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IT IS ESSENTIALto carry out a careful oral examination to mechanical parameter. The mechanical mobility (a recipro-
establish a definite diagnosis. In particular, the exami- cal of mechanical impedance) of human teeth has also been
nation of periodontal tissues including the appearance of reported (NoYEs et al., 1968; NoYEs and SOLT, 1972; 1973;
the gingiva surface, a measurement of the periodontal 1977) but has not been widely used in clinical dentistry.
pocketing, X-ray examination, and in some cases a histo- This paper aims at interpreting tooth mobility by a
pathological examination is indispensable to the diagnosis. mechanical mobility measurement using an impedance
A manual examination of tooth mobility is carried out head device. Mechanical mobility measurements may have
regularly because it may give an indication of the degree of some relationship to the underlying histopathology. They
attachment loss. Increased tooth mobility may also give an also more accurately measure tooth mobility. The possible
indication of the state of the periodontium, which may be relationships between periodontal pathology and mechani-
altered in inflammatory periodontal disease and occlusal cal mobility are investigated using tooth model experi-
trauma (HALSTEAD et al., 1982). The measurement of ments. Lastly it is proposed that tooth mobility may give
mobility is important in planning treatment and in evalu- an indication of the degree of periodontal attachment loss.
ating its results. Manual tooth mobility is estimated by
moving a tooth with the fingers or dental hand instru-
ments. The readings of trained observers may correspond
to the degree of tooth movement, but their interpretation 2 Measurement and modelling of periodontal
requires skill and experience. tissues
Recently the Periotest method (VON KONIG et al., 1981;
2.1 Measuring device for biomechanical properties of the
D'HOEDT et al., 1985) has been designed to measure tooth
periodontal tissues
mobility objectively. However, the readings for this
method (the contact time per impact between rod and Fig. 1 shows a block diagram of a portable measuring
device for investigating the biomechanical properties of the
First received 6th April and in final form 15th August 1988 periodontal tissues (OKA and YAMAMOTO,1985; OKA et al.,
~) IFMBE: 1989 1987). The vibrator is driven by a random wave which is
Medical & Biological Engineering & Computing January 1989 75
i ow.r
amplifier H filter H r'~176
source
~
amplifier ~[
charge AID
convertor
vibrator~-~
loadce~ l~
.:;;',t
-'t
Fig. 1 Block diagram of the portable measuring device for investiffating the biomechanical properties of the periodontium
restricted by a low-pass filter and amplified by a power and mandibular periodontal tissues as proposed by NoYEs
amplifier. The periodontal tissues are vibrated by a sharp and SOLT(1973). In their paper, they say that 'The mass m~
vibrating tip which is placed on the impedance head. has a quantitative relation to the tooth mass itself. The
Because the preload which is applied to the periodontal spring value k may be related to the stiffness of the perio-
tissues influences the measured value, a load cell is placed dontal ligaments, because the collagen bundles of liga-
in the vibrating rod to read the preload. ments seem spring-like. As blood and lymph in small
The impedance head generates the output signals which vessels and tissue fluid of the ligament may act as fluid
are proportional to input acceleration and force response. damping systems, the periodontal fluids are responsible for
They are amplified by charge amplifiers and sampled by an the damping c~. The lower region of mechanical mobility
analogue-to-digital convertor inserted in a microcomputer spectrum gives information about structures which are
(PC-9801, NEC, Japan). The FFT (Fast Fourier transform) anatomically deep to the periodontium, i.e. the alveolar
processing of both signals is performed using a Hanning bone (c2, m2)'. The mechanical mobility 2 of this equivalent
window function and the mechanical mobility is obtained. model is
The impedance head and vibrator are handled manually
and it takes about 1.4 s to obtain a spectrum below 1 kHz. 1/2 = l/{1/(c I + k/jog) + 1/C2 + 1/jtom2} + jogm I (1)
Therefore fluctuation in the preload and involuntary body where 09 is angular frequency. The broken lines of Fig. 3
movement during measuring can be ignored. During this
measurement the preload is 50gf and the teeth are actu-
1
T
ated buccolingually.
