Copyright C Munksgaard 1999

J Clin Periodontol 1999; 26: 485498

Printed in Denmark . All rights reserved

ISSN 0303-6979

Review article

Furcation diagnosis
Muller H-P, Eger T: Furcation diagnosis. J Clin Periodontol 1999; 26:
485498. C Munksgaard, 1999.
Abstract. One of the most important and at present unsolved problems in clinical
periodontology is the predictable successful treatment of periodontitis-affected
furcations of multirooted teeth. Since several therapeutic approaches are proposed, i.e., conservative, resective or regenerative, a proper diagnosis of these
lesions is demanding. The aim of the present article is to review the current
information on the impact of a proper diagnosis of a furcational lesion as well
as tooth morphology on decision making with regard to different treatment modalities and to emphasize the need for a detailed clinical, radiographical and
intraoperative diagnosis of the furcation lesion beyond the usually performed
diagnosis of the degree of furcation involvement.

In 1884, Farrar reported on so-called

radical and heroic treatment of alveolar abscess by amputation of roots
of teeth, in order to enable nature to
have a better chance for cure. He absolutely correctly stated that, if an
entire tooth should be extracted from
a diseased socket, the treatment might
be termed highly radical, and further
... such treatment might not only be
unwise and unnecessary but absolutely
wrong and unscientific (Farrar 1884).
Thus, in these old days, far before the
development of modern periodontics
and endodontics, the author regarded,
for scientific reason, the heroic furcation therapy (root amputation) as
being more appropriate than tooth extraction. Even at the end of our century, the treatment of a multirooted
tooth with a furcation involvement is
still a challenge and a problem that
has actually not been solved. In several longitudinal studies of treated
periodontitis patients, it has been unequivocally demonstrated that (furcation-involved) molars are at high
risk for extraction even in a situation
where supportive periodontal therapy
is provided (Hirschfeld & Wasserman
1978, McFall 1982, Goldman et al.
1986, Wang et al. 1994). And still,
heroic treatment modalities as, e.g.,
regenerative procedures, are proposed,

today more than ever also with a

scientific background (Carnevale et al.
1995).
The decision for a specific treatment
mode for a periodontitis-affected furcation certainly depends on several
factors, with both a general and local
perspective. First of all, the age of the
patient, his or her general condition
and the form or expression of periodontal disease have to be taken into
account. Next, the overall strategic
importance of the respective tooth and
its possible role in a comprehensive
treatment plan must be considered.
Tooth type and degree of furcation involvement may be regarded by the
majority of therapists as the most important factors influencing the decision for one or the other treatment
mode (Muller et al. 1995). However,
further aspects as, e.g., tooth or root
morphology, the anatomical and topographical relation between different
roots, the morphology of the bony
lesion, the remainder of the periodontal attachment apparatus around
single roots and their expected mobility, have to be carefully considered.
And finally, the operators experience
and skill must be taken into account.
A careful diagnosis is a prerequisite
for appropriate therapy. Novel treatment modalities compel the therapist

Hans-Peter Muller1 and

Thomas Eger2
Departments of 1Operative Dentistry and
Periodontology, University of Heidelberg and
2
Periodontology, German Armed Forces
Central Hospital, Koblenz, Germany

Key words: furcation involvement;

periodontitis; tooth morphology; lesion
morphology; regenerative procedures
Accepted for publication 3 November 1998

to acquire the necessary data and to

correctly interpret the respective observations. The current concept for
treatment of interradicular periodontitis is complex (Carnevale et al.
1995, Muller & Eger 1998). Not only
technical skill of the therapist is required but also understanding, confidence and compliance of the patient.
The more expensive measures may
only be justified, if the operator is
able to give at least the patient account of success or failure. And last
but not least, a thorough and detailed
diagnosis of all aspects of furcation
involvement is demanding in clinical
experimentation.
The aim of the present article is to
review the current information on the
impact of proper diagnosis of the entire
furcational lesion, including tooth morphology, on decision making with regard to different treatment modalities
for periodontitis-affected multirooted
teeth and to emphasize the need for a
detailed clinical, radiographic and intraoperative diagnosis of the interradicular lesion for proper treatment of
these lesions. While it should be kept in
mind that differing pathogenetic mechanisms as, e.g., occlusal traumatism,
pulpal pathosis or iatrogenic accidents,
may also result in inflammatory lesions
within the furcation region, the present

486

Mller & Eger

review article is exclusively dedicated to

the thorough diagnosis of periodontitisaffected multirooted teeth.
Morphology of the root complex of
multirooted teeth
Fundamental features

Without any doubt, the progression of

destructive periodontitis lesions into the
furcal region of multirooted teeth is
promoted to a large extent by the morphology of the root complex with its
macroscopical and, in a sense, unforeseeable and bizarre microscopical structures (Schroeder & Scherle 1987). Although, in general, periodontitis may
also affect the primary dentition, this
paragraph deals exclusively with the
morphology of permanent multirooted
teeth.
Tooth morphology and the root complex, in particular, have been delineated
in detail by several authors (Taylor
1978, Carlsen 1987, Schumacher et al.
1990, Schumacher 1997). Because of its
very rigorous and systematic manner of
description of the macromorphology of
human teeth, the following outline of
the root complex is mainly based on the
work of Carlsen (1987), supplemented
by recent observations. The root complex of a tooth is that part which is
located apically from the cemento-enamel junction. It is usually covered by
root cementum. The basic element of
every root is the so-called root cone. It is
a constant morphological unit (Carlsen
1987). Two or more root cones may be
separated at a certain level of the root.
A root consists in general of 2 or 3 root
cones. Maxillary molars have usually a
root complex consisting of 3 roots, a
mesiobuccal, distobuccal and palatal.
The root complex of mandibular molars is always composed of 2 roots, a
mesial and a distal. At a certain level,
the root complex may be incompletely
or completely separated. The respective
separation structures are called root
groove and interradicular projection.
The part of a root complex that is
located between separated root cones or
roots is called furcation. It mainly consists of the horizontal part of the interradicular projection. The transition between the more vertical part of the interradicular
projection
and
its
horizontal part is called furcation entrance.
The maximum furco-apical extension of the root complex in relation to
its total length is called separation de-

gree. The part of the root complex that

extends between the cemento-enamel
junction and the furcation entrance is
called root trunk. Its height may be
measured in millimeters or given in relation to the maximum length of the
root complex. In spite of the relatively
few morphological components of a
root complex even at multirooted
teeth, there is a very high variation of
findings, which increases from maxillary premolars to mandibular molars
and first, second and third maxillary
molars (Carlsen 1987). This, however,
should be considered as absolutely normal. Although it makes obviously
sense to describe the perplex situation
of root complexes with a limited number of elements, some authors approach from the other direction and report frequencies of (so-called abnormal) root fusions (Ross & Evanchik
1981, Hou & Tsai 1994) which may exert an increased risk for the development of destructive periodontal disease
(Hou et al. 1997b).
Roots frequently diverge in an apical
direction. The angle between two root
cones or roots is called degree of divergence. In case of a negative angle, one
should better speak of convergence of
the roots. Although cervically separated, two or more root cones or roots
may fuse in the apical part of the root
complex.
Maxillary molars

