Temporo-mandibular joint.

Implantology and
paradontology

Catedra de Radiologie și Imagistică Medicală

Temporomandibuolar Jont

• Temporal bone
• Mandibular condyle
• Disk
• Disk-condyle complex
• Joint capsule
ATM în normă
ATM examen radiologic
Deplasarea anterioara cu
reducere
Deplasarea anterioara fara
reducere
Deplasarea anteromediala
cu reducere
Deplasarea mediala cu
reducere
Disc biconcav in pozitie superioara cu
perforare centrala mica
Modificari degenerative cu perforare
mare
Temporomadniblar Joint Disturbances

• Developmental disturbances
• Trauma, accidents
• Spreading inflammation
• Systemic disorders
• Neoplasia
• Occlusal dysharmony
 Imaging Procedures
• Panoramic Radiograph
• Axial Cranial Radiograph
• Conventional Tomography
• Posterior-Anterior Cranial Radiograph
• Lateral Transcranial Radiograph
• Computed Tomography
• High-resolution Ultrasonography
• Magnetic Resonance Imaging
 Panoramic Radiograph

• Confirmation of presumed degenerative bone

changes.
• Diagnosis of unsuspected pathology
• Classification of the stage of a disease
process.
• Evaluation of the effectiveness of therapeutic
measures (Kaplan 1991).
 Panoramic Radiograph

• Degenerative changes in the right joint

• The most common finding in a degenerating temporomandibular
joint is a change (regressive adaptation) of the condylar bone that is
accompanied by a more or less pronounced flattening of the contour
(arrows). In spite of the altered bony structure, the fibrocartilaginous
joint surface may be completely adapted. In that case the joint is
functionally intact and in no need of treatment. If the joint surfaces
are not well adapted there will be a clinically detectable crepitus
 Panoramic Radiograph

Temporomadibular joint disturbance on the left side (degenerative

changes)
• Abnormal positioning of the condyle during closure. The dorsal
displacement of the right condyle and the ventral position of the left
condyle.
Axial Cranial Radiograph
 Conventional Tomography

• Left: a normally structured and positioned condyle.

• Right: the ventral position and the advanced arthrosis of the condyle
are clearly visible in this case with perforated disc.
 Conventional Tomography

• A large osteophyte eminating from the anterior aspect of the condyle

(short arrow) and a IIjoint mousell (long arrow) positioned anterior to
the condyle in the joint space
• Lateral tomogram illustrating a large erosion of the anterosuperior
condylar head accompanied by severe erosions of the temporal
component, including the articular eminence.
Mandibular Posterior-Anterior
Cranial Radiograph
Lateral Transcranial Radiograph
Computed Tomography
 In dentistry, the practitioners' favorite is conical beam
CT (CBCT), because it can provide them with complex
information on the oro-maxillofacial region, by simultaneously
acquiring images in 2 planes of space (frontal, axial, oblique),
on the basis of which can create multi-dimensional and three-
dimensional reconstructions, eliminating artifacts that appear
on an axial acquisition CT.
The machine consists of 2
scanning systems, one that performs a single
360-degree motion around the patient's head,
and the other scanner emits the conical beam
(with diverging rays), with a fixed position.

This technology appeared in 2001.

 High-resolution Ultrasonography

• Drawing shows
technique of
examining TMJ region
with sonographic
transducer positioned
against patient's face
overlying zygomatic
arch and TMJ.
Magnetic Resonance Imaging

Normal TMJ: 1- resting position, 2- mid-

opening position, 3- full opening position
Normal closed mouth MRI of the TMJ
Normal open mouth MRI of the TMJ
•Teleradiography is a method of radidiagnosis commonly used
in orthodontics

• Three types of teleradiographs are known:

• lateral teleradiography (profile)

• right now

• axial

• All types of teleradiographs allow the analysis of the

functional and aesthetic harmony of the dento-maxillofacial
system at a given time and in evolution.
Implantology
Dr. Per-Ingvar Branemark
1965 Gosta Larsson
Sven Johansson
Phases of imaging
Phase I 
Pre-surgical
implant
imaging
Phase II

