buccal and lingual flaps were raised to expose the furcation area of tooth #19 and allow adequate visualization of, and access to, the CEP. Figure 1.7.4 shows that the CEP extended apically almost to the level of bone crest. A diamond burr was then used to remove the CEP completely (Figure 1.7.4) and the furca was debrided using a Cavitron and hand instruments. The flap was eventually sutured back into its original position. Postoperative instructions were given and the patient was seen two weeks later for a follow‐up. Six months later, localized probing at tooth #19 showed a probing depth of 4 mm without bleeding on probing.
Discussion
The patient presented with a probing depth of 8 mm on the buccal furcation area of tooth #19, possibly due to the presence of a CEP that extended deep into the furcation. The presence of the CEP prevented proper soft tissue attachment at the furcal area, leading to the formation of a deep periodontal pocket. Bone loss at the furcal area was most likely due to prolonged plaque accumulation in this periodontal pocket that subsequently led to chronic inflammation and hence attachment loss. By removing the CEP, enamel at the furcation was eliminated to expose the underlying dentin, thereby allowing soft tissue attachment to occur over this area. In so doing, a periodontal pocket was eliminated. Note that a grade II furcation can also be treated with guided tissue regeneration or a bone graft.
It is critical to identify all local etiologic factors because they may accelerate periodontal disease progression and affect the diagnosis, prognosis, and treatment of the disease.
Self-Study Questions
1 What are some anatomic factors that may contribute to periodontal disease?
2 Describe the anatomy of a furcation and define furcation invasion.
3 Name different classification systems of furcation invasion.
4 How should you diagnose a furcation invasion?
Answers located at the end of the chapter.
ACKNOWLEDGMENT
We would like to thank Dr. David Yu for providing Figure 1.7.8.
References
1 1. McGuire MK, Nunn ME. Prognosis versus actual outcome. II. The effectiveness of clinical parameters in developing an accurate prognosis. J Periodontol 1996; 67:658–665.
2 2. Masters DH, Hoskins SW. Projection of cervical enamel into molar furcations. J Periodontol 1964; 35:49–53.
3 3. Bissada NF, Abdelmalek RG. Incidence of cervical enamel projections and its relationship to furcation involvement in Egyptian skulls. J Periodontol 1973; 44:583–585.
4 4. Swan RH, Hurt WC. Cervical enamel projections as an etiologic factor in furcation involvement. J Am Dent Assoc 1976; 93:342–345.
5 5. Moskow BS, Canut PM. Studies on root enamel (2). Enamel pearls. A review of their morphology, localization, nomenclature, occurrence, classification, histogenesis and incidence. J Clin Periodontol 1990; 17:275–281.
6 6. Bower RC. Furcation morphology relative to periodontal treatment. Furcation root surface anatomy. J Periodontol 1979; 50:366–374.
7 7. Haskova JE, Gill DS, Figueiredo JAP, et al. Taurodontism: a review. Dent Update 2009; 36:235–236.
8 8. Everett FG, Jump EB, Holder TD, Williams GC. The intermediate bifurcational ridge: a study of the morphology of the bifurcation of the lower first molar. J Dent Res 1958; 37:162–169.
9 9. Burch JG, Hulen S. A study of the presence of accessory foramina and the topography of molar furcations. Oral Surg Oral Med Oral Pathol 1974; 38:451–455.
10 10. Ben‐Bassat Y, Brin I. The labiogingival notch: an anatomical variation of clinical importance. J Am Dent Assoc 2001; 132:919–921.
11 11. Schwartz SA, Koch MA, Deas DE, Powell CA. Combined endodontic–periodontic treatment of a palatal groove: a case report. J Endod 2006; 32:573–578.
12 12. Vertucci FJ, Williams RG. Furcation canals in the human mandibular first molar. Oral Surg Oral Med Oral Pathol 1974; 38:308–314.
13 13. Dunlap RM, Gher ME. Root surface measurements of the mandibular first molar. J Periodontol 1985; 56:234–238.
14 14. Tal H. Relationship between the depths of furcal defects and alveolar bone loss. J Periodontol 1982; 53:631–634.
15 15. Bower RC. Furcation morphology relative to periodontal treatment. Furcation entrance architecture. J Periodontol 1979; 50:23–27.
16 16. Hermann DW, Gher ME Jr, Dunlap RM, Pelleu GB Jr. The potential attachment area of the maxillary first molar. J Periodontol 1983; 54:431–434.
17 17. Gher MW Jr, Dunlap RW. Linear variation of the root surface area of the maxillary first molar. J Periodontol 1985; 56:39–43.
18 18. Booker BW 3rd, Loughlin DM. A morphologic study of the mesial root surface of the adolescent maxillary first bicuspid. J Periodontol 1985; 56:666–670.
19 19. Gher ME, Vernino AR. Root morphology: clinical significance in pathogenesis and treatment of periodontal disease. J Am Dent Assoc 1980; 101:627–633.
20 20. Glickman I. Clinical Periodontology, 2nd edn. Philadelphia, PA: Saunders, 1958:694–696.
21 21. Hamp SE, Nyman S, Lindhe J. Periodontal treatment of multirooted teeth. Results after 5 years. J Clin Periodontol 1975; 2:126–135.
22 22. Tarnow D, Fletcher P. Classification of the vertical component of furcation involvement. J Periodontol 1984; 55:283–284.
23 23. Hardekopf JD, Dunlap RM, Ahl DR, Pelleu GB Jr. The “furcation arrow.” A reliable radiographic image? J Periodontol 1987; 58:258–261.
24 24. Ross IF, Thompson RH Jr. Furcation involvement in maxillary and mandibular molars. J Periodontol 1980; 51:450–454.
TAKE‐HOME POINTS
A.
Proximal Contact Relation
Open interproximal contacts or uneven marginal ridge relations may encourage food impaction between the teeth. If proper oral hygiene is absent, food impaction can lead to inflammation, thereby potentially resulting in attachment loss in the interproximal area (Figure 1.7.5).
Root Proximity
Close root proximity between the two adjacent teeth will render oral hygiene difficult to maintain for both the patient and the dental professionals. Hence without good oral hygiene there can be loss of attachment between the two teeth (Figure 1.7.6).
Cervical Enamel Projections and Enamel Pearls
CEPs are extensions of enamel to the furcal area of the root surface. CEPs may potentially predispose a furcation to attachment loss because they prevent connective tissue attachment at furcation. As such, a periodontal pocket may form, leading to plaque accumulation and possibly furcation invasion.
Most clinicians agree there is a correlation between CEPs and the incidence of furcation invasion. Masters and Hoskins reported that 90% of mandibular furcation invasions have CEPs [2]. Bissada and Abdelmalek reported a 50% correlation between CEPs and furcation invasion [3]. Swan and Hurt observed a statistically significant association between