Tooth Mobility : A Review

Dr. Sajili Mittal Dr. Prerna Kataria Dr. Vishal Arya Dr. Lavina Taneja Arya Reader & Acting HOD Reader Reader Reader Dept. of Public Health Dentistry, Dept. of Periodontics Dept. of Paediatric Dentistry Dept. of Oral Medicine Inderprastha Dental College D.J. Dental College & Research Centre PDM Dental College & Research Institute Diagnosis & Radiology & Hospital, Ghaziabad Modinagar, Ghaziabad Bahadurgarh, Haryana PDM Dental College & Research Institute Bahadurgarh, Haryana

Introduction periodontal structures become adapted to an due to reduced stresses. 2, 4 ncreased tooth mobility has altered functional demand. It is self limiting.4 7. Periapical Pathology: An acute concerned dentists since the 19th 9. Hypermobility is a form of increased inflammatory response within the Icentury1. The stability of the dentition mobility persisting after completion of periodontal ligament as occurs with a is dependent on the resistance of the periodontal treatment. It is often referred to periapical or periodontal abcess, can cause supporting structures of the teeth and the as 'residual mobility'.4, 7 disorganization & destruction of principle magnitude, frequency, duration and the 10. Increasing or Progressive Mobility fibres. 2, 4 direction of forces acting upon them2. To is of a progressive nature and can be identified 8. Para-functional Habits such as evaluate the effectiveness of periodontal only through a series of repeated tooth Bruxism treatment, the examination of tooth mobility mobility measurements carried out over a 9. Supporting Structures of the is significant & should therefore be accurate. period of several days or weeks.4, 7 Teeth: A decrease in the supporting structures Examination of tooth mobility is an important 11. Initial and Secondary Tooth of teeth or an increase in the magnitude, diagnostic aid in determining the severity of Mobility - Muhlemann (1954) in a series of direction, duration and frequency of forces, or periodontal disease3 studies, while using progressively increasing a combination of both may result in tooth Pathophysiology of Tooth Mobility forces (50-1500g) showed that the force / mobility.2 Types of Tooth Mobility displacement relationship had a typical 10. Tooth Morphology: The degree of 1. Physiologic Tooth Mobility is the pattern which could be illustrated by a double mobility depends upon the number of roots; limited tooth movement or tooth sloped curve which had two points defined as their length & diameter as well as the displacement that is allowed by the resilience "initial" (ITM) and "secondary" (STM) tooth relationship of the alveolar crest to the of a healthy and intact periodontium when a mobility components. During ITM forces cement-enamel junction. moderate force is applied to the crown of the smaller than 100g moved the crown by 0.05 to The contour of the root i.e. flat, conical or tooth. It is 4-12/100 mm for 500 g force 0.1 mm and is the result of intra alveolar dilacerated and the relationship of two or applied with incisors have the highest (10- displacement of the root. On the other hand, more roots of a multi rooted tooth to each 12/100 mm) and molar the lowest (4-8/100 during STM part forces ranging between 100- other i.e. divergent or convergent, may also mm). Children and females obtain higher 1500 g allowed additional tooth movement by influence tooth resistance.2, 4 values than adults & males respectively. The the distortion and compression of the 11. Overjet & Overbite are directly greatest tooth mobility is observed upon periodontium on the pressure side .4 During proportional to tooth mobility.4 arising, and decreases during the day5 mastication, teeth & their supporting 12. Loss of Supporting Bone can be due 2. Pathologic Tooth Mobility includes structures are generally subjected to severe to gingival inflammation or trauma from any degree of movement that may be reduced occlusal forces, upto 50 Kgs.8 occlusion4. or eliminated once the pathologic cause is Causes of Tooth Mobility 14. Occlusal Prematurities: A gross identified and corrected.5 Tooth mobility can I. Local Factors: prematurity between two occluding teeth be detected by holding the ball of a finger on 1. Marginal inflammation: Disruption often results in pathologic mobility of one or the facial surface of a tooth while the patient of the gingival, transseptal and circular fibres both of the involved teeth.6 goes through various mandibular which contribute significantly to the firmness 15. Afunctional Occlusal Habits: movements.6 of the tooth.6 Grinding, clamping & “doodling” (grinding 3. Altered Tooth Mobility represents a 2. Periodontal inflammation & on one tooth) habits can result in marked transient or permanent change in periodontal Trauma from Occlusion: The excessive elevations in tooth mobility in the absence of tissues as a result of therapy e.g. after occlusal forces change the pathway of the clinically detectable gingival inflammation surgery4. spreading inflammation so that it extended and bone loss.6 4. Functional Mobility or fremitus is the directly into the periodontal ligament leading 16. Tooth Loss: When a large number of movement of teeth during function or para- to angular resorption of the alveolar bone and teeth have been lost, the remaining teeth must function 4 and signifies occlusal traumatism2. infrabony pocket formation (Glickman and assume all functional demands. These teeth 5. Adaptive Mobility is the absence of Smulow 1962). It was observed that the often display pathologic mobility values.6 an etiologic factor that might be improved furcation regions were the most susceptible to 17. Transient Increases In Tooth upon to directly improve stability by trauma from occlusion (Glickman, Stein and Mobility: Large increases in tooth mobility decreasing or eliminating tooth mobility, Smulow, 1961). This was known as may be seen after the insertion of large example, short roots, poor crown to root Glickman's codestruction hypothesis. restorations, after endodontic treatment, on ratio5. 3. Trauma From Occlusion 7 contiguous teeth after extractions, 6. Passive Mobility relates to how loose 4. Pathology of Jaws like tumours, periodontal therapeutic procedures and after teeth are on palpation, while Dynamic cysts, osteomyelitis etc4. traumatic injuries to the teeth.12 The injury Mobility defines how loose teeth are during 5. Traumatic Injuries to dentoalveolar may be transient or lasting depending on the functional and parafunctional movements.5 units. Torquing force applied to clasped teeth intensity and nature of the insult to the 7. Reduced tooth Mobility is seen in an by removable partial dentures can result in supporting tissues. 4, 6,9 ankylosed tooth after failing reimplantation marked increase in tooth mobility in the II. Systemic Factors or if autogenous bone grafts are placed in absence of bone loss. 1. Age: In the absence of periodontal contact with detached root surfaces. 4, 7 6. Hypofunction: The periodontal disease, older individuals showed somewhat 8. Increased / Static Tooth Mobility is ligament of a non-functional tooth undergoes more mobility for both maxillary central usually due to trauma from occlusion, but disuse atrophy with a concomitant loss of incisor and second molar.4,10 may be due to periodontal diseases where the resistance. In teeth without antagonists there 2. Sex & Race: Mobility has higher is widening of periodontal ligament initially

40 Heal Talk | November-December 2012 | Volume 05 | Issue 02 Mittal, et al. : Tooth Mobility : A Review incidence in females and in Negroes.4,10 relative to the adjacent teeth was detected anterior and posterior teeth in reasonable 3. Menstrual Cycle: Increased by the two strain gauges. alignment through the second molar in horizontal tooth mobility has been suggested 8. Parfitt (1958)15 recorded the tooth both arches. during 4th week of menstrual cycle. 