Phase III
Surgical
 Post-
and
prosthetic
intraoperat
imaging
ive implant
imaging
 1) Pre-surgical implant imaging
o To assess the overall status of
the remaining dentition

o To identify and characterize the

location and nature of the
edentulous regions, particularly
to determine the quantity ,
quality and angulationsoofTo determine the relationship of
bone
critical structures to the proposed
implant site
o To detect regional anatomic
abnormalities and pathologies.
 2) Surgical & intraoperative
implant imaging
• Evaluates the sites
during and immediately
after surgery

• Assist in the optimal

position and orientation
of dental implants

• To evaluate the healing

and integration phase of
implant surgery
 3) Post-prosthetic imaging
• To evaluate the long-term maintenance of
implant rigid fixation and function
• To assess the Crestal bone levels around
each implant
• To evaluate the implant complex
 Imaging modalities
• The decision to image the patient is based
on the patients clinical needs and its
availability.

• Imaging modalities can be:

Two-dimensional /
Analog / Digital Three –
imaging dimensional
modalities imaging modalities
 Periapical radiography
Indications:
• Evaluation of small
edentulous spaces ,
Eg: in case of single
tooth replacement
• Alignment and
orientation of implants
during surgery Intraoral periapical
• Recall/maintenance radiograph displaying the
implant placed at the site
evaluations of 11, and its relation to
adjacent structures
Advantage
o Amount of bone loss and peri-
implantitis can be visualized
o Subtle variations in bone activity is
clearly seen
o Minimal magnification with high
resolution
o They are easy to obtain in the dental
Disadvantages
oThey are susceptible to
unpredictable magnification of
anatomic structures, which
does not allow reliable
measurements. o Distortion is particularly accentuated in
edentulous areas, where missing teeth and
resorption of the alveolus necessitate film
placement at significant angulation in
relation to the long axis of the teeth and
alveolar bone
Disadvantages
›Periapical radiographs are
two-dimensional
representations of three-
dimensional objects and do
not provide any information
of the buccal-lingual
dimension of the alveolar
ridge. Structures that are
distinctly separated in the
buccal-lingual dimension
appear to be overlapping.
 Disadvantages

• The periapical image is limited by the size of film

being used

• Often, it is not possible to image the entire height

of the remaining alveolar ridge, and when
extensive mesial-distal areas need to be
evaluated, multiple periapical films are required
 Digital radiography
• Process wherein the film is replaced by a
sensor that collects the data

• The analog information received is then

interpreted by specialized software and an
image is formulated by a computer monitor
• The resultant image
can be modified in
terms of gray scale,
brightness, contrast,
inversion and color
enhancement

• Computerised software
programs like
Dexisimplant are
available that allowing
for calibration of
magnified images ,
Advantages
• Less radiation
• Superior resolution
• Instantaneous speed of image formation
is highly useful during surgical placement
of implants and the prosthetic verification
of component placement

•
Disadvantage
Size and thickness of the film and position of the connecting cord
sometimes makes film placement difficult in some sites , such as those
adjacent to tori or in case of tapered arch form in the region of canines
 Panoramic radiograph
o They display image slices through the jaws by
producing a single image of the maxilla and mandible
and their supporting structures in a frontal plane

o The image receptor is either the radiograph film or

can also be a digital storage phosphor plate or a
digital charge – coupled device receptor
 Indications:

• Indicated when multiple implant placements are

planned.

