Parameters That Influence the Position of the Facial Gingival Margin on Maxillary Anterior Teeth

Parameters That Influence the Position of the Facial Gingival Margin on Maxillary Anterior Teeth Philip J. Vassilopoulos, DDS, DMD, Nicolaas C. Geurs, DDS, MS, and Mia L. Geisinger, DDS, MS The free gingival margin in the maxillary anterior teeth plays a key role in the esthetics of the patient s smile. The upper anterior teeth and their associated gingiva frame the smile of the patient and compliment the esthetic appearance of the face. The free gingival margin is a part of the dentogingival complex, with the underlying anatomy to define its location. Other parameters and conditions that influence the final location of free gingival margin are described, such as alveolar crest position, periodontal biotype, altered passive eruption, and malpositioned teeth. Moreover, edentulous areas associated with congenitally missing lateral incisors, peg laterals, and teeth lost due to trauma can change the location of the free gingival margin and affect which site development clinical techniques are to be implemented to restore it back to normal. A comprehensive periodontal evaluation is of utmost importance in detecting periodontal disease and recording the position of the free gingival margin. Annual reassessment of the free gingival margin can lead to treatment decisions that improve the therapeutic outcomes. (Semin Orthod 2013;19:37-48.) 2013 Elsevier Inc. All rights reserved. Anatomy of the Gingiva in Health The oral mucosa is divided into the gingiva and alveolar mucosa. These 2 tissues are distinct clinically and histologically, 1 and the proportions of each in a patient can predispose that individual to an increased likelihood of mucogingival deformities. 2,3 In health, the facial gingiva begins at the mucogingival junction and continues coronally, covering the alveolar process to the free gingival margin. The gingiva forms the epithelial attachment to the tooth by means of the junctional epithelium at the cervix of the tooth. 4 Department of Periodontology, UAB School of Dentistry, Birmingham, AL. Address correspondence to Philip J. Vassilopoulos, DDS, DMD, Department of Periodontology, UAB School of Dentistry, 1720 2nd Avenue South, SDB 412, Birmingham, AL 35294-0007. E-mail: pvass@uab.edu 2013 Elsevier Inc. All rights reserved. 1073-8746/13/1901-0$30.00/0 http://dx.doi.org/10.1053/j.sodo.2012.10.005 Gingiva is not mobile but does vary in presentation between a thick phenotype (firm, flat gingival scallop, thick, deeply stippled) and a thin phenotype (thin and highly scalloped with minimal stippling). 5,6 Gingival width varies by age, 7,8 tooth type, and individual patient. 9 The facial gingival margin location changes throughout life, but most commonly is identified as concurrent with the cementoenamel junction (CEJ) in a healthy adult. 10 Apical to the contact area between 2 teeth, the interdental gingival possesses a concave form when viewed from a buccal-lingual view. This concavity is called a col and is located apical to the contact point of the teeth and therefore not visible clinically. The col can be described as a connection between the junctional epithelia of 2 adjacent teeth and thus is not keratinized. As the shape of the contact points between teeth differs, the depth and position of the col also differs based on the tooth morphology and position, with a narrow col Seminars in Orthodontics, Vol 19, No 1 (March), 2013: pp 37-48 37

38 Vassilopoulos, Geurs, and Geisinger present at incisor teeth and a broader col present at posterior teeth. 11 The Interdental Papillae The interdental papilla occupies the interdental or embrasure space and acts as a barrier to protect underlying periodontal structures 12 and also plays an esthetic role. 13 The distance from the contact point (CP) to the interproximal alveolar crest (BC) has been identified as a critical factor in the presence of a complete papilla, with nearly 100% of papillae complete if CP BC is 5 mm. 14 Age, 15 inter-radicular distance, 16,17 and embrasure area have also been shown to influence papilla presence or absence. It has been discussed that the interdental papilla can be considered a house and that the components of the integrity of that house include the roof (contact point), roof contour (proximal tooth surface morphology), roof-wall junction (CEJ), walls (interdental distance), floor (bone crest), house height (embrasure dimensions), and cleanliness of the roof (plaque control) (Fig 1). 