4, 10 movement in an axial direction using the 12. Korber and Korber (1963)19 and 4. Oral Contraceptives: Periodontal adjacent tooth as the reference point. The K.H.Korber (1970)20 have described and disease and attachment loss are more instrument was fastened to the posterior employed a system that employs common among women on pills.4, 11 teeth with impression compound. Both electronic transducers of an inductive 5. Pregnancy: Tooth mobility can systems used transducers, and test output non-contact design. Extremely small increase during the course of pregnancy and could be read on D.C. meters, strip-chart movements can be detected and recorded post-partum.4 recorders or X-Y recording force and with this system. 6. Systemic Diseases: Certain systemic movement. Parfitt stated that the axial diseases aggravate periodontal disease viz movement could be measured with an Papilon Lefevre syndrome, Down's accuracy of 0.001mm +7 percent. syndrome, Neutropenia, Chediak Higashi s y n d r o m e , H y p o p h o s p h a t a s i a , Hyperparathyroidism, Acute leukaemia, Pagets disease etc.4 Measurement of Tooth Mobility Method for Measuring Tooth Mobility 1. Direct visualization when tooth is held between two rigid instruments. 2. Direct observation of movement Fig. 5: During measurement the Periotest handpiece must resulting from occlusal forces (functional always be held perpendicular to the tooth axes. An audible mobility). signal from the computer indicates unacceptable deviations. The point of impact, that is, the point of 3. Percussion sound measurement, is the middle of the anatomical crown. 4. Electronic devices.12 Fig. 4: Periodontometer positioned to assess the mobility 5. Miller (1950)12 recognized three grades of the maxillary right first molar. Five hundred grams of force is being applied to the tooth from the palatal surface. of tooth mobility. 9. A method whereby mobility of maxillary 6. The first to report the use of a dial and mandibular teeth could be measured indicator mounted on an impression tray simultaneously was developed by and fixed in the mouth by means of quick 16 13 Goldberg (1961) . It consisted of a setting plaster was Muhlemann (1954) . carriage device which was used with a The indicator pointer was adapted to the dial indicator described in Muhlemann's labial or buccal surfaces of the teeth and periodontometer or with other measuring measurements made in hundredths of devices. With cold cure acrylic or millimeters. The deflections of the teeth Figure 6: The Periotest measurement must be made in a impression plaster the carriage device midbuccal direction. to be measured were obtained with a was fixed in the oral cavity whereby the forcemeter by means of which a static occlusal surfaces of the posterior teeth of force was applied ranging from 200 to maxillary and mandibular arches were 1000 grams. Muhlemann termed his engaged. m e t h o d p e r i o d o n t o m e t r y a n d 17 10. Joel (1958) described a technique in d i s t i n g u i s h e d b e t w e e n m a c r o - which a mirror was attached to the tooth periodontometry and micro-periodonto- and the tooth movement was shown by a metry, depending upon the size of his reflected image on the opposite wall or equipment. The application of macro- any suitable surface. Another mirror was periodontometry is limited to attached to the tooth some distance away measurements on incisors, canines and and if this reflected image did not move, first bicuspids and was used preferably in the measurement was reported to be the upper jaw. The reproducibility Figure 7: Exposed tooth necks enlarge the clinical crown accurate. To move the teeth, a force was appears to be very high. Readings can be and must be taken into consideration employed with a V-notch cut in a cement made to one ten thousandth of an inch. 13. The Periotest Method 14 spatula. 7. Picton (1957) demonstrated axial tooth 18 After many years of research the authors 11. O’Leary and Rudd (1963) designed mobility relative to its neighbors by the established, in 1972, an interdisciplinary the USAFSAM Periodontometer which use of resistance wire strain gauges. Any group of scientific investigators and after permits assessment of the mobility of all change in the position of the test tooth 12 years of research, the Periotest method