• Initial assessment of vertical height of bone

• Evaluation of gross anatomy of the jaws and any

related pathologic findings
Advantages:
o They display anatomic structures like nasal
cavity, maxillary sinus, inferior alveolar canal
and mental foramen.

o Convenience, ease and speed in performance dental office

 Disadvantages
o The resolution is lesser when compared to intraoral
radiograph.
o Cross sectional view is not demonstrated and is of
little use in depicting the spatial relationship between
othe structures
A10-20% image magnification occurs, which is non
uniform. This magnification is undesirable for both
implant selection and implant site assessments.
o Geometric distortion and overlapping of images of
teeth can occur.
o Overlapping of anterior region by vertebral
column occurs.
 Tomography
Tomo= slice ; Graph=picture
o Tomographic units
produce cross-sectional
slices of the jaws that
can be as thin as 1 mm
and are suitable for pre-
and o This technique enables the
post-implant
assessment visualization of patient’s
anatomy by blurring regions
above and below the
• The basic principle of tomography is that the x-ray
tube and film are connected by a rigid bar called the
fulcrum bar, which pivots on a point called fulcrum.
• When the system is energized, the x-ray tube
moves in one direction with the film plane moving in
the opposite direction and the system pivoting about
the fulcrum
• The fulcrum remains stationary and defines the
section of interest or the tomographic layer
• Different patterns of movement, including
linear, circular, spiral or hypocycloidal have
been attempted to reduce blurring artifacts
and provide a sharper and more useful
image.

• Linear tomography is the simplest form ,

which has a one dimensional motion and
produces blurring of adjacent sections and
results in linear steak artifacts in the
• Circular, spiral and
hypocycloidal are two-
dimensional motions

• Hypocycloidal is
generally accepted as
the most effective
blurring motion

• This technique is
 Transtomography / sectional
tomography
• This technique enables the appreciation of spatial
relationship between the critical structures and the implant
site and quantification of the geometry of the implant site.

The tomographic layers are thick and have

adjacent structures that are blurred and
superimposed on the image, limiting the
usefulness of this technique for individual sites,
Advantages
• Cross- sectional
views Disadvantages:
• Constant • Technique-
magnification sensitive
• Blurred images
• High radiation dose
• Multiple images
needed
• Expensive
 Computerised Tomography
o CT is a digital imaging technique, which can
generate 3D images using a very narrow “fan
beam” that rotates around the patient, acquiring one
thin slice (image) with each revolution

o It was first applied successfully in

The dental CT in
implantology can
thebe1980s.
performed with a conventional CT, a
spiral CT or a multislice CT scanner
o It allows clinicians to visualize the bony
architecture, nerves, joints, sinuses and other
structures much more completely than traditional flat
radiographs

o CT scans have been shown to be very accurate with

the magnification effect, the same for both the anterior
and posterior area, from a range of 0% to 6% in
Advantages
• Negligible magnification
• High contrast image
• 3 dimensional bone models
• Interactive treatment
planning

‘FAN BEAM” Geometry

Disadvantages:
• High dose of
radiation
• Technique –
sensitive
 Recent advances in CT
Cone Beam Volumetric Tomography

Microtomograph
 Dentascan
o DentaScan is a computed tomography (CT) software
program that allows the mandible and maxilla to be
imaged in three planes: axial, panoramic and cross-
sectional.

o Data acquisition time for maxilla or mandible is about

15 min.
o The effective dose of the standard DentaScan
 Cone Beam Volumetric
•
Tomography
Because of higher radiation exposure, higher cost, huge
footprint and difficulty in accessibility associated with CT,
a new type of CT, CBVT was developed.

MercuRay by Hitachi

NewTom 3G by AFP 3D Accuitomo by J. Morita

 The x- ray tube on these scanners
rotates around 360 degrees and
will capture images of the maxilla
and mandible in 36 seconds , in
which only 5.6 seconds is needed
The images recorded are placed onto a
forcharge-
exposure
coupled device chip and is then
converted into axial, sagittal and coronal
slices and permit reformatting to view
traditional radiographic images as well
“ Cone beam”
geometry as 3- dimensional soft tissue or osseous
images
 Indications:

CBVT allows precise measurement of distance, area and volume.