18 This succinct discussion allows for a clear visualization of factors that play a role in papillae maintenance in a clinical setting. A mucogingival deformity is a departure from the normal dimension and morphology of and/or interrelationship between gingiva and alveolar mucosa. Gingival recession or marginal tissue recession is one of multiple mucogingival deformities. It is defined as the location of the marginal periodontal tissues apical to the CEJ. Recession results in localized or generalized root exposures, leading to possible esthetic Figure 1. Interdental papillae. (Color version of figure is available online.) Figure 2. Gingival recession due to periodontitis. (Color version of figure is available online.) problems, hypersensitivity, root caries, and tooth abrasion. 19 The most common etiologic factors associated with gingival recessions include periodontal disease (Fig 2), traumatic toothbrushing, anatomic variations (fenestration dehiscence and abnormal tooth position), thin gingival phenotype, orthodontic treatment, iatrogenic factors related to the location of restoration margins, previous periodontal surgery, high muscle attachment and aberrant frenum, and the use of smokeless tobacco. 20-23 Factors Affecting the Position of the Free Gingival Margin There are several factors that determine the position of the free gingival margin. The following are considered the most important: 1. Alveolar crest position 2. Gingival biotype 3. Altered passive eruption 4. Malpositioned teeth Alveolar crest position The distance from the gingival margin to the alveolar crest has been extensively studied. A distance of approximately 3 mm is commonly accepted as the distance between the alveolar crest and the gingival margin. This distance is occupied by the connective tissue attachment, the epithelial attachment, and the sulcus. Histologic evaluations found this distance to be equally divided among these 3 zones. The mean epithelial attachment was 0.97 mm and the mean connective tissue attachment was 1.07 mm

Parameters that Influence the Position of the Facial Gingival Margin 39 for a total soft-tissue attachment of 2.04 mm. The broad range of data which indicated 0-6.5 mm for the connective tissue attachment were likely due, and the challenges associated with, the processing of the autopsy material without any information acquired for previous periodontal disease, or consideration of tooth type, were considered to be some of the limitations of this study. 24 To reduce errors of tissue processing, these measurements were repeated later in nondecalcified human autopsy material. In this study, the range of biological width was 0.75-4.33 mm in the mandibular teeth, and 3.75 mm was the average dentogingival height. An additional finding was that 15% of dental restorations violated the biological width. It was suggested that in these cases, the dimension of the biological width might be even 2 mm in restored teeth. 25 The distance from alveolar crest to the gingival margin has also been measured on maxillary central incisors with bone sounding. An average of 3 mm was found on the midfacial and an average of 3-4.5 mm interproximally. 26 Similar measurements were found in a study after the healing of denuded interproximal bone areas. After 3 years, a mean distance of 4.3 mm developed between the free gingival margin and the alveolar crest. 27 In another study using the bone sounding technique mentioned previously, an overall mean of 3.70-mm gingival height was found at the midfacial aspect and 4.04-mm gingival height at the mesial-facial aspect of the dentogingival unit of maxillary central incisors. 28 Bone sounding measurements are clinical measurements with questionable accuracy. Using cone-beam computed tomography, the papillary height measurements were correlated to the biotype. In a thin biotype, a greater distance between CEJ and alveolar crest was found compared with a thick biotype. 29 The papillary height averaged 4.43 mm in the thin biotype and 2.85 mm in the thick biotype. A classification system was proposed by Kois 30 for the distance of CEJ to the alveolar crest. A normal crest, defined as 3 mm apical to the CEJ, occurs in 85% of the population. A high crest, 3 mm apical to the CEJ, occurs in 2% of the population. A low crest, 3 mm apical to the CEJ, occurs in 13% of the population. In conclusion, the 3-mm rule is a good indication of the distance from the free gingival margin to the alveolar crest in the facial aspect of anterior teeth. That distance is different in the interproximal papillary area and can increase up to 4.3-mm mean dimension in thin gingival biotype cases. When the distance is greater than these measurements, caution should be taken in exposing these teeth to orthodontic movement, as they may be more prone to recession of the gingival margin. Gingival biotype The morphology of gingivae is associated with the underlying bone anatomy, tooth length, form, and shape. 