Trauma from occlusion

Dr P MIKITHA
2ND YEARPG
AECSMAARUTI COLLEGEOF DENTAL SCIENCES

CONTENTS
 Introduction
 Definition
 Synonyms
 Historical aspects
 Adaptive capacity of
periodontium to the occlusal
forces
 Etiology
 Classification of TFO
 Stages of tissue response of TFO
 Clinical examination and diagnosis
 TFO and plaque associated
periodontal disease
 Periodontal significance of non-
functional occlusion
 Therapeutic goals
 Treatment considerations
 Conclusion
 References

introduction
 Trauma from occlusion is a term used to describe pathologic
alterations or adaptive changes which develop in the periodontium as
a result of undue force produced by masticatory muscles.
 It is only one of the many terms that have been used to describe such
alterations in the periodontium.
 In addition to producing damage in periodontal tissues, excessive
occlusal forces may also cause injury in TMJ, masticatory muscles
and the pulpal tissues.
Fermin AC. Periodontal response to external forces in Carranza’s clinical periodontology, Elsevier, 12, 2013; 682-689.

definition
• STILLMAN in 1917 defined it as “ a condition where injury
results to the supporting structures of the teeth by the act of
bringing the jaw into a closed position”.
• WHO in 1978 defined it as “ damage in periodontium caused by
stress on the teeth produced directly or indirectly by teeth of
opposing jaw”.
• In “glossary of periodontic terms” (American Academy of
Periodontology, 1986) occlusal trauma was defined as “ an injury to
attachment apparatus as a result of excessive occlusal forces”.
Singh DK, Jalaluddin M, Rajeev R. Trauma from occlusion: The overstrain of the supporting structures of the teeth. Indian J Dent Sci 2017;9:126-32

• When occlusal forces exceeds the adaptive capacity of the tissues,
tissue injury results. The resultant injury is termed trauma from
occlusion - Glickman
• A term used to describe the pathological alterations or adaptive
changes which develop in the periodontium as a result of undue
force produced by the masticatory muscles- lindhe 5th edition.
Lindhe J, Svanberg G. Influence of trauma from occlusion on progression of the experimental periodontitis in the beagle dogs. J Clin Periodontol 1974; 1(1): 13-14.

synonyms
 Occlusal trauma
 Occlusal traumatism, periodontal traumatism
 Traumatogenic occlusion
 Traumatizing occlusion
 Overload traumatic occlusion
 TFO

Karolyi
1901
first one to start the most controversial issue by introducing in 1901 the
concept of bruxism as a significant factor in the pathogenesis of
periodontitis. It is known as the “Karolyi effect.”
Talbot
(1917)
first comprehensive study of the role of occlusal stress on teeth in
relation to periodontal disease, pointed out that man is predisposed
to disease of the supporting tissues of the teeth because jaw function
has been greatly decreased by modern methods of food preparation.
Box (1935)
and
Stones
(1938)
experiments in sheep and monkeys, the results seemed to indicate that
“TFO is an etiologic factor in the production of periodontal disease
in which there is vertical pocket formation associated with one or a
varying number of teeth”
Historical aspects

Glickman
and
Smulow
1960
traumatogenic occlusion may act as a cofactor in the progression of
periodontitis. This theory is known as the “co destructive theory.”
Goldman
(1956)
proved that occlusal trauma was not the cause of soft tissue lesions such
as Stillman’s clefts and McCall’s festoons.
Waerhaug
(1979)
proved the involvement of TFO in the pathogenesis of infrabony pockets.