 Indications:
• Assessment of the positions and states of the
structures critical for adequate implant
placement (e.g., inferior alveolar canal, location
of the neurovascular bundle and the incisive and
mental foramina, pneumatization of the
maxillary sinus, floor of the maxillary sinus,
nasal fossa);
 Indications
• Examination after
placement of implants and
bone grafts;

• Evaluation of bone
resorption and root
retention, as well as
lesions of the facial
skeleton.
 Contraindications

• Patients with claustrophobia,

• Parkinson disease

• tremors

• disabling conditions that might cause a patient to

be uncooperative
 o Radiation dose from a CBVT
Advantages
scanner is approx. 12.0 mSv ,
which is equivalent to 25 % of

o Almost 0% magnificationradiation from a typical

panoramic radiograph or to five
o No D-speed dental x-rays
superimposition or
overlapping of
images, hence
ominimal
lowerdistortion
cost and more feasible compared to
the computerised tomography
 Interactive computed
tomography
• This technique enables the radiologist to transfer the
imaging study to the practitioner as a computer file
and enables the practitioner to view and interact with
the imaging study on their own computer
• It helps to measure the length and the width
of the alveolus, measure bone quality and
change the window and level of the
grayscale of the study to enhance the
perception of critical structures
 An important feature of ICT
is that the dentist and
radiologist can perform
electronic surgery (ES) by
selecting and placing arbitrary-
sized cylinders that simulate
 With an appropriately designed
root form implants in the
diagnostic template, ES can be performed
images.
to develop the patient’s treatment plan
electronically in 3D
 Superimposed on the CBVT
image, electronic implants can be
virtually previewed at arbitrary
positions and orientations with
respect to each other, the
 ES and ICT enable the
alveolus, critical structures and the
development of a 3D treatment
prospective occlusion and
plan that is integrated with the
esthetics.
patient’s anatomy and can be
visualized before surgery.
 Surgical guides
• Computer generated drilling guides that are
fabricated through the process of stereolithography
using SimPlant software for ideal implant positioning
These successive diameter surgical osteotomy
drill guides may be either bone, teeth or
mucosa-borne
Surgiguides have metal cylindrical tubes that
correspond to the number of desired osteotomy
preparations and specific drill diameters

The diameter of the drilling tube is usually 0.2 mm

larger than the corresponding drill, thus making
angle deviation highly unlikely
CT based surgical guidance templates
and navigation systems
• These systems allow the transfer of the
pre-surgical plan to the patient , thus
indicating when there is deviation from
the predetermined drilling parameters

• Therefore the depth and trajectory of

drilling sequence is made to the exact
location of the pre-planned position
IMAGING OF VITAL
STRUCTURES IN ORAL
IMPLANTOLOGY
Mental foramen and mandibular canal
• While using the two-dimensional radiographs for
imaging Mental foramen and mandibular canal ,it is
mainly dependent on the positioning.

• The x-ray beam must be perpendicular to the

tangent of the area in question between the foramen
and the most anterior tooth
• If the image is taken from the mesio-oblique
orientation, measurements will be fore-
shortened

• If disto-obliquely oriented then measurements

will be elongated

• Always the radiographic density should not

increase above 2.8, after which the foramina
becomes less apparent
• In edentulous
mandibles, the risk of
error is high because of
the increased resorption
of alveolar crest
Studies have shown that
the location of mental
foramen on periapical
and panoramic
radiograph are inaccurate
and sometimes on
panoramic radiograph it
• Several studies have shown CT to be the most
accurate and highly recommended when
measurements are needed for the inferior
alveolar canal and mental foramen
 Mandibular lingual concavities
• When there is advanced
atrophy of posterior mandible,
lingual concavities may be
present

• Within these concavities

branches of facial artery may
be present

• Over estimation of the amount

of bone may lead to
perforation of lingual plate
 Mandibular ramus

• Donor site for autogenous onlay bone grafting

and is extremely variable in the amount of bone
present . Hence adequate assessment of host
bone present is not possible

