cal, furcation & mobility
TRANSCRIPT
CAL, CAL, FURCATIONS & FURCATIONS &
MOBILITYMOBILITY
CALCAL
The clinical attachment level (CAL) refers The clinical attachment level (CAL) refers to the estimated position of the structures to the estimated position of the structures that support the tooth as measured with a that support the tooth as measured with a periodontal probeperiodontal probe
The CAL provides an estimate of a tooth’s The CAL provides an estimate of a tooth’s stability and the loss of bone supportstability and the loss of bone support
Two terms are commonly used in conjunction with the Two terms are commonly used in conjunction with the periodontal support system:periodontal support system:
Clinical attachment level and clinical attachment loss. Both Clinical attachment level and clinical attachment loss. Both of these terms may be abbreviated as CAL and can be of these terms may be abbreviated as CAL and can be used synonymouslyused synonymously
Clinical attachment loss (CAL) is the extent of periodontal Clinical attachment loss (CAL) is the extent of periodontal support that has been destroyed around a toothsupport that has been destroyed around a tooth
As an example of the use of these two terms, a clinician As an example of the use of these two terms, a clinician might report that the“might report that the“clinical attachment levels were clinical attachment levels were calculated for the facial surface of tooth 32 and calculated for the facial surface of tooth 32 and there is 6 there is 6 mm of mm of clinical attachment loss.”clinical attachment loss.”
Rationale for computing Rationale for computing CALCAL
Probing depths are not reliable indicators of the Probing depths are not reliable indicators of the extent of bone support because these extent of bone support because these measurements measurements are made from the gingival margin. are made from the gingival margin. The position of gingival margin changes with tissue The position of gingival margin changes with tissue swelling, overgrowth, and recessionswelling, overgrowth, and recession
Clinical attachment levels (CALs) are calculated Clinical attachment levels (CALs) are calculated from measurements made from a fixed point from measurements made from a fixed point that does that does not change—the cemento-enamel junction not change—the cemento-enamel junction (CEJ). Because the bone level in health is (CEJ). Because the bone level in health is approximately 2 mm apical to the CEJ, clinical approximately 2 mm apical to the CEJ, clinical attachment levels provide a reliable indication of the attachment levels provide a reliable indication of the extent of bone support for a toothextent of bone support for a tooth
The location of the gingival margin is The location of the gingival margin is important in determining the CAL, important in determining the CAL, which includes both periodontal which includes both periodontal pocket depth and recession pocket depth and recession measurementsmeasurements
When the gingival margin coincides with the When the gingival margin coincides with the CEJ, the CAL and the pocket depth are equalCEJ, the CAL and the pocket depth are equal
CAL=POCKET DEPTHCAL=POCKET DEPTH
When the gingival margin is apical to the CEJ, When the gingival margin is apical to the CEJ, the CAL is greater than the pocket depth and the CAL is greater than the pocket depth and equal to the amount of visual recession plus equal to the amount of visual recession plus the depth of the pocketthe depth of the pocket
CAL= RECESSION + POCKET CAL= RECESSION + POCKET DEPTHDEPTH
In cases of gingival inflammation or In cases of gingival inflammation or hypertrophy when the gingival margin is on hypertrophy when the gingival margin is on the enamel, the attachment loss is less than the enamel, the attachment loss is less than the pocket depththe pocket depth
CAL= POCKET DEPTH-AMOUNT OF CAL= POCKET DEPTH-AMOUNT OF
ENLARGEMENTENLARGEMENT
The gingival margin placement above the CEJ The gingival margin placement above the CEJ must be measured and this reading must be measured and this reading subtracted from the periodontal probe subtracted from the periodontal probe reading to obtain the CALreading to obtain the CAL
For example, if a client has For example, if a client has generalized 6-mm probe readings generalized 6-mm probe readings but 2-mm of coronal movement of but 2-mm of coronal movement of the gingival margin, the actual CAL is the gingival margin, the actual CAL is 4-mm4-mm
If a client has generalized 3-mm of If a client has generalized 3-mm of recession and 3-mm pocket readings, recession and 3-mm pocket readings, the recession and the pocket reading the recession and the pocket reading must be added together to obtain the must be added together to obtain the actual CAL of 6-mmactual CAL of 6-mm
Attachment loss over time Attachment loss over time (disease (disease activity) activity) indicates actual progression indicates actual progression of periodontal diseaseof periodontal disease
