JOURNAL CLUB

PRESENTATION

By- Richa Bhosale

II MDS
 The location of cemento enamel junction for CAL
measurement: A clinical crisis
Authors : Vandana K. L., Ira Gupta

Journal of Indian Society of Periodontology - Volume 13, Issue 1, Jan-Apr 2009

 INTRODUCTION

 An important parameter to assess periodontal destruction is

loss of connective tissue attachment to the tooth root surface

Also known as :

 Clinical Attachment Loss/Clinical Attachment Level/Loss of attachment

( CAL ) / ( LOA )

 Measured from Cemento-enamel junction (CEJ) which acts as a static landmark

To the base of the pocket

 CAL is considered as “Gold Standard ” to record disease status

Periodontal Diseases: Diagnosis by Gary C Armitage* Ann Periodontol 1996:1:37-215.
 Recordings of attachment loss made from points other than CEJ is referred as Relative
attachment level (RAL).

 Assesment of CAL from a fixed point other than CEJ is referred as Fixed Reference Point
(FRP)

 The CEJ represents the anatomic limit between the crown and the root surface.

“ The area of union of the cementum and enamel at the cervical region of the tooth”

 The CEJ is not a regular line with a mild or regular contour

 Types of relationship between enamel & cementum at cervical region are:

 Problems faced while measuring CEJ:

 Subgingival position of CEJ

 CEJ obscured by calculus or dental restorations.

 The three hard tissues found at the CEJ region are unpredictable and irregular

 Variation on clinician’s part

 Calculating CAL

1. In presence of gingival recession

2. When the Gingival Margin covers the CEJ

3. When the Gingival Margin is at normal level

Nield-Gehrig JS, Fundamentals of Periodontal Instrumentation and Advanced Root Instrumentation, 7th ed
 OBJECTIVE
The objective of this study is to locate CEJ before (close) and after
(open) flap reflection using a fixed reference point (FRP) to determine
the number of times the close CEJ was under, over or equi-estimated
with the open CEJ measurements.
 MATERIALS AND METHODS

 Subjects - Males/Females from the outpatient department of Periodontics,

College of Dental Sciences, Davangere, Karnataka, India.

 Age group - 16 to 45 years.

 Inclusion criteria - patients who required periodontal flap surgery.

 Exclusion group - patients with a history of known systemic

diseases/pregnant and lactating women.

 Total no. of sites - 232.

 Paired-‘t’ test was used to make intra-group comparison of measurements for

CEJ, before and after reflection of flap
Recording of CEJ

 Custom made stent and (Hu-Friedy) UNC-15 probe were used.

 The stent was made with the cold cure acrylic by the sprinkle method.

 It covered the occlusal/incisal 1/3rd on the buccal and the lingual side.

 The thickness of the stent was about 2-3 mm.

 The vertical grooves were made on the stent on buccal and lingual side using straight
fissure bur and air-rotor handpiece
 RESULTS

Comparison of close and open measurement of CEJ

Distribution of the number and percentage of sites of close and open CEJ at different levels
Higher % of overestimated values for:

 Mesiobuccal
 Distobuccal
 Midbuccal
 Mesiolingual
 Midlingual

 For six distolingual sites, a higher % of the close CEJ measurements was
underestimated (50%).

 Equi-measurements of close and open CEJ numerical data was remarkably lower
than the under and overestimation of measurements (25%)
 DISCUSSION
 The Clinical attachment levels (CAL) provides better information relating to gain or
loss of attachment to the root surface and in assessing the disease progression than
pocket depth measurements.

 Recording of CAL using close CEJ measurements estimates risk and progression of
periodontitis, as well the outcome of periodontal therapy.

 The open CEJ measurements are the true measurements as the location of CEJ is
visualized after flap reflection.
 The relative attachment level is an alternative to CAL and not a substitute as the
FRP is always coronal to CEJ and the true attachment level measurements are
from CEJ to base of the pocket (BOP).

 CAL measurements done without FRP is subjected to great variation

+ Aspects
 The FRP provided by the custom stent serves as a good tool to understand the
over/under estimation of CEJ location before and after flap reflection

 The reproducibility of periodontal measurements is better using a stent.

 The RAL measurements are beneficial in non-surgical periodontics

Drawbacks

 The stent can be lost or broken or may become distorted

 The tooth may be restored

 Use of relative reference points provides no information relating to

attachment levels at a single examination
 CONCLUSION

 Periodontal therapy is based upon information regarding longitudinal attachment level

data.

 Accurate, reliable measurement of attachment level is an important aspect of

periodontal diagnosis and treatment.

 Ultimately improve the diagnosis and treatment of periodontitis.

 Despite certain disadvantages of stent, the fixed reference point provides a simple
solution for CAL measurement.
Other Techniques
 A study by Jeffcoat MK et al used Automated periodontal probe for CEJ
detection and measured attachment level relative to the CEJ in a single
measurement but used as a research tool only.

 Marks et al used Florida probe a third generation, commercially available,

periodontal probe that combines controlled force application, automated
measurement and computerized data collection and provides a means of
recording attachment changes over time.

 Computerized CEJ probe –

 tested by Preshaw et al.
 A study by R.Deepa et al concluded it has better accuracy than FSP and
Manual probing
Computerized CEJ probe Florida Probe Unit

UNC probe
Similar studies :

 A study by V.L. Barbosa et al in 2016 compared CAL (direct) & CAL (indirect)
values and concluded that indirect values are over estimated than the direct
readings which are taken from FRP i.e. CEJ

 A study by Ahmed S. AlZahrani in 2017 recorded the position of the gingival

margin (GM) relative to the CEJ by means of a UNC-15 probe along with a
customized stent to compare the reproducibility of the measurements of GM-CEJ
distance before and after flap elevation where the closed flap measurements were
over -estimated
THANK YOU