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Q U I N T E S S E N C E I N T E R N A T I O N A L

VOLUME 45 • NUMBER 6 • JUNE 2014

Root resective procedures vs implant therapy in themanagement of furcation-involved molars

Adrian Kasaj, PD Dr med dent1

Therapeutic decision making and successful treatment of fur-

cation-involved molars has been a challenge for many clin-

icians. Over recent decades, several techniques have been

advocated in the treatment of furcated molar teeth, including

nonsurgical periodontal therapy, regenerative therapy, and

resective surgical procedures. Today, root resection is consid-

ered a relevant treatment modality in the management of fur-

cation-involved multirooted molars. However, root resective

procedures are very technique-sensitive and require a high

level of periodontal, endodontic, and restorative expertise.

Given the high documented success rates of implant treat-

ment, the clinician is increasingly confronted with the dilemma

of whether to treat a furcated molar by traditional root resec-

tive techniques or to extract the tooth and replace it with a

dental implant. This article reviews the outcomes of root resec-

tive therapy for the management of furcation-involved multi-

rooted teeth and discusses treatment alternatives including

implant therapy. Treatment guidelines for root resective thera-

py, along with advantages and limitations, are presented to

help the clinician in the decision-making process.

(Quintessence Int 2014;45:521–529; doi: 10.3290/j.qi.a31806)

Key words: furcation involvement, furcations, molar, periodontal disease, root resection

GENERAL DENTISTRY

Adrian Kasaj

teeth without furcation involvement.3,4 Even with a

surgical approach selected to improve access for root

surface debridement, complete calculus removal in the

furcation area is rare.5 The compromised results in fur-

cation areas can be attributed to the limited accessibil-

ity of the furcation entrances for complete debride-

ment as well as the complex anatomy and morphology

of molar teeth.6 Moreover, the morphology of the fur-

cation area provides an environment favorable to bac-terial deposits, which hampers professional as well as

self-performed plaque control.7

Various therapeutic approaches have been intro-

duced for several decades that aim to retain furcation-

involved molars, including nonsurgical and surgical

mechanical debridement, regenerative therapy, and

resective surgical procedures. Root resection is one

treatment option for preserving molars with furcation

The management and long-term retention of furcated

molar teeth has always been a challenge for clinicians.

Furcation involvement is defined as interradicular bone

resorption and attachment loss in multirooted teeth

caused by periodontal disease. The interradicular space

of the molar teeth is inaccessible for proper mainte-

nance, and long-term stability of molars with furcation

involvement is compromised. Thus, maxillary molars

are the most common teeth lost, followed closely bymandibular molars.1,2 In addition, furcation-involved

multirooted teeth generally respond less favorably to

treatment compared with single-rooted teeth or molar

1 Associate Proessor, Department o Operative Dentistry and Periodontology,

School o Dental Medicine, University o Mainz, Mainz, Germany.

Correspondence: Dr Adrian Kasaj, Department of Operative Dentistry

and Periodontology, University of Mainz, School of Dental Medicine,

Augustusplatz 2, 55131 Mainz, Germany. Email: [email protected]

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involvement. Through root resection therapy, furcation-

involved molars can be converted to nonfurcated/sin-

gle root teeth and provide a favorable environment for

oral hygiene maintenance by eliminating plaque reten-tive morphology. The procedure of root resection has

been used in the treatment of furcation-involved

molars for more than 100 years.8 However, the interest

in root resective procedures has declined in recent

years due to complications and failures and the fact that

modern implant dentistry has modified the treatment

planning process. Indeed, it seems that today furcation-

involved molars are extracted more frequently in favor

of implant placement. Thus, today the ethically oriented

practitioner is challenged with the question whether to

treat furcation-involved molars by “traditional” root

resective techniques or to replace it with an implant.

This paper will review root resection procedures as

well as the different therapeutic alternatives, especially

implant therapy, for furcation-involved molars. Treat-

ment guidelines for root resective therapy, indications,

and contraindications are presented to help the practi-

tioner in the decision-making process with regards to

furcation-involved molars.