31 Two gingival biotypes are described: the scalloped/thin and the flat/thick. Thin and thick biotypes are characteristically different. A thin gingival biotype is characterized by high-scalloped thin soft tissue, slender teeth, and long interproximal gingival embrasure spaces with small contact points located at the incisal third of teeth (Fig 3). The scalloped gingivae were correlated to a tapered tooth form and thin alveolar bone, whereas the flat gingivae were combined with square tooth form and thick bone. 32,33 The clinical appearance of these biotypes can be evaluated by visual assessment, assessment with utilization of the periodontal probe, and assessment based on cone-beam computed tomography. Visual evaluation relies on identification of specific features associated with each biotype, as described previously, and it is subject to personal perception. In 2003, a new methodology was introduced to evaluate the type of biotype by using the periodontal probe for the investigation of the thickness and height of periimplant mucosa around 2-stage maxillary ante- Figure 3. Thin gingival biotype. (Color version of figure is available online.)

40 Vassilopoulos, Geurs, and Geisinger probe visibility can be a valid and an easy way to assess the biotype. Clinical and radiographic studies support the existence of 2 different biotypes: thin and thick. Figure 4. Periodontal probing on the maxillary central incisors. (Color version of figure is available online.) rior implants. Thin peri-implant tissues allowed the periodontal probe to shine through the free gingivae in contrast to thick peri-implant mucosa, where the periodontal probe became invisible. 34 The periodontal probe technique has been used in a population of periodontally healthy subjects to distinguish between the 2 biotypes. 35 Although this technique is noninvasive and easily reproducible, it can be less accurate in the assessment of gingival thickness on the maxillary central incisors area 36 (Fig 4). Direct measurements of the gingival thickness with a periodontal probe can also be used to determine the type of biotype. Thick biotype is characterized by 1.5-mm gingival tissue thickness and thin biotype is 1.5-mm thickness. The accuracy of this technique is dependent on the angulation of the probe, distortion of tissue during the measurements, and the way of adjusting to the nearest mm on a probe with 1-mm calibration markings. 37 Cone-beam computed tomography can be used to correlate clinical measurements to radiographic measurements. In a study of 22 fresh cadaver heads, a moderate association between the labial alveolar bone morphology and the corresponding gingival thickness was found. 38 When combining information from cone-beam computed tomographs, diagnostic impressions, and clinical examinations, the periodontal biotype can be related to gingival thickness, facial plate thickness, position of alveolar crest, zone of keratinized tissue, gingival architecture, and probe visibility. 29 In conclusion, there are several methods to detect the tissue biotype, and the periodontal Altered passive eruption The active eruption of the tooth continues and is complete when the tooth comes in contact with the opposing dentition. Passive eruption of the tooth follows when the dentogingival unit moves apically toward the CEJ. Altered or delayed passive eruption is defined as the condition where the free gingival margin is located on the enamel of the tooth and is a distance farther coronally from the CEJ, resulting in short clinical crowns (Fig 5). Altered passive eruption can be classified based on the location of the mucogingival junction and the position of the alveolar crest. Type 1 is characterized by a wide band of keratinized gingiva, with the mucogingival junction apical to the alveolar crest. Type 2 indicates a narrow zone of keratinized gingivae, with the position of the mucogingival junction at the level of the CEJ. Subtype A requires a distance of 1.5-2 mm between the CEJ and the alveolar crest, and subtype B denotes that the alveolar crest and CEJ are at the same level. Subtype B is common in the phase of the mixed dentition. When the CEJ is in close proximity to the alveolar crest, there is no space for the dentogingival unit to move apically toward the root of the tooth. This condition represents type 1B, according to Coslet, 39 and is frequently seen. An evaluation of the morphology of the dentogingival unit in 123 individuals diagnosed with Figure 5. Altered passive eruption. (Color version of figure is available online.)

