Q U I N T E S S E N C E I N T E R N AT I O N A L
GENERAL DENTISTRY
Root resective procedures vs implant therapy in the
management 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-
Key words: furcation involvement, furcations, molar, periodontal disease, root resection
The management and long-term retention of furcated
molar teeth has always been a challenge for clinicians.
Furcation involvement is dened 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 by
mandibular molars.1,2 In addition, furcation-involved
multirooted teeth generally respond less favorably to
treatment compared with single-rooted teeth or molar
1 Associate Professor, Department of Operative Dentistry and Periodontology,
School of Dental Medicine, University of 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: Kasaj@gmx.de
VOLUME 45 NUMBER 6 JUNE 2014
Adrian Kasaj
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;45:521529; doi: 10.3290/j.qi.a31806)
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
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Q U I N T E S S E N C E I N T E R N AT I O N A L
Kasaj
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 modied 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 dierent 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 classication
The glossary of periodontal terms denes 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 classication 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 Hamps classication,13 dening periodontal
destruction in a horizontal direction. Three dierent
classes of severity were identied:
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.
522
Tarnow and Fletcher12 later on further described the
extent of furcation involvement with a subclassication
evaluating the degree of vertical involvement:
Subclass A, 13 mm
Subclass B, 46 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, ecacy 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
rst 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 aects
the development of furcation involvement and the
mode of treatment is the length of the root trunk. This
length is dened 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
VOLUME 45 NUMBER 6 JUNE 2014
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a b c

d e f
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) A
maxillary molar with a narrow furcation entrance between the buccal roots and concave and convex areas in the interradicular root
surface area. (d) Maxillary molar with fused roots and (e) roots that diverge coronally but fuse apically. (f) Enamel pearl in the furcation
entrance area.

Figs 2a and 2b (a) An extracted man-

dibular molar used to demonstrate that
the entrance of the furcation is often nar-
rower than the width of the curette blade.
(b) Preference should be given to slim
ultrasonic scaler tips to enable greater
access and ecient periodontal debride-
a b ment in the furcation area.

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 sucient
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
dened 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 ber
attachment on the enamel extensions. However, the
presence of cervical enamel projections is often dicult
to 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.

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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 of
furcation involvement is generally based upon probing
and radiographic ndings. 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 dicult to
assess and it may not be possible to probe the furcation
in its entirety. Thus, two opposite furcations classied
as degree II by the practitioner actually may be a true
degree III furcation. Indeed, Zappa et al20 found dier-
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 signicantly improved the diagnostic accu-
racy of furcation involvement compared to standard
pre-anesthetic probing. Taken together, these ndings
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 are
that 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
524
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 conrmed by the intrasurgical ndings. The
authors concluded that CBCT provides high accuracy in
assessing the loss of periodontal tissues and classica-
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 rst introduced by Farrar8 in 1884
as radical and heroic, and since then has been com-
VOLUME 45 NUMBER 6 JUNE 2014

a b
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
dened 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 dened 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 aecting 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 dierent studies. In a recent sys-
tematic review on the eect 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
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Figs 3a and 3b Intraoperative view of a
right maxillary rst molar with a root prox-
imity and a degree II distopalatal furcation
involvement. While the second maxillary
molar is hopeless and should be extracted,
a root amputation of the distobuccal root
of the rst molar can be performed. (a) The
root trunk is short and the remaining roots
exhibit sucient bone support. (b) In con-
trast, the high root trunk and the insu-
cient bone support of the mesiobuccal
root make this left maxillary rst molar a
poor candidate for root-resective therapy.
mainly related to endodontic complications and root
fractures and not to periodontal disease recurrence.
The signicant variations in the success rates may, at
least in part, be attributed to dierent inclusion criteria,
outcome denitions, 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-specic 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
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a b c

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

tooth loss following resective periodontal therapy if the
aected 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 signicantly 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 root
resection a at 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 rst 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 aps in order to establish a favorable environ-
ment for oral hygiene.
Root resection therapy in mandibular molars
requires some additional considerations. A mandibular
rst molar typically presents with two well-dened
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 a
gure-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 dicult
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

526 VOLUME 45 NUMBER 6 JUNE 2014


molar is more frequent when the mesial root is
retained.36,37 The remaining single root following resec-
tion is insucient to maintain the occlusion of a man-
dibular molar. Therefore, the remaining root should be
incorporated into a more extended xed 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, patients
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 dicult 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, therapeutic
skills, and patient compliance. Therefore, it seems dif-
cult 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.
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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, Zaropou-
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 reported
failure 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 dicult than
management with root resective therapy.
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Although a direct comparison between the two
treatment approaches is dicult, 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 signicant 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 inammation-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
528
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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