Heal Talk | November-December 2012 | Volume 05 | Issue 02 41 Mittal, et al. : Tooth Mobility : A Review was successfully developed (German ¾ mm (295X10-4") of bucco-lingual mobility, however, is not clear. Since many of Patent 2617779, Patented February 11, movement the therapeutic modalities employed in its 1982). The 'Periotest value' depends 3. Moderate Mobility: Up to approximately treatment have negative aspects, the decision mainly on the damping characteristics of 2 mm (790X10-4") movement bucco- to treat or not to treat mobility should be based the periodontium. An electro- lingually upon & critical evaluation of the possible magnetically driven, electronically 4. Severe Mobility: More than 2 mm advantages and disadvantages of the controlled tapping head in a handpiece (790X10-4") of movement proposed therapy. percusses the tooth 16 times, 4 times per Index Utilized by Nyman et al. (1975) References second (Figure 4). The tapping head is Mobility degree 0 = horizontal mobility or 1. Turnelis H. Pameijer, Richard E. Stallard : A method -4" for quantitative measurements of tooth mobility. J decelerated when it hits the tooth. The mesiodistal of less than 0.2 mm (79X10 ) Periodontol volume 44, Number 6; 339-346. greater the stability of the periodontium, Mobility degree 1 = horizontal mobility or 2. Timothy, J.O 'Leary : Indices for measurement of the higher is the damping effect and the mesiodistal of 0.2-1 mm (79-394X10-4") tooth mobility in clinical studies J. Periodontal Res 9, faster the deceleration. This 'braking' 1974; Suppl. 14; 94-105. Mobility degree 2 = horizontal mobility or 3. Gerald S. Wank, Yale J. Kroll : Occlusal trauma - An -4" effect is recorded by an accelerometer in mesiodistal of 1-2 mm (394-788X10 ) evaluation of its relationship to periodontal the tapping head. The contact time Mobility degree 3 = horizontal mobility or prosthesis, Dental Clinics of North America 25, No. between tooth and tapping head, -4" 3, July 1981; 511-532. mesiodistal exceeding 2 mm (788 X10 ) 4. Neiderud A-M, Ericcson I & Lindhe J : Probing approximately a millisecond, is the signal and/or vertical mobility. pocket depth at mobile/non-mobile teeth J Clin used for analysis by the periotest system. Treatment Periodontol 1992 ; 19 : 754-759. Diseased or functional changes of the Various Methods for Controlling Tooth 5. Bernard H. Wasserman, Arnold M. Geiger, Livia. R. periodontal tissue, including bone, can be Turgeon : Relationship of occlusion and periodontal Mobility Are: disease : Part VII - Mobility J. Periodontol, quantitatively recorded with great 1. Periodontal Treatment September 1973, volume 44, Number 9, 572-578. accuracy even if there is no radiological The elimination of periodontal pockets 6. Dr. Shrinidhi M.S., Dr. G.V. Pramod, Dr. D.S. Mehta : evidence. Tooth mobility in clinical periodontics : JISP (2003) 21 by definitive periodontal treatment and Vol. 6, Issue 2 : 94-99. 14. Zwick Method An artificial model as optimal procedures for plaque control 7. W. Schulte & D. Lukas : The Periotest method : described by Berthold et al was used. It practiced by the patient should establish International dental journal (1992) 42, 433-440. consisted of a round aluminium base with total control of plaque-induced 8. Sigurd P. Ramfjord and Major M. Ash : Significance six alveolar sockets, arranged in a half of occlusion in the etiology and treatment of early, inflammatory disease and related moderate and advanced periodontitis J Periodontol round arc to stimulate an almost naturally alveolar bone loss. 1981 September 511-515. shaped dental arch. To allow increased 2. Occlusal Adjustment / Treatment of 9. Sudhir Kamath, Neeta V. Bhaskar : Periodontal tooth mobility, close to the clinical splints - a boon or bane : The Journal of Indian Society Occlusal Habits of Periodontology : 21-25. situation of injured loose teeth, the two Various Methods of Treating Occlusal 10. Matthew Kessler : A variation of "A" splint: 268-271. middle sockets were enlarged. The root Disease Are: 11. David S. Greenfield, Dan Nathanson : Periodontal and the crown section of the simulation splinting with wire and composite resin - A revised 1. S e l e c t i v e g r i n d i n g ( O c c l u s a l approach : J Periodontol, August