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GOOD MORNING!!!!
PERIODONTAL RESPONSE TO
EXTERNAL FORCES
DEEPTHI P.R. FINAL YEAR BDS
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
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
CONTENTS
• Signs of Trauma from Occlusion
• Treatment Planning
• Occlusal treatment
• Physiologic & Pathologic Occlusion
• Pathologic Tooth Migration
• Conclusion
• Bibliography
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
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
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
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)
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)
TRAUMA FROM OCCLUSION
SYNONYMS
• Traumatizing occlusion
• Occlusal trauma
• Traumatogenic occlusion
• Periodontal traumatism
• Overload
• Traumatism
NB
Occlusal trauma: Diagnosis
Traumatogenic occlusion: Etiology
TRAUMATIC OCCLUSION/
TRAUMATOGENIC OCCLUSION
‘An occlusion that produces forces that cause an
injury to the attachment apparatus’
TRAUMA FROM OCCLUSION
CLASSIFICATIONS
I. Acute & Chronic
II. Primary & Secondary
TRAUMA FROM OCCLUSION
ACUTE TFO
Causes :
• An abrupt occlusal impact
• Restorations/prosthetic appliances
Manifestations :
• Tooth pain
• Sensitivity to percussion
• Increased tooth mobility
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
Periodontal response to external forces
TRAUMA FROM OCCLUSION
CHRONIC TFO
• More common & significant
• Gradual changes by:
- tooth wears
- drifting movement & extrusion
- parafunctional habits
• Malocclusion not necessarily TFO
TRAUMA FROM OCCLUSION
• Traumatic Occlusal relationships
-Effect of the occlusion on the periodontium
Also known as:
Occlusal disharmony
Functional imbalance
Occlusal dystrophy
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
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
Periodontal response to external forces
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
PARAFUNCTIONAL HABITS
• Duration of tooth contact greatly increased
• Magnitude of force during bruxism much
greater
• Bruxism / clenching involve most of the teeth
• Occlusal appliances
PARAFUNCTIONAL HABITS
• Foreign object biting – localized to few teeth
• Encourage habit elimination
• Distinguish between adaptive periodontium &
one that is in trauma
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
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
Periodontal response to external forces
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
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
Periodontal response to external forces
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.
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
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
Periodontal response to external forces
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
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
GLICKMAN’S CONCEPT
• Character of progressive tissue destruction of
periodontium at a “traumatized” tooth
different from that in a “non-traumatized”
tooth
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
GLICKMAN’S CONCEPT
Periodontal structures divided into two zones
1. Zone of Irritation
2. Zone of co-destruction
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
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
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
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
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
WAERHAUG’S CONCEPT
• The loss of connective attachment & bone
resorption - exclusively due to inflammation
associated with subgingival plaque
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
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
STAGES OF TISSUE RESPONSE TO
INCREASED OCCLUSAL FORCES
3 STAGES:
INJURY
REPAIR
ADAPTIVE REMODELLING OF THE
PERIODONTIUM
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
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
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
INJURY
GREATER PRESSURE
Gradation of Changes
• Compression of fibers Areas of hyalinization
• Injury to fibroblasts & other cells: Necrosis of
PDL
• Vascular
Within 30 minutes
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
INJURY
SEVERE TENSION
• Widening of PDL
• Thrombosis
• Haemorrhage
• Tearing of the PDL
• Resorption of the alveolar bone
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
INJURY
Injury to Periodontium: Temporary depression
• Mitotic activity
• Proliferation & Differentiation of Fibroblasts
• Collagen & Bone formation
• Normal after dissipation of forces
REPAIR
• Normal periodontium: Constant repair
• TFO - increased reparative activity
• Damaged tissues removed & formation of new
 Cells
 Fibers
 Bone
 Cementum
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
REPAIR
BUTTRESSING BONE FORMATION
• Important feature of Repair after TFO
• Inflammation
• Osteolytic tumors
Central Buttressing:
 Within the jaw
 New bone deposition
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
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
HISTOMETRIC DIFFERENTIATION
• Injury phase: resorption formation
• Repair phase: resorption formation
• Adaptive remodeling: both return to normal
EFFECTS OF INSUFFICIENT OCCLUSAL
FORCE
• Injurious to periodontium
• Thinning of the PDL
• Atrophy of fibers
• Osteoporosis of the alveolar bone
• Reduction in bone height
EFFECTS OF INSUFFICIENT OCCLUSAL
FORCE
Can result from:
Open-bite relationship
Absence of functional antagonists
Unilateral chewing habits
REVERSIBILITY OF TRAUMATIC LESIONS
• TFO –Reversible
• Artificially created TFO- extrusion & intrusion
& repair on removal
• Not always correct itself
• Injurious force- relieved for repair
REVERSIBILITY OF TRAUMATIC LESIONS
• Conditions not permitting adaptation to
occlusal forces- damage worsens/persists
• Plaque induced inflammation- impairs the
reversibility of traumatic lesions
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
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
Periodontal response to external forces
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
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
Periodontal response to external forces
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
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
INTERACTION OF TFO &
INFLAMMATION
• Inflammation proceeds to PDL
• Angular bone loss & infrabony pockets
• Areas of root resorption exposed without
gingival attachment – plaque & calculus
Periodontal response to external forces
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
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
Periodontal response to external forces
STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
