3. CONTENTS
• Introduction
• Trauma from Occlusion-Definitions
• Classifications
• Extension of Gingival inflammation to bone
• Different concepts of Periodontal Response to
Occlusal Trauma
• Stages of tissue response to increased occlusal
forces
4. CONTENTS
• Effects of Insufficient Occlusal Force
• Reversibility of traumatic lesions
• Effects of excessive Occlusal Forces on Dental
Pulp
• Influence of Trauma from Occlusion on
Marginal Periodontitis
• Studies and researches in Occlusal trauma
6. INTRODUCTION
• Adaptive capacity of periodontium to forces
exerted is variable
Occlusal forces
magnitude direction duration frequency
• Magnitude
-widening of the PDL space
-increase in the no. & width of PDL fibers
-increase in the density of alveolar bone
7. INTRODUCTION
• Direction
-Reorientation of stress & strain
-Principal fibers of PDL Occlusal forces
along the long axis of the tooth
-Lateral/Horizontal & Torque/Rotational:
Injure the periodontium
• Duration
-Constant pressure > intermittent
• Frequency
-Frequent application of intermittent force:
injurious
8. TRAUMA FROM OCCLUSION
DEFINITIONS
‘When occlusal forces exceed the adaptive
capacity of the tissues , tissue injury results.
The resultant injury is termed as trauma from
occlusion’
- Carranza
‘A term used to describe pathological alterations
or adaptive changes which develop in the
periodontium as a result of undue force produced
by the masticatory muscles’
-Lindhe
9. TRAUMA FROM OCCLUSION
DEFINITIONS
‘A condition where injury results to the
supporting structures of the teeth by the act
of bringing the jaws into a closed position’
-Stillman(1917)
‘Damage in the periodontium caused by stress
on teeth produced directly or indirectly by
teeth of the opposing jaw’
-WHO(1978)
10. TRAUMA FROM OCCLUSION
DEFINITIONS
‘An injury resulting in tissue changes within
the attachment apparatus as a result of
occlusal forces’
- Rose & Mealey
‘An injury to the attachment apparatus as a
result of excessive occlusal forces’
-Glossary of Periodontal Terms
(AAP in 1986)
14. TRAUMA FROM OCCLUSION
ACUTE TFO
Causes :
• An abrupt occlusal impact
• Restorations/prosthetic appliances
Manifestations :
• Tooth pain
• Sensitivity to percussion
• Increased tooth mobility
15. TRAUMA FROM OCCLUSION
Force dissipated
i. Shift in tooth position heals
ii. Wearing &
iii. Correction of restoration subsides
Or else
Periodontal injury Necrosis+ perio. abscess
or Cementum tears
17. TRAUMA FROM OCCLUSION
CHRONIC TFO
• More common & significant
• Gradual changes by:
- tooth wears
- drifting movement & extrusion
- parafunctional habits
• Malocclusion not necessarily TFO
18. TRAUMA FROM OCCLUSION
• Traumatic Occlusal relationships
-Effect of the occlusion on the periodontium
Also known as:
Occlusal disharmony
Functional imbalance
Occlusal dystrophy
19. TRAUMA FROM OCCLUSION
PRIMARY TFO
Definition:
Injury resulting in tissue changes from excessive
occlusal forces applied to a tooth or teeth with
normal support
• TFO – the only etiology in periodontal
destruction
• Occlusion results in the only local alteration of
teeth
• Parafunctional habits
20. TRAUMA FROM OCCLUSION
Causes
• High filling
• Prosthetic replacement
• Drifting / extrusion
• Orthodontic movement into
functionally unacceptable positions
Primary TFO no changes in connective tissue
attachment level & no pocket formation
22. CLASSIFICATION OF
PARAFUNCTIONAL HABITS
Tooth to Tooth
Bruxism
Clenching
Oral musculature to tooth
Lip biting
Tongue thrusting
Foreign objects to tooth
Finger nail biting
Pipe/Cigar biting
Other objects
23. PARAFUNCTIONAL HABITS
• Duration of tooth contact greatly increased
• Magnitude of force during bruxism much
greater
• Bruxism / clenching involve most of the teeth
• Occlusal appliances
24. PARAFUNCTIONAL HABITS
• Foreign object biting – localized to few teeth
• Encourage habit elimination
• Distinguish between adaptive periodontium &