Iz
E 161
2.2 Mechanical modelling parameters
Fig. 2 shows a dynamic mechanical model of maxillary ~5
o
162
E
Y 10 -3
10
, J , , i
I00
I ,ll , i , , , l|ll
I000
frequency.Hz
90
c1 ~" 0 t i i i i 1,, i
o
t-
110 ~ f r100
equency, Hz 1000
777777
-90 -- --
Fig. 3 Mobility spectrum of the maxillary left central incisor
c2 [/I (solid line) and its curve fitting (broken line)
show the mobility spectrum obtained using eqn. 1. The
lowest frequency negative slope gives m2 and the ampli-
tude at the nadir gives 1/C2. The mid-frequency positive
slopes gives k and the amplitude of the peak gives 1/cl
Jr 1/C2. The negative slope at the highest frequency gives
mI 9
77777-/ Accordingly it is possible to determine the modelling
Fig. 2 Dynamic mechanical model of the periodontium proposed parameters cl, c 2 and k using graphical techniques. In this
by NOYES and SOLT (1973) study these parameters were obtained rapidly and easily
76 Medical & Biological Engineering & Computing January 1989
from a curve-fitting method using a personal computer. obtained by manual examination. M0 coincides with M0'
Though it is possible to determine five parameters, only in 78.7 per cent, M1 in 100 per cent, M2 in 71.4 per cent
c~, c 2 and k are chosen, because they appear to relate best and M3 in 100 per cent. The curve-fitting error of model-
to the mechanical properties of the periodontal ligament. ling parameters and mistaken diagnoses of tooth mobility
As the measuring frequency is below I kHz, at times non- by a clinician were considered to be the causes of disagree-
peak amplitude at the highest frequency is obtained. In ment. This method produced an accurate and objective
this case, it is difficult to determine c~ accurately. When c~ clinical measurement of tooth mobility, rather than a sub-
changes, the phase spectrum of the mechanical mobility jective estimate which would result from clinical exami-
greatly changes. Therefore c~ is determined from a full nation.
consideration of the phase spectrum. Fig. 3 shows a curve
fitting (broken line) of the mobility spectrum of the maxil-
lary left central incisor (solid line). 3.2 N e w clinical mobility with mobility triangle figure
To understand clinical mobility by visual interpretation
a new mobility triangle figure (MT figure) is proposed (Fig.
3 Clinical tooth mobility 4). The centroid of an equilateral triangle is 0 and each
3.1 Clinical mobility with discriminant score
k
The modelling parameters of the maxillary right and left
central incisors are determined from their mobility spectra e J 9
and curve fittings.
The most common approach to testing tooth mobility
clinically is to support the crown of the tooth on the
lingual surface with an instrument or forefinger and apply
force to the facial surface. The degree of movement is
ascertained by comparison with adjacent teeth that are not
C1 C2 C1 C2
being moved. The mobility is grouped on an M0 to M3
a MO b M11
scale, with the higher number indicating the greater move-
ment both buccolingually and apically (MUHLEMANN,
k k
1967; SCHLUGER et al., 1977; GRANT et al., 1979; HAL-
jl' /l"
STEAD et al., 1982). They are as follows:
M0 = clinically firm tooth within normal range
M 1 = palpable mobility, buccolingually
M2 = visible mobility, buccolingually but with no mobility J
direction c M2 I d M3 I
Z1 = 0"3376c~ + 0"0169c2 - 0"1334k - 4"3020 Fig. 4 Reference mobility triangle figure: (a) MO', (b) MI', (c)
M2', (d) M3' and (e) deciduous tooth
Z2 = -0"0396c~ + 0"0063c 2 + 0"1863k - 1"4773
vertex is a standardised mean value of the modelling
Z3 = -0"0164c 1 + 0"0013c2 + 0'0283k - 0'0407 (2) parameters of healthy periodontium (M0'). Fig. 4a shows a
The scores of the linear discriminant functions are calcu- reference M T figure of M0' with the standard deviation of
lated by an observation (c~, c2 and k). The biggest score in the parameters (shown by I [). Fig. 4b shows that of
Z0, Z1, Z2 and Z3 gives the new group of the observation. MI', Fig. 4c shows that of M2' and Fig. 4d shows that of
If the biggest score is Z0, then the new group is M0', if Z1 M3' also with standard deviations. Although the standard
then Ml', if Z2 then M2' and if Z3 then M3'. deviations are large, it is possible to determine the tooth
Table l shows the relationship between the groups cal- mobility group to which the M T figure belongs. When
culated according to discriminant score and those periodontal pathology advances and tooth movement
becomes greater, the M T figure shrinks and modelling
parameters decrease accordingly.