• Recommended : CT
 Mandibular symphysis

• Donor site for autogenous graft

• Panoramic radiographs mostly overestimate the

height of the available bone in the anterior region

• An imaging technique that depicts the true

bucco-lingual amount of bone is recommended

• Recommended: conventional CT
 Maxillary sinus
• For implant placement detailed information is
needed regarding the position of septa, maxillary
sinus anatomy, sinus pathologies
No radiographic
modality till date
gives more
information on the
above mentioned
features than CT
and hence
 Intraoperative imaging
• To verify the positioning and location of an osteotomy site
or for identification of a vital structure, processing of
standard radiograph film can take upto 6 minutes and
hence is time- ineffcient
• Current day digital imaging system gives instant images
that can be manipulated, and allows accurate
measurements and maintains aseptic protocol
Immediate post operative imaging

• A periapical or panoramic radiograph should be

taken post surgically so that a baseline image
can be used to evaluate against future images

• Additional imaging tools may be used to

evaluate a zone of safety around the vital
structures
 Abutment and prosthetic
component imaging
• When evaluating for transfer of impressions along with
the two- piece implant abutment component placement
, radiographs should be taken to verify secure
adaptation

• Intraoral radiographs are recommended because of

their high geometric resolution to evaluate for any fit
discrepancy

• X-ray beam should be directed at right angle to the

longitudinal axis of the implant. Even a slight
angulation may allow a slight gap to be noticed
 Post prosthetic imaging

• When investigating complications after implant

placement, a panoramic radiograph is the most
ideal technique

• Whenever Single implant image or a detailed

information of implant viewed on panoramic
image is needed, a periapical radiograph

• A post prosthetic radiograph helps in future

evaluation of component fit verification and also
for marginal bone level evaluation
 Recall and maintenance imaging

• Follow up or recall radiographs are to be taken 1

year of functional loading and yearly for the first 3
years to asses the marginal bone levels
Radiographic sequence for dental implants
imaging
• Pretreatment
• Immediate post surgical (baseline)
• Healing period ( if necessary)
• Second stage surgery
• Post prosthetic surgery ( baseline)
• 1 year postoperatively
• After 1st year, every 2 years
 Fabrication of diagnostic
templates
• The surfaces of the proposed restorations and the
exact position and orientation of each dental implant
should be incorporated into the diagnostic CT
templates

The design may vary from a vaccuformed reproduction

of the wax-up - to one processed from acrylic
reproduction of the diagnostic wax-up – to a
• The processed acrylic template may be modified by
coating the proposed restorations with a thin film of
barium sulfate and filling a hole drilled through the
occlusal surface of the restoration with a gutta-
percha

• While radiographic examination GP point will be

seen as radiopaque and will help in determining the
position and orientation of the proposed implant
The vaccuform templates involve either coating
of the proposed restorations with a thin film of
barium sulfate. This does not depict the ideal
position and orientation of the proposed implant

Another method is to blend 10% barium

sulfate and 90% cold cure acrylic ,
which makes the proposed restoration
radiopaque and evident but again does
not give idea about the position and
orientation

The next design modifies the previous design by drilling a 2 mm hole

through the occlusal surface of the proposed restoration at the ideal
position and orientation of the proposed implant site with a twist drill
• Recently radiographic teeth specifically
designed for the fabrication of diagnostic
templates have been introduced .

• These are time saving, placed easily,

provide consistently high radiopacity, have
molds corresponding to prosthetic teeth
used in the final restoration and are bonded
easily with the template-based material
 Conclusion
• Although many modalities are available for
imaging the implant site, the correct and
required technique should be adopted
depending on the case and the clinician’s
judgment to interpret the image acquired.

• The choice of pre-implant imaging must be

considered carefully due to the radiation dose,
the cost of each examination and the anticipated
information that may be provided by the imaging
study.
Periodontology
 Classification of periodontal diseases 1999-2000

Type I. Gum disease:

A. Diseases of the gum of microbial (plaque) origin.
B. Non-microbial gum disease.
Type II. Chronic periodontitis:
A. Located.
B. Generalized.
Type III. Aggressive periodontitis:
A. Located.
B. Generalized.
Type IV. Periodontitis as an expression of general disorders:
A. As an expression of the disorders of the blood system.
B. As an expression of genetic deviations.
C. As an expression of other general conditions.
Type V. Necrotic periodic disorders:
A. Ulcerative necrotic gingivitis (GUN).
B. Ulcer-necrotic periodontitis (PUN).
Type VI. Periodontal abscess.
Type VII. Periodontitis in association with endodontic pathologies.
Type VIII. Congenital and acquired malformations.
 Classification of periodontal diseases 2018

