Connective tissue graft wall technique for mandibular Class II furcation defects: Two case reports

BACKGROUND: Furcation involvement (FI) represents one of the most challenging conditions in periodontal therapy due to limited accessibility and the progressive interradicular attachment loss that compromises long-term tooth stability. Deep periodontal pockets in molars and premolars often present as combined defects, including horizontal FI and infrabony components. Conventional non-surgical and surgical approaches, including resective procedures, have shown limited long-term advantages. Recently, regenerative strategies have gained increasing interest in the treatment of Class II and selected Class III FI; advances in biomaterials, biologic agents, and tissue management can promote clinical attachment gain while minimizing postoperative recession. METHODS: Two patients with mandibular Class II FI were treated using the connective tissue graft (CTG) wall technique, combining a coronally advanced flap (CAF), CTG, and enamel matrix derivative (EMD). Healing was evaluated through clinical and radiographic parameters. RESULTS: Both cases demonstrated resolution of Class II FI (Class 0) at 18-month follow-up, with probing pocket depth reduction from 7 to 3-4 mm, clinical attachment level gain of 3-4 mm at the buccal site, and stable gingival margin position. Bleeding on probing resolved completely in both cases. Radiographic examination showed changes consistent with bone fill in the interradicular area. CONCLUSIONS: Regenerative therapy represents a valuable treatment option for selected furcation defects. The CTG wall technique, combining CAF, CTG, and EMD, achieved furcation resolution, clinical attachment gain, and stable soft tissue outcomes in two mandibular Class II furcation cases. The autogenous CTG may confer additional biologic advantages by enhancing wound stability, space maintenance, and soft tissue phenotype. Controlled clinical trials are needed before routine recommendations. KEY POINTS: Regenerative treatment combined with soft tissue augmentation may represent a valuable option for selected mandibular Class II furcation defects. The connective tissue graft wall technique is designed to improve clot stabilization, space maintenance, and soft tissue support around furcation defects. Furcation closure and stable clinical outcomes were observed at 18 months in the two cases presented, supporting further investigation of this approach. PLAIN LANGUAGE SUMMARY: Furcation defects are areas of bone and tissue loss that develop between the roots of multi-rooted teeth affected by periodontal disease. These defects are particularly difficult to treat because of their complex anatomy and limited accessibility. Traditional treatment approaches often focus on controlling disease progression, while regenerative procedures aim to rebuild lost periodontal tissues. This report describes the treatment of two patients with mandibular Class II furcation defects using a combined surgical approach that included a coronally advanced flap, a connective tissue graft, and enamel matrix derivative. The connective tissue graft was positioned as a biological soft-tissue wall over the defect to improve wound stability and protect the healing area. After 18 months, both patients showed resolution of the furcation defect, reduction in periodontal pocket depth, gain in clinical attachment, and stable soft tissue conditions. No postoperative complications were observed. Although these findings are limited to two cases, they suggest that combining regenerative therapy with soft tissue augmentation may represent a promising treatment option for selected furcation defects. Larger clinical studies are needed to confirm the effectiveness and predictability of this approach.