The 3 roots of the upper 1st molar are

in most instances clearly separated (3rooted variant). Thus, 3 interradicular
projections can be differentiated, a buccal, a mesial (which is located in the
dental arch mesiopalatally), and a distal. In about 10% of teeth, the mesial
root is separated from a non-separated
distal and palatal root, or the distal
root from the non-separated mesial and
palatal root, i.e., 2-rooted variants
(Carlsen 1987). Very infrequently, a 1rooted variant is observed.
The buccal roots of the 1st molar are
composed of at least 2 root cones each,
a buccal and a palatal, which are generally not separated. Thus, both roots
show mesial and distal root grooves. In
addition, a mediomesial root cone may
be found at the mesiobuccal root with
the consequence of a third root groove
located on the buccal aspect of that
root. The palatal root is composed of a
mesial and distal root cone frequently
with a corresponding palatal root

groove. The 5 theoretically possible

numbers of root grooves at non-separated roots are not always observed. In
case of a 1-rooted variant, a buccal, mesial and distal root groove are found
(Carlsen 1987).
The buccal furcation entrance is narrower than the mesial or distal (Bower
1979a, Svardstrom & Wennstrom 1988,
Hou et al. 1994, Roussa 1998). In general, the root trunk has a mean height
of far more than 3 mm (Carlsen 1987).
Average root trunks of between 3.53.6
for the mesial aspect, 3.54.2 for buccal
roots and 4.14.8 mm for the distal aspect have been reported (Gher & Dunlap 1985, Roussa 1998). The degree of
separation is about 2/3 to 3/4 for the
buccal roots as well as the mesial and
palatal roots. The distal furcation entrance is located more apically with a
mean root trunk of between 1/2 to 2/3
(Carlsen 1987). A large degree of divergence is regularly found between one of
the buccal and the palatal roots. Between buccal roots, it is smaller and
may reach zero (Carlsen 1987). Tworooted variants have smaller degrees of
divergence. In relation to the crown
axis, the cervical 2/3 of the mesiobuccal
root is inclinated to the mesial and facial, the distobuccal root is inclinated
to the distal and the palatal root to the
palatal. The apical third of the mesial
root is inclinated to the distal, whereas
the apical thirds of the distal and palatal roots are inclinated to the mesial
and facial, respectively (Carlsen 1987).
According to a physiologically horizontal zeroplane, which may be defined
by the 3 furcation entrances (Svardstrom & Wennstrom 1988), the mesiobuccal root is standing in a mainly vertical position while the distobuccal and
palatal roots are inclinated to a varying
degree (Svardstrom & Wennstrom
1988). In particular the mesiobuccal
root is largely compressed in a mesiodistal direction, with the furcal concavity
being more pronounced than the mesial
(Bower 1979b, Svardstrom & Wenntrom
1988, Roussa 1998). Thus, root concavities within the furcation are virtually
confined to the mesiobuccal root with
an average depth of 0.35 mm (Roussa
1998). Outside the furcation entrances,
the root surfaces are more even than inside. However, the concavity formed by
the furcation extends closely to the cemento-enamel junction. Average concavities coronal to the furcation ranged
between 0.5 mm at the distal and 0.7 at
the buccal aspect of the tooth, whereas

Furcation diagnosis
at the level of the furcation roof, mean
concavities between 1.2 mm at the distal
aspect and 2.7 mm at the mesial aspect
were observed (Roussa 1998). The root
surface at the buccal and distal furcation entrances is more steeper than at
the mesial entrance. Therefore, the former entrances are more distinctly
marked since there is more or less
abrupt transition from a predominantly
vertical to a mainly horizontal outline
of the root surface (Svardstrom &
Wennstrom 1988).
Many morphological characteristics
of maxillary 1st molars are also found
at the 2nd and 3rd molars. However,
the variation of several components is
even greater. Usually, the 2nd molar has
3 roots, but 2-rooted and 1-rooted variants are more frequent than for 1st molars; and finally, the frequencies of these
variants were even greater for 3rd molars (Carlsen 1987). The only root of
this tooth group, which is usually composed of 3 root cones is the mesiobuccal
of the 1st molar. All other roots consist
of 2 root cones. Sometimes, the mesiobuccal root is separated. Both separation degree and degree of divergence
decrease from the 1st molar to the 2nd
and 3rd molar (Carlsen 1987). Concurrently, root fusions are rarely found at
1st molars but frequencies increase for
2nd and 3rd molars (Hou & Tsai 1994).
Short root trunks have been reported to
be more common buccally, whereas
long root trunks were more commonly
found mesially and distally in both 1st
and 2nd molars (Hou & Tsai 1997a),
however, racial differences may exist
(Gher & Dunlap 1985, Roussa 1998).
Enamel projections may extend from
the cemento-enamel junction into the
furcation. In the upper jaw, they are
most frequently found at buccal furcations of 1st molars (Moskow & Canut
1990a). A classification scheme was
proposed by Masters & Hoskins (1964).
Thus, small extensions of the cementoenamel junction covering only the root
trunk, medium-sized spurs reaching the
furcation entrance and extended lancets
within the furcation area may be distinguished. In general, enamel projections seem to occur on rather rare occasions (Roussa 1998). Further enamel
structures can be found on the root
complex as enamel pearls, islands and
tongues, which originate from activated
parts of Hertwigs epithelial root sheet
(Moskow & Canut 1990b). Within the
furcation area, the root surface is either
regularly covered by cellular mixed

stratified cementum, or a T-shaped

bulge of cementum is found that may
extend on the furcal root surfaces far
apically (Gher & Dunlap 1985, Schroeder & Scherle 1987, Svardstrom &
Wennstrom 1988).
Mandibular molars

The root complex of the 1st molar of

the mandible consists of 2 clearly separated roots, a mesial and a distal. Thus,
2 interradicular projections are found,
a buccal and a lingual. Both roots are
usually composed of 2 root cones each,
a buccal and a lingual, which may be
separated apically. In rare instance, the
mesial root of the mandibular 1st molar
consists of 3 root cones, a buccal, a mediomesial and a lingual. Accordingly, 2
or 3 more or less pronounced root
grooves may be found (Carlsen 1987).
In a cross section, both roots are
shaped like a sand-glass. Particularly
the mesial root has marked concavities
both on the furcal as well as the mesial
aspect (Bower 1979b, Svardstrom &
Wennstrom 1988). Within the furcation,
average concavities at mesial roots
amounted to 0.5 mm as compared to
0.3 mm at distal roots (Roussa 1998).
Therefore, the surface of the mesial root
is considerably larger than that of the
distal root (Anderson et al. 1983, Dunlap & Gher 1985).
According to a physiologically horizontal zeroplane, which may be defined
by the 2 furcation entrances and that
point of the approximal tooth surfaces
with the most coronal cemento-enamel
junction, the lingual furcation entrance
is located more apically than the buccal
(Svardstrom & Wennstrom 1988). Furcation entrances have similar widths
(Svardstrom & Wennstrom 1988, Hou
et al. 1994, Roussa 1998). Outside the
furcation area, the root surface is
usually concave up to the cemento-enamel junction with a mean depth of the
concavity of about 1 mm (Roussa
1998). At the level of the furcation roof,
deep concavities of between 3.3 and 3.7
mm for buccal and lingual aspects, respectively, were reported, on average
(Roussa 1998). Whereas Dunlap &
Gher (1985) calculated an average
height of the root trunk of about 4 mm,
Roussa (1998) observed considerably
shorter root trunks of 2.8 mm at buccal
and 3.5 mm at lingual aspects, on average, which might permit furcation invasion in a relatively early stage of periodontitis (Larato 1975). The degree of

487

separation ranges between 2/3 and 4/5.

Roots have usually a high degree of divergence. In relation to the crown axis,
the cervical 2/3 of the mesial root are
inclinated to the mesial, whereas the
apical third is inclinated to the distal.
From an approximal aspect, both mesial and distal roots inclinate to the lingual (Carlsen 1987).
Many characteristics of 1st molars in
the lower jaw are also found at the 2nd
and 3rd molars. Although the root
complexes of 2nd and 3rd molars consist of 2 roots, a mesial and a distal, the
frequencies of separation decrease from
mandibular 1st molar to 2nd molar and
3rd molar. In contrast, both the absolute and relative height of the root
trunk increase from 1st to 3rd molars
(Carlsen 1987, Hou & Tsai 1997a).
Roots of the 2nd and 3rd molar are
composed of 2 root cones each, which
are rarely separated. These roots have a
degree of separation of maximum 1/2.
The frequency of incomplete separation
structures (root grooves) decreases from
the 1st to the 2nd and 3rd molar. Apical
bend of roots as well as root fusions are
most often seen at 3rd molars.
As compared with maxillary molars,
enamel projections into the furcation
are present more frequently in mandibular molars (Hou & Tsai 1997b,
Roussa 1998). It is noteworthy that the
prevalence of pronounced projections
seems to be greater in Asian (Kawasaki
et al. 1976, Hou & Tsai 1987, 1997b)
than in Caucasian populations (Pedersen & Thyssen 1942, Masters & Hoskins
1964, Grewe et al. 1965, Leib et al.
1967, Tsatsas et al. 1973, Risnes 1974).
Recently, Roussa (1998) reported a 20%
prevalence of enamel projections for
mandibular 1st and 60% prevalence for
2nd molars. The roof of the furcation,
its fornix, is either covered by a plain
bulge of cellular mixed stratified cementum which may extend on the furcal root surface far apically (Schroeder & Scherle 1987) or shows a distinct
cementum ridge (Everett et al. 1958,
Hou & Tsai 1997b). Attempts have
been made to associate projections
(Masters & Hoskins 1964, Grewe et al.
1965, Leib et al. 1967, Hou & Tsai
1987, 1997b) as well as cementum
ridges (Hou & Tsai 1997b) with furcation involvements. Thus, in certain
populations, enamel projections may
actually increase the risk for destructive
periodontal disease. For example,
Hou & Tsai (1987) presented data suggesting an about twofold increased risk