Polson
(1980)
used squirrel monkeys as their animal model.
Houston
et
al.(1987)
concluded that there is no correlation between periodontal disease and
bruxism; they seldom occurred in the same individual, and bruxism and
occlusal status are not closely associated
Burgett et
al. (1992)
found no significant difference in the reduction in tooth mobility between
the adjusted and the nonadjusted groups.
stated that “a periodontium remained healthy despite the persistent forces
that caused the drifting of the teeth and significant changes in occlusion.”
Wolffe et
al.(1991)

Adaptive capacity of the periodontiumto
occlusal forces
• Widening of pdl space
• Increase in width of PDL fibres
• Increase in density of alveolar bone
MAGNITUDE
• Reorientation of stresses within periodontium
• Lateral forces and torque injure the
periodontium
DIRECTION
• Constant pressure is more injurious
• More frequent the application of intermittent
force more injurious is the force to
periodontium
DURATION AND
FREQUENCY
OF FORCE

Etiology
 Ross has divided the factors causing chronic destructive
periodontal disease into two groups:
PRECIPITATING
FACTORS
PREDISPOSING
FACTORS
EXTRINSIC
FACTORS
INTRINSIC
FACTORS

• Etiologic factors of periodontal occlusal trauma can be
divided into four categories:
1. Situation that increases the magnitude or frequency of
occlusal forces
2. Situations that change the direction of occlusal forces
3.Circumstances that decrease the resistance of the periodontium
to occlusal forces
4. Combination of all three factors

• Situation that increases the magnitude or frequency of occlusal
forces:
a. Long sustained occlusal contacts from parafunctional habits such as
clenching, bruxism, and chewing on pipe stems
b. Parafunctional habits stimulated by occlusal interferences such as
centric prematurities and balancing side contacts
c. Parafunctional habits and/or the direction of an entire occlusal load
onto one or a few teeth triggered by restorative and prosthetic
dentistry that does not harmonize with the entire occlusion
d. Fixed and removable prosthetic appliances

• Situations that change the direction of occlusal forces
Changing the direction of occlusal forces causes a reorientation of the
stresses and strains within the periodontium.
a.Tipping forces from occlusal interferences such as centric prematurities
and balancing side contacts, which usually occur on inclined planes
b. Parafunctional habits in extreme eccentric positions
c. Restorative and prosthetic treatment that generate tipping occlusal
forces
d. Tilting and drifting of teeth.

• Circumstances that decrease the resistance of the periodontium to
occlusal forces:
a. Loss of alveolar bone and periodontal ligament (PDL) support
b. Loss of a number of teeth, thereby requiring fewer teeth to absorb
the entire occlusal load.
• Combination of all three factors All the three, i.e., combination
may be found in case of moderate-to-severe periodontitis
combined with missing and drifted teeth, occlusal disharmonies,
and parafunctional habits.

Classification OF TFO
 GLICKMAN’S CLASSIFICATION (1953)
acute
chronic
DURATION
primary
secondary
NATURE
AND
CAUSE

BOX’S CLASSIFICATION
• Physiologic occlusion: A condition, in which the systems of
forces acting on the tooth during the occlusion are in a state of
equilibrium, and they do not and cannot change the normal
relationship existing between the tooth and its supporting
structures, defined by box.
• Traumatic occlusion: The damage produced in the periodontium
is due to the overstress produced by the occlusion.

HAMP, NYMAN, AND LINDHE’S
CLASSIFICATION (1975)
• This classification is based on a horizontal component of tissue
destruction that has occurred in the interradicular area.
• Degree I: Horizontal loss of periodontal tissue support not exceeding
one-third of the width of the tooth.
• Degree II: Horizontal loss of periodontal support exceeding one-third
of the width of the tooth.
• Degree III: Horizontal through-and-through destruction of the
periodontal tissue in the furcation area.

ACUTE TFO
 Develops from:
 Abrupt occlusal impact such as by biting on a hard object
 Restorations or prosthetic appliances that interfere with or
alter the direction of occlusal force
 C/F:
 Tooth pain, sensitivity to percussion and increased tooth
mobility

 Outcome:
Forces dissipated
 Shift in tooth position
 Wearing heals
 Correction of restoration subsides
Or else
PDL injury necrosis+ perio. Abscess or cementum
tears

CHRONIC TFO
 More common and significant
 Gradual changes by:
Tooth wears
Drifting movement and extrusion
Parafunctional habits
 Malocclusion not necessarily TFO