Furcation involvement classification The glossary of periodontal terms defines furcation as

“the anatomic area of a multirooted tooth where the

roots diverge” and furcation invasion refers to the

“pathologic resorption of bone within a furcation”.9

Several classification schemes have been introduced to

describe the degree of periodontal tissue destruction in

the interradicular area. Most of them are based on the

extent of periodontal destruction in a horizontal and/or

vertical direction.10-12 A simple and commonly used

system is Hamp’s classification,13 defining periodontaldestruction in a horizontal direction. Three different

classes of severity were identified:

• Class I, horizontal loss of periodontal tissue support

< 3 mm

• Class II, horizontal loss of support > 3 mm, without

extending through the opposite side

• Class III, horizontal through-and-through destruc-

tion of periodontal tissue in the furcation.

Tarnow and Fletcher12 later on further described the

extent of furcation involvement with a subclassification

evaluating the degree of vertical involvement:

• Subclass A, 1–3 mm• Subclass B, 4–6 mm

• Subclass C, ≥ 7 mm.

Molar root anatomy

The practitioner must have a thorough understanding

of the complex furcation anatomy for accurate diagno-

sis and selection of treatment modalities. Thus, several

problematic anatomical features exist in multirooted

teeth such as furcation entrance width, presence of

root concavities, bifurcation ridges, root trunk length,

cervical enamel projections, and enamel pearls (Fig 1).14

The diameter of the furcation entrance was evaluated

by Bower,15 with the majority of entrances measuring

< 0.75 mm. Considering that the blade width of com-

monly used periodontal curettes ranges from 0.75 mm

to 1.10 mm, it is unlikely that proper debridement of

the furcation area can be achieved with curettes alone

(Fig 2). Moreover, efficacy of periodontal therapy in the

furcation area may be limited by the presence of root

concavities and ridges in the interradicular root surface

area.15,16 The position of the furcation entrance, particu-

larly in maxillary molars, is also important with respect

to accessibility. Thus, the mesiopalatal entrance of the

first maxillary molar is located approximately two thirds

towards the palatal aspect of the tooth, while the disto-

palatal furcation is in the middle portion of the tooth.

Therefore, a buccal or palatal approach can be used

when probing the distopalatal furcation, whereas a

palatal approach is indicated when probing the mesio-

palatal furcation. Another important factor that affects

the development of furcation involvement and themode of treatment is the length of the root trunk. This

length is defined as the distance between the cemento-

enamel junction and the furcation. In a tooth with a

short root trunk less attachment needs to be lost before

the furcation is involved. On the other hand, a tooth

with a short root trunk is more amenable to root resec-

tive procedures and is also more accessible to mainte-

nance procedures compared to teeth with a longer

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root trunk. Alternatively, the furcation of a tooth with a

long root trunk will be invaded at a later stage, but suc-

cessful resective therapy is not as predictable because

the length of the remaining roots may not be sufficient

for support. Other important anatomical variations that

can be considered as local cofactors in causing furca-tion lesions include cervical enamel projections and

enamel pearls. The cervical enamel projection has been

defined as an extension of the cervical enamel margin

either toward or into the root furcation area.17 They are

most commonly found on the buccal surfaces of man-

dibular molars.18 Hou and Tsai19 revealed the presence

of cervical enamel projections in 45.2% of the molars.

The prevalence of cervical enamel projections in molars

with or without furcal involvement was 82.5% and

17.5%, respectively. Thus, cervical enamel projections

can be considered as an important predisposing factor

in the initial furcation invasion due to the lack of fiber

attachment on the enamel extensions. However, the

presence of cervical enamel projections is often difficultto detect for the clinician, especially in the non-dis-

eased dentition. The other category of ectopic enamel

formation with lower prevalence is the enamel pearl.

Similarly to cervical enamel projections, enamel pearls

prevent the formation of a connective tissue attach-

ment and thus contribute to the etiology of furcation

involvement.

