Management of Class II furcations: the challenge of 5-year stability

The treatment of Class II furcation defects remains one of the most complex exercises in surgical periodontology, as local morphology often complicates the long-term stability of regenerative results. While the therapeutic arsenal has been enriched with high-performance biomaterials, soft tissue stability and the long-term maintenance of bone filling constitute the real clinical challenge for the practitioner. This retrospective study focuses specifically on a combined approach: the use of recombinant human fibroblast growth factor-2 (rhFGF-2) associated with carbonate apatite and an adjacent connective tissue graft (CTG).

The precise objective of this study is to evaluate the long-term clinical and radiographic results (up to 60 months) of this protocol on 14 Class II buccal furcation defects. The authors tested the hypothesis that a connective tissue graft, in addition to guided tissue regeneration, would not only achieve significant attachment gain, but above all stabilize the gingival phenotype and prevent recession over a 5-year period, thereby transforming the prognosis of these multi-rooted teeth.

Methodology: a 5-year clinical and radiographic follow-up

This retrospective exploratory study was conducted on 14 patients, each presenting with an isolated class II buccal furcation defect. The objective was to evaluate the long-term stability and efficacy of a complex regenerative approach.

The therapeutic protocol implemented combined three specific components:

• Tissue engineering: application of recombinant human fibroblast growth factor-2 (rhFGF-2).
• Biomaterials: use of carbonate apatite (CO3Ap) as a bone substitute.
• Muco-gingival approach: addition of a connective tissue graft (CTG) to reinforce the buccal wall.

Clinical follow-up spanned a 60-month period, with intermediate measurements taken at 12 and 36 months. The researchers evaluated the following parameters:

• Probing and attachment: probing pocket depth (PPD), clinical attachment level (CAL) and gingival recession.
• Gingival phenotype: keratinized tissue width (KTW) and phenotype assessment via a chromatic probe (at baseline and 60 months).
• Radiography: analysis of the bone filling of the furcation defect.

Data analysis was performed using non-parametric statistical tests to compare the results at each follow-up stage against the baseline data.

Results: Clinical and radiographic stability at 5 years

Analysis of the 14 class II furcation defects (14 patients) treated with the combination of rhFGF-2, carbonate apatite, and a connective tissue graft (CTG) reveals robust and long-lasting healing kinetics. Non-parametric statistical tests confirm that early gains are maintained over the long term.

In terms of soft tissues, the keratinized tissue width (KTW) increased significantly throughout the study. At the same time, gingival recession showed a constant downward trend between baseline and the 5-year follow-up. The assessment of the gingival phenotype, performed using a colorimetric probe, confirms this qualitative improvement of the marginal periodontium.

The most striking result concerns imaging: at 60 months, complete radiographic filling of the furcation defect was observed in 13 of the 14 treated sites, representing a success rate of 92.9%. This stability of furcation conditions, observed in a cohort followed for 5 years, highlights the effectiveness of the combined approach for these traditionally complex lesions.

Analysis of results and clinical durability

The data from this retrospective study confirm remarkable clinical and radiographic stability at 60 months for the treatment of class II furcation defects. The complete radiographic fill rate, reaching 92.9% (13 out of 14 sites), suggests that the combined use of recombinant FGF-2, carbonate apatite, and a connective tissue graft (CTG) outperforms conventional regenerative approaches, which are often limited by the instability of peri-lesional soft tissues.

Beyond bone grafting, the contribution of CTG appears decisive for the gingival phenotype. The significant increase in keratinized tissue width and the trend towards reduced gingival recession observed at the practice indicate that the graft acts as a stable biological barrier, protecting the underlying regeneration process. Maintaining a reduction in probing pocket depth (PPD) and clinical attachment gain (CAL) over 5 years in an area as complex as the furcation is a compelling result that validates the viability of this combined approach.

Limits and perspectives

The weak point of this work lies in its retrospective and exploratory design, as well as in the modest size of the cohort (n=14). Although the results are statistically significant, they do not allow for a systematic generalization of the technique without larger-scale prospective randomized studies. However, the rarity of 5-year follow-ups in the current literature gives these data a definite clinical value for the practitioner faced with risky mandibular or maxillary furcations.

Summary of results

This retrospective study demonstrates that at 60 months, the protocol combining rhFGF-2, carbonate apatite, and connective tissue graft (CTG) ensures complete radiographic filling in 92.9% of cases (13/14 sites). The gains in pocket depth and clinical attachment level achieved from the 12th month remain stable over 5 years, accompanied by a significant increase in keratinized tissue.

In concrete terms, for the practitioner:

• Stabilize your results: The systematic addition of a connective tissue graft (CTG) strengthens the gingival phenotype and prevents long-term post-surgical recession.
• Opt for a combined approach: For buccal class II furcation defects, the combination of a growth factor (rhFGF-2) and a bone substitute (carbonate apatite) maximizes the chances of complete regeneration.
• Preserve rather than extract: This technique offers a predictable and durable alternative for saving molars, even in anatomically complex areas, subject to rigorous maintenance.

Technical lexicon of the study

Class II furcation involvement: Complex horizontal periodontal defect affecting multi-rooted teeth, characterized by inter-radicular bone loss of more than 3 mm that does not result in a through-and-through communication.

rhFGF-2 (recombinant human Fibroblast Growth Factor-2): Recombinant polypeptide growth factor used in this protocol to stimulate cell proliferation and neo-angiogenesis required for the regeneration of the periodontal complex.

Carbonated apatite: Bone substitute material (alloplast) used as a mineral scaffold, featuring biocompatibility and absorbability close to natural human bone.

Connective Tissue Graft (CTG): Adjuvant surgical procedure used in this study to reinforce the soft tissue wall, increase gingival thickness, and stabilize the regeneration site over the long term.

Keratinized tissue width (KTW): Measurement of the keratinized gingiva band, from the free margin to the mucogingival junction; the study shows a significant increase in this parameter over 60 months thanks to the contribution of the connective tissue graft.

Gingival phenotype: Morphological characterisation of soft tissues (thickness, architecture) evaluated in this study via a specific colorimetric probe to quantify post-operative tissue changes.

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