PRIMARY AND SECONDARY TFO
 TFO may be caused by:
 Alterations in occlusal forces
 Reduced capacity of the periodontium to withstand occlusal
forces
 Or both

PRIMARY TFO
 When TFO is the result of alterations in occlusal forces-primary TFO
 The primary form includes a tissue reaction which is elicited around a
tooth with normal height of the periodontium
 Occurs if:
 TFO is considered the primary etiological factor in periodontal
destruction
 Occlusion results in the only local alteration of teeth
 Parafunctional habits

 Ex:
 Insertion of a high filling
 Inseration of a prosthetic replacement that creates excessive forces
on abutment and antagonist teeth
 Drifting movement or extensionof teeth into spaces created by
unreplaced missing teeth or
 Orthodontic movement of teeth into functionally unacceptable
positions

SECONDARY TFO
 Occurs when the adaptive capacity of the tissues to withstand
occlusal forces is impaired by bone loss resulting from
marginal inflammation.

Stages of tissue responses
Stage 1 INJURY:
 Tissue injury is produced by excessive occlusal forces.
 The areas of the periodontium most susceptible to injury from
excessive occlusal forces are the furcations.
 Injury to the periodontium produces a temporary depression in
mitotic activity and the rate of proliferation and differentiation of
fibroblasts, in collagen formation, and in bone formation.
 These return to normal levels after dissipation of the forces.

WITH SLIGHT EXCESSIVE PRESSURE:-
A. PRESSURE SIDE:-
 Bone resorption with widening of periodontal ligament
space.
 Blood vessels are numerous and reduced in size.
B. TENSION SIDE:-
 Bone apposition with elongation of PDL fibers.
 Enlarged blood vessels.

C. WITH SEVERE EXCESSIVE PRESSURE:-
 Causes thrombosis, hemorrhage, tearing of periodontal ligament
fibers and resorption of alveolar bone.
 Pressure severe enough to force the root against bone causes
necrosis of the periodontal ligament and bone.
 The bone is resorbed from viable periodontal ligament adjacent to
necrotic areas and from marrow spaces, a process called
undermining resorption.

D. WITH GREAT EXCESSIVE FORCE:-
 Compression of fibers- hyalinization
 Injury to fibroblasts and other connective tissue cells leads to
necrosis of areas of ligament.
 Vascular changes are produced
 Increased resorption of bone and tooth surface.

Stage 2- Repair:-
 Repair is constantly occurring in the normal periodontium, and
trauma from occlusion stimulates increased reparative activity.
 The damaged tissues are removed, and new connective tissue
cells and fibers, bone, and cementum are formed in an attempt to
restore the injured periodontium .

 Forces remain traumatic only as long as the damage produced
exceeds the reparative capacity of the tissues.
 When bone is resorbed by excessive occlusal forces, the body
attempts to reinforce the thinned bony trabeculae with new bone.
 This attempt to compensate for lost bone is called buttressing bone
formation and is an important feature of the reparative process
associated with trauma from occlusion.

 Central buttressing- bone formation within the jaw, endosteal cells
deposit new bone which restores bony trabeculae and reduces the
size of the marrow spaces
 Peripheral buttressing occurs on the facial and lingual surfaces of
the alveolar plate

Stage 3-Adaptive remodeling of periodontium:-
 If the repair process cannot keep pace with the destruction caused
by the occlusion, the periodontium is remodeled in an effort to
create a structural relationship in which the forces are no longer
injurious to the tissues.
 This result in a widened periodontal ligament, which is funnel
shaped at the crest, and angular defects in the bone, with no pocket
formation. The involved teeth become loose.

Clinical examination and diagnosis
1. History
2. Clinical examination:
 Masticatory system
 Assessment of tooth mobility
Sangeetha S, Mitra K, Yadalam U, Narayan SJ. Current concepts of trauma from occlusion - A review. J Adv Clin Res Insights 2019;6:14-19.