488

Mller & Eger

for furcation involvement in case of a

class 2, i.e., medium-sized (Masters &
Hoskins 1964) enamel projection. As in
the case of upper molars, enamel pearls
may occasionally be observed (Moskow & Canut 1990b).
Premolars and other occasionally
multirooted teeth

The root complex of maxillary premolars generally consists of 2 (buccal,

palatal), and infrequently 3 root cones
(mesiobuccal, distobuccal and palatal).
In case of 3 root cones, 3 variants have
been described (Carlsen 1987). Root
cones may be either non-separated, or
the buccal cones are not separated with
the palatal root separated (2-rooted variant), or separation of all root cones results in a 3-rooted variant. Accordingly,
different separation structures are
found. Whereas the 2nd premolar in the
maxilla usually shows 1 or 2 root
grooves, the 1st premolar has most often
an interradicular projection. Variants
with 3 or 4 separation structures are frequently registered. In particular the mesial root surface of the 1st premolar has
in most instances a pronounced concavity starting already at the cementoenamel junction (Booker & Loughlin
1985). If the root complex consists of 2
roots, the palatal (furcal) surface of the
buccal root is concave in more than 60%
of cases with a mean depth of the concavity of 0.5 mm, whereas the palatal
root is generally convex (Joseph et al.
1996). These teeth have a degree of separation of about 1/2. The distance between the cemento-enamel junction and
the furcation entrance is about 8 mm
(Booker & Loughlin 1985). A somewhat
excentrically (mesially) located cementum ridge may be found in most instances within the furcation area of
maxillary 1st premolars. Enamel pearls
are less frequently observed (Schroeder & Scherle 1987).
Other teeth of the dentition are regularly single-rooted. However, incomplete separation structures as root
grooves are frequently noted. Occasionally, multirooted variants of mandibular
1st (10%) and 2nd premolars (5%) and
mandibular canines (56%) are observed (Carlsen 1987). A particular separation structure is the palato-radicular
groove of maxillary 1st and notably 2nd
incisors (Hou & Tsai 1993). This groove
may be seen at the mesial-cervical area
of the palatal crown surface and may
advance up to the apex.

In conclusion, a careful consideration of the complexity of all combinations of primary structures of the
root complex of a multirooted tooth inevitably gives rise to a more detailed diagnosis of the neighbourhood of periodontitis lesions, which may not be
confined within clearly separated roots
or root cones. Apparently, an appropriate assessment of all possible separation
structures, i.e., root grooves and interradicular projections, is demanding. By
all means, this also includes a recording
of incomplete separations, degree of
separation, degree of divergence and
surrounding infrabony lesions. In the
following chapters the diverse traditional and more recent attempts to
account for this diagnostic challenge
are reviewed in detail.
Clinical Diagnosis
Cardinal symptoms

Redness and swelling of the tissues, increased temperature, pain, and loss of
function, i.e., the cardinal symptoms of
inflammation, may be found with varying expression also in periodontitis. The
unique morphology of the root complex certainly favours the development
of periodontitis lesions in the furcation
area. In advanced cases, the close topography of the roots of a multirooted
tooth may even promote the development of a painful periodontal abscess.
In such a case, the (vital) tooth may be
perceived elongated and mobile
which may result in impaired function.
Some other cardinal symptoms of inflammatory reactions in the gingiva are
regularly found in established gingivitis
and any case of destructive periodontal
disease. Thus, redness and edematous
swelling of the gingival tissue as well as
increased temperature within the periodontal pocket are direct consequences
of an enhanced vascularity as well as increased dilatation and permeability of
vessels in the connective tissue. Although valuable parameters for assessing the degree of inflammation of
the gingival tissues (Armitage 1996),
these symptoms, as well as the resulting
increased bleeding tendency upon
gentle probing, nor occasional suppuration, are by no means specific for interradicular periodontitis.
Attachment loss

A more specific feature of the furcational lesion is the development of

horizontal attachment loss, which means

that the pocket has now a lateral extension. It is generally accepted (however,
not well understood, nor actually
proven) that the microbial front in a
periodontal pocket usually advances in
an apical direction. By definition,
attachment loss is measured from the
cemento-enamel junction, the level of
fibrous attachment in a pristine situation. The unique feature of horizontal
or circumferential pocketing has been
described in the first place at singlerooted teeth of sheep with so-called
broken mouth periodontitis (Cutress
1976, Spence et al. 1980, Page & Schroeder 1982). In multirooted teeth, bacteria may gain access to the furcation
area when the furcation entrance is
reached by the advancing inflammatory
lesion. As a consequence, the horizontal
component of the pocket, i.e., horizontal attachment loss, may be measured.
The respective landmark from where
the loss of attachment is frequently estimated is an imaginary tangent applied
at both roots or root cones at the level
of the furcation entrance. If the furcation entrance is located subgingivally,
the respective concavity of the root surface may be probed first. Several problems with such a measurement have to
be discussed in more detail.
The relatively poor validity and
limited reliability of measuring the vertical attachment loss are known for
many years. The validity of attachment
level measurements describes the potential to detect the apical termination of
the junctional epithelium, or in other
words, the most coronal fibers of the
attachment apparatus. Fowler et al.
(1982) examined, for example, the histologic probe position in human periodontal tissues after biopsy. When employing a probe with a diameter of 0.4
mm and a probing force of 0.5 N in a
chronically inflamed situation, these
authors observed a 0.45 mm penetration of the probe beyond the termination of the junctional epithelium, on
average. In contrast, after treatment the
probe stopped coronally to this landmark by a mean of 0.73 mm. The great
problems with estimating loss of periodontal attachment by probing the
tissue seem to be even more aggravating
for the furcation area, as was demonstrated in a similar experiment by Moriarty et al. (1989). When ignoring the
horizontal component of the pocket,
vertical measurements in the facial furcation area employing a pressure con-