1. Healthy periodontological, gingivitis and other

conditions
2. Periodontitis
3. Other conditions affecting periodontal tissues
4. Peri-implant diseases and conditions
1. Healthy periodontological, gingivitis and other
conditions
Periodontal health is the absence of clinical signs of
inflammation, it is the biological level of stability of the
immune system, consisting of a clinically healthy gum and
a state of homeostasis. Clinical health can be achieved
with gingivitis and periodontitis.
Classification of clinically healthy gums:
Clinically healthy gums with intact periodont
Clinically healthy gums with reduced periodont:
Patients with stabilized periodontitis (successfully treated)
Patients without periodontitis (surgical extension,
recession)
Intact periodontium means the absence of a clinically
detectable loss of attachment and bone.
Predisposing and modifying factors:

1. Local risk factors (predisposing)

- factors of retention of the microbial plate (biofilm) - the
anatomy of the teeth, the edges of the restorations
- dry mouth - decreased quantity and quality of saliva (cm
Sjogren, medicine, oral breathing)

2. Systemic risk factors (modifying factors)

- smoking
- Metabolic factors (hyperglycemia)
- Dietary factors (Vit. C)
- Pharmacological factors
- Sex hormones (puberty, pregnancy)
- Hematological disorders
Intact periodont Healthy Gingivitis
Loss of
Not Not
attachment
Depth of
≤3 mm ≤3 mm
sounding

Bleeding at the
˂10% Da
sounding

Radiographic
No No
bone loss
Loss of periodontal
tissue in non-
periodontal patients
Healthy Gingivitis
(gum recession,
after surgical
extension)
Loss of attachment Yes Yes
Depth of sounding ≤3 mm ≤3 mm
Bleeding at the
˂10% Yes
sounding

Radiographic bone
Possible Possible
loss
Patients with
periodontitis Inflammation of
Healthy
successfully ginfiva
treated and stable

Loss of attachment Yes Yes

≤4 mm

Depth of sounding (there are no areas ≤3 mm

≥4 mm with
bleeding)
Bleeding at the
˂10% Yes ( ˃10%)
sounding

Radiographic bone
Yes Yes
loss
Periodontitis is a chronic multifactorial disease of
inflammatory nature associated with bacterial dysbiosis
and characterized by the progressive destruction of the
tissues around the tooth.
Primary categories: periodontal tissue loss, clinically
manifested as loss of attachment and radiographic bone
loss, periodontal bags and bleeding.
The patient with periodontitis: loss of interdental
attachment that is detected in the area of 2 or more
teeth, not adjacent. Loss of oral or oral attachment of ≥3
mm with bags mm3 mm detected in the area of two or
more teeth. Loss of attachment found cannot be caused
by other causes, other than periodontitis, such as gum
trauma, cervical cavities, endodontic lesions and tooth
fractures.
Key elements of the periodontal disease classification:

1. Severity - the degree of periodontal tissue destruction

2. The complexity (difficulty) of the treatment is the type
of bone loss (horizontal / vertical), the depth during the
probe, the involvement of the fork, the mobility of the
teeth, the number of teeth lost, the occlusal / furcational
aspects.
3. Extension (prevalence): number of teeth with
detectable tissue destruction
4. Progression rate: direct or indirect evidence of the
rate of periodontal tissue destructionFactorii de risc:
fumatul, diabetul, sănătatea generală, conformitatea
generală
• Stage
• Classifies the severity and prevalence of existing
tissue loss, including tooth loss, due to periodontitis.
• Includes the level of complexity of the treatment
regarding the functional and aesthetic rehabilitation of
the patient
•
• Degree
• It includes the following categories: a
history of periodontal development rate, the risk of
further progression, the expected outcome of the
treatment, the risk that the disease or its treatment will
lead to a negative impact on the overall health of the
patient.
Disease
severity and
Stage I Stage II Stage III Stage IV
complexity of
treatment