Volume 51, Number teeth were made of stainless steel. The 5 equilibration) 8, 465-468. PDL for the uninjured teeth was made 2. Occlusal appliances to stabilize mobile 12. Ralph P. Pollock : Non-Crown and bridge with silicon while the PDL of the injured teeth & eliminate interferences. stabilization of severely mobile, periodontally teeth was made of silicon and rubber involved teeth : A 25 year perspective : Dental 3. Splinting Clinics of North America, Volume 43, Number 1, foam. For fine adjusting tooth mobility 4. Tooth movement (correction of axial January 1999; 77-103. apical screws were used. Tooth mobility inclinations and tooth-to-tooth as well as 13. Howard E. Strasslar, Alireza Haeri, Jerrold P. Gultz : was measured in the horizontal and then arch-to-arch relationships) New - generation bonded reinforcing materials for in the vertical dimension with the anterior periodontal tooth stabilization and splinting : 5. Extraction of hopeless teeth. Dental Clinics of North America, Volume 43, universal testing machine Zwick value. A 3. Restorative Dentistry Number 1, January 1999. 105-126. continuous load of 0-10 N was used. The Prematurities may be corrected by 14. A. Jon Goldberg, Martin A. Frelich: An innovative Zwick method provides quantitative pre-impregnated glass fiber for reinforcing establishing new occlusal relationship composites : Dental Clinics of North America, metric information about tooth mobility. through restorative techniques, i.e., Volume 43, Number 1, January 1999,127-133. Indices Used For Measuring Tooth onlays or crowns. Prosthodontic 15. Neville Mc Donald, Howard E. Strassler : Evaluation Mobility replacement of missing teeth may of tooth stabilization and treatment of traumatized Miller's Index teeth : Dental Clinics of North America, Volume 43, distribute those forces, thus reducing Number 1, January 1999, 135-149. Grade I: The first distinguishable sign mobility. 7 16. Stuart D. Josell : Tooth stabilization for orthodontic of movement. 4. Fixed and removable splinting retention : Dental Clinics of North America, Volume Grade II: A movement of the tooth 43, Number 1, January 1999;151-165. In the absence of successful reattachment 17. Howard E. Strassler, David A. Garber : Anterior which allows the crown to deviate within 1 procedures, the most reliable method of esthetic considerations when splinting teeth : Dental mm of its normal position and completely eliminating mobility is to Clinics of North America, Volume 43, Number 1, Grade III: Easily noticeable and allows distribute the forces over a maximum January 1999, 167-178. the tooth to move more than 1 mm in any 18. http://www.thejcdp.com/issue012/bernal/ number of teeth by splinting. The figure01.htm direction or to be rotated or depressed in the presence of splints, however, often makes 19. Robert J. Cronin, David R. Cagna: An update on fixed socket. it difficult for the patient to achieve prosthodontics, JADA; Volume 128. April 1997, 425- Index suggested by Prichard (1972) 436. adequate plaque control and thus may 20. Michael W. O' Riordan, Curt S Ralstrom, Susan E 1. Slight mobility predispose to further periodontal Doerr : Treatment of avulsed permanent teeth: an 2. Moderate mobility destruction.6 update: JADA Volume 105, December 1982: 1028- 1030. 3. Extensive movement in a lateral or Conclusion mesiodistal direction combined with 21. Christine Berthold, Friedrich Johannes Auer, Sergej Tooth mobility is considered to be Potapov, Anselm Petschelt: In vitro splint rigidity vertical displacement in the alveolus. significant when evaluating the effectiveness evaluation comparison of a dynamic and a static Plus and minus sign can be used for added 1 measuring method. Dental traumatology 2011; 27: of periodontal therapy. The etiology of refinement. 414-421 mobility has been attributed to either a Index given by Waserman et al, (1973) reduction in the resistance of the teeth or to an 1. Normal accentuation of the magnitude of the forces 2. Slight mobility: Less than approximately placed upon them. The significance of

42 Heal Talk | November-December 2012 | Volume 05 | Issue 02