بسم الله الرحمن الرحيم

Occlusal trauma

We know that our teeth are at function all the time and have attachment apparatus which is anatomically and histologically organized in a way to adapt the forces ( otherwise you cant work on them like if ankylosed or hard) but sometimes those teeth with this

criteria can get injury from occlusion .

In this lec. we want to know :1 -The definition of occlusal trauma

2 -Who is susceptible to it? 3 -How to diagnose it?

4 -What are the effects of it on periodontium?

Note :

When we said occlusal trauma this is the diagnosis , but the etiology is

"traumatogenic occlusion."

Definition: Injury that is resulting in tissue

changes within the periodontal

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attachment apparatus as a result of occlusal forces (notice not excessive or

abnormal just occlusal forces).

فانك" ... ... شئت ما واعمل مفارقه فانك شئت من وأحبب ميت فانك شئت ما عش" به مجاز

Attachment apparatus * Consist of : periodontal ligament (the

most affected) +bone(secondly affected after PDL)+ cementum (may be affected but slowly) + gingiva( not affected).

Fremitus A palpable or visible movement when

subjected to occlusal forces.

Ask the patient to bite while you put your finger on the tooth that may be have fremitus, and you will feel it move so it's

called fremitus .

**It's different from occlusal trauma because if tooth has fremitus this tooth will be a big problem because every time patient bite, the tooth will shift , and we have to do something (take it out of bite or decrease the force ) because every single time it's moving from its socket ,

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and will end by coming out so we must take it in our consideration.

"Fremitus "you feel it and/or see it , it happens usually in anterior teeth or premolars , but in occlusal trauma you

can't see it move .

**To differentiate between miller class 3 (which is mobility index ) from

fremitus: Fremitus : tooth does not move a lot ,

only when the patient bites you can see it and feel it move .

يدوم .... لن همه بأن هما يحمل لمن قلالهموم .... تفنى هكذا السعادة تفنى فكما

Class 3: tooth does not move even if the patient bites , the only way to detect it is by hard instrument

**not each tooth with class 3 index should have fremitus , e.g : there is tooth- with no opposing tooth- had supraerupted and moved, when you do mobility index to it, it will be class 3 index(even there is no opposing tooth) because there is no attachment apparatus.

To detect occlusal trauma:

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Any patient for the first time has to run an occlusal evaluation for him clinically

and radiographiclly :

1 -facets :(clinically)Pic. slide 4 page 1 ( right pic )

On the cusp itself or restoration (more rapid wear) ,everything is very flat, this is indicating that there is a force which cause this wear , by the time everyone will have facets so this is more

applicable for young patients .

2 -mostly there are bone loss (vertical) and furcation areas

involvement (radigrapgically) Pic. slide 4 page 1 (left pic)

All periodontium is good except for the tooth that has excessive forces , patient will end with cracked tooth or root (when it has RCT and leave it without crown so pocket will have pus and root cracked, so it's preferable to put crown on the tooth after RCT)

حالوة ... فيها مرة هي ما كثر على نشربها التي كالقهوة نعيشها التي الحياة

3 -centric relation vs. centric occlusion

slide 5 page 1 (right pic) Pic.

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Not all patients have an ideal centric relation or centric occlusion

but if there is no deviation ,no clicking you consider it normal , otherwise if you notice that there is excessive force…etc ,you have to make sure that this

patient has trauma from occlusion .

4 -excursive contacts

The common clinical signs of occlusal trauma

1 -increasing tooth mobility and migration or drifting

2 -fremitus 3 -persistent discomfort on eating :

Patient says: whenever I chew on this tooth, it cause pain for me , so we must think of excessive force on this tooth.

The common radiographic signs of occlusal trauma:

1 -discontinuity and thickening of lamina dura

2 -widening of periodontal ligament space

3 -radiolucency and condensation of alveolar bone or root

resorption

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When there is a strong force the PDL will spread as much as possible , the bone protect itself by thickening and this is till a specific stage after it there will be bone loss (tooth will move from one side to other, there will be resorption from where it move and thickening to where it

move ),”as the dr said.”