Table 1 Evaluation of classification by Fig. 4e shows a reference M T figure generated from four
means of discriminant score deciduous teeth which have a healthy periodontium. The
M0' MI' M2' M3' subjects were 4-5 years old and permanent teeth had
M0 37 6 4 0 begun their development. As there are few observations of
M1 0 9 0 0 deciduous teeth, the M T figure is shown without any stan-
M2 0 1 5 1 dard deviations. The modelling parameters of deciduous
M3 0 0 0 6 teeth are smaller than those of permanent teeth.
Medical & Biological Engineering & Computing January 1989 77
4 Measurement of tooth model dental ligament space, which is one of the above (a) of
periodontal changes. The hardness of impression materials
4.1 T o o t h model is varied on the above assumption (b) representing its
To examine the physical basis of the modelling param- changes. The height of the surrounding improved stone is
eters of periodontium, some tooth models with different varied on the above assumption of loss of alveolar bone
mountings have been made. One is shown in Fig. 5. Patho- support, which is also one of the changes above (a).
logical mobility is caused by one or more of the following The artificial tooth consists of a resin (maxillary left
factors (CARRANZA,1984): central incisor, B2-306, Nissin) and artificial periodontal
ligaments arc made of silicone impression materials. The
artificial alveolar bone is an improved stone (Vermix stone,
resin tooth Kerr). The silicone impression materials arc of three types:
(a) Xantopren Gr~in Plus (Griin)
(b) G-C's Flcxicon Regular (Regular)
silicone (c) Xantopren (Plus).
impression moterio[
The hardness of these materials is 52 (Griin), 47 (Regular)
and 33 (Plus) as tested by a hardness tester (JA, Shimazu).
improved stone The width of these materials is 0.28mm, 0-56mm and
0.84mm, respectively. The height of the surrounding
improved stone, which is divided into 17 levels between
Fig. 5 Tooth model with different tooth mountings
cervical line and root apex and carefully scraped, is 0
(a) loss of tooth support (bone loss). The amount of tooth (cervical line) to 7.
movement depends upon the severity and distribution
of the tissue loss on individual root surfaces, the length
and shape of the roots, and the root size compared 4.2 Modelling parameters o f the tooth model
with that of the crown.
Fig. 6 shows the modelling parameters cl, c2 and k
(b) the extension of inflammation from the gingiva into the
when the hardness of silicone impression materials is fixed
periodontal ligament results in degenerative changes
and the width is varied. In Fig. 6 9 is Plus, A is Griin and
which increase mobility. The changes usually occur in
x is Regular. (a) is the change of el, (b) is change ofc 2 and
periodontal disease which has advanced beyond the
(c) is change of k. These figures suggest that Cl, c2 and k
early stages, but pathological mobility is sometimes
decrease when the width of the impression materials
observed in severe gingivitis.
increases. The coefficient of their correlation is - 0 . 8 6 to
In this study, the width of impression materials is varied -0.99.