one that is in trauma
25. TRAUMA FROM OCCLUSION
• Normal bone levels & attachment levels
• Excessive occlusal forces
• Normal periodontium with normal bone
height
• A state of stability through Adaptive
remodeling
*mobility no longer increasing
*clinical, radiographic, histologic changes
don’t worsen
26. TRAUMA FROM OCCLUSION
SECONDARY TFO
Definition
Injury resulting in tissue changes from normal or
excessive occlusal forces applied to a tooth
with reduced support
• Adaptive capacity – impaired by bone loss due
to inflammation
• Reduces periodontal attachment area
• Alters the leverage on the remaining tissues
28. TRAUMA FROM OCCLUSION
• More vulnerable to injury
• Previously well tolerated forces become
traumatic
• Normal periodontium/Marginal periodontitis
with reduced bone height
• Tooth displaced into the remaining alveolus by
any force
29. TRAUMA FROM OCCLUSION
• Active periodontitis/ after resolution of
inflammatory periodontitis
• Condition serious if- progressively increasing
mobility, bone loss, widening of PDL
• Splinting indicated- if teeth are to be retained
Alternate Mechanism for Secondary TFO
• Systemic disease
31. TRAUMA FROM OCCLUSION
• The distinction between primary & secondary
TFO – no meaningful purpose
• The alterations in the periodontium are similar
& independent of the height of the target
tissue, i.e. the periodontium.
32. EXTENSION OF GINGIVAL
INFLAMMATION TO BONE
• Gingival inflammation collagen fiber
bundles blood vessels alveolar bone
• Interproximally, through the vessels
perforating the crest of the interdental
septum
• Directly into the PDL & from there into the
interdental septum
33. EXTENSION OF GINGIVAL
INFLAMMATION TO BONE
• Facially & lingually , spreads along the outer
periosteal surface & penetrates into the
marrow spaces through vessel channels
• Destroys the transseptal & gingival fibers on
the course
Once bone is reached:
• Spreads into the marrow spaces & replaces
marrow with exudate
35. EXTENSION OF GINGIVAL
INFLAMMATION TO BONE
• Bone resorption proceeds from within the
marrow spaces
• Thinning of bony trabeculae & enlargement of
the marrow spaces
• Bone destruction & a reduction in bone height
• Fatty bone marrow replaced with fibrous
marrow
36. GLICKMAN’S CONCEPT
• Concept given in 1965,1967
• The pathway of the spread of a plaque-
associated gingival lesion can be changed if
forces of an abnormal magnitude are acting
on teeth harboring subgingival plaque
37. GLICKMAN’S CONCEPT
• Character of progressive tissue destruction of
periodontium at a “traumatized” tooth
different from that in a “non-traumatized”
tooth
38. GLICKMAN’S CONCEPT
• Even destruction of periodontium & bone-
suprabony pockets & horizontal bone loss in
uncomplicated plaque associated lesions
• Angular bony defects & infrabony pockets
when exposed to abnormal occlusal force +
inflammation
40. GLICKMAN’S CONCEPT
ZONE OF IRRITATION
• Marginal gingiva & interdental gingiva
• Soft tissues bordered by the hard tissue on one
side
• Not affected by the occlusal forces
• Gingival inflammation not induced by TFO;but by
irritation from microbial plaque
• Lesion in a non-traumatized tooth propagates in
apical direction by first involving the alveolar
bone & later the PDL
41. GLICKMAN’S CONCEPT
ZONE OF CO-DESTRUCTION
• PDL, Root cementum & alveolar bone
• Coronally demarcated by the transseptal &
the dentoalveolar collagen fiber bundles
• TFO may cause a lesion here
42. GLICKMAN’S CONCEPT
• Fiber bundles separating the two above
mentioned zones from two different
directions:
Inflammatory lesion by plaque in the zone of
irritation
Trauma induced changes in the zone of co-
destruction
• Fiber bundles dissolved or oriented parallel to
the root surface
43. GLICKMAN’S CONCEPT
• The spread of inflammation is from the zone
of irritation directly down into the PDL; not
via the interdental bone.
