- ticular significance in cases of root resection of
tom fabricated tapered cast post. In this respect, upper molars leaving two connected roots: in such a
Torbjorner (50) et al. studied 788 parallel (Para-post) case resection of the osseous margin to establish a
and tapered posts over a 4- to 5-year observation proper biological width will lead to opening of the
period. The cumulative failure rate was 8% for the furcation between the two residual roots.
Para-post group and 15% for the taper post group.
Prosthodontic research has disputed the belief
Surgical phase
that specific foundation restorations reinforce endo-
dontically treated teeth. Various foundation ma- Root separation and resection in periodontal pa-
terials and techniques have been directly tested for tients has been generally described as part of pocket
retention and resistance to fracture. However, the elimination resective osseous surgery. Carnevale et
differences are of limited clinical significance be- al. (15) and Basten et al. (4) suggest that bone recon-
cause full-coverage crowns, which have been shown touring to recreate a positive architecture and apic-
to negate these differences (2), are usually placed on ally positioned flaps must be employed in order to
top of these crown build-ups and therefore afford obtain an environment conducive to good hygiene
some protection to these foundations. and easy dental care.
The marginal area of a complete crown that ex- Following these indications, bone recontouring is
tends onto the tooth structure apical to the founda- accomplished utilizing rotary instruments to reduce
tion material creates a ferrule effect. This is con- the thickness of alveolar bone, while hand instru-
sidered a critical component in the reconstruction ments are then utilized to create a scalloped bone
of a root-resected tooth and for the prevention of contour in such a way that buccal and lingual parab-
technical complications in particular. It appears olae are positioned apical to the interdental bone
from tooth-loading characteristics that, clinically, septum.
the buccal and lingual ferrule locations would be During surgery the presence of root lips un-
most critical for the prevention of fracture. Less than detected during the prosthetic phase or irregular
1.5 mm of this ferrule effect increases the risk of fail- root contours has to be carefully evaluated and elim-
ure (2). Therefore, the type of core material and inated since maintenance of such morphology can
whether a post is used may not be as important as lead to plaque accumulation and disease pro-
the length of the apical extent of the crown prepara- gression. Newell (38) has demonstrated in a survey
tion (49). of 70 root-resected teeth that over 30% of the exam-
The type of margin of the full coverage restoration ined teeth have a faulty resection of the root. Re-
is also significant. Given the limited width of the re- sidual root fragments, furcation lips and ledges were