Figs 1a to 1f Root anatomy of mandibular and maxillary molars. (a) A cross-sectioned mandibular molar with the mesial root char-acterized by root concavities on the mesial and distal surfaces, whereas the distal root is more robust and has only a minimal concav-ity on the mesial aspect of the root. (b) Third mandibular molar with pronounced curved roots and a short supernumerary root. (c) Amaxillary molar with a narrow furcation entrance between the buccal roots and concave and convex areas in the interradicular rootsurface area. (d) Maxillary molar with fused roots and (e) roots that diverge coronally but fuse apically. (f) Enamel pearl in the furcationentrance area.

Figs 2a and 2b (a) An extracted man-dibular molar used to demonstrate thatthe entrance of the furcation is often nar-

rower than the width of the curette blade.(b) Preference should be given to slimultrasonic scaler tips to enable greateraccess and efficient periodontal debride-ment in the furcation area.

a

d

a

b

e

b

c

f

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Diagnosis of furcation involvement in molars

An accurate diagnosis of furcation involvement is

essential for adequate choice of treatment, tooth prog-

nosis, and maintenance procedures. The diagnosis offurcation involvement is generally based upon probing

and radiographic findings. Although a straight peri-

odontal probe may be used, detection of subgingival

furcations is best accomplished using a curved, color-

coded probe, eg Nabers (PQ2N, Hu-Friedy). Unfortu-

nately, horizontal measurements are often difficult to

assess and it may not be possible to probe the furcation

in its entirety. Thus, two opposite furcations classified

as degree II by the practitioner actually may be a true

degree III furcation. Indeed, Zappa et al20 found differ-

ences between surgical and clinical measurements of

up to 9 mm, which means that the magnitude of the

discrepancy between clinical and surgical values

encompassed 2 degrees of involvement. A classic study

by Ross and Thompson21 demonstrated that the detec-

tion of furcation involvement by clinical examination

alone occurred in only 3% of maxillary and 9% of man-

dibular molars. The use of presurgical transgingival

probing or bone sounding may help to improve diag-

nosis of furcation involvement by providing a more

accurate assessment of underlying bony contours.

Mealey et al22 reported that post-anesthesia bone

sounding significantly improved the diagnostic accu-

racy of furcation involvement compared to standard

pre-anesthetic probing. Taken together, these findings

indicate that periodontal probing of furcation areas is

an error-prone task, which might be due to disease-

related alterations of periodontal tissues and the com-

plex anatomy of multirooted teeth.

Radiographs are commonly taken as an adjunct in

diagnosis of furcation involvement. The advantages arethat important information may be gained with regard

to the anatomy and topography of the root complex

(number and form of roots, separation degree, diver-

gent roots), as well as the neighboring teeth and ana-

tomical structures. However, one of the main draw-

backs of using conventional radiographs is the overlap

of anatomical structures and lack of three-dimensional

(3D) information. Moreover, the amount of bone loss

which is imaged by both panoramic as well as peri-api-

cal radiographs has been found to underestimate the

actual amount of bone destruction.23 Ross and Thomp-

son21

reported that the diagnosis of furcation involve-ment based on the radiographic appearance alone was

possible in only 22% of cases. Some weak evidence for

advanced furcation involvement in maxillary molars

may be provided by a small, triangular radiolucent

shadow across the mesial or distal roots of these teeth,

the so-called furcation arrow.24 More recently, however,

Deas et al25 reported that in cases where furcation

involvement was truly present, the furcation arrow was

seen in less than 40% of sites. Thus, it appears that con-

ventional radiographs alone are of limited value in the

diagnosis of furcation defects. With the introduction of

cone beam computed tomography (CBCT), a more

accurate and detailed imaging of periodontal destruc-

tion seems possible. In a more recent study, Walter et

al26 reported that CBCT and intrasurgical assessment of

maxillary molar furcation involvement were found to be

in substantial agreement. Overall, 84% of the CBCT data

were confirmed by the intrasurgical findings. The

authors concluded that CBCT provides high accuracy in

assessing the loss of periodontal tissues and classifica-

tion of furcation involvement.