اليك ينظر احدا بان يخبرك هاديء صوت الضمير

but in primary ( not chronic ) cases there will be widening and thickening of lamina dura (well defined around tooth) but in worst cases will be bone resorption and even root resorption will

happen.

**Pic. slide 2 page 2 (left Pic) There is attrition on incisal edges and bone

loss all over , so this is from occlusal trauma combined with periodontal disease ( this

called secondary occlusal trauma ). )in the primary occlusal trauma the bone is

the same everywhere, only one side will have changes,so it's not generalized as secondary(

.

Classification of occlusal trauma: **primary occlusal trauma

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Injury resulting in tissue changes from excessive occlusal forces(EOF) applied to a tooth or teeth with normal support There will be:

1-normal bone levels 2-normal attachment levels

3-excessive occlusal force

So everything is perfect(normal bone levels, normal attachment levels) except excessive forces(could be iatrogenic :high restoration ,or abnormal occlusion).

**So periodontal ligament tissues can respond with traumatic occlusion changes when a normal periodontium is affected by increased occlusal loading due to bruxicing clenching(which is a habit , not a must to end with signs of occlusal trauma , may only muscles affected) or high restoration

**secondary occlusal trauma Injury resulting in tissue changes from

normal or EOF applied to tooth or teeth with reduced support

There will be :1-bone loss

2-attachment loss

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3-normal/EOF

**Not every perio patient must have occlusal trauma but they are susceptible

if there is signs .

But if the patient lost his teeth or has collapsed occlusion , this patient will never have a good forces on his teeth , it will hurt him –due to the bite collapse- because there is no posterior stops, so the anterior teeth will take excessive forces so they will procline , move and lose bone quickly.

But if he had mild chronic periodontitis this doesn’t mean he is really susceptible unless you see widenenig

and other clinical signs .

**Clinical and radiographic signs for primary and secondary are very much the same except that in primary (periodontium is normal ) but in secondary (dentition is not healthy and there is attachment apparatus loss so the normal forces will act as traumatic

forces). Other classification :

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**Acute: from occlusion occurs following an

abrupt increase in occlusal load e.g. As a result of biting unexpectedly on a hard

object.

**Chronic: from occlusion is more common and

has greater clinical significance(takes time to happen ,it represents most of

secondary occlusal trauma).

In exam classification mean primary and secondary note:

Role of occlusion in the pathogenesis of periodontal disease

Many animal studies rats , monkeys and dogs evaluated the effect of occlusal

forces on periodontium.

Periodontal disease is initiated by plaque which start at sulcus (gingiva --->supracrestal fibers --->. bone ) this is the usual pathway.

but Occlusal trauma starts in bone and periodontal ligament , and if the

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sulcus stays intact (no pocket) it can't cause gingival inflammation .

So the plaque is in Zone of irritation (coronal part)… but occlusal trauma is in Traumatic zone (co-destructive zone: mean both together : forces and

periodontal disease)…

لو كانت الحياة وردة ... لنجح الجميع باستنشاق رحيقها

**Pic. in slide 2 page 4: Zone of co-destruction occurs when plaque

induced periodontitis, and occurs in a tooth that also has traumatic occlusion resulting in more severe bone loss than that seen with

periodontitis alone.

If zone of irritation goes to co-destruction zone there will be more bone loss( if go

downward--->more destruction).

Occlusal trauma is bad because most people have initial periodontal disease so if they have excessive force … very quickly they can have advanced periodontal disease but never ever start periodontal disease just by occlusal trauma it's only enhance (accelerate)the changes.

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So the results of the studies do not support the concept that occlusal trauma was a causative agent of periodontal destruction.

**In usual pathway: Infection of pocket goes to blood vessels and destructs the

normal periodontium .

In trauma it looks for other spaces so the periodontal ligament spaces open

and the pathway completely changes .