• This altered pathway of spread
angular bony defects
“TFO is an etiologic factor (co-destructive
factor) of importance in situations where
angular bony defects combined with infrabony
pockets are found at one or several teeth ”
-1967 Review Paper
44. WAERHAUG’S CONCEPT
• Examined autopsy specimens(1979)
• Distance between subgingival plaque &
the periphery of the associated
inflammatory cell infiltrate in the gingiva
the surface of the adjacent alveolar bone
Conclusion : Angular bony defects &
infrabony pockets occur equally at
periodontal sites of teeth which are not
affected by TFO
45. WAERHAUG’S CONCEPT
• The loss of connective attachment & bone
resorption - exclusively due to inflammation
associated with subgingival plaque
46. WAERHAUG’S CONCEPT
• Angular bony defects & infrabony pockets
--subgingival plaque has reached a level more
apical than the microbiota on the
neighbouring tooth
--when the volume of the alveolar bone
surrounding the roots is comparatively large
47. WAERHAUG’S CONCEPT
• Supported by findings by Prichard (1965) &
Manson(1976)
The pattern of loss of supporting structures:
the form & volume of the alveolar bone
the apical extension of the microbial
plaque on the adjacent root surfaces
48. STAGES OF TISSUE RESPONSE TO
INCREASED OCCLUSAL FORCES
3 STAGES:
INJURY
REPAIR
ADAPTIVE REMODELLING OF THE
PERIODONTIUM
49. INJURY
• Excessive Occlusal forces: Tissue Injury
• Repair of injury & Restoration of periodontium
if-
i. Forces are diminished
ii. Tooth drifts away from them
• Chronic forces: Remodeling of periodontium
i. Widened at the expense of bone
ii. Angular bone defects without pockets
loose teeth
50. INJURY
• Occlusal forces: Tooth rotation around a
Fulcrum/ Axis of Rotation
Junction of middle & apical third of clinical
root
• Areas of pressure & tension created on
opposite sides of the fulcrum
51. INJURY
SLIGHTLY EXCESSIVE PRESSURE
• Resorption of the alveolar bone
• Widening of the PDL space
• Numerous blood vessels- reduced in size
SLIGHTLY EXCESSIVE TENSION
• Elongation of the PDL fibers
• Apposition of alveolar bone
• Enlarged blood vessels
52. INJURY
GREATER PRESSURE
Gradation of Changes
• Compression of fibers Areas of hyalinization
• Injury to fibroblasts & other cells: Necrosis of
PDL
• Vascular
Within 30 minutes
53. INJURY
Impairment & stasis of blood flow in 2-3 hours
Blood vessels packed with RBC’s fragment in
1-7 days
Disintegration of blood vessel walls- contents
discharged into the surrounding
• Increased resorption of alveolar bone &
tooth surface
55. INJURY
SEVERE PRESSURE
• Force the root against bone
• Necrosis of the PDL & bone
• Bone resorption from viable PDL & marrow
spaces Undermining Resorption
• Most susceptible areas of Injury- Furcations
56. INJURY
Injury to Periodontium: Temporary depression
• Mitotic activity
• Proliferation & Differentiation of Fibroblasts
• Collagen & Bone formation
• Normal after dissipation of forces
57. REPAIR
• Normal periodontium: Constant repair
• TFO - increased reparative activity
• Damaged tissues removed & formation of new
Cells
Fibers
Bone
Cementum
58. REPAIR
• Forces : Traumatic as long as the damage
exceeds the reparative capacity
• Bone resorbed by excessive occlusal forces
• Thinned bony trabeculae reinforced with new
bone
59. REPAIR
BUTTRESSING BONE FORMATION
• Important feature of Repair after TFO
• Inflammation
• Osteolytic tumors
Central Buttressing:
Within the jaw
New bone deposition
60. REPAIR
Peripheral Buttressing:
Facial & lingual surfaces of the alveolar plate
LIPPING : Severe ‘shelf like’ thickening of the
alveolar margin
Pronounced bulge in the contour of the facial
& lingual bone
Following trauma:
Cartilage like material
Crystal formation from RBC’s
61. ADAPTIVE REMODELING OF THE
PERIODONTIUM
Repair = Destruction: remodeled so that the
forces are not injurious
• PDL - Thickened & funnel shaped at the crest