Degree А
Evidence or Degree В
risk of rapid
progression,
expected
Individual stage and degree
response to
treatment and Degree С
effects on
general health
 Stages
Stage IV
Stage III
Stage II Severe
Stage I Severe
periodontitis
The stage of periodontitis Periodontitis periodontitis
Initial with severe
of moderate with a
periodontitis tooth loss
severity tendency to
and tendency
lose teeth
to adenitis

Loss of
interdental
1-2 mm 3-4 mm ≥5 mm ≥5 mm
attachment in the
most difficult area
Distribution at Distribution at
Radiographic Coronary third Coronary third the middle the middle
Gravity
bone loss (˂15%) (15-33%) third of the third of the
root root

≤4 teeth were ≤5 teeth were

Teeth loss related There are no tooth loss
lost due to lost due to
to periodontitis associated with periodontitis
periodontitis periodontitis
 Stage IV
Stage III
Stage II Severe
Stage I Severe
periodontitis
The stage of periodontitis Periodontitis periodontitis
Initial with severe
of moderate with a
periodontitis tooth loss
severity tendency to
and tendency
lose teeth
to adenitis

In addition to
stage III: the
need for
rehabilitation
associated with
In addition to secondary
the second lesion of
Maximum
Maximum probe stage: occlusion
probing depth
depth ≤5 mm. Probing depth (mobility ≥2),
≤4 mm. Bone
Complexity Bone loss ≥6 mm, vertical malocclusion,
loss
predominantly bone loss ≥3 tooth migration,
predominantly
horizontal mm, class II-III prominence
horizontal
forcing, severe and tremor
ridge defects formation in
less than 10
antagonists,
chewing
dysfunction,
 Stage IV
Stage III Severe
Stage II periodontiti
Stage I Severe
s with
The stage of periodontitis Periodontitis periodontiti
Initial severe
of moderate s with a
periodontitis tooth loss
severity tendency to
and
lose teeth
tendency to
adenitis

Added to each For each stage, it is described as localized (˂30%

Spreading step as teeth involved), generalized or type of incisors-
description molars
 Degrees
Degree A Degree B Degree C

Primary Direct evidence Long-term follow- 5 years evidence ˂2 mm for 5 years ≥ 2 mm for 5 years
criterion of progression up (radiographic without loss
bone loss or loss
of attachment)
Indirect proof of The percentage ˂0.25 0.25-1.0 ˃1.0
progression of bone loss
Phenotype A large number Destruction The destruction is
of dental corresponds to disproportionate to
deposits and a dental deposits a small amount of
small degree of deposits; evidence
destruction of periods of rapid
progression or
early onset of the
disease; poorly
anticipated
response to
therapy

Modifying Risk factors Smoking No smoking ˂10 cigarettes a ˃10 cigarettes a

criterion day day
Diabetes Normoglycemia / Glycated Glycated
without diagnosis hemoglobin ≤7.0% hemoglobin ≥7.0%
of diabetes in the patient with in a patient with
diabetes diabetes
Practical application of classification:

Step 1: Initial evaluation of cases

X-ray screening, depth probing, missing
teeth
Determine this initial and moderate or
severe and developed periodontitis.
Step 2: Determine the degree
Determine maximum x-ray of perspiration or
bone loss,
Determine the horizontal or vertical bone
loss
Grade I or II
Teeth loss due to periodontitis
Determine the complexity of the treatment
(charter, furcation, occlusion / function, need
for extensive rehabilitation)
Grade III or IV
Step 3: Define the stage
History \ risk of progression \ age
Risk factors
Medical status and systemic diseases
Response to standard therapy removal
(removal of dental deposits and polishing of
roots) and plaque control
Detailed evaluation, stage determination
Step 4: Treatment plan

Initial and moderate Severe and developed

periodontitis periodontitis

Grade I or II Grade III or IV

Stage A,B,C
Complex
Standard periodontal
multidisciplinary
treatment
treatment