In practice, periodontal diagnosis of furcation

involvement is best accomplished using a combination

of radiographs, periodontal probing with a curved

explorer or Nabers probe, and bone sounding.27

Root resection therapy of

furcation-involved molars

A wide range of treatment modalities for multirooted

teeth with furcation involvement has been suggested

based on the depth of furcation involvement.28 Thus,for teeth with shallow furcation defects recommended

therapies include nonsurgical/surgical scaling and root

planing with or without furcation plasty. For furcations

with advanced degree of involvement, root resection,

tunnel preparation, regenerative procedure, or tooth

extraction are the treatments of choice. The procedure

of root resection was first introduced by Farrar8 in 1884

as “radical and heroic”, and since then has been com-

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monly used as a treatment modality for molars with

advanced furcation involvement. In the current litera-

ture there is no uniformity in the terms used for root

resective techniques. Root resection generally is

defined as the removal of a root without reference to

how the crown is treated.28 The surgical removal of a

root without its accompanying portion of the crown is

referred to as root amputation. Trisection is defined as

the surgical removal of a maxillary molar root together

with the corresponding part of the clinical crown,

whereas the same procedure is called a “hemisection”

when performed on a mandibular molar. Root separa-

tion is indicated as the sectioning of the root complex

and the maintenance of all roots.17 Commonly accepted

indications for root resective procedures include:

• class II or III furcation involvement

• severe bone loss affecting one or more roots

• severe root proximity to an adjacent tooth

• severe recession or dehiscence of a root

• root fracture or perforation, root resorption, deep

root caries

• elimination of an endodontically failed or untreat-

able root.

The prognosis of root resection has been well docu-mented, but a considerable heterogeneity is noticeable

when comparing the different studies. In a recent sys-

tematic review on the effect of periodontal therapy on

the survival of multirooted teeth with furcation involve-

ment, Huynh-Ba et al29 reported a success rate for root

resection therapy ranging from 62% to 100% after an

observation period of 5 to 13 years. The authors con-

cluded that the reasons for tooth extraction were

mainly related to endodontic complications and root

fractures and not to periodontal disease recurrence.

The significant variations in the success rates may, at

least in part, be attributed to different inclusion criteria,

outcome definitions, follow-up periods, maintenance

program, and the methods of restoration of the tooth.

Since there is no consensus for the inclusion criteria,

some studies may have retained more questionable

teeth, which may have led to less favorable success

rates, while others extracted them during initial peri-

odontal therapy. Indeed, Hamp et al13 described a

5-year follow-up of periodontal treatment of multi-

rooted teeth, with 44% of all teeth with furcation

involvement being extracted as part of the initial treat-

ment. In contrast, Lee et al30 used root resection as a

“last resort” therapy, including teeth that presented

with pretreatment < 50% radiographic bone support.

A high success rate of this treatment approach was

commonly related to appropriate periodontal therapy,

successful endodontic treatment, and proper restor-

ation design. Moreover, all authors emphasize the

importance of meticulous patient oral hygiene and

regular maintenance care for the resected molars to

prevent periodontal disease.

Root resection is very technique-sensitive and com-plex, therefore proper case selection is essential (Fig 3).

The following tooth-specific factors should be consid-

ered when deciding which root should be retained: the

degree of periodontal destruction and furcation

involvement, the root and root canal anatomy, end-

odontic conditions, periapical condition, and the mobil-

ity of each separated root (Fig 4).13 A recent investiga-

tion by Lee et al,30 reported an increased risk for early

Figs 3a and 3b Intraoperative view of aright maxillary first molar with a root prox-imity and a degree II distopalatal furcationinvolvement. While the second maxillarymolar is hopeless and should be extracted,

a root amputation of the distobuccal rootof the first molar can be performed. (a) Theroot trunk is short and the remaining rootsexhibit sufficient bone support. (b) In con-trast, the high root trunk and the insuffi-cient bone support of the mesiobuccalroot make this left maxillary first molar apoor candidate for root-resective therapy.a b

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tooth loss following resective periodontal therapy if the

affected molars exhibited pre-resective mobility of

degree II or above. Park et al31 demonstrated that

molars with bone support > 50% of the remaining roots

at the time of root resection had a significantly higher

survival rate than those with < 50% bone support.