SIGNS AND SYMPTOMS OF TFO
Clinical signs:
1. Traumatic crescent – a crescent-shaped bluish red zone of gingiva
confined to about one-sixth of the circumference of the root
2. Recession of the gingiva, which may be asymmetrical, associated
with resorption of the alveolar crest
3. Stillman’s clefts – indentations in the gingival margin, generally on
one side of the tooth
4. McCall’s festoons - discrete semilunar enlargement of the marginal
gingiva
5. Absence of stippling – interpreted as evidence of edema secondary
to trauma

 Increased tooth mobility:
 Hallmark of TFO
 Can be easily measured by blunt ends of two dental
instruments which are placed approx. at the buccal and
lingual heights of contour of the tooth and force are applied
in the bucco-lingual direction

 MILLER’S MOBILITY INDEX (1950):
 Grade 1: first distinguishable sign of movement greater than
normal
 Grade 2: movement of 1mm from normal position in any
direction
 Grade 3: greater than 1mm and rotation or depression

The periotest scale (schulte et al 1987) ranges from -8 to +50:
 -8 to +9: clinically firm teeth
 10-19: first distinguishable sign of movement
 20-29: crown deviates within 1mm of its normal position
 30-50: mobility is readily observed.

 Fremitus Test:
 Test to detect TFO
 Fremitus is a measurement of the vibratory pattern of the teeth
whenthe teeth are placed in contacting position and movements
 Class 1: mild vibrations or movement detected
 Class 2: easily palpable vibration but no visible movement
 Class 3: movement visible with naked eye

 Occlusal prematurities:
 Articulating paper, thin sheets of wax or occlusal indicator
wax
 Study models
 T scan

Radiographic signs:
1. Widening of the PDL space, often with thickening of the
lamina dura along the lateral aspect of the root in the apical
region and in bifurcation areas
2. Vertical rather than horizontal destruction of the interdental
septum, with the formation of infrabony defects
3. Radiolucency and condensation of the alveolar bone
4. Root resorption

Clinical Features of Occlusal Trauma
1. No periodontitis
2. Tooth wear (mild faceting or marked attrition)
3. Fractures of the enamel or restorations
4. Occlusal interferences (either from the retruded contact position to
intercuspal position (ICP) or in lateral excursions/protrusive
movements)
5. Ridging of buccal mucosa
6. Indentations in lateral border of the tongue
7. Reddening of the tip of the tongue.

TFO and plaque associated periodontal disease
 The interaction between TFO and plaque associated periodontal
disease in humans was frequently discussed in the period 1955-
1970 in connection with “report of a case”, “in my opinion”
statements, etc.
 Early studies on trauma from occlusion typically used autopsied
material that provided no information on periodontal conditions
and occlusal forces that occurred before studies.

 However, controversy still prevails whether tooth hypermobility and
trauma from occlusion act as codestructive factors in the progression
of periodontal diseases.
 This can best be illustrated if “Glickman’s concept “ is compared
with “Waerhaug’s concept “of what autopsied study have revealed
regarding trauma from occlusion and periodontal diseases.

Glickman’s concept
 In 1965 and 1967 he claimed that the pathway of spread of a plaque
associated gingival lesion can be changed if forces of an abnormal
magnitude are acting on teeth harbouring subgingival plaque.
 Instead of even destruction of periodontium and alveolar bone ie.
Suprabony pocket and horizontal bone loss, which according to Glickman
occurs at sites with uncomplicated plaque associated lesion, sites which
are also exposed to abnormal occlusal force will develop angular bony
defect and infrabony pockets.

Zone of irritation:
 Includes the marginal and interdental
gingiva
 Soft tissue- bordered by hard tissue
only on one side and is not affected by
forces of occlusion.
 This means that gingival inflammation
cannot be initiated by TFO but rather
due to irritation from plaque

Zone of co-destruction:
 Consists of PDL, Cementum, alveolar
bone and is coronally delineated by the
transseptal and dentoalveolar collagen
fiber bundles.
 The tissue in this zone may become the
seat of a lesion caused by TFO.