The pathway of inflammation will not be as simple as when there is no trauma and there will be vertical bone loss( study using rhesus monkeys demonstrated a phenomenon described as "altered pathway of destruction" when EOF present, which means there is change in orientation of periodontal and gingival fibers which occurred in presence of EOF allowing gingival inflammation to extend along the PDL

and lead to vertical bone loss).

Different schools of study Scandinavian studies *

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Done by Gothenberg on begagles dogs , excessive jiggling cap bar –splint(very high force)

*American studies Done by Roxchester on squirrel

monkey , light force(really slow force), orthodontic lightures

GotenbergRochesterVariableDogmonkeyModelsevereMild-

tomoderateperiodontitis

infrabonySupracrestaldefectcapsplaintMesio-distalForcesevereModerateForce

magnitudeOne year10 weektime

So Gotenberg said that occlusal trauma is bad and cause more diceases

Conclusion 1 -in the absence of inflammation , TFO

will not cause a loss of connective tissue attachment:

Occlusal trauma could cause mobility but not attachment loss which is the gold standard to measure the

periodontal disease.

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أحزانه.. .. غريبة قصة الدمعه قمة وهي باكيها جفن تريح

2 -in a healthy periodontium , TFO will result in mobility , widened

PDL and loss of the crestal bone hard tissue and volume.

3 -with inflammation , TFO will accelerate bone and connective

tissue loss in the dog but not the monkey.

4 -bone regeneration and healing will

occur in the presence of tooth hypermobility if inflammation is

controlled: i.e : Mobility is a bad thing so we

condemn tooth extraction if we notice the mobility ,

E.g. Progressive mobility :If you notice miller class 2 and after 4 months it is become class 3 so we must extract the tooth

E.g. In anterior teeth which have a single and short root and if we have bone loss and mobility index class 2 we

will not extract .

**Mobility ber see is not much really big factor in decrease the chances of this

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tooth to do surgery , Although regeneration studies were hate mobility in teeth, and said they cant put a membrane or do grafting when there is excessive forces because one of the success factors is "no mobility" , but this does not mean if you have inflammation

you can not do it.

Many clinicians believe that traumatic occlusion causes intrabony periodontal defects but this is not so , this defect is caused by dental plaque with accentuation due to the open contact (…sorry the pic cover some of the sentence and Dr. not read it all )

جنسه من آفة� شئ د� ...ولكل المبر� عليه سطا الحديد� حتى

بغير ... كالمفتخر حاله غير ادعى من و ماله غير من أعطاك كمن حاله بغير وعظك منماله

Pic. slide 1 page 4 ** This bone loss is from this high amalgam

restoration but not from it alone , there is cratering bone defect not only from occlusal forces ( it should come with periodontal

disease ) .

In summary irritating factors are plaque that

induces gingivitis which progresses to periodontitis , traumatizing factors from

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occlusion cause tissue changes in periodontal ligament space .

It's just a tissue changing (histologically and on x-ray) but does not appear on tooth itself (except if there is only mobility and facets it's only clinical

pictures) and there is no CAL.

slide 4 page 4 **Pic. Histology of intrabony defect due to plaque

induced periodontitis ( arrow shows subgingival plaque on root surface which will result in inflammation and increased

vascularity and proliferation of cells…) .

**Host- parasite reaction between bacterial plaque and host inflammatory response is the cause of pocket depth and attachment loss, the presence of traumatic occlusion can accentuate the damage when periodontitis proceeds apically into the periodontal ligament space.

Tissue changes due to traumatic occlusion

The first reaction to increased occlusal loading is increased vascularity in the

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periodontal ligament space , and no changes are seen in gingival tissues

Pic. slide 2 page 5** Normal periodontal ligament with normal

occlusal forces showing dense collagen fibers attached to bone and cementum with

minimal vascularity.

slide 3 page 3 **Pic. With excessive occlusal loading the

collagen fibers lose their connections between cementum and bone , blood vessels proliferate, cells increase, and fibroblast cells

number decreases .

