CAL, FURCATIONS & MOBILITY

CAL

The clinical attachment level (CAL) refers to the estimated position of the structures that support the tooth as measured with a periodontal probe The CAL provides an estimate of a tooths stability and the loss of bone support

Two terms are commonly used in conjunction with the periodontal support system: Clinical attachment level and clinical attachment loss. Both of these terms may be abbreviated as CAL and can be used synonymously Clinical attachment loss (CAL) is the extent of periodontal support that has been destroyed around a tooth As an example of the use of these two terms, a clinician might report that theclinical attachment levels were calculated for the facial surface of tooth 32 and there is 6 mm of clinical

attachment loss.

Rationale for computing CAL

Probing depths are not reliable indicators of the extent of bone support because these measurements are made from the gingival margin.
The position of gingival margin changes with tissue swelling, overgrowth, and recession

Clinical attachment levels (CALs) are calculated from measurements made from a fixed point that does not changethe cemento-enamel junction (CEJ).
Because the bone level in health is approximately 2 mm apical to the CEJ, clinical attachment levels provide a reliable indication of the extent of bone support for a tooth

The location of the gingival margin is important in determining the CAL, which includes both periodontal pocket depth and recession measurements

When the gingival margin coincides with the CEJ, the CAL and the pocket depth are equal CAL=POCKET DEPTH

When the gingival margin is apical to the CEJ, the CAL is greater than the pocket depth and equal to the amount of visual recession plus the depth of the pocket CAL= RECESSION + POCKET DEPTH

In cases of gingival inflammation or hypertrophy when the gingival margin is on the enamel, the attachment loss is less than the pocket depth CAL= POCKET DEPTH-AMOUNT OF ENLARGEMENT

The gingival margin placement above the CEJ must be measured and this reading subtracted from the periodontal probe reading to obtain the CAL

For example, if a client has generalized 6-mm probe readings but 2-mm of coronal movement of the gingival margin, the actual CAL is 4-mm

If a client has generalized 3-mm of recession and 3-mm pocket readings, the recession and the pocket reading must be added together to obtain the actual CAL of 6-mm

Attachment loss over time (disease activity) indicates actual progression of periodontal disease

CAL is measured from the CEJ to the base of the periodontal pocket Periodontal pocket is measured from the gingival margin to the base of the periodontal pocket Gingival recession is measured from the CEJ to the gingival margin

Furcations

Pose an anatomic challenge Difficult to instrument Difficult to maintain clean

Mandibular Molars

Buccal

Lingual

Mandibular molars have two furcations: Buccal & Lingual Maxillary molars have three furcations: Buccal, mesial & distal

Buccal furcation in mandibular teeth is accessed from buccal side Lingual furcation in mandibular teeth is accessed from lingual side

Buccal furcation of maxillary teeth is accessed from buccal side Mesial furcation of maxillary teeth is accessed from palatal side

Distal furcation is accessed from the palatal side

Diagnosis

Diagnosis of furcation involvement

Thorough clinical examination

Careful probing/inspection

Furcation involvement (invasion): Loss of bone and attachment at the furcation area in multi-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

Glickmans (1953)
Hamp, Nyman & Lindhe (1975) Tarnow and Fletcher (1984) Easley and Drennan (1969)

Glickmans Classification

Grade I IV Based on horizontal measurement of attachment loss in the furcation

Grade I

Incipient furcation involvement Suprabony pocket No radiographic changes

Early bone loss

Grade II

Loss of furcal bone but not through and through Radiographic changes not always possible to see

Grade III

Through and through but not clinically visible

Soft tissues may covers furcation

Grade IV

Bone & soft tissues receded

Through & through defect clinically visible grade IV

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 prognosis

Local Factors To Examine

Tooth Bone Adjacent teeth

Nabers Probe

Probing

CEPs

Enamel Pearls

Bone

Pattern of bone loss

Extent of bone loss

Adjacent Teeth

Condition of teeth
Root proximity

Tooth mobility

Mobility is the loosening of a tooth in its socket. Mobility may result from loss of bone support to the tooth 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 toothfirst with one, then with the other instrument handle

1.

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

Millers mobility classification

Class I: Slight mobility, up to 1 mm of horizontal displacement in a facial-lingual direction Class II: Moderate mobility, greater than 1 mm of horizontal displacement in a facial-lingual direction Class III: Severe mobility, greater than 1 mm of displacement in a facial-lingual direction combined with vertical displacement (tooth depressible in the socket)

Wrong technique of mobility measurement

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