Waerhaug’s concept
 He examined autopsy specimens similar to Glickman’s but
measured in addition the distance between subgingival plaque and
the periphery of associated inflammatory cells infiltrate in the
gingiva.
 He refuted the findings of Glickman’s concept and stated that
angular bony defect is as common in periodontal sites which are
uncomplicated with occlusal trauma as the sites which are
complicated with occlusal trauma.

 Waerhaug concluded that angular bony defects and infrabony
pockets occur when the subgingival plaque of one tooth has
reached a more apical level than the microbiota on the
neighbouring teeth and when the volume of the alveolar bone
surrounding the roots is comparitively large.

Clinical trials
 Fleszar et al. (1980) reported on the influence of tooth mobility on
healing following periodontal therapy including both root
debridement and occlusal adjustment.
 They concluded that "pockets of clinically mobile teeth do not
respond as well to periodontal treatment as do those of firm teeth
exhibiting the same disease severity.

 Pihlstrom et al. 1986 studied the association between trauma from
occlusion and periodontitis by assessing a series of clinical and
radiographic features at maxillary first molars.
 Pihlstrom and his associates concluded from their measurements and
examinations that teeth with increased mobility and widened
periodontal ligament space had, in fact, deeper pockets, more
attachment loss and less bone support than teeth with-out these
symptoms.

 Burgett et al. (1992) studied the effect of occlusal adjustment in the
treatment of periodontitis.
 They found that probing attachment gain was on the average about 0.5 mm
larger in patients who received the combined treatment, i.e. scaling and
occlusal adjustment, than in patients in whom the occlusal adjustment was
not included.
 The findings by Fleszar, Pihlstrom and Burgett and co-workers lend some
support to the concept that trauma from occlusion (and increased tooth
mobility)may have a detrimental effect on the periodontium.

 Nunn and Harrel (2001) and Harrel and Nunn(2001) examined the
relationship between occlusal discrepancies and periodontitis in 2
studies.
 It was observed that teeth with occlusal discrepancies had
significantly deeper PPD values and higher mobility scores than
teeth without occlusal trauma and also that teeth exposed to
occlusal adjustment responded better to NSPT than teeth with
remaining occlusal discrepancies.

Animal studies
Rochester group Gothenburg group
 Squirrel monkeys were used
 Orthodontic type of forces were
imposed on experimental teeth
 Duration- 10 weeks
 Conclusion- occlusal trauma doesn’t
influence periodontal disease
progression as they found no evidence
of accelerated attachment loss when
occlusal trauma was present in the
presence of plaque.
 Beagle dogs were used
 Jiggling type of forces using a cap splint
were imposed on the experimental teeth
 Duration 1 year
 Conclusion: occlusal trauma could
accelerate the progression of the
periodontal disease as they found
evidence of the attachment losss when
both plaque and occlusal forces were
present.

Jiggling type trauma
Healthy periodontium with normal bone height:
 The combined tension and pressure zones are characterized by
signs of acute inflammation, including collagen resorption, and
cementum resorption
 As a result of bone resorption, the PDL space gradually increases
in size on both sides of the teeth as well as in the periapical
region

Healthy periodontium with reduced height:
 Ericsson and lindhe 1977
 Gradual increase in the width of the PDL and progressive increase in
tooth mobility during a period of several weeks but do not lead to
further loss of CT attachment
 After occlusal adjustment, the width of PDL is normalized and the
teeth are stabilized

Periodontal significance of non-functional
occlusion
 Insufficient occlusal force may also be injurious to the
supporting periodontal tissues.
 Insufficient stimulation causes:
 Thinning of PDL
 Atrophy of fibres
 Osteoporosis of alveolar bone
 Reduction in bone height

TFO and IMPLANTS
Bone reactions to functional loading:
 Berglundh et al 2005- addressed the reaction peri-
implant bone after longstanding functional loading
compared to non-loaded controls.
 Based on the radiographic and histologic results this
study has demonstrated that functional loading may
enhance osseointegration (direct bone-to implant
contact) rather than inducing marginal bone loss.

