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

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