Parameters that Influence the Position of the Facial Gingival Margin 41 Figure 6. Gingival recession on the lower left central incisor. Figure 8. Gingival recession corrected with orthodontic movement. delayed passive eruption was performed by clinical examination and parallel profile radiography of upper central incisors. Although the gingival position on the teeth with altered passive eruption is more coronal to the CEJ, probing depths (PDs) were found to be shallow, and no correlation was found between PDs deeper than 3 mm and altered passive eruption. 40 In a systematic review of the literature on the status of clinical crown height on different age-groups and tooth types, the gingival margin was found to change with time, as indicated by the crown length measurements. 41 Eruption takes place during puberty and adulthood and finishes at the end of adolescence and the third decade of life, resulting in the position of the gingival margin toward the cervical area of the anatomic crown of teeth. 42 In conclusion, the clinical crowns of teeth are continually increasing and, subsequently, the position of gingival margin is changing and moving apically. Malpositioned teeth Tooth malposition plays a role in the position of the free gingival margin. Andlin-Sobocki and Bodin 43 examined malpositioned teeth in 38 children aged 7-12 years in relation to changes of widths of attached and keratinized gingivae and clinical crown height. Clinical crown height decreased as the teeth moved facially and increased as teeth moved lingually within the contours of the alveolus. The same was found when lingually displaced lateral incisors were moved facially to be aligned properly within the dental arch (Figs 6 9). 44 Figure 7. Gingival recession on the lower left central incisor. Figure 9. Gingival recession corrected with orthodontic movement.

42 Vassilopoulos, Geurs, and Geisinger In conclusion, a minor 1-mm incorrect position of the tooth can cause apical movement of the gingival margin. The misalignment of teeth can be corrected with orthodontic movement. That movement can influence the coronal location of the gingival margin and can increase the dentogingival dimension and clinical crown length. Gingival Margin and Missing Anterior Teeth The incidence of congenitally missing teeth is approximately 4%-5%. 45,46 The incidence is similar between the maxilla and mandible. Bilateral agenesis is far more prevalent than unilateral agenesis. Most often congenitally missing teeth are the mandibular premolars and maxillary lateral incisors. 47 For the replacement of congenitally missing teeth, treatment with osseointegrated implants should always be considered. However, because the development of the alveolus does not occur with congenitally missing lateral incisors, it often leads to an underdeveloped ridge, which is especially true for the maxilla (Fig 10). 48 Orthodontic movement can be used for the augmentation of the underdeveloped alveolar ridge. Orthodontic movement of adjacent teeth through the edentulous alveolar ridge can develop adequate alveolar ridge dimensions without resorting to grafting procedures. 49 It has been suggested that strategic eruption of a canine into a site of a congenitally missing lateral followed by distal movement can develop a site with proper dimensions able to receive an implant without a graft. 49,50 Figure 10. Maxillary deficiency in the lateral incisors area. (Color version of figure is available online.) However, other studies indicate that orthodontic treatment to create space for an endosseous dental implant can result in a significant decrease in the width and height of the alveolar ridge in patients congenitally missing a maxillary lateral incisor who received orthodontic treatment. 51,52 By tipping maxillary incisors in the direction of the angular defect to increase alveolar bone volume in the implant site, simultaneous improvement of the interproximal papillary height can also be expected. 53 Gingival development, tooth eruption, and alveolar development are correlated. 54 Therefore, sites with congenitally missing teeth often have deficient thickness and width of keratinized mucosa. Augmentation of both the keratinized mucosa and osseous tissues is frequently necessary. The soft tissue surrounding a dental implant is essential for successful implant restoration. This success includes the establishment of health, function, and esthetics. The functional implant restoration has to have a component that traverses the oral mucosa. As with a natural tooth, there is a need to provide a connection or seal around the neck of the implant or an abutment. The development process of the tooth has the formation of a biological connection between the living tissues. For a dental implant, this connection has to be created during the healing process after placement of the implant. The implant soft-tissue interface is notably similar to that of natural teeth. The function of the epithelium surrounding dental implants is similar to gingival epithelium. It includes an oral epithelium, a sulcular epithelium, and a junctional epithelium with underlying connective tissue. From the gingival margin into the sulcus, the epithelium changes to sulcular epithelium and ends in a junctional or barrier epithelium. 