Moreover, the authors reported that following root

resection, maxillary molars had more periodontal fail-

ures, whereas the mandibular molars had more root

fractures and dental caries. Newell32 attributed the

higher failure rate in the maxilla to residual root frag-

ments, furcation lips, and ledges that were not readily

observed in the radiographs of the maxilla. These sub-

gingival structures can easily lead to plaque accumula-

tion and disease recurrence.17 Thus, following rootresection a flat contour that follows the root morphol-

ogy is essential for the establishment of an environ-

ment conducive to the maintenance of adequate

plaque control. Majzooub and Kon33 reported that 86%

of distobuccal root-resected maxillary first molars will

leave less than 3 mm of available root structure in this

area. Only 6% of the resected molars had an overall

topography that was easily amenable to periodontal

maintenance and restorative procedures. Therefore, an

adequate soft tissue width between the restorative

margin and the osseous crest should be established

during surgery, and irregular root contours have to be

carefully evaluated and eliminated. Carnevale et al28

suggested osseous recontouring and apically pos-

itioned flaps in order to establish a favorable environ-

ment for oral hygiene.

Root resection therapy in mandibular molars

requires some additional considerations. A mandibular

first molar typically presents with two well-defined

roots. Most commonly, two root canals are located in

the mesial root and one canal in the distal root.34 The

mesial root is characterized by prominent root depres-

sions on the mesial and distal surfaces giving the root afigure-eight shape in cross section, a widened buccolin-

gual surface, and a root curvature to the distal. 35 In

contrast, the distal root is usually less curved than the

mesial root. Therefore, the mesial root is more difficult

to treat endodontically, and the mesial root concavities

are less accessible for plaque control. Thus, removal of

the mesial root is preferred over the distal root for root

resection. Indeed, fracture of the resected mandibular

Figs 4a to 4e (a) Baseline clinical situation following nonsurgical periodontal therapy and root canal treatment of a maxillary rightfirst molar requiring distal root resection. (b) Intraoperative view after flap elevation, a degree II distobuccal furcation involvement isevident. (c) Amputation of the distobuccal root while leaving the entire crown intact. A smooth, flat surface is established at the resec-tion site to avoid any residual plaque-retentive subgingival overhangs. (d) Suture and flap closure. (e) Clinical situation 2 years follow-ing root resective therapy and regular supportive periodontal care.

a

c

b

d

c

e

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molar is more frequent when the mesial root is

retained.36,37 The remaining single root following resec-

tion is insufficient to maintain the occlusion of a man-

dibular molar. Therefore, the remaining root should beincorporated into a more extended fixed dental pros-

thesis, rather than restoring it with a single crown with

a mesial or distal cantilever. Moreover, the use of posts

and cores should be avoided if possible to minimize the

chance of root fracture.38

Additional factors to consider when evaluating

treatment outcomes include the strategic value of the

tooth in relation to the overall treatment plan, patient’s

age, general health conditions, and oral hygiene stan-

dards.7,30,39

Considering all these parameters, the clinician is

often faced with a dilemma when deciding whether or

not to extract a furcation-involved molar. It should be

emphasized that it is generally difficult to determine

the precise long-term prognosis of furcation involved

molars in advance. Indeed, McGuire40 reported that

initial prognosis based on common clinical parameters

did not adequately predict tooth survival, particularly

that of molar teeth. Recently, Miller et al41 introduced a

quantitative scoring system to determine the long-

term prognosis of periodontally involved molars. This

scoring index is based on data from 816 molars in 102

patients with a minimum of 15 years post treatment.

The factors evaluated include age, probing depth,

mobility, furcation involvement, smoking, and molar

type. The authors reported that molars with lower

scores (1 to 3) exhibited a 15-year survival rate of 98%

to 96%, whereas in molars with higher scores (7 to 10)

the survival rates ranged from 86% to 67%. However,

one should be aware that such a scoring system does

not consider factors like clinical experience, therapeuticskills, and patient compliance. Therefore, it seems dif-

ficult to objectively determine the prognosis of furca-

tion involved molars based on such a scoring system,

and the decision to extract a furcated molar remains a

sophisticated process.

Root resection therapy vs

endosseous implants

It is obvious that root resective therapy has a high

degree of complexity, which contributes to the vari-ability in reported clinical outcomes. Thus, the question

can be raised whether the use of dental implants after

extraction of furcation-involved molars may provide a

more predictable alternative to root resective therapy.