• Angular defects in the bone
• No pockets
• Teeth become loose
62. HISTOMETRIC DIFFERENTIATION
• Injury phase: resorption formation
• Repair phase: resorption formation
• Adaptive remodeling: both return to normal
63. EFFECTS OF INSUFFICIENT OCCLUSAL
FORCE
• Injurious to periodontium
• Thinning of the PDL
• Atrophy of fibers
• Osteoporosis of the alveolar bone
• Reduction in bone height
64. EFFECTS OF INSUFFICIENT OCCLUSAL
FORCE
Can result from:
Open-bite relationship
Absence of functional antagonists
Unilateral chewing habits
65. REVERSIBILITY OF TRAUMATIC LESIONS
• TFO –Reversible
• Artificially created TFO- extrusion & intrusion
& repair on removal
• Not always correct itself
• Injurious force- relieved for repair
66. REVERSIBILITY OF TRAUMATIC LESIONS
• Conditions not permitting adaptation to
occlusal forces- damage worsens/persists
• Plaque induced inflammation- impairs the
reversibility of traumatic lesions
67. EFFECTS OF EXCESSIVE OCCLUSAL
FORCES ON DENTAL PULP
• Not established
• Disappearance of pulpal symptoms after
correction of excessive occlusal forces-
reported
• Pulpal reactions in animals subjected to
increased
68. INFLUENCE OF TFO ON PROGRESSION
OF MARGINAL PERIODONTITIS
• Accumulation of plaque that initiates gingivitis
& results in pocket formation affects the
marginal gingiva, but TFO occurs in the
supporting tissues & does not affect the
gingiva
• Marginal gingiva unaffected by TFO
• TFO doesn’t cause gingivitis
70. INFLUENCE OF TFO ON PROGRESSION
OF MARGINAL PERIODONTITIS
• No effect on inflammatory process confined to
the gingiva
• When gingivitis periodontitis;
occlusion influences
It is important to eliminate the marginal
inflammatory component in case of TFO
because the presence of inflammation affects
bone regeneration after the removal of the
traumatizing contacts
71. INFLUENCE OF TFO ON PROGRESSION
OF MARGINAL PERIODONTITIS
• No progressive destruction in regions kept
healthy after elimination of periodontitis
• Change in the shape of the alveolar crest:
Widening of the marginal PDL space
Narrowing of the interproximal alveolar bone
Shelf like thickening of the alveolar margin
73. INFLUENCE OF TFO ON PROGRESSION
OF MARGINAL PERIODONTITIS
• Thus there’s alteration in the architecture of
the inflamed site
• Inflammation absent:
adaptation to increased forces
• Inflammation present:
Angular bone loss
Pockets become infrabony
74. INTERACTION OF TFO &
INFLAMMATION
• TFO alter the pathway of inflammation to the
underlying tissues
collagen density & no.of
Leukocytes
Osteoclasts increasingly mobile
Blood vessels teeth
75. INTERACTION OF TFO &
INFLAMMATION
• Inflammation proceeds to PDL
• Angular bone loss & infrabony pockets
• Areas of root resorption exposed without
gingival attachment – plaque & calculus
77. INTERACTION OF TFO &
INFLAMMATION
• Supragingival plaque Subgingival
Orthodontically tilted
Migration into edentulous area
Suprabony pocket becomes intrabony
• Increased mobility : Pumping effect on plaque
metabolites increase diffusion
78. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Early investigators - important role to TFO-
etiology
• High crowns & restorations in dogs & monkeys
• High crown + orthodontic appliance ‘jiggling
forces’
• Interproximal wedging
• Jiggling trauma + plaque induced
inflammation
80. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Eastman Dental Center
• Squirrel monkeys
• Repetitive interdental wedging
• Mild to moderate inflammation
• 10 weeks
• No increase in attachment loss
81. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
University of Gothenburg
• Beagle dogs
• Cap splints & orthodontic
appliances
• Severe inflammation
• 1 year
• Increase in the periodontal destruction
induced by periodontitis
82. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Wentz & coworkers
• Monkeys- PDL widening up to 3 times more