165
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

present in this group. Failures where more frequent Resection versus alternatives
in maxillary resections (33%) as compared with
mandibular resections (23%). These deficiencies The efficacy of root separation and resection therapy
were radiographically detectable in the mandible but is most often compared to access flap or to regenera-
detectable in only 38% of the maxillary cases. In light tive techniques such as guided tissue regeneration
of the high incidence of residual root fragments, all for the treatment of the furcation defect. While the
root resections should be done using a flap approach goal of guided tissue regeneration therapy in the
(Fig. 4, 5). treatment of furcation defects is to eliminate the fur-
cation through the reconstruction of lost periodon-
tium, resective therapy aims to remove the remain-
ing structure of the tooth that defines the shape of
Tooth contour after root the furcation defect. Both therapies hope to alter the
separation or resection topography of the defect. Scaling and root planing
with or without access flap ‘‘conservative’’ ap-
The morphology of the portion of the tooth remain- proaches, conversely, are aimed at the maintenance
ing after root separation and resection therapy is of of the high risk site represented by the furcation
primary importance for the subsequent mainten- through meticulous plaque control and professional
ance of the tooth. supportive periodontal care (see Cattabriga et al. in
Schmitt & Brown (47) suggest that the preparation this volume).
of the crown must be ‘‘barreled in’’ to follow the pro- Compared with guided tissue regeneration, root
file of the root complex. This procedure when in resection procedures may have an advantage in the
presence of root concavities or shallow class II fur- maxilla. Pontoriero & Lindhe (42) have demon-
cations requires that the preparation of the crown strated that guided tissue regeneration is no better
follows the root contour by eliminating the furcation than open flap debridement in the treatment of me-
roof and thus creating a concave shape of the root sial and distal furcations of maxillary molars. This is
trunk and crown. Such a shape may not offer an probably due to the problem of accessibility to the
ideal surface for oral hygiene procedures; patients furcations, the technical manipulation of the soft
should therefore pay special attention to these areas. tissues in the area and the high risk of membrane
In contrast to this solution, Di Febo et al. (17) sug- exposure and contamination encountered with
gest a ‘‘combined preparation’’ to modifying the guided tissue regeneration procedures in maxillary
emergence profile. This procedure has the objective molars (37; see also Sanz & Giovannoli in this
of creating convex surfaces that are more conducive volume).
to effective oral hygiene procedures. It must be car- Given the higher rate of fracture in mandibular
ried out during surgery; in fact, root shape has to be molars treated by root separation and resection re-
modified at the emergence from bone. The root pro- ported in some studies (31) and the better success of
file is modified by preparing a chamfer on the con- guided tissue regeneration in moderate mandibular
vex portion of the root, without touching the con- class II furcation defects (45), guided tissue re-
cave portions, thereby flattening the tooth’s surface. generation procedures may represent a reasonable
In performing this preparation, the location of the alternative for class II furcation in the mandibular
filled root canal and pulp chamber should carefully arch, especially if the treatment objective can be set
be taken into account. In fact, when this technique as attachment gain and pocket depth reduction at
is used it is of paramount importance not to excess- the furcation site rather than complete closure of the
ively reduce the dentinal wall in order to decrease furcation.
the risk of root fracture. To this end, great care has Table 6 summarizes some periodontal anatomical
also to be taken not to over-instrument the root ca- considerations that may guide the clinician in the
nal during the endodontic phase. Also, this tech- selection of the optimal treatment modality of fur-
nique requires the final preparation of the tooth to cation defects.
be a knife-edge preparation. In fact the paucity of
the residual root structure will not allow for any
other finish line. According to the authors flat sur- Summary
faces obtained with ‘‘combined preparation’’ allow
for easy plaque control and better maintenance of Resective therapy for the treatment of furcation de-
periodontal health (15–18). fects is an essential part of the periodontal thera-

166
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
Resective periodontal surgery in furcation defects

pist’s armamentarium. Root resection can success-

Table 6. Comparison of characteristics of ideal furcation defects for periodontal procedures used to manage furcation defects [modified from Murphy
fully treat specific furcation defects that cannot be

Mandibular, buccal

Maxilla (mandible)
Arch preference
solved by other surgical and nonsurgical approaches.
Complications with these resective procedures are

Mandible
not rare but are usually avoidable when specific en-
dodontic, surgical and restorative guidelines are fol-

None
Position of furca relative to lowed.
interproximal bone height

Similar interproximal and

Similar interproximal and

High interproximal bone
References
furcal bone heights

furcal bone heights

Not significant

1. Abdallah F, Kon S, Ruben MP. The furcation problem: etiol-

ogy, diagnosis, therapy and prognosis. J West Soc Peri-
odontol 1987: 35: 129–141.
2. Allen EP, Bayne SC, Donnovan TE, Hansson TL, Klooster J,
Kois JC. Annual review of selected dental literature. J Pros-
thet Dent 1996: 76: 56–93.
Short to moderate
Root trunk length

3. Atkinson SR. Changing dynamics of the growing face. Am J

Long (±4 mm)

Orthod 1949: 35: 815.

4. Basten CH-J, Ammons WF, Persson R. Long-term evalu-
Moderate

ation of root-resected molars: a retrospective study. Int J

Periodontics Restorative Dent 1996: 16: 207–219.
Short

5. Bender IB, Seltzer S. The effect of periodontal disease on

the pulp. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
1972: 33: 435.
6. Bergenholtz A. Radectomy of multirooted teeth. J Am Dent
Divergence of roots

Mild to moderate

Assoc 1972: 85: 870–875.

‘‘key-hole’’ shape
most successful
Not significant

Well displayed

Well displayed

7. Blömlof L, Jansson L, Appelgren R, Ehnevid H, Lindskog

S. Prognosis and mortality of root resected molars. Int J
Periodontics Restorative Dent 1997: 17: 191–201.
8. Bower RC. Furcation morphology relative to periodontal
treatment: furcation root surface anatomy. J Periodontol
1979: 50: 366–374.
9. Bower RC. Furcation morphology relative to periodontal
Vertical attachment

treatment: furcation entrance architecture. J Periodontol

loss in furcation

1979: 50: 23–27.

10. Buhler H. Evaluation of root-resected teeth. Results after 10
years. J Periodontol 1988: 59: 805–810.
Moderate

Moderate

Moderate
Minimal

11. Buhler HB. Survival rates of hemisected teeth: an attempt

to compare them with survival rates of alloplastic implants.
Int J Periodontics Restorative Dent 1994: 14: 537–543.
12. Burch JL, Hulen S. A study of the presence of accessory
foramina and the topography of molar furcations. Oral Surg
Horizontal attachment loss

Oral Med Oral Pathol Oral Radiol Endod 1974: 38: 451.
in furcation involvement

13. Caffesse RG. Resective procedures. In: World Workshop in

Periodontics. Chicago: American Academy of Periodonto-
Class I (minimal)

(less than 4 mm)

logy, 1989.
Class II or less

14. Carnevale G, Gianfranco D, Tonelli M, Marin C, Fuzzi M. A

Class II or III

retrospective analysis of the periodontal prosthetic treat-

Class III

ment of molars with interradicular lesions. Int J Peri-

odontics Restorative Dent 1991: 11: 189–205.
15. Carnevale G, Pontoriero R, Hurzeler M. Management of
furcation involvement. Periodontol 2000 1995: 9: 69–89.
16. Chen, SY, Wang H-L, Glickman GN. The influence of endo-
Root resection
Guided tissue

or separation

dontic treatment upon periodontal wound healing. J Clin

regeneration
root planing
Scaling and

Tunneling

Periodontol 1997: 24: 449–456.

Procedure

17. Di Febo G, Carnevale G, Sterrantino SF. Treatment of case

of advanced peridontitis: clinical procedures utilizing the
(37)]

‘‘combined prepartion’’ technique. Int J Periodontics Re-

storative Dent 1985: 1: 52–63.

167
 16000757, 2000, 1, Downloaded from https://onlinelibrary.wiley.com/doi/10.1034/j.1600-0757.2000.2220110.x by Univ de Buenos Aires, Wiley Online Library on [27/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
DeSanctis & Murphy