Fugazzotto37 compared the success rates of root-

resected molars and implants placed in the molar

region for a period of up to 15 years. Resection of the

distal root of a mandibular molar demonstrated the

lowest success rate (75%), whereas all other success

rates for various root resected molars in function

ranged from 95.2% to 100%. In comparison, lone stand-

ing implants in second molar positions demonstrated

the lowest success rate (85%), while all other implants

in molar positions had a success rate of 97.0% to 98.6%.

Cumulative success rates were 96.8% for root resected

molars and 97.0% for molar implants. Thus, molar root-

resection therapy displayed a success rate comparable

with that of implant placement. In contrast, Zafiropou-

los et al42 retrospectively reported that 32.1% of post-

treatment complications occurred in hemisected

molars compared to 11.1% in molar implants after ≥ 4

years. Moreover, most of the posttreatment complica-

tions in hemisected molars were not salvageable and

included root caries, apical abscesses, and root fracture.

On the other hand, almost all post-treatment complica-

tions in molar implants were salvageable. The authors

concluded that implants replacing furcation-involved

molars exhibit fewer complications than hemisected

mandibular molars. Kinsel et al43 reviewed the treat-

ment of furcation-involved molars comparing root-

resection versus single-tooth implants. The reportedfailure rate was 15.9% for root-resection therapy com-

pared to 3.6% for single implants. Hence, the authors

concluded that root-resection therapy shows poor

long-term results unless a high level of expertise is

available in all applicable disciplines. In addition, it was

suggested that surgical and restorative procedures

related to implant placement may be less difficult than

management with root resective therapy.

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Although a direct comparison between the two

treatment approaches is difficult, a couple of variables

should be considered by the practitioner. Following

tooth extraction of a periodontally compromised maxil-lary molar the amount of the remaining crestal bone is

further reduced due to vertical ridge resorption and

increased pneumatization of the maxillary sinus. Fur-

thermore, a significant implant failure in the posterior

maxilla has been noted due to the very spongious bone

quality found in this area.44 Similarly, in the mandibular

molar area the position of the inferior alveolar nerve

may limit the amount of bone available for dental

implants. Therefore, in these cases bone augmentation

procedures (simultaneous or staged approach) are

required. In contrast, teeth in proximity to anatomical

landmarks can be treated safely by root-resection ther-

apy. Furthermore, the maintenance of a furcation-

involved molar in an inflammation-free environment

will prevent resorptive processes, thereby not preclud-

ing implant placement in the future. One should be

also aware that biological and technical long-term

complications associated with dental implants are fre-

quent. Indeed, Simonis et al45 followed up 162 implants

for 10 to 16 years and reported a cumulative complica-

tion rate of 48.03%. Furthermore, patients with a his-

tory of periodontitis had lower implant survival rates

than patients without a history of periodontitis and

were more prone to biological complications such as

peri-implant mucositis and peri-implantitis. Finally,

root-resection therapy may be a more viable treatment

option than implant therapy in medically compromised

patients, thus avoiding several surgical procedures.

CONCLUSION

The successful long-term management of the furca-

tion-involved molar remains a major clinical challenge

in periodontal treatment. As yet, there are no rules or

scores to provide a straightforward answer in the deci-

sion-making process for furcation-involved molars. The

choice of treating a furcated molar should be based on

patient-, tooth-, and prognostic-related factors. Root

resective therapy is a predictable procedure and should

be considered a valuable treatment modality for furca-

tion-involved molars. A proper case selection and care-

ful interdisciplinary approach including periodontal

therapy, endodontic treatment, prosthetic reconstruc-tion, and supportive periodontal care are essential for

successful treatment outcomes. When root resective

procedures are rendered appropriately, furcation-

involved molars can be maintained for prolonged peri-

ods of time displaying a success and longevity rate

comparable with that of implant placement. Since

dental implants are not devoid of complications, root

resective procedures should be considered for the

retention of furcation-involved molars to optimize the

longevity of the dentition before extraction and

replacement with a dental implant is undertaken.

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