on the assumption that it represents widening the perio- Fig. 7 shows the variation in modelling parameters
9 1000 60
T O A ~ ~ E
E E A z
Ut 0
x o a = (2 o %
Z
X 0 z X ~< Z~
ca x J" o X
2
X O
0 I I J 0 I I I 0 i
XI
0 0'84 0 0'84 0 0 84
d.mm d, mm d, mm
a c1 b c2 c k
Fig. 6 Modelling parameters' changes when the hardness of a silicone impression material is fixed and its width is varied
9 Plus A Grin x Regular
1000 60
A A
I
"T X E
X A "~
E E O z A
ul O X X
Z 0 X Z X --x O
a~ O -
ca O ca ar X X
O O
0
I I I 0 I I I 0 i i I
51 33 51 33 51 33
h Q r d n e s s , JIS h Q r d n e s s , JIS hQrdness, JIS
a c1 b c2 c k
Fig. 7 Modelling parameters' changes when the width is fixed and the hardness is varied. J I S : Japanese Industrial Standard
A 0.28 mm x 0.56 mm 0 0"84 mm
78 Medical & Biological Engineering & Computing January 1989
8 700 3O
0
'T
0
3 "7 0 E
E 2 E 0 Z
x O
X & 0
Z O
X 6 z
u & x g 8 dr
• • x x
,~
~
o
x
o
ix
I I I I i i 0 I I I I I i i i i Q
o 7 0 7 0 7
resorption resorption resorption
a c1 b c2 c k
Fig. 8 Modelling parameters' changes when the surroundinff stone is scraped and the root of the artificial tooth is exposed
0 0.28 mm A 0"56 nun x 0"84 mm
when the width is fixed and the hardness is varied. /X is trolled rod percusses the tooth four times per second. The
0.28ram, x is 0.56mm and O is 0-84mm. These figures rod is decelerated when it impinges on the tooth. After
also suggest that the modelling parameters decrease when hitting the tooth, the rod recoils. The contact time per
the hardness decreases. The coefficient correlation is impact between rod and tooth can be recorded by the
- 0 . 7 0 to --0.99. microcomputer of the Periotest unit. It calculates the mean
Fig. 8 shows the experimental results when the sur- contact time from roughly 16 percussion signals per tooth.
rounding improved stone is scraped and the root of the The result obtained t h e n represents the Periotest (PT)
artificial tooth is exposed. The impression material is Plus; value ( - 8 to 50) of the tooth. In comparison with manual
O is 0.28mm, A is 0-56ram and x is 0.84mm. It is found tooth mobility examination, the PT value can be broken
that the modelling parameters decrease when the loss of down into the following ranges: M 0 = - 8 to +9,
alveolar bone support advances. Their correlation coeffi- M1 = 10 to 19, M2 = 20 to 29 and M3 = 30 to 50. This
cient is - 0 . 8 3 to -0.97. value constitutes reproducible, quantitative information of
These experimental results make it clear that (as the state of the periodontium, i.e. damping effect, but its
expected) the greater a tooth mobility becomes, the smaller correspondence to the mechanical structure of periodon-
the modelling parameters become. All the modelling tium is not clear.
parameters were influenced by the changes. The peculiarity of the present method will be described
below. Maxillary right and left central incisors whose radi-
ographs are shown in Figs. 9a and b were diagnosed as
M0 or M1 and M1 or M2, respectively, by a clinician.
5 Discussion Their discriminant scores are shown in Table 2 and
In the Periotest (Siemens) method, an electrically con- suggest that the maxillary right and left teeth in Fig. 9a are
o MO-M1 b M1 - M 2
Fig. 9 Radiographs of maxillary right and left central incisors which are inaccurately diagnosed as MO or M I by a clinician
'T
E
I/I
O
o o
O %I
-
z 0
~
oo 0
-
z oO O
O
Z
:o-O o X X
r'l
0 ~ t I I I 0 i J i f 0 I I I !
0 4O o 40 0 800
-I -1 -I
Cl,NSm c1 , Nsm c2. Nsm
a c I and c 2 b c 1 ond k c c_ a n d k
Z
Fig. 11 Correlation of c 1, c 2 and k of 69 teeth 0 MO A M1 x M2 [] M3
8O Medical & Biological Engineering & Computing January 1989
1987'10/18 (Sun)
[ parameters ] score ]
c, 26.604 z, 6.849
c2 421.236 z2 4.172
U
k 266439.0 z= 3.496
m, [g] 10.562 z, 1.997
m= 0.609
.O
O
E
CI C2
Mobility Triangle
frequency
File name: a071018 Message : clinical mobility " M 0
Fig. 12 A complete diagnosis which is given by the automatic diagnosis system of tooth mobility
Acknowledgments--H. Oka wishes to thank Professor R. Suzuki NOYES, D. H. and SOLT, C. W. (1972) Relationship between
of Tokyo University for his helpful advice. "tooth mobility" and "mechanical mobility of teeth", d. Perio-
dontol., 43, 301-303.
NO'd~s, D. H. and SOLT, C. W. (1973) Measurement of mechanical
mobility of human incisors with sinusoidal forces. J. Biomech.,
References 6, 439-442.