18. Donald HL, Jeansonne BG, Gardiner DM, Sarkar NK. In- 37. Murphy KG. The role of guided tissue regeneration in the
fluence of dential adhesives and a prefabricated post on treatment of furcation defects. In preparation.
fracture resistance of silver amalgam cores. J Prosthet Dent 38. Newell DH. The role of the prosthodontist in restoring
1997: 77: 17–22. root-resected molars: a study of 70 molar root resections. J
19. Erpenstein H. A 3-year study of hemisectioned molars. J Prosthet Dent 1991: 65: 7–15.
Clin Periodontol 1983: 10: 1–10. 39. Newell DH. Personal communication. Presented at Ameri-
20. Goldman MJ, Ross IF, Goteiner D. Effect of periodontal can Academy of Periodontology, 1997: San Diego.
therapy on patients maintained for 15 years or longer. A 40. Palcanis K. Surgical pocket therapy. In: World Workshop in
retrospective study. J Periodontol 1986: 57: 347–353. Periodontics. Ann Periodontol 1996: 1: 589–617.
21. Guzy GE, Nichols JI. In vitro comparison of intact endo- 41. Parashis AO, Anagnoou-Varetzides A, Demetriou N. Calcu-
dontically treated treated teeth with and without endo-post lus removal from multirooted teeth with and without surgi-
reinforcement. J Prosthet Dent 1979: 42: 39–42. cal access. II. Comparison between external and furcation
22. Hallmon WW, Carranza FA, Drisko CL, Rapely JW, Robinson entrance width. J Clin Periodontol 1993: 20: 71–77.
P. Periodontal literature reviews. Chicago: American Acad- 42. Pontoriero R, Lindhe J. Guided tissue regeneration in the
emy of Periodontology, 1996. treatment of degree II furcations in maxillary molars. J Clin
23. Hamp SE, Nyman S, Lindhe J. Periodontal treatment of Periodontol 1995: 22: 756–763.
multirooted teeth. Results after 5 years. J Clin Periodontol 43. Pontoriero R, Lindhe J. Guided tissue regeneration in the
1975: 2: 126–135. treatment of degree III furcations in maxillary molars. J Clin
24. Hamp SE, Ravald N, Teiwik A. Perspective a long terme des Periodontol 1995: 22: 810–812.
modalities de traitment des lesions interradiculaires. J Par- 44. Ross IE, Thompson RH. A long term study of root retention
odontol 1991: 11: 11–23. in the treatment of maxillary molars with furcation involve-
25. Helldén LB, Elliot A, Steffensen B, Steffensen JEM. The ment. J Periodontol 1978: 49: 238–244.
prognosis of tunnel preparations in treatment of class III 45. Schallhorn RG, McClain PK. Combined osseous composite
furcations. A follow-up study. J Periodontol 1989: 60: 182– grafting, root conditioning, and guided tissue regeneration.
187. Int J Periodontics Restorative Dent 1988: 8: 9–31.
26. Hirschfeld L, Wasserman B. A long-term survey of tooth 46. Schmitt SM, Brown FH. Management of root amputated
loss in 600 treated periodontal patients. J Periodontol 1978: maxillary molar teeth: periodontal and prosthetic consider-
49: 225–237. ations. J Prosthet Dent 1989: 61: 648–652.
27. Hou GL, Tsai CC. Relationship between periodontal fur- 47. Schroer M, Kirk C, Wahl T, Hutchens L, Moriarity J, Bergen-
cation involvement and molar cervical enamel projections. holtz B. Closed versus open debridement of facial grade II
J Periodontol 1987: 58: 715–721. molar furcations. J Clin Periodontol 1991: 18: 323–329.
28. Kalkwarf KL, Kaldahl WB, Patil KD. Evaluation of furcation 48. Smukler H, Tagger M. Vital root amputation. A clinical and
region response to periodontal therapy. J Periodontol 1988: histologic study. J Periodontol 1976: 47: 324–330.
59: 794–804. 49. Sorensen JA, Martinoff JT. Intracoronal reinforcement and
29. Klavan B. Clinical observations following root amputation coronal coverage: a study of endodontically treated teeth. J
in maxillary molar teeth. J Periodontol 1975: 46: 1–5. Prosthet Dent 1984: 51: 780–784.
30. Langer B, Stein SD, Wagenberg B. An evaluation of root re- 50. Torbjorner A, Karlsson S, Odman PA. Survival rate and fail-
sections. A ten-year study. J Periodontol 1981: 52: 719–722. ure characteristics for two post designs. J Prosthet Dent
31. Little L, Beck F, Bagri B, Horton H. Lack of furcal bone loss 1995: 73: 439–444.
following the tunneling procedure. J Clin Periodontol 1995: 51. Wang H, Burgeti F, Shyr Y, Ramfjord S. The influence of
22: 637–641. molar furcation involvement and mobility on future clin-
32. Majzooub Z, Kon S. Tooth morphology following root re- ical periodontal attachment loss. J Periodontol 1994: 65:
section procedures in maxillary molars. J Periodontol 1992: 25–29.
63: 290–296. 52. Wood WR, Greco GW, McFall WT Jr. Tooth loss in patients
33. Marin G, Carnevale G, Di Febo G, Fuzzi M. Restoration of with moderate periodontitis after treatment and long term
endodontically treated teeth with interradicular lesions be- maintenance. J Periodontol 1989: 60: 516–520.
fore root removal and/or root separation Int J Periodontics 53. Carnevale G, Pontoriero R, Lindhe J. Treatment of fur-
Restorative Dent 1989: 9: 43. cation-involved teeth. In: Lindhe J, Karring T, Lang NP, eds.
34. Masters DH, Hoskins SW. Projection of cervical enamel into Clinical periodontology and implant dentistry. 3rd edn.
molar furcations. J Periodontol 1964: 33: 49–53. Copenhagen: Munksgaard, 1997: 682–710.
35. Matia J, Bissada N, Maybury J, Ricchetti P. Efficiency of 54. Shillinburg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE.
scaling the molar furcation area with and without surgical Preparations for periodontally weakened teeth. In: Funda-
access. Int J Periodontics Restorative Dent 1986: 3: 6–25. mentals of fixed prosthodontics. 3rd edn. Chicago: Quin-
36. McFall WT Jr. Tooth loss in 100 treated patients with peri- tessence, 1997: 211–223.
odontal disease. A long-term study. J Periodontol 1982: 53: 55. American Academy of Periodontology. Guidelines for peri-
539–549. odontal therapy. J Periodontol 1998: 69: 405–408.

168