CAL is measured from the CEJ to the CAL is measured from the CEJ to the base of the periodontal pocketbase of the periodontal pocket
Periodontal pocket is measured from Periodontal pocket is measured from the gingival margin to the base of the the gingival margin to the base of the periodontal pocketperiodontal pocket
Gingival recession is measured from Gingival recession is measured from the CEJ to the gingival marginthe CEJ to the gingival margin
Furcations
Pose an anatomic challenge
Difficult to instrument
Difficult to maintain clean
Mandibular MolarsMandibular Molars
Buccal Lingual
Mandibular molars have two Mandibular molars have two furcations: Buccal & Lingualfurcations: Buccal & Lingual
Maxillary molars have three Maxillary molars have three furcations: Buccal, mesial & distalfurcations: Buccal, mesial & distal
Buccal furcation in mandibular teeth Buccal furcation in mandibular teeth is accessed from buccal sideis accessed from buccal side
Lingual furcation in mandibular teeth Lingual furcation in mandibular teeth is accessed from lingual sideis accessed from lingual side
Buccal furcation of maxillary teeth is Buccal furcation of maxillary teeth is accessed from buccal sideaccessed from buccal side
Mesial furcation of maxillary teeth is Mesial furcation of maxillary teeth is accessed from palatal sideaccessed from palatal side
Distal furcation is accessed from the Distal furcation is accessed from the palatal side palatal side
Diagnosis
Diagnosis of furcation Diagnosis of furcation involvementinvolvement
Thorough clinical examination
Careful probing/inspection
Furcation involvement Furcation involvement (invasion): (invasion): Loss of bone and Loss of bone and attachment at the furcation area in attachment at the furcation area in multi-rooted teethmulti-rooted teeth
Radiographic Examination
Helpful
But
Of limited value
Bitewings are more helpful
Than Periapicals
Classification Several systems:
Horizontal probing
Vertical probing
Combination
Classification Systems
Glickman’s (1953)
Hamp, Nyman & Lindhe (1975)
Tarnow and Fletcher (1984)
Easley and Drennan (1969)
Glickman’s ClassificationGlickman’s Classification
Grade I – IV
Based on horizontal measurement of attachment loss in the furcation
Grade IGrade I Incipient furcation
involvement
Suprabony pocket
No radiographic changes
Early bone loss
Grade IIGrade II Loss of furcal bone but not
through and through
Radiographic changes not always possible to see
Grade IIIGrade III
Through and through but not clinically visible
Soft tissues may covers furcation
Grade IVGrade IV
Bone & soft tissues Bone & soft tissues recededreceded
Through & through Through & through defect clinically defect clinically visiblevisible grade grade IVIV
Hamp, Nyman & Lindhe
Grade I (initial) : loss of interradicular bone less than or equal to 1/3 width of tooth
=< 3mm
Grade II (partial)
Loss of interradicular bone more than 1/3 but the defect is not through and through
>3 , < 9 mm
Grade III (total)
Through & through loss of interradicular bone
=> 9 mm
Tarnow & Fletcher Grade A : vertical loss
of 1-3 mm
Grade B : vertical loss of 4-6 mm
Grade C : vertical loss of 7+ mm
From roof of furcation apically
Classification:
I A, I B, I C
II A, II B, II C
III A, III B, III C
Furcation grade III C has the worst Furcation grade III C has the worst prognosisprognosis
Local Factors To Examine
Tooth
Bone
Adjacent teeth
Nabers ProbeNabers Probe
ProbingProbing
CEP’s
Enamel Pearls
BoneBone
Pattern of bone loss
Extent of bone loss
Adjacent Teeth
Condition of teeth
Root proximity
Tooth mobilityTooth mobility Mobility is the loosening of a tooth in its socket. Mobility may
result from loss of bone support to the tooth
1. Horizontal tooth mobility is the ability to move the tooth in a facial-lingual direction in its socket. Horizontal tooth mobility is assessed by putting the handles of two dental instruments on either side of the tooth and applying alternating moderate pressure in the facial-lingual direction against the tooth—first with one, then with the other instrument handle
2. Vertical tooth mobility, the ability to depress the tooth in its socket, is assessed using the end of an instrument handle to exert pressure against the occlusal or incisal surface of the tooth
Miller’s mobility Miller’s mobility classificationclassification
Class I: Class I: Slight mobility, up to 1 mm of horizontal Slight mobility, up to 1 mm of horizontal displacement in a facial-lingual directiondisplacement in a facial-lingual direction
Class II: Class II: Moderate mobility, greater than 1 mm Moderate mobility, greater than 1 mm of horizontal displacement in a facial-lingual of horizontal displacement in a facial-lingual directiondirection
Class III: Class III: Severe mobility, greater than 1 mm of Severe mobility, greater than 1 mm of displacement in a facial-lingual direction displacement in a facial-lingual direction combined with vertical displacement (tooth combined with vertical displacement (tooth depressible in the socket)depressible in the socket)
Wrong technique of Wrong technique of mobility measurementmobility measurement
THANK YOU!THANK YOU!