Furcation diagnosis
trolled probe set at 0.5 N yielded a
penetration of the probe of about 2 mm
into the inflamed connective tissue, on
average, whereas the probe tip was
located a mean 0.4 mm apical to the alveolar crest (Moriarty et al. 1989). A
plausible explanation may be the difficulty to follow the contour of the tooth
with the probe in the furcation area as
compared to the flat surfaces of singlerooted teeth. Bone sounding, i.e., transgingival probing to the bone crest under
local anaesthesia, has been reported to
permit a relatively accurate assessment
of the osseous topography (Renvert et
al. 1981, Ursell 1989). Mealey et al.
(1994) tried to improve the accuracy of
furcation measurements by bone
sounding. These authors identified the
intitial, frequently subgingival, concavity of the furcation entrance as a reference point for measuring vertical and
horizontal furcation dimensions in 67
patients with moderate or advanced
periodontitis. Results of vertical and
horizontal probing the tissues before,
and respective bone sounding after local anaesthesia were compared with intrasurgical measurements. By employing post-anesthesia sounding, both
the vertical and horizontal agreement
with intrasurgical measurements was
significantly improved. For instance,
bone sounding revealed a result within
2 mm of the intrasurgical assessment in
88% of the cases. In general, underestimation of surgical furcation depths
by pre-anaesthesia probing was much
more common than overestimation.
Tooth type and furcation location
seemed not to play a significant role. It
should be critically noted that the
identification of the reference for measurements, an initial fluting of the root
surface, is expected to considerably
contribute to measurement error. If this
concavity is in a subgingival location,
the examiner relies on tactile sensation
alone. Errors in detecting this landmark will certainly result in considerable variation of the measurements
taken before and after flap elevation.
Besides the paramount importance
of the validity of a measurement, clearly
also its reliability has to be considered.
Reliability of a diagnostic measure is its
potential to reproduce the measurement
after a short period of time in a reasonable and satisfactory way. It has been
shown that, in general, the result of
periodontal probing may depend on (i)
the inflammatory status of the respective tissues, (ii) probing force, (iii) form

and shape of the probe (Armitage 1996)

or (iv) training of the operator (Abbas
et al. 1982), provided, the examiners are
actually able to repeatedly identify and
probe the same periodontal site. The inter-individual reproducibility of probing measurements in facial and lingual
furcations of maxillary and mandibular
molars of untreated patients was examined by Moriarty et al. (1988) by employing a pressure-sensitive, straight
probe with a 0.5 mm diameter set at
about 0.5 N. 3 examiners were brought
into action. Unfortunately, the design
of the constant force probe generally
prevented horizontal probing at mesial
and distal furcation in maxillary molars, and horizontal probing of most of
the facial and lingual furcations was not
possible because of anatomical characteristics as gingival height and a shallow
vestibular sulcus. The authors provided
the intraclass correlation coefficient of
reliability, which estimates the magnitude of the variance of error-free scores
as related to the sum total of the 2 components of variance, i.e., error-free
score variability plus variability of random errors (Fleiss 1986). Only a moderate coefficient of 0.68 was calculated
for horizontal measurements. Whereas
the furcation height, as assessed on
radiographs, had generally no effect on
the reliability of vertical probing measurements, the reproducibility of horizontal measurements was somewhat
better at sites with a vertical dimension
of the furcation in the 1 to 2 mm
range (0.78) as compared to shallower
or higher furcations (0.57 and 0.64, respectively). According to Fleiss (1986),
no universally applicable standards are
possible for what constitutes poor, fair,
or good reliability. Frequently, intraclass correlation coefficients of reliability of below 0.4 are taken to represent poor reliability and values above
0.75 as excellent. However, a respective
conclusion on what is good or excellent
reliability of a diagnostic test should depend on the consequences of a faulty
decision. Clearly, the pressure-controlled, straight probe seems not to be
suitable for measuring horizontal
attachment loss in furcations. Of particular interest was that, apart from the
questionable suitability of this particular probe to measure furcation involvements, significant differences in probing
emerged among examiners. Thus, one
examiner produced 0.51 mm lower
measurements, on average, than both
other observers.

489

In a recent series of papers, Eickholz

and co-workers estimated the validity
and reliability of measurements with regard to the horizontal attachment loss
in furcations in considerable detail
(Eickholz & Staehle 1994, Eickholz
1995, Kim et al. 1996, Steinbrenner et
al. 1997, Eickholz & Kim 1998). These
authors investigated Nabers curved,
colour-coded probe with 3 mm increments and subsequently compared
the results with a rigid and a flexible,
pressure-controlled probe with regard
to the parameters (i) intraindividual reproducibility of measurements as well
as (ii) validity as compared to the
depth of the lesion measured intraoperatively. In general, assessments
with regard to the horizontal attachment loss were made to the nearest 0.5
mm from a fictitious tangent at the respective roots, and repeated within 10
to 14 d during initial periodontal therapy. The standard deviation for single
measurements as a measure for reliability was shown to depend on the
location of the respective furcation. For
example, the measurement error was
0.56 and 0.60 mm for lingual and buccal furcations, respectively, but 0.76 mm
for mesiolingual and 1.10 mm for distolingual furcations (Eickholz & Staehle
1994). As may be expected, the validity
of the measurement was better in case
of a wide furcation entrance as well as
in buccal and mesiolingual furcations,
provided the neighbouring tooth was
absent (Eickholz & Staehle 1994). The
error of furcation measurement also
seemed to depend on the depth of the
lesion, paradoxically with a lower reproducibility at sites with no or incipient involvement (Eickholz 1995). And
finally, repeated bleeding upon probing
appeared to have a significantly negative impact on the reliability of furcation measurements (Steinbrenner et
al. 1997).
Clinical attachment levels are usually
measured with a straight probe. Gentle
probing means that a pressure is exerted
that does not inadvertendly traumatize
the tissue and provoke bleeding in a
healthy situation. In order to standardize measurements, pressure-controlled
probes are frequently used, and a probing force of about 0.25 N has been recommended by most authors for probes
with a diameter of, say 0.4 or 0.5 mm
(Lang et al. 1991, Karayiannis et al.
1992). When periodontitis affected furcations should be diagnosed, a somewhat different approach is required.

490

Mller & Eger

Since the furcation entrance lies subgingivally in most cases, the operator has
to search for a concavity at the respective site and then to penetrate into the
area between the roots. Consequently, a
pressure controlled, flexible, plastic
probe (Hunter et al. 1992) was shown to
hamper a correct furcation assessment
especially in case of a through-andthrough involvement (Kim et al. 1996,
Eickholz & Kim 1998). On the other
hand, bleeding on probing, which has
been shown to negatively affect the reproducibility of furcation measurements (Steinbrenner et al. 1997), is expected to be provoked more frequently
with the searching probe trying to
gain access to this area. Since the
pocket has a vertical and horizontal
component, conventional straight probes may also underestimate the severity
of the furcation involvement (Eickholz & Kim 1998). Provided, measurements are normally distributed with a
mean difference of zero and a standard
deviation of differences s, which may
be, at least for vertical measurements,
an erroneous assumption in most instances (Janssen et al. 1987), a standard
deviation of a single measurement s/!2
of 0.50.7 mm, as reported for buccal,
lingual and mesiolingual furcations by
that group of investigators, may correspond to the measurement errors observed with rigid, not pressure-controlled, periodontal probes for vertical
attachment loss, as calculated by several authors (Goodson et al. 1982, Haffajee et al. 1983, Aeppli et al. 1985,
Goodson 1986, Gibbs et al. 1988).
However, when considering the reported sample standard deviation, a
measurement error of 1.1 mm for distolingual furcations (Eickholz & Staehle
1994, Eickholz & Kim 1998) may be
comparable to a standard deviation of
differences being generated by chance.
Especially in case of a further tooth
being present distal to the respective
furcation site, clinical diagnosis of the
distolingual furcation appears to lack
the desired accuracy. Moreover, the
concept of a fictitious landmark, the
tangent applied at the root concavities
at the level of the entrance of the furcation, may not be very convincing. If
the furcation entrance is in a subgingival location, the height of the root
trunk is actually not known. Thus, an
accurate measurement (actually something else than an estimate) to a fictitious tangent is unfortunately not
possible, and identification of an initial

fluting or concavity is burdened with

considerable tactile uncertainty. And
finally, in some situations, the entrance
of a furcation may be narrower than the
probe diameter (Bower 1979a), leading
to false-negative results with regard to
furcation involvement. Therefore, because of spurious and enigmatic results,
attempts to measure the horizontal
component of the pocket in furcations
with subgingival entrance and unknown
height of the root trunk remain by and
large questionable.
Classification