55-57 The ability of biomaterials to promote epithelial wound healing and to establish a junctional epithelium is an important aspect of the success of dental implants. The protection of the connective tissue and osseous tissue surrounding the implant by providing this barrier is crucial for the maintenance of peri-implant structures and the stability of the implant system. The lack of consensus regarding peri-implant soft-tissue health is related to multifactorial issues. Oral hygiene, host immunologic responses, implant design, location in the mouth, local

Parameters that Influence the Position of the Facial Gingival Margin 43 anatomy, function, and surgical techniques make it difficult to design studies that will provide conclusive answers. The advantages of keratinized attached mucosa surrounding the implant are less controversial. It is the preference of most clinicians to surround the implant with an adequate zone of keratinized mucosa. The advantages include the overall health of the tissues, greater patient satisfaction, and fewer complications. 58 The stability of the mucosa will provide better support for the underlying connective tissue, and the junctional epithelium will provide the seal around the implant. Because of the increased stability of the tissues, prosthetic techniques are more precise. Challenges to the soft tissue during the prosthodontic phase are better absorbed by keratinized tissue. 59-61 When considering the final esthetics, a wide band of keratinized mucosa is a prerequisite. 62,63 A thick biotype offers the ability to hide the shine-through of the underlying structures. 61,64 The Papilla Around Implant Restoration The interdental papilla is an important aspect of the esthetic appearance of a smile. The lack of the dental papilla results in a dark triangle that will make the esthetics less desirable. Between natural teeth, the presence of the papilla is dependent on the presence of 2 adjacent teeth, a contact point, and supporting bone. If the crest of the bone is within 5 mm of the contact point, the full presence of a papilla is predictable. If the distance increases, the likelihood of the papilla being present decreases. 14 A similar relationship has been reported around dental implants. The important measurement is the level of the bone on the proximal surface of the adjacent tooth. The average distance to the crest of bone on restorations with papillae is slightly reduced than from between natural teeth. 65 The support on the tooth provides for the support of the papilla. 66 The situation between dental implants is different. The interimplant is supported by 2 implant surfaces. As outlined above, the soft tissue lacks the insertion of fibers. There is potential for overlapping crestal resorption if the implants are placed too close together. Implants placed closer than 3 mm to each other exhibit greater amounts of bone loss. 67 The height of the interimplant papilla is limited and, particularly when the distance of the contact point of the implant crowns from the underlying alveolar crest is greater than 3 mm. 68,69 In the esthetic areas, the results may be more esthetic by avoiding 2 dental implants adjacent to each other (Fig 11) or choosing implants of a smaller diameter to ensure a minimum of 3 mm between the implants. 69 In areas of limited space, small-diameter implants could be considered. The smaller diameter leaves a greater space for soft tissues and provides a created osseous base for the support of soft tissues around an implant. 70 The gingival scaffold frames the shape of the implant restoration and is important for the appearance to simulate the natural dentition. 71 The treatment planning of edentulous spaces in the esthetic zone presents surgical and restorative challenges. Soft-tissue examination before implant procedures is of great importance in determining the predictability of a treatment approach. Belser et al (2004) 72 proposed a series of objective criteria relating to dental esthetics. 73 The evaluation of a tooth-bound edentulous site should include periodontal examination and probing, ridge mapping, bone sounding, and gingival biotype. When a tooth needs to be extracted and is to be replaced by a dental implant, the implant-site soft-tissue evaluation begins with the clinical examination of periodontal status of the specific tooth and the adjacent teeth. Periodontal probing will determine the periodontal attachment levels of these teeth and will identify any existing pathology. Probing should be complemented by periapical radiographs Figure 11. Two dental implants placed next to each other with poor esthetic outcome. (Color version of figure is available online.)