• ‘At one point , the damaging effect of jiggling
trauma was nullified by the extreme width of
the PDL space & no future resorption occured’
83. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Svanberg & Lindhe
• Jiggling trauma in dogs
• Increased mobility
• PDL space widening
• Loss of crestal bone height
• Series of cellular alterations
84. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
• Thrombosis
• Haemorrhage
• Increased vascular permeability
• Collagen destruction & Bone resorption
• Changes ceased after 60 days
• Increased mobility & width of PDL remained
constant
• Physiologic adaptation in the absence of
plaque induced inflammation
85. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Svanberg & Lindhe- 2nd Swedish study
• Physiologic adaptation didn’t occur- presence
of plaque induced periodontitis
• ‘Attachment apparatus inhibited in its ability
to adapt to jiggling type trauma in the
presence of supracrestal plaque- induced
inflammation’
86. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
• ‘TFO combined with experimental
periodontitis accelerated periodontal
breakdown characterized by continuous
periodontal pocket formation & loss of fiber
attachment’
87. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Nyman & coworkers
• Experimental periodontitis – test & control teeth
• Jiggling type trauma- test teeth
• attachment loss in 80% of test teeth
• ‘Excessive occlusal forces have the potential to
increase the degree of periodontal destruction’
88. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Polson & coworkers
• Monkey model
• Traumatic forces without periodontal
inflammation
• Widening of the PDL space
• Increased tooth mobility
• Loss of crestal bone height & bone volume
89. STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
• Changes ceased once physiologic adaptation
complete
• Withdrawal of traumatic forces – lost bone
volume restored
• Persisting plaque induced inflammation
90. SIGNS OF TFO
MOBILITY
• Measurement of horizontal & vertical tooth
displacement created by the examiner’s force
• Blunt ends of two dental instruments
approximately at the buccal & lingual height
of contour
• Forces applied buccolingually
• Assessed in mesiodistal direction when
possible
• Comparing a fixed point on the tooth against a
fixed point on the adjacent tooth
91. SIGNS OF TFO
CLASS I : Less than 1mm
buccolingual/mesiodistal
CLASS II : 1mm or more – buccolingual/
mesiodistal , no abnormal mobility in an
occlusoapical direction
CLASS III : 1mm or more- buccolingual or
mesiodistal & abnormal mobility in an
occlusoapical direction
92. SIGNS OF TFO
FREMITUS/FUNCTIONAL MOBILITY
• Measurement of the vibratory patterns of the
teeth when the teeth are placed in contacting
positions & movements
• A finger – buccal & labial surfaces- maxillary
teeth
• Tap the teeth together in the maximum
intercuspal position
• Grind symmetrically in lateral, protrusive &
lateral-protrusive contacting movements
94. SIGNS OF TFO
• Mandibular teeth assessed in edge to edge
occlusion
CLASS I: Mild vibration detected
CLASS II: Easily palpable vibration but no visible
movement
CLASS III: Movement visible with the naked eye
95. SIGNS OF TFO
Fremitus vs Mobility:
Tooth displacement created by patient’s own
occlusal force
• Ability of patient to displace & traumatize
teeth
• Mobility without fremitus: Probably no
Occlusal Trauma
96. SIGNS OF TFO
RADIOGRAPHIC ASSESSMENT
• Degree of bone loss from the CEJ to Apex
• Width of the PDL space around each tooth
• Examine for angular bony defects
• But these findings not necessarily with TFO
97. SIGNS OF TFO
OCCLUSAL SUMMARY CHART
• Future treatment decisions & response to
therapy
• Minimum information
• Assess the relation between occlusal forces &
periodontal status
99. TREATMENT PLANNING
Decide whether occlusal treatment is needed:
Surface adjustment/Appliance
Symptoms
• Sensitive to temperature changes
• Pain on chewing
• Mobility
• Wear facets
Extent of periodontal destruction
Patient’s ability to function
100. TREATMENT PLANNING
Occlusal treatment indicated
• Occlusal discrepancies
• Periodontal disease
X Occlusal treatment not indicated
• Asymptomatic
• No significant periodontal disease
101. TREATMENT PLANNING
Decision to treat made in the reevaluation
appointment :
• Non surgical treatment
• Mobility & fremitus reduced
• Need for treatment diminished
102. OCCLUSAL TREATMENT
• After non surgical treatment
• Exception: difficulty/ pain on chewing due to
occlusal trauma
2 APPROACHES
BITE APPLIANCE
ALTERING OCCLUSAL RELATIONSHIPS OF
TEETH
103. OCCLUSAL TREATMENT
BITE APPLIANCE
• Fits over the teeth
• An artificial occlusal surface for the opposing
dentition to contact
• Hard acrylic: Cushions contact forces
• Heat/cold cured hard acrylic over soft acrylic
• Maxillary bite Appliance: Stabilise potentially
loose maxillary teeth & prevent flaring
105. OCCLUSAL TREATMENT
OCCLUSAL ADJUSTMENT
• Permanent alteration:
- Orthodontic therapy
- Selective grinding
• Permanent change – distribution of occlusal
forces
• Care & skill
106. PHYSIOLOGIC & PATHOLOGIC
OCCLUSION
Determined after diagnosis of occlusal trauma
PHYSIOLOGIC:
• Survives despite deviations from the ‘ideal’
occlusion
• Maybe anatomic malocclusion
• Free of occlusally induced disease
108. PATHOLOGIC TOOTH MIGRATION
DEFINITION
‘Tooth displacement that results when the
balance among the factors that maintain
physiologic tooth position is disturbed by
periodontal disease ’
109. PATHOLOGIC TOOTH MIGRATION
• Common & early sign
• Gingival inflammation
• Pocket formation
• Anteriors frequent
• Any direction
• Mobility & Rotation
Extrusion: Pathologic migration in the incisal/
occlusal aspect
111. PATHOLOGIC TOOTH MIGRATION
PATHOGENESIS
Health & normal height of the periodontium
Forces exerted on the teeth: Occlusion &
Pressure
Forces of occlusion
Tooth morphology & cuspal inclination
Full complement of teeth
Physiologic tendency towards mesial
migration
112. PATHOLOGIC TOOTH MIGRATION
Nature & location of contact point
relationships
Proximal, incisal & occlusal attrition
Axial inclination of teeth
113. PATHOLOGIC TOOTH MIGRATION
WEAKENED PERIODONTAL SUPORT
• Unable to maintain normal position
• Moves away from opposing force unless
restrained by proximal contact
• Forces accepted by normal periodontium
become injurious
114. PATHOLOGIC TOOTH MIGRATION
• Position change - subjected to abnormal force-
aggravate periodontal destruction &
migration
• Continue after loss of antagonist
• Forces from tongue, food bolus, granulation
tissue
• Also an early sign of Localized Aggressive
Periodontitis
115. PATHOLOGIC TOOTH MIGRATION
CHANGES IN FORCES EXERTED ON THE TEETH
A. Unreplaced missing teeth
• Drifting into edentulous spaces
• Not due to periodontal destruction
• Conducive for periodontal diseases
• Aggravates the tooth movement
• Mesial with tilting / extrusion
124. PATHOLOGIC TOOTH MIGRATION
OTHER CAUSES
TFO: itself or combination
PRESSURE FROM TONGUE: absence of
disease/ reduced periodontal support
PRESSURE FROM GRANULATION TISSUE OF
PERIODONTAL POCKET: with periodontal
destruction ; may return after pocket
elimination
126. CONCLUSION
• Occlusal traumatic forces- the major external
force encountered by the periodontium
• Trauma from occlusion - no inflammation of
the periodontium by itself
• Alters the pathway of inflammation &
aggravates the condition once the
periodontitis stage is reached
127. BIBLIOGRAPHY
• Carranza’s Clinical Periodontology- 10th edition
• Clinical Periodontology & Implant Dentistry- Lindhe,4th
Edition
• Periodontics –Medicine, Surgery &Implants -
Rose ,Mealey, Genco, Cohen
• Fundamentals of Periodontics- Wilson & Kornman, 2nd
Edition -
• www.google.com