Whereas investigators have tried, in

clinical experiments, to more accurately
assess the destruction of the periodontium within the furcation area and healing of the respective lesions following
different modes of therapy by measuring horizontal attachment loss, in
most clinical situations a simple scoring
system is recommended. In principle,
the diseased furcation may be assigned
to 3 classes or degrees of involvement.
Some authors classify furcation involvements epically and in a rather subjective
manner. Thus, a grade I involvement as
described by Glickman (1958) and subsequently Carranza & Takei (1990) is
the incipient or early lesion. The pocket
is suprabony, involving the soft tissue;
there may be slight bone loss in the furcation area. In cases of a grade II involvement bone is destroyed on one or
more aspects of the furcation, but a
portion of the alveolar bone and periodontal ligament remains intact, permitting only partial penetration of the
probe into the furcation, a cul-de-sac
lesion. The varying depth of the horizontal component of the pocket determines whether the furcation involvement is early or advanced. And finally,
in cases of a grade III involvement the
inter-radicular bone is completely absent but the facial and lingual orifices of
the furcation are occluded by gingival
tissue, whereas a grade IV involvement
describes a situation with a throughand-through furcation where the gingiva has receded apically, so that the
furcation opening is clinically visible
(Glickman 1958, Carranza & Takei
1990). Basaraba (1990) is similarly narrative and describes a class I or incipient lesion as a site where the probe will
sink into the shallow V-shaped notch in
the crestal outline. There is no intrabony lesion. A class II involvement is
diagnosed as a patent furcal invasion,

whereas a class III furcation is a patent

invasion that communicates with a 2nd
or 3rd furcal opening.
Most authors use the absolute horizontal attachment loss to define degrees
or classes of furcation involvements.
For instance, an estimated incipient
horizontal attachment loss up to 2 mm
(Ramfjord & Ash 1979) or 3 mm
(Lindhe & Nyman 1975, Hamp et al.
1975) is designated a degree I involvement, horizontal loss exceeding 2 or 3
mm, but not encompassing the total
width of the furcation area is a degree II
involvement, and through-and-through
destruction is a degree III involvement.
Others take into account the various
tooth diameters and define a degree I as
a furcation with an estimated horizontal attachment loss of up to 1/3 and a
degree II of more than 1/3 of the tooth
diameter (Hamp & Nyman 1989, Nyman & Lindhe 1997), which may only
be roughly estimated. In a sense, a degree I or II furcation involvement as described by all of these authors might
characterize more specifically the depth
of Glickmans grade II involvement
(Fedi 1985). Some of the problematic
nature of diagnosing furcation invasions might be highlighted by these
equivocal, and to a large extent, subjective definitions of classes, degrees or
grades of involvement.
Zappa et al. (1993) compared the
classification systems based on the 2
mm or more criterium for a degree II
involvement as described by Ramfjord & Ash (1979) and the 3 mm or
more criterium as described by Hamp
et al. (1975) with the true depth of the
interradicular bony defect of molars as
assessed by intraoperative measurements and microscopic analysis of rubber-based impression material, which
had been applied in vivo. Clinical measurements were performed with Nabers
curved probes with respective increments, i.e., 2 or 3 mm, whereas intraoperative measurements were done with
a straight probe equipped with a plastic
stopper resting on the convex surfaces
of the respective roots. Thus, the
authors attempted to describe the validity of both the clinical scoring and metric measurement with the intraoperative
assessments as a standard. Several
examiners were employed, the data
were, however, pooled, and interrater
reproducibility was not checked. Interestingly, when using the probe with 2
mm increments, 5% horizontal measurements in furcations with clinical de-

Furcation diagnosis
gree I involvement, 40% in furcations
with degree II involvement and 43%
readings in degree III furcations were
actually overestimations (2 mm or more
discrepancy) as compared to intrasurgical measurements, which were shown
to correspond, by and large, with the
respective analysis of the impression
material applied into the furcation area.
This finding may be in contrast to the
results reported by Mealey et al. (1994)
who performed 2 measurements, a first
from the gingival margin to the concavity in the respective tooth surface,
from where a 2nd was done to estimate
the horizontal attachment loss. As discussed earlier, a constant source for
measurement error is the coronal position of the gingiva relative to the furcation entrance which prevents the desired control of the location of a probes
increments. With regard to the probe
with 3 mm increments, Zappa et al.
(1993) reported that 7% of the measurements in degree I furcations, 24% in degree II, but none in degree III furcations were overestimations as compared to intrasurgical assessments.
Moreover, a surgically proven throughand-through involvement was not detected clinically in 43 and 27% with the
2 mm or 3 mm probes, respectively,
whereas a surgical degree II involvement was diagnosed in 4 and 21% of
cases as degree III. Such false diagnoses
may condemn a molar to premature extraction or at least to unnecessary sur-

gical intervention. According to the

authors, these results suggest that furcation diagnosis may be of rather
limited value even if only classes or degrees of involvement are considered.
Apart from a rather complicated descriptive presentation of the validity of
the diagnosis of furcation involvements,
Zappa et al. (1993) included a kappa
statistic as a measure for ordinal agreement between clinical and surgical assessments. For example, with the 2 mm
increments probe, a k of 0.255 was calculated when the degree was compared
with an intrasurgical furcation assessment. k is frequently referred to as a
measure of chance corrected agreement,
in other words, agreement beyond
chance. Its interpretation may be similar to that of an intraclass correlation
coefficient (Fleiss 1981). Hence, a figure
of 0.255 must be considered very poor
agreement of measurements. However,
if one of the sources of ratings may be
viewed as a standard, as is actually the
case for the intrasurgical measurement,
k is not an appropriate measure for assessing agreement (Fleiss 1981)*.
Recently, Eickholz & Kim (1998) presented the reliability of furcation involvement scores according to the 3 mm
or more criterium of Hamp et al. (1975)
using the squared error, weighted k statistic. When the data to be analysed are
measured on an ordered categorical
scale, e.g., increasing severity of furcational lesions, weighted k had been

491

advocated for analysis of agreement

data (Fleiss 1981). Weighted k incorporates the concept of partial credit
for near agreement with the amount of
credit depending on the magnitude of
the discrepancy and the weighting system employed. Eickholz & Kim (1998)
contrasted results obtained with Nabers curved, colour-coded probe with results obtained with the flexible, pressure-controlled probe and a rigid,
straight probe. Weighted k ranged between 0.589 to 0.891 for assessments
made with Nabers probe, 0.498 to
0.797 for the flexible, pressure-controlled probe, and 0.525 to 0.717 for the
rigid, straight probe. In general, the reliability of scorings in distolingual furcations was lowest for all probes tested.
As with the horizontal attachment level
measurements, Nabers curved probe
performed best, whereas the other two
probes were found to underestimate the
situation as compared to the curved
probe. The authors also presented some
evidence of no difference of preoperative and intrasurgical scoring of the furcation lesion with Nabers probe, which
was in contrast to results obtained with
the other probes. However, weighted k
statistic as a measure of agreement has
been criticized because of a number of
serious deficiencies**. The reported reliability, which should now be interpreted as some kind of association
(Graham & Jackson 1993), should
therefore be dealt with very cautiously.