44 Vassilopoulos, Geurs, and Geisinger that reveal the interproximal bone levels of the adjacent teeth. The attachment levels of the adjacent teeth are the predetermining factor for the level of interproximal bone and soft-tissue height. For an edentulous site, the assessment may require ridge mapping. 74 Mapping entails a series of soft-tissue thickness buccal and lingual measurements of the area. The clinician can then transfer these measurements onto a cast by taking an impression of this area, pouring a diagnostic cast, sectioning the cast through the proposed implant site, and transferring the soft-tissue thickness around the alveolar crest. Information related to the soft-tissue profile, the underlying bone morphology, and bone dimensions is readily available in the cast and could be of use for the clinician when determining the need for bone grafting or even additional soft-tissue grafting of the implant site. Although cone-beam computed tomography may provide more accurate and detailed information of implant sites, bone mapping of a single-tooth edentulous area is a quick and inexpensive method of assessing bone and soft-tissue volume. Bone sounding is a technique-sensitive procedure that detects the height of bone at the cervical region of a tooth that needs to be extracted. The accuracy and successful outcome in using this technique is based on a clinician s experience and accurate measurements of anatomical variations such as tooth crown morphology and thickness of the alveolar crest. Bone sounding is best used to examine soft tissue around a tooth, which will be extracted and immediately replaced by an implant. The soft-tissue examination should include the assessment of the gingival biotype of the implant site and adjacent teeth. This type of evaluation is particularly useful in immediate implant situations. There is a strong correlation of thin biotype with the presence of bone fenestrations and dehiscence. Moreover, a thin biotype is susceptible to soft-tissue recession after surgical procedures. Conversely, a thick gingival biotype has a low-scalloped thick soft tissue, square teeth and small gingival embrasure spaces, and long contact surfaces positioned at the middle third of teeth. This biotype is more resistant to recession after surgical manipulation of soft tissue. 33,75-77 Frequently, soft-tissue augmentation is needed to enhance the quality and thickness of the tissue. This is both important for health and to hide the underlying hardware from shining through the tissues. Many techniques of soft-tissue augmentation have been described. Pedicle full or split-thickness palatal flaps for primary coverage of postextraction placed implants and treatment of maxillary peri-implant defects have been described. 78 A palatal subepithelial connective tissue flap method can be used to cover maxillary defects. A palatal paramarginal incision was made from the molar region to the defect to be covered. The length of the incision depended on the size of the defect. 79 Free gingival grafts have been used to correct soft-tissue complications around endosseous implant permucosal abutments. The rationale for free gingival grafting is largely to prevent periimplantitis and its associated bone loss by increasing the amount of keratinized mucosa adjacent to the implant abutment. 80 The firmer keratinized tissue may, therefore, protect the implants and improve their prognosis by decreasing potential discomfort and inflammation that could occur from vigorous oral hygiene at a mucosal implant interface. The use of subepithelial connective tissue grafts around dental implants was a natural extension from their utilization to cover exposed root surfaces with greater predictability and superior clinical gingival color match over free gingival grafts. 81 Connective tissue grafts have been used as a soft-tissue barrier to close over an immediate postextraction implant as a soft-tissue extension over a barrier membrane or in place of the barrier membrane. 82,83 In a prospective case series to evaluate the healing outcome of soft-tissue dehiscence coverage at implant sites, 10 patients with 1 mucosal recession defect at an implant site and a contralateral unrestored clinical crown without recession were recruited. 84 The soft-tissue recessions were surgically covered using a coronally advanced flap in combination with a free connective tissue graft. The implant sites revealed a 66% coverage of the dehiscence and clinically significant improvement after coronal mucosal displacement in combination with connective tissue grafting; however, completeimplant soft-tissue dehiscence coverage could not be achieved in any sites. For that reason, gingival grafting as a method of changing the gingival phenotype of both nat-