Eastman Dental Center
• Squirrel monkeys
• Repetitive interdental wedging
• Mild to moderate inflammation
• 10 weeks
• No increase in attachment loss
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
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’
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
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
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’
STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
• ‘TFO combined with experimental
periodontitis accelerated periodontal
breakdown characterized by continuous
periodontal pocket formation & loss of fiber
attachment’
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’
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
STUDIES & RESEARCHES ON OCCLUSAL
TRAUMA
• Changes ceased once physiologic adaptation
complete
• Withdrawal of traumatic forces – lost bone
volume restored
• Persisting plaque induced inflammation
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
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
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
Periodontal response to external forces
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
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
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
SIGNS OF TFO
OCCLUSAL SUMMARY CHART
• Future treatment decisions & response to
therapy
• Minimum information
• Assess the relation between occlusal forces &
periodontal status
Periodontal response to external forces
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
TREATMENT PLANNING
Occlusal treatment indicated
• Occlusal discrepancies
• Periodontal disease
X Occlusal treatment not indicated
• Asymptomatic
• No significant periodontal disease
TREATMENT PLANNING
Decision to treat made in the reevaluation
appointment :
• Non surgical treatment
• Mobility & fremitus reduced
• Need for treatment diminished
OCCLUSAL TREATMENT
• After non surgical treatment
• Exception: difficulty/ pain on chewing due to
occlusal trauma
2 APPROACHES
BITE APPLIANCE
ALTERING OCCLUSAL RELATIONSHIPS OF
TEETH
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
Periodontal response to external forces
OCCLUSAL TREATMENT
OCCLUSAL ADJUSTMENT
• Permanent alteration:
- Orthodontic therapy
- Selective grinding
• Permanent change – distribution of occlusal
forces
• Care & skill
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
PHYSIOLOGIC & PATHOLOGIC
OCCLUSION
PATHOLOGIC:
• Disease due to occlusal activity
• Requires therapeutic alteration
PATHOLOGIC TOOTH MIGRATION
DEFINITION
‘Tooth displacement that results when the
balance among the factors that maintain
physiologic tooth position is disturbed by
periodontal disease ’
PATHOLOGIC TOOTH MIGRATION
• Common & early sign
• Gingival inflammation
• Pocket formation
• Anteriors frequent
• Any direction
• Mobility & Rotation
Extrusion: Pathologic migration in the incisal/
occlusal aspect
Periodontal response to external forces
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
PATHOLOGIC TOOTH MIGRATION
Nature & location of contact point
relationships
Proximal, incisal & occlusal attrition
Axial inclination of teeth
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
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
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
Periodontal response to external forces
PATHOLOGIC TOOTH MIGRATION
• Premolars drift distally
• Doesn’t always occur
Periodontal response to external forces
PATHOLOGIC TOOTH MIGRATION
B. Failure to replace First Molars
• Second & third molars tilt reducing the vertical
dimension
• Premolars - distally & mandibular incisors-drift
lingually
• Anterior overbite increased & mandibular
incisors traumatize the gingiva
Periodontal response to external forces
PATHOLOGIC TOOTH MIGRATION
• Maxillary incisors pushed labially & laterally
• Anterior teeth extrude because incisal
apposition has largely disappeared
• Diastemata created- anterior teeth
Periodontal response to external forces
PATHOLOGIC TOOTH MIGRATION
Proximal contacts disturbed:
Food impaction
Gingival inflammation
Pocket formation
Bone loss
Mobility
Altered positions- traumatize supporting
tissues- aggravate destruction
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
Periodontal response to external forces
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
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
THANK YOU YOU

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Periodontal response to external forces

  • 2. PERIODONTAL RESPONSE TO EXTERNAL FORCES DEEPTHI P.R. FINAL YEAR BDS
  • 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
  • 5. CONTENTS • Signs of Trauma from Occlusion • Treatment Planning • Occlusal treatment • Physiologic & Pathologic Occlusion • Pathologic Tooth Migration • Conclusion • Bibliography
  • 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)
  • 11. TRAUMA FROM OCCLUSION SYNONYMS • Traumatizing occlusion • Occlusal trauma • Traumatogenic occlusion • Periodontal traumatism • Overload • Traumatism NB Occlusal trauma: Diagnosis Traumatogenic occlusion: Etiology
  • 12. TRAUMATIC OCCLUSION/ TRAUMATOGENIC OCCLUSION ‘An occlusion that produces forces that cause an injury to the attachment apparatus’
  • 13. TRAUMA FROM OCCLUSION CLASSIFICATIONS I. Acute & Chronic II. Primary & Secondary
  • 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
  • 39. GLICKMAN’S CONCEPT Periodontal structures divided into two zones 1. Zone of Irritation 2. Zone of co-destruction
  • 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
  • 54. INJURY SEVERE TENSION • Widening of PDL • Thrombosis • Haemorrhage • Tearing of the PDL • Resorption of the alveolar bone
  • 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
  • 107. PHYSIOLOGIC & PATHOLOGIC OCCLUSION PATHOLOGIC: • Disease due to occlusal activity • Requires therapeutic alteration
  • 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
  • 117. PATHOLOGIC TOOTH MIGRATION • Premolars drift distally • Doesn’t always occur
  • 119. PATHOLOGIC TOOTH MIGRATION B. Failure to replace First Molars • Second & third molars tilt reducing the vertical dimension • Premolars - distally & mandibular incisors-drift lingually • Anterior overbite increased & mandibular incisors traumatize the gingiva
  • 121. PATHOLOGIC TOOTH MIGRATION • Maxillary incisors pushed labially & laterally • Anterior teeth extrude because incisal apposition has largely disappeared • Diastemata created- anterior teeth
  • 123. PATHOLOGIC TOOTH MIGRATION Proximal contacts disturbed: Food impaction Gingival inflammation Pocket formation Bone loss Mobility Altered positions- traumatize supporting tissues- aggravate destruction
  • 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