*At this point of discussion, a first remark is demanding. In a common clinical situation, the periodontist makes a diagnosis and thereafter
plans the necessary treatment. Therefore, for a therapist, his or her reproducibility of scores may be of special interest, i.e., intrarater agreement.
It should be emphasized, however, that especially for scientific reason, the question might arise, whether different raters come to different
conclusions. Various k statistics exist, which should be applied specifically in the different situations of reliability assessment. Although
originally developed for the measurement of interrater agreement, the applicability of k statistics extends far beyond this specific problem,
thus, allowing for measuring, on both ordinal and nominal categorical data, similarity, or concordance. Since, in the study by Zappa et
al. (1993), several examiners diagnosed molar furcation sites in the patients with regard to classes or degrees of involvement, interrater reliability
would be of considerable interest, which may be estimated with the k statistic for multiple ratings. Numerous examples for application of the
different k statistics are given by Fleiss (1981).
**Whereas the ordinary k statistic disregards all disagreement in an agreement table, weighted k generalizes unweighted k by employing differential cell weights which reflect differences in the magnitude of disagreement. Thus, weighted k may be appropriate in case of categorical data with
a natural ordering like severity degrees of furcation involvement. Among several possible weighting systems, 2 are mentioned by Fleiss (1981), the
squared error weights and the absolute error weights. Under both weighting schemes, the cells on the leading diagonal (perfect agreement) have
weight equal to 1 and cells representing extreme disagreement are given zero weight. However, for all other cells, squared error and absolute error
weights differ. Thus, the values of weighted k may differ dramatically according to the applied (more or less arbitrary) weighting system, and
likewise their possible interpretations. Fleiss & Cohen (1973) have shown that the intraclass correlation coefficient may be asymptotically equivalent to the weighted k under the squared error system, however investigators did not settle on a certain weighting system. Graham & Jackson (1993)
present an example where relatively high and moderate values of squared and absolute error weighted k are obtained, respectively, even in the case
of no agreement at all. There are several further concerns with regard to the use of weighted k as evidence for reliability, including (i) loss of
information from summarizing the table by a single number, (ii) sensitivity of the value to the form of the marginal distributions, and (iii) subsequent problems in comparing values of k from different tables. Graham & Jackson (1993) recommend weighted k to be interpreted as a measure
of association rather than agreement. Whereas the main focus in agreement studies should be the propensity for pairs to be in agreement, the
presence of off-diagonal association in an agreement table will ususally also be of some interest. When a high level of agreement is observed in a
reproducibility study, the presence of off-diagonal association may further strengthen claims about the underlying quality of the diagnostic instrument. It is not clear how a single index such as weighted k can reflect both differences in exact agreement and differences in off-diagonal association.
Consequently, the possibility of modeling ordinal agreement data in a way outlined in detail, e.g., by Agresti (1988) and others is emphasized, to
get additional information apparently not provided by the weighted k statistic.

492

Mller & Eger

In this context, differing results obtained in studies dealing with both the
validity and reliability of furcation diagnosis as well as respective interpretations and attitudes of the authors are
remarkable. As compared to intrasurgical measurements, Mealey et al. (1994)
claimed that the common underestimation of the situation by clinically probing the furcational lesion may largely be
corrected by bone sounding under local
anaesthesia. Zappa et al. (1993) reported both under- and overestimations
and concluded that furcation diagnosis
may be of limited value, whereas Eickholz & Kim (1998), based on their calculations of squared error, weighted k,
consider measurements with Nabers
colour-coded, curved probe appropriate for both clinical and scientific purposes. On the other hand, there seems
to be agreement that pressure-controlled probes are not suitable for assessing the furcational lesion (Moriarty
et al. 1988, Kim et al. 1996, Eickholz &
Kim 1998).
Location of assessment

In order to make a proper diagnosis

of furcation involvements, profound
knowledge of the locations of respective
furcation entrances is demanding. As
was outlined in detail earlier in this text,
different separation structures, i.e., root
grooves and interradicular projections,
may contribute to the periodontal pathology and should carefully be considered. In untreated patients, these
structures are regularly located in a subgingival location and therefore invisible. Traditionally, before searching for
furcation invasions, probing of the periodontal tissues is exerted at 4 sites of
every tooth present: mesiobuccally,
midbuccally, distobuccally and midlingually (Nyman & Lindhe 1997). In case
of probing only 4 sites, for instance,
lesions at the mesiopalatal furcations of
1st and 2nd maxillary molars or at
upper premolars may be overlooked.
Kuhner & Raetzke (1991) stressed that,
especially at maxillary molars, 6 meas-

urements per tooth provide considerable more information on the extent of

the disease than 4 measurements.
Therefore, 6 or more measurements
around each tooth, or at least assessments midbuccally and at 3 lingual sites
(mesiolingual, midlingual and distolingual) are recommended. Whereas minor
problems are expected with buccal and
lingual furcation diagnosis at mandibular molars, the mesial and distal furcation entrances of maxillary molars
should be probed from a palatal aspect.
In order to diagnose furcation areas of
maxillary premolars it might be necessary to probe mesially and distally, both
from a buccal and palatal aspect.
Radiographic Diagnosis

A careful radiographic diagnosis often

provides early evidence for interradicular periodontitis, although Carranza &
Takei (1990) point to the fact that, since
bone loss is minimal, the incipient
lesion may not be seen radiographically
in most instances. Depending on the
composition of the respective tissues,
the X-ray beam, which passes the respective regions of interest, will expose
the silver-halide emulsion of the film
with various intensity. Structures as
teeth and alveolar bone will absorb
more energy than, e.g., soft tissues of
the periodontium. X-rays are virtually
the only diagnostic tool to reliably determine the height of the alveolar bone
crest in relation to the tooth length. In
addition, limited but important information may be gained with regard to
the anatomy and topography of the
root complex, i.e., number and form of
roots, separation degree, divergence of
roots etc., as well the neighbouring anatomical structures and teeth.
In practice, periapical or vertical bitewing exposures in combination with a
long cone as well as panoramic tomograms are commonly used for the diagnosis of the periodontal condition. The
dilemma of any conventional radiograph is the fact that 3-dimensional
structures of bone, teeth and surround-

ing tissues are represented as a 2-dimensional image. Mainly for that reason, an
initial furcal lesion, in particular in
maxillary molars (and correspondingly
periapical lesions), may actually be
better uncovered on a panoramic tomogram (Rohlin et al. 1989), which frequently images the central plane of the
alveolar bone including the furcation
area, whereas structures not in the interesting plane are blurred. In contrast,
with the naked eye and without any
special equipment, an eventually present buccal and/or lingual bone plate
may actually obscure an incipient furcal
lesion on periapical or vertical bitewing
radiographs (Gurgan et al. 1994).
Therefore, the actual severity of an advanced furcal lesion as assessed by intrasurgical measurements may be
understimated by periapical radiographs or vertical bitewings, whereas
that of an initial lesion may be overestimated by panoramic tomograms
(Topoll et al. 1988).
Some weak evidence or hint for a
more advanced furcation invasion in
maxillary 1st or 2nd molars may be
provided by a small, triangular radiographic translucency across the mesial
or distal roots of these teeth, the socalled furcation arrow. Hardekopf et
al. (1987) radiographed dry human
skulls with and without proximal furcation involvement in maxillary 1st or
2nd molars and found this furcation arrow in 40 out of 96 furcations diagnosed according to Hamp et al. (1975)
as degree II or III (42% sensitivity). On
the other hand, of 186 furcations with
no or incipient involvement, the arrow
was absent in 159 (85% specificity)*.
Evidently, a radiographic image of a
furcation arrow should induce the periodontist to carefully further assess the
severity of furcation invasions clinically
and, if need be, intra-operatively.
With the aid of high-resolution computed tomography a more detailed, 3dimensional interpretation of bony
lesions and tooth structures especially
in the furcation area seems possible
(Fuhrmann et al. 1997). Unlike to con-

*Data provided in this paper may illustrate the properties of a diagnostic test and its usefulness in practice. For instance, if the prevalence
of advanced furcation involvement of maxillary molars in a given population of older adults is estimated as about 4% (see below), then the
false-positive rate, i.e., the proportion of unaffected molars among those with a radiographic image of a furcation arrow, may be calculated
as about 90%, whereas the false-negative rate, i.e., the proportion of affected molars without a furcation arrow, is 2.8% (Fleiss 1981). Interestingly Hardekopf et al. (1987) stress that absence of a furcation arrow does not mean that there is no bony defect within the furcation area.
However, when calculating false-positive and false-negative rates in case of an estimated prevalence of 4%, a striking argument can be made
that, in spite of a radiographically visible furcation arrow, severe furcation involvement may still be rather exceptional. Especially in case
of a low prevalence of severe furcation involvement in a given population, the test may be considered successful. However, from another point
of view, its large false-positive rate qualifies the test a failure.