Excessive occlusal load on implants:
 Heitz-maryland et al. 2004- in an experimental dog study, The effect
of excessive occlusal load following placement of titanium implants
in the presence of healthy peri-implant mucosal tissues was
evaluated.
 In the presence of peri-implant mucosal health, a period of 8 months
of excessive occlusal load on titanium implants did not result in loss
of osseointegration or marginal bone loss when compared with non-
load implants.

Therapeutic goals
 Elimination or reduction of tooth mobility
 Establish or maintain a stable, reproducible intercuspal position
 Provide freedom of movement to and from the intercuspal position,
including movement in all direction regardless of the initial point of
contact
 Develop a comfortable occlusion
 Provide efficient masticatory function
 Eliminate or modify parafunctional habits

Treatment considerations
 Evaluation of occlusal symptoms should continue throughout the course of
therapy
 Treatment may need to be repeated or revised
 Treatment for chronic periodontitis patient with occlusal traumatism
includes:
a. Occlusal adjustment
b. Management of parafunctional habits
c. Splinting
d. Orthodontic tooth movement
e. Occlusal reconstruction
f. Extraction of selected teeth

Occlusal adjustment
 The reshaping of the occlusal/incisal surfaces of the tooth/teeth or
coronoplasty involves selective grinding of the teeth to achieve a
harmonious relationship of the teeth in the opposite arches.

Indications Contraindications
 Reduce traumatic forces to
teeth.
 Achieve functional
relationships and masticatory
efficiency.
 As an adjunctive therapy, to
reduce the damage from
parafunctional habits
 Reshaping of the teeth
 Occlusal adjustment without
careful pre-treatment study,
documentation
 Prophylactic adjustment without
evidence of the signs and
symptoms of occlusal trauma
 As a primary treatment of
microbial-induced inflammatory
periodontal disease

Management of parafunctional habits
 Night guards are very helpful- bruxism
Methods by which the patient with bruxism can be treated:
 Electromyographic biofeedback
 Medications aimed at altering sleep arousal
 Appliances for maxillary stabilization

splinting
 A splint is an appliance used for immobilization or stabilization.
 Splinting is stabilization, achieved by joining two or more teeth
to increase resistance to the forces applied.
 The types being the short-term splint, the provisional or long-
term splint.

Orthodontic treatment
 Patient with impinging overbite
 Functional anterior crossbite
 Uprighting of tipped teeth
 Intrusion of extruded teeth or forced eruption
 Extensive openbite
 Correction of malposition leading to gingival recession

extraction
 A tooth which has a poor prognosis and by the extraction of
which, the prognosis of the remaining teeth improves, then
the tooth in question should be extracted.

conclusion
Occlusal forces are transmitted to the periodontal attachment
apparatus, and those forces can cause changes in the bone and
connective tissue. These changes can affect tooth mobility and
clinical probing depth. While occlusal forces do not initiate
periodontitis, results are inconclusive on the interactions between
occlusion and the progression of attachment loss due to
inflammatory periodontal disease.

references
 Fermin AC. Periodontal response to external forces in Carranza’s
clinical periodontology, Elsevier, 12, 2013; 682-689.
 Lindhe J, Svanberg G. Influence of trauma from occlusion on
progression of the experimental periodontitis in the beagle dogs. J Clin
Periodontol 1974; 1(1): 13-14.
 Waerhaug J. The angular bone defect and its relationship to trauma
from occlusion and downgrowth of subgingival plaque. J Clin
Periodontol 1979;6:61-82.

 Glickman I, Smulow JB. Alterations in the pathway of gingival
inflammation into the underlying tissues induced by excessive
occlusal forces. J Periodontol 1962;33:7-13.
 Sangeetha S, Mitra K, Yadalam U, Narayan SJ. Current concepts of
trauma from occlusion - A review. J Adv Clin Res Insights 2019;6:14-
19.
 Singh DK, Jalaluddin M, Rajeev R. Trauma from occlusion: The
overstrain of the supporting structures of the teeth. Indian J Dent Sci
2017;9:126-32

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