CARRANZA,F. A. (1984) Glickman's clinical periodontology. W. B. NOYE.S, D. H. and SOLT, C. W. (1977) Elastic response of the
Saunders Co., 283-284. temporo mandibular joint to very small forces. J. Periodontol.,
D'HOEDT, B., LUKAS, O., MOHLBRADT, L., SCHOLZ, F., SCHULTE, 48, 98-100.
W., QUANTE, F. and TOPKAYA, A. (1985) Das OKA, H. and YAMAMOTO,T. (1985) Measuring device for bio-
Periotestverfahren-Entwicklung und klinische Prfifung. Dtsch mechanical properties of human paradentium using impedance
Zahn~rztl., Z-40, 113-125. head. Proc. XIV ICMBE and XII ICMP, Med. & Biol. Eng. of
GRANT, D. A., STERN, I. B. and EVERETT,F. G. (1979) Periodontics Comput. Suppl., Part 2, 1275-1276.
in the tradition of Orban and Gottlieb. The C. V. Mosby Co., OKA, H., YAMAMOTO,T. and OKUMtmA, Y. (1987) Measuring
475-477. device of biomechanical impedance for portable use. lnnov.
HALSTEAD,C. L., BLOZIS,G. G., DRINNAN,A. J. and GIER, R. E. Tech. Biol. Med., 8, 1-11.
(1982) Physical evaluation of the dental patient. The C. V. SCHLUGER,S., YUODEUS,R. A. and PAGE, R. C. (1977) Periodontal
Mosby Co., 317-322. disease--basic phenomena, clinical management, and occlusal
MOHLEMANN, H. R. (1967) Tooth mobility: a review of clinical and restorative interrelationships. Lea & Febiger, 310-311.
aspects and research findings. J. Periodontol., 38, 686--713. VON KONm, M., LUKAS, D., QUANTE, F., SCHULTE, W. and
NOYES, D. H., CLARK, J. W. and WATSON,C. E. (1968) Mechani- TOPKAVA, A. (1981) MeBverfahren zur quantitativen Beurteil:
cal input impedance of human teeth in vivo. Med. & Biol. Eng., ung de Schweregrades von Parodontopathien (Periotest).
6, 487-492. Dtsch. Zahn?zrztl., Z---36, 451-454.
Authors' biographies
Hisao Oka was born in Hyogo, Japan, in Tatsuma Yamamoto was born in Okayama,
January 1954. He received BE and ME Japan, on the 31st August 1927. He received
degrees in Electrical Engineering from the BE degree in Electrical Engineering from
Okayama University, Japan in 1976 and 1978, Himeji Technical College in 1953 and a Ph.D.
respectively, and completed a DE degree in from Kyoto University in 1967. From 1953 to
Biomechanical Property Measurement at 1963 he was an instructor at the Himeji Tech-
Osaka University in 1988. He joined the nical College, then joined the Department of
Department of Electrical Engineering, Electrical Engineering, Okayama University,
Okayama University in 1978. He is currently in April 1963. He became a Professor of Elec-
interested in measurements and applications of biomechanical trical Engineering in 1969. His research interests are electrical
properties. He is a member of the Institute of Electrical Engineers and mechanical properties of biological substances, and their
of Japan, the Japan Society of Medical Electronics & Biological measurements. Dr Yamamoto is a member of the Japan Society
Engineering and the Institute of Electronics, Information & of Medical Electronics & Biological Engineering and the Institute
Communication Engineers of Japan. of Electronics, Information & Communication Engineers of
Japan.
Takayoshi Kawazoe was born in Hyogo,
Keiji Saratani was born in Osaka, Japan, in Japan, in January 1942. He received his DDS
1954. He received his DDS degree from Osaka degree from Osaka Dental University, Japan,
Dental University, Japan, in 1980 and his in 1966, and Ph.D. there in 1970. He has been
Ph.D. there in 1984. He joined the Second a Professor of the Second Department of
Department of Prosthetic Dentistry, Osaka Prosthetic Dentistry, Osaka Dental Uni-
Dental University, in 1984. He is currently versity, since 1982. He is presently interested in
interested in dynamic analysis of tooth- the diagnosis of occlusion and tempo-
supporting structures. He is a member of the romandibular joint disorders. He is a member
Japan Society of Medical Electronics & Bio- of the Japan Society of Medical Electronics & Biological Engin-
logical Engineering and the Japan Prosthodontic Society. eering and the Japan Prosthodontic Society.