Furcation diagnosis
ventional tomography, all structures
not in the plane of interest are removed
from the image, resulting in a clear
visualization of the respective slices.
Direct axial scanning parallel to the
occlusal plane has been recommended
for detection of infrabony pockets, furcation involvements and buccal or lingual bone dehiscences (Fuhrmann et
al. 1997). A serious drawback of computed tomography and other radiographic techniques is the exposure with
ionizing radiation of organs at relatively high risk for the development of
undesired pathology as the thyroid
gland or the eyes lens. To gain all information, numerous exposures are
necessary, which may drastically increase the radiographic burden of the
patient. At present, computed tomography is mainly performed in hospitals due to considerable expenditure
and costs.
Largely standardized radiographs
may allow for comparison of bone
levels, e.g., before and after therapy. It
is of interest that, with the rapid development of a larger spectrum of treatment modalities in clinical periodontology in recent years, this concept has
evolved a main aspect of radiographic
examinations of the periodontal structures. Not infrequently, following successful therapy of inflammatory periodontal disease, both increases in bone
density and gain of bony support may
be observed. Evidence for healing in
furcations may be provided by computer-assisted densitometric image
analysis (Payot et al. 1987a & b, Bragger et al. 1989) as well as qualitative
and quantitative digital subtraction
radiography (Bragger & Pasquali 1989,
Christgau et al. 1996, Eickholz &
Hausmann 1997). Obviously, these
techniques require a highly standardized radiographic technique with minimal vertical or horizontal angulations
of the central beams between consecutive exposures, which may not easily be
achieved by commonly used X-ray
beam aligning systems trying to control for central beam angulations
(Eickholz & Hausmann 1997). Computer programs are available to correct
for different brightness and contrast
(Ruttimann et al. 1986) and image distortion caused by film placement
(Webber et al. 1984). By using reference points (Wenzel 1989) and novel
computer algorithms (Samarabandu et
al. 1994) some problems with misaligning errors due to a manual super-

imposition (Benn 1990) may be solved.

With digital subtraction radiography,
absolute increases of bone volume and
mass (Ruttimann & Webber 1987) as
well as relative alterations (Bragger et
al. 1989, Christgau et al. 1996) may be
estimated. At present, these methods
are mainly employed for scientific reason to examine the equivalence or superiority of new treatment modalities
as compared to conventional measures.
Meanwhile, it may be anticipated that,
for the documentation of treatment
success or failure, digital subtraction
radiography will be widely distributed
and applied in daily practice in only a
couple of years. The manifold possibilities of illicit manipulation of digitized
radiographs was recently stressed by
Visser & Kruger (1997).
Intraoperative Measurements

Comprehensive information with regard to the morphology of a periodontal defect may be further achieved
by intrasurgical inspection. Not infrequently, a definite conclusion for
one or the other treatment modality
can therefore only be drawn intra-operatively. This is especially true for
periodontitis lesions within the furcation area with its bizarre and unforeseeable topography of roots, root cones and bone. After surgically opening
of the defect, removal of the granulation tissue and careful debridement
of the root surfaces within and outside
the interradicular projection, the actual
extent of periodontal destruction may
be visible. Concomitantly, the operator
gains information with regard to access
to all concavities and niches of the furcation as well as a feeling for efficacy
of root debridement. This intraoperative, careful re-assessment of the lesion
within the furcation is by no means
dispensable. Based on intrasurgical
findings, the periodontist may be
forced to thoroughly alter his or her
treatment plan. In certain instances, a
tooth may even be considered hopelessly diseased and condemned for extraction.
For example, in a pioneer, splitmouth, controlled clinical trial to assess
the therapeutic effect of placing a barrier membrane for guided tissue regeneration in mandibular molars with
furcation involvement, Pontoriero et al.
(1989) diagnosed only 1 of 42 furcations clinically as class III involvement. However, all turned out to be

493

through-and-through intrasurgically. 6
months after surgery, clinical re-assessments revealed that 3 of 21 test furcations treated with membranes were
completely open, but 11 of 21 control
furcations treated with conventional
flap surgery were still class III involvements. Interestingly, the intrasurgically
estimated surface area of the furcation
entrance appeared to influence the postsurgical outcome. Thus, whereas the
vast majority of class III test furcations
with a 4.5 mm2 or larger entrance remained open after surgery, the critical
area for regenerative closure was about
3 mm2. Since clinical diagnosis before
surgery was so uncertain as compared
with the intra-operative observations, it
can only be speculated whether the two
treatment modalities actually resulted
in any improvement of the situation.
This study may be a further strong argument for distrusting sole clinical furcation diagnosis. It should be stressed,
however, that the authors used a
straight,
pressure-controlled
periodontal probe for measurements. As
was mentioned earlier in this text, Moriarty et al. (1988) had demonstrated
that a pressure-controlled probe largely
prevented a proper clinical furcation diagnosis.
Apart from intrasurgical assessment
of the intraalveolar defect around a
multirooted tooth (Heins & Canter
1968) with its number of bony walls and
relative depth of the 3-, 2- and 1-wall
components (Renvert et al. 1981) and
varying circumference, the actual degree of furcation invasion can now be
judged by inspection and the horizontal
loss of periodontal support be measured more accurately. Distinct vertical
bony defects within the furcation as,
e.g., clinically and radiographically difficult-to-assess hemifurcas and crescentintrafurcal defects (Langer & Wagenberg 1997), i.e., osseous defects that are
usually circumferential in nature and
affect only one half of the furcation or
both roots, can only now properly be
diagnosed.
Some authors suggested to subclassify also the height of the furcation,
i.e., the distance between the roof of the
furcation and the interradicular bone
(Eskow & Kapin 1984, Tarnow &
Fletcher 1984). According to Tarnow &
Fletcher (1984), a subclass A would
correspond to a furcation height of up
to 3 mm, a height of 46 mm would be
a subclass B and subclass C is a furcation with more than 6 mm height.

494

Mller & Eger

Furcation involvement chart

Patient: A. G.

*: 08.10.1971

Date: 23.05.1996

Tooth: 16

mobility (0, 1, 2, 3)
elongation (0, 1)
sensibility testing (1: vital; 2: not vital)
endodontic diagnosis (0: okay; 1: revision necessary)
caries, restorations (0: caries free; 1: small caries or filling; 2: extended
caries, large filling; 3: artificial crown)
Mesial root
Radiographic diagnosis

Distal root

bone loss
0: 1/3 root length
1: 1/3, 2/3 root length
2: >2/3 root length

2
0
1
0
0

Buccal root
m

m/d roots

m/p roots

d/p roots

separation degree
0: 1/3
1: 1/3

degree of divergence
0: 30
1: 30

Clinical measurements

mb

BOP (0, 1)

plaque (0, 1)

PPD

5.0

2.0

vCAL

2.0

2.0

Palatal root
m

b/p roots

db

dl/p

l/p

1.5

4.0

5.5

7.0

2.0

6.0

1.5

4.0

5.0

7.0

2.0

6.0

ml/p

hCAL

0.0

5.0

5.0

degree

II

II

Intraoperative measurements

mb

db

dl/p

l/p

ml/p

furcation height

0.0

4.0

3.0

furcation width

0.0

4.0

3.0

furcation depth

0.0

3.0

3.0

degree corrected

II

II

BD-CEJ

5.0

4.5

2.0

2.5

6.0

7.0

6.5

6.5

BD-LA

0.0

0.5

0.0

0.0

2.0

0.0

0.0

0.0

Moriarty et al. (1988) tried to assess the

furcation height clinically by probing,
however, these estimates were not compared with true measurements made intrasurgically. As was suggested by data
provided by Pontoriero et al. (1989),
not only the height of the respective furcation may be of importance for treatment planning, but also its width,
which may be measured from the intersection between the bone crest and the
respective roots. Recently, the height of
the root trunk or, in other words, the
separation degree, was suggested to
supplement furcation classification
(Hou & Tsai 1997a). Accordingly, a furcation associated with a short root trunk

Fig. 1. Proposal for a furcation involvement

chart. Note additional clinical measurements
at the prominence of the respective roots,
where appropriate. Further possible measurements at, e.g., the distal (furcal) surface
of the mesiobuccal root, the mesial (furcal)
surface of the distobuccal root etc., were
mentioned by Moriarty et al. (1988) and may
be recorded. Several sites within the furcation
are clinically not measurable. Divergence of
mesial/buccal or distal/buccal roots can only
be roughly estimated on radiographs and
should be further assessed intraoperatively.
Explanation of abbreviations: BOP: bleeding
on probing; PPD: probing pocket depth;
vCAL, hCAL: vertical and horizontal
attachment level, respectively; BD-CEJ, BDLA: the distance between the bottom of the
bony defect and the cemento-enamel junction and the bottom of the bony defect to the
limbus alveolaris, respectively. If after healing, a surgical re-entry is not possible, some
measurements may be made by bone sounding after anaesthesia.

of less than 1/3 of the root complex (corresponding to a separation degree of

more than 2/3) is a subtype A, whereas
the respective subclasses B and C correspond to medium-sized root trunks of
50% of the root complex (separation degree 1/2) and 2/3 of the root complex
(separation degree 1/3), respectively.
All the respective clinical, radiographic and intrasurgical measurements should be documented in an appropriate chart. A proposal for such a
Furcation Involvement Chart is presented in Fig. 1, which might be modified according to personal preferences
or supplemented with further information. Clearly, anamnestic data, the

expression or form of the disease, the

overall preliminary treatment plan, the
periodontists appraisal of the strategic
as well as the patients subjective assessment of the general importance of the
respective tooth should obviously also
be recorded.
Concluding Remarks

At present, no epidemiologic study provide any direct information with regard

to the prevalence, extent and severity of
furcation invasion due to periodontal
disease. Indirect evidence, however, may
suggest that the furcation problem is actually confined to a rather small frac-

Furcation diagnosis
tion within the total population*.
Despite this impression of being only a
minor problem in the population, in
affected people after periodontal therapy furcation involvement may increase
the risk for further attachment loss and
recurrent disease (Wang et al. 1994,
Rams et al. 1996). This holds true especially for mobile molars with furcation
involvement (Wang et al. 1994), although it should be noted that there is
some data suggesting the opposite
(Chace & Low 1993). In the past, resective measures as root amputation or
hemisection of the tooth as well tunnel
preparation had been frequently advocated (Carnevale et al. 1995). A proper
diagnosis beyond simply assessing degree of involvement is necessary even
for these traditional treatment modalities. For example, a tunnel preparation
at mandibular 1st and 2nd molars may
only be successful, if the degree of divergence is larger than 30 or so, to enable the daily brushing with, e.g., an
interdental brush. Root amputation
may result in a (prosthetic) failure, if
the tooth morphology is not accurately
acknowledged (Majzoub & Kon 1992).
A separation degree of about 1/3 obviously interferes with root amputation
or hemisection. With the development
of novel, regenerative treatment modalities, a more careful documentation of
the pre- and postsurgical outcome is demanding. Clearly, only closure of a furcational defect should be regarded an
endpoint of therapy. Therefore, a thorough intrasurgical assessment of factors increasing the chances to obtain
this result seems to be necessary. This
should include the recording of, for instance, the height of the root trunk,
presence of infrabony pockets, the
height of the interproximal bone as well
as the position of the gingival margin
in relation to the furcation entrance. In
addition, unfavorable conditions interfering with root debridement or flap

management and therefore proper healing should supplement the clinical and
radiographic furcation diagnosis. For
example, even thickness of the mucoperiosteal flap had been identified as a
factor influencing the postsurgical outcome after regenerative procedures in
furcations (Anderegg et al. 1995). Interestingly, it has recently been demonstrated that the overall significance of
regenerative procedures in the treatment of furcations may be rather
limited if the available information
from the literature is considered, even
in case of a clientele which is mainly
affected
by
periodontal
disease
(Muller & Eger 1997). Postoperative
control of healing of furcational lesions
is a further challenge. Especially in clinical research bone sounding under local
anaesthesia may be a valuable surrogate
if, after healing of the lesion, a re-entry
operation is not allowed by the patient
(Mealey et al. 1994). Self-evidently, assessment of a contingent furcation closure has to be supplemented by sensitive, largely standardized, radiographical techniques.

495

compared to the 19851986 NIDR survey of employed adults. Nevertheless,

the direct evidence of the NHANES III
survey by-and-large corroborates the
calculations presented in the respective
footnotes of this article.
Zusammenfassung
Furkationsdiagnostik
Eines der wichtigsten und zum gegenwrtigen Zeitpunkt ungelstes Problem in der klinischen Parodontologie ist die vorhersagbare
erfolgreiche Behandlung der von Parodontitis befallenen Furkationen bei mehrwurzeligen Zhnen. Da verschiedene therapeutische
Anstze vorgeschlagen worden sind, z.B.
konservative, resektive oder regenerative,
wird eine richtige Diagnostik dieser Lsionen
erforderlich. Das Ziel des vorliegenden bersichtsartikels ist es, die gegenwrtigen Erkenntnisse fr eine richtige Diagnose der
Furkationslsion sowie der Zahnmorphologie aufzuzeigen, um im Hinblick auf die verschiedenen Therapiemglichkeiten eine Entscheidung zu treffen. Gleichzeitig wird die
Notwendigkeit fr eine detaillierte klinische,
rntgenologische und intraoperative Diagnostik der Furkationslsion ber die gewhnliche Diagnostik der Furkationsbeteiligung in
Graden hinaus betont.

Addendum

Since preparation of this manuscript, a

study by Albandar et al. (1999) reported, for the first time, on estimates
of prevalence and extent of furcation involvement in a representative sample of
adults, 30 years of age and older, in the
USA (NHANES III). The prevalence of
furcation involvement for all age groups
was 13.7%, and the extent was 6.8% of
posterior teeth per person. There were
significantly higher prevalence of persons and higher extent of teeth affected
in males than females and in blacks and
Mexican Americans than in whites. Because NHANES III reported periodontal findings from employed as well
as unemployed persons, prevalence of
periodontitis was somewhat higher as

Resume
Diagnostic dans les furcations
Un des proble`mes les plus importants en parodontologie clinique, et jusqu a` present non
resolu, consiste a` trouver pour les furcations
atteintes de parodontite dans les dents multiradiculees un traitement dont le succe`s soit
previsible. Puisqu on dispose de plusieurs
approches therapeutiques, par conservation,
par resection ou par regeneration, un diagnostic adequat de ces lesions est tre`s exigeant. Le but du present article est de passer
en revue linformation actuelle sur limpact
dun diagnostic adequat de la lesion de furcation ainsi que de la morphologie dentaire sur
la decision a` prendre en ce qui concerne les
differentes modalites de traitement, et de
souligner la necessite detablir un diagnostic
clinique, radiographique et intra-operatoire
detaille de la lesion de furcation en plus du

*Assume, for example, the height of the root trunk of a molar of about 4 mm, on average (Dunlap & Gher 1985, Gehr & Dunlap 1985,
Roussa 1998). Then, a 5-mm attachment loss should lead to definite furcation involvement. Of 192 possible periodontal sites (mesiobuccal,
buccal, distobuccal, distolingual, lingual and mesiolingual sites at 32 teeth), only 30 are associated with furcation entrances of molars. Since
the root trunks of premolars are about twice as high (Booker & Loughlin 1985) these teeth are not considered in the following calculation. In
a representative sample of the employed adult U.S. population from the 19851986 survey of the NIDR (Brown et al. 1990) a 5 mm or more
(vertical) attachment loss was observed in 25% of 45 to 54 years old individuals and 35% of 55 to 64 years old people. However, only 1.4 and
2% sites were affected, respectively. These estimates are probably lower than the actual prevalence and extent due to partial recording. However,
even if the extent is underestimated by, say 100%, advanced periodontal disease with an attachment loss of 5 mm or more is expected at only
4% of tooth surfaces in the oldest age group (Brown & Le 1990). Thus, 1.2 furcations (4% of 30) may be involved, on average. This is a little
bit higher than the figure for about 60-years-old subjects reported by Larato (1970), who studied dry Mexican skulls. Even in case of a rather
realistic assumption of a twofold increased risk for periodontitis at molar teeth, only 2 or 3 furcations may be affected in the 55 to 64 years
age group.

496

Mller & Eger

diagnostic du degre de latteinte de la furcation habituellement pratique.

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Address:
Hans-Peter Muller
Department of Operative Dentistry and
Periodontology
University of Heidelberg
Im Neuenheimer Feld 400
D-69120 Heidelberg
Germany
Fax: 49 6221 565074