Parameters that Influence the Position of the Facial Gingival Margin 45 ural teeth and implants with subepithelial connective tissue graft has been advocated. The resulting tissues appear to be more resistant to recession. 85 Soft-Tissue Allografts Initial reports examined the clinical efficacy of acellular dermal matrix allograft to achieve increased peri-implant keratinized mucosa around implants. 86 These proof-of-concept studies used a sheet form of acellular dermal matrix allograft to increase the attached keratinized mucosa. Park 86 demonstrated a statistical difference in pocket depth and modified plaque index at 6 months compared with the baseline measurements, and the width of peri-implant keratinized mucosa increased. Geurs et al 87 investigated the application of micronized acellular dermal graft for the reconstruction of papillae around teeth. The micronized allograft technique showed promise for repair of interproximal areas of tissue loss. Buccal augmentation with acellular dermal grafting has been used to thicken the peri-implant mucosa to either mask the shine-through of a gray cast from an implant abutment or collar where the host tissue biotype is thin. This technique in preliminary reports has been effective in improving the esthetics along with the increase in tissue thickness. In addition, facial acellular dermal grafts have been used in combination with particulate bone grafts to augment tissue on the facial surface of implants. 88-90 Comprehensive Periodontal Examination A thorough periodontal examination includes the assessment of the potential etiologic factors, the extent of gingival inflammation, and a quantification of the loss of periodontal structures, as well as an appraisal of factors that may affect the success of therapeutic intervention. Periodontal diseases are initiated by mixed bacterial infections associated with specific putative periodontal pathogens. 91,92 Two main purposes of a periodontal examination are to systematically record (1) PDs and (2) clinical attachment level (CAL) around each tooth (Fig 12). Periodontal pockets are pathologically deepened gingival sulci and represent the subgingival habitat for putative Figure 12. Interproximal probing. (Color version of figure is available online.) periodontal pathogens. 93 CAL measurement taken at 2 different time points is the best established method to identify if progression of periodontitis has occurred. 94 Information collected during a comprehensive periodontal evaluation is critical in determining the diagnosis and prognosis of a patient s dentition and in formulating a predictable treatment plan. Comprehensive Periodontal Examination Armamentarium 1. 23/UNC 12 (University of North Carolina) Double-end Instrument Explorer/Periodontal Probe. 2. Nabers Probe 3-6-9-12 mm, Furcation Probe. 3. 11/12 ODU (Old Dominion University) Explorer. Comprehensive Periodontal Examination Procedure 1. Review medical history. 2. Perform extraoral examination, to include: a. Visual examination of patient s overall presentation b. Visual and bidigital palpation of head and neck structures c. Temporo mandibular joint examination 3. Have current radiographs available and review radiographic findings. 4. Perform intraoral examination, to include: a. Oral cancer screening b. Plaque Index (including plaque disclosing) c. Caries examination d. Restoration examination

46 Vassilopoulos, Geurs, and Geisinger e. Edentulous site examination f. Comprehensive periodontal charting i. PDs at 6 sites per tooth: distal-buccal (DB), buccal (B), mesial buccal (MB), mesial lingual (ML), lingual (L), distal lingual (DL) ii. CAL at 6 sites per tooth iii. Bleeding on probing (BoP) at 6 sites per tooth iv. Mobility v. Furcation involvement vi. Mucogingival examination vii. Occlusal findings/interferences viii. Dietary analysis and caries risk assessment 5. Record all findings on a periodontal charting form and other chart forms. 6. Formulate all applicable diagnoses and formulate a treatment plan to address the diagnoses. 7. Demonstrate oral hygiene techniques and effective plaque removal, including toothbrushing using an appropriate technique (most frequently the Modified Bass Technique), use of floss and interdental cleaning aids, and use of adjunctive oral hygiene aids. 8. Reinforce proper home care, hygiene aid use, and continued dental care and examinations. 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