**Pic. slid 4 page 5 This initial increased vascularity results in a

more compressible periodontal ligament and increased clinical mobility.

**Pic. slide 5 page 5 Changes in apical periodontal ligament

vascular patterns can also result in increased vasodilation of the pulp with increased sensitivity and pain to hot and cold stimuli secondary to traumatic occlusion,

So pulp may be involved without caries ….etc , and maight end with non vital tooth and

may need pulp treatment.

slide 6 page 5 **Pic.

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In traumatic occlusion after initial change of increased vascularity, there is a stimulation of osteoclasts which cause bone loss and a widened periodontal ligament

space this also causes increased mobility .

These changes are called secondary occlusal trauma or secondary trauma

from occlusion ,In teeth with bone loss due to periodontal disease, the previously

تعلم ال وانت حب حالة في تكون فقد انسان على بالغيره متلبسا نفسك ضبطت اذا

well tolerated occlusal loading can become traumatic and cause

changes in the periodontal ligament tissues, so all these changes are due to secondary trauma that is why normal forces can cause more destruction of periodontal ligament space and more proliferation of blood vessels once there

is periodontal disease going on .

**Pic. slide 3 page 6 Radiograph of lower molar with traumatic

occlusion : widened periodontal ligament space on mesial surface all the way around the apex (the black line) and lamina dura thickening ,with beginning of bone loss in furcation , and this tooth has increased

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mobility and pulp may undergo calcification because of high occlusal forces so hard to do

RCT to it.

Pic. slide 5 page 6 ** First molar has traumatic occlusion causing

the bone loss in the furcation , clinically there is no pocket depth nor periodontitis in the furcation , so the diagnosis is traumatic occlusion (Furcation involvement of occlusal trauma because the bone level does not decrease in other side -crestal bone level is not bad- so it will not be due to periodontal disease) and the treatment is occlusal

adjustment to reduce occlusal loading . So furcation involvement could be due to

perio or endo or occlusal trauma .

slide 6 page 6 Pic. ** Both premolars have traumatic occlusion,

and there is an addition periodontitis related bone loss and pockets on mesial surface of the first premolar, this is Secondary trauma because the support is not enough and he has extracted teeth, so it couldn’t be primary, this tooth has bone loss so may

have recession.

**When generalized bone density decreases so it's secondary not primary, and 100% there is recession and CAL

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**If one tooth is involved, it may be primary, inflammation of perio is not localized only in cases of localized aggressive and involving many teeth so there is no disease localized in one area.

but many patients have posteriorly 2 crowns with incipient periodontitis, this may be from occlusal forces but along with inflammation so it ends up like secondary but more localized in this site but mainly the forces are heavier, but in presence of plaque it makes a pocket in

this site .

slide 1 page 7 Pic. ** Gingival recession is not caused by

traumatic occlusion but is related to inadequate keratinized gingival and excessive tooth brushing (keratinized gingiva

at least must be 2 mm but here it's zero).

Occlusal trauma may cause recession but you have to have no other factor, but if there is any other factor it will be

stronger than occlusal trauma .

slide 2 page 7 ** Pic.

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Wedge shaped defect in root of lower first premolar is due to traumatic tooth brushing

and is not related to traumatic occlusion.

تعلم انت و اثم حالة في تكون فقد انسان من بالغيره متلبسا نفسك ضبطت اذا و

Tooth brushing causes recession and Abfraction on the neck of teeth due to excess forces which causes them instead

of facets .

Pic. slide 3 page 7 ** If there is excessive force on tooth and you

open a flap, the bone will be thick (hyperplastic bone called buttressing bone: means ledges of bone, its not good, will

create undercut beneath it ).

Effects of occlusal discrepancies Patients who have occlusal

discrepancies have no more severe destruction than patients without occlusal discrepancies if he not have initiating factors.

You can do -to patients with occlusal trