Trauma from occlusion (Including TFO around dental implants)

Trauma from occlusion
HKES S.N. Dental college
Dr. Jignesh Patel,
MDS, Periodontology.

Healthy periodontium and
occlusion
PDL and A.bone depends on the functional occlusal
forces
Factors influencing adaptive capacity of the periodontium
to occlusal forces are:
Magnitude
Direction
Duration & frequency

What is Trauma from occlusion ?
 When occlusal forces exceeds the adaptive capacity of
the periodontal tissues, the tissue injury results that is
called as TFO.1
Occlusal trauma is a injury resulting in tissue changes
within the periodontal attachment apparatus as a result of
occlusal forces.2
1. Coolidge et al., Orban et al., Gottlieb et al.
2. Glossary of periodontal terms, AAP, 2001.

Varieties of occlusal trauma
1. Primary TFO
Traumatic injury results due to
altered occlusal forces applied to a
tooth or teeth with normal
periodontal support

2. Secondary TFO
Tissue injury resulting from
normal or excessive
occlusal forces applied to a
tooth or teeth with reduced
periodontal support

 Acute trauma
 Chronic trauma

Role of occlusion in the
pathogenesis of TFO

Association of periodontal destruction with excessive
occlusal forces was first reported in 1901 by Karolyi
In 1917, Stillman- occlusal forces must be controlled
Controversies !!!
Is there any role of excessive occlusal force on periodontal
disease initiation and progression?
 How to evaluate occlusal forces?
At what point forces become “excessive”?
When should treatment be initiated and how should be
accomplished?HKES S.N. Dental college

Review of studies done on animal
models or Human autopsy material
Oraban & Weinmann (1933)
and Weinmann et. al. (1941)
using human autopsy
material, concluded that
occlusal forces play no part in
periodontal destruction
Glickman et al. (1962)
proposed Glickman’s concept
using dogs and Rh monkeys

 Waerhug (1979) examined relationship between subgingival
plaque and morphology of osseous defects
 Waerhug’s concept:
‘Plaque front’ followed the morphology of the bony defect
He refused ‘zone of co-destruction’
Infrabony defect occurs when subgingival plaque level has
reached more apical compared to subgingival plaque level of
adjacent tooth

Polson et.al
(1976)
• Squirrel
monkeys
• Mesial-distal
direction of
forces
Lindhe et. al
(1977)
• Beagle dogs
• Buccal-lingual
forces using
high contact
points
Compared excessive occlusal forces in
absence and presence of plaque

Review of human studies and clinical
trails
Pihalstorm et al. (1986) studied association between
association of TFO and Periodontitis
Teeth with TFO (hypermobility and widened PDL
space) had deeper PDs, CAL and less bone support
than teeth without these symptomes
McQuire et al. (1996) studied parafunctional habits
and periodontitits

Burgett et al. (1992)
• Studied effect of
occlusal adjustment in
the treatment of
periodontitis
• occlusal adjustments
showed gain in CALs
Harrel and Nunn (2001)
•Examined advanced
periodontitis patients with
occlusal discrepancies
•Slowing of progression
of periodontal destruction
with occlusal therapy

Conclusion of studies
1. In healthy periodontium, no relation of occlusal trauma in
initiation of gingival recession, pocket depth and loss of
CAL
2. In teeth with progressive plaque associated disease,
enhance the rate of progression of the disease (act as a
co-destructive risk factor)
3. Correction of occlusal discrepancy can restore
periodontium to normal health

Stages of tissue response to
increased Occlusal forces

Three stages given by Carranza FA Jr,
(1970)
 Stage I: Injury
Ligament is widened at the
expense of bone
Angular bone defects without
pocket formation
Tooth mobility
Areas most susceptible to injury are
furcations (Glickmen et al. 1961)

Stage II: Repair
Trauma stimulates increased reparative activity
Buttressing bone formation
Central buttressing- endosteal bone
Peripheral buttressing may lead to shelf like thickening
of the alveolar margin, reffered to as “Lipping”

Stage III: Adaptive remodelling of the
Periodontium
When repair process can’t keep pace with
destruction- remodelling occurs to create a
structural relationship
Thickened funnel shaped PDL at creast
Angular defects in bone with no pockets
Involved tooth becomes loose

Clinical detection of TFO by
occlusal analysis

Analysis of occlusal relationship as a part of
comprehensive periodontal examination
But, What to include in occlusal analysis ?
1. Initial contact in centric relation
(retruded position of mandible)
2. Centric occlusion

3. check for pattern of occlusion according to Angle’s
classification
4. detection of overbite, overjet and cross bite
5. Detection of fremitus
6. Attrition and location of wear facets

Check for Occlusal Stability
1. maximum intercuspal position
• Light or absent anterior contacts
• Well-distributed posterior contacts
• Coupled contacts between opposing teeth
• Cross tooth stabilization
• Forces directed along long axis of each tooth
2. Smooth excursive movements without interferences
3. Favorable subjective response to occlusal form and functionHKES S.N. Dental college

Clinical and Radiographical
signs of TFO

1. Tooth mobility
2. Fremitus
3. Occlusal descripansces
4. Wear facets in presence of other indicators
5. Tooth migration
6. Fractured tooth/teeth
7. Thermal sensitivity
mobility
Increased increasing
Clinical signs

Radiographical signs

Therapeutic goals and
Rx consideration

 To maintain periodontium in comfort and function
Treatment considerations
 Occlusal adjustment (coronoplasty)
 Management of parafunctional habits
 Temporary, provisional or long term stabilization of mobile
teeth with splinting and removable or fixed appliances
 Orthodontic tooth movement
 Extraction of selected teeth
Ultimate goal of therapy

Indications of coronoplasty
1. To reduce traumatic forces to teeth exhibiting
increasing mobility
2. To achieve functional relationship in restorative and
orthodontic treatment
3. To reshape teeth contributing to soft tissue injury
4. To adjust marginal ridge relation and cusps that are
contributing to food impaction

Clinical situation 1
Rx: Correction of occlusal descrepancies

Rx: Correction of occlusal descrepancies

Rx: splinting if chewing ability and/or patient’s
comfort are disturbed.

Rx: occlusal adjustment with fixed permanent
splinting
Clinical situation 4 (increasing mobility)

 Adell et al. (1981) and Lindquist et al. (1988)-
considered excessive loading as most common reason
for implant loss
 Sagara et al. (1993) early loading may impede
successful osseointegration
 Isidor et al. (1997) tested non axial forces on implants
and found to be a risk factor for osseointegration

Bone reactions to functional loading
 Berglundh et al. (2005) studied reaction of peri-implant
bone after long standing functional loading compared
to non-loaded controls.
1.AstraTech Implant system 2. Branemark Implant systemHKES S.N. Dental college

 Results and conclusion :
Functional loading of implants may enhance
osseointegrationHKES S.N. Dental college

Excessive occlusal loads on implants
 Heitz-Mayfield et al. (2004) did experimental Dog study using
two Titanium plasma sprayed implant and two sandblasted acid
etched implants on each side of the mandible

TFO occurs in the supporting tissues and
does not affect the gingiva

When TFO is eliminated, reversal of bone loss occurs,
except in the presence of periodontitis. (inflammation
inhibits the potential for regeneration )

In the absence of inflammation, the response to TFO is
limited to adaptation to the increased forces.
In the presence of inflammation, changes in the shape of
the alveolar crest may be conducive to angular bone
loss, and existing pockets may become infrabony.

Occlusal therapy reduces the excessive loading of teeth
that have lost bone to periodontal disease
Clinician should develop the skill to diagnose occlusal
status, use splints for occlusal stability, and develop the
techniques of occlusal adjustment
Many patients will benefit when occlusal therapy include
as a part of the overall periodontal treatment protocol.

References:
1. Jan Lindhe, Thorkild Karring . Niklaus P. Lang, Textbook of Clinical Periodontology
and Implant Dentistry, 4th ed. by Blackwell Munksgaard, a Blackwell, Publishing
Company, 2003.
2. Fermin A. Carranza, Jr., Michael G. Newman,Textbook of Clinical
periodontology.,1oth ed., WB saunders &Co.,2008.
3. Hallmon W., Harrel S., Occlusal analysis, diagnosis and management in
periodontal practice. Periodont. 2000, Vol. 34, 2004, 151-164.J. De Boever, A. De
Boever. Occlusion and periodontal health, section 3, Text book of clinical practice
and occlusion
4. Puri M., GroverH., Gupta A. Splinting – A Healing Touch for an Ailing Periodontium.
J Oral Health Comm Dent 2012;6(3)145-148.
5. Rupprecht D. Trauma from occlusion: a review. Clinical Update Naval Postgraduate
Dental School, 2004, Vol. 26, No. 25-27.
6. Consolaro A. Diagnosis of occlusal trauma: Extrapolations for peri-implant bone
region can be done. Dental Press Implantol. 2012 Oct-Dec;6(4):22-37.

Trauma from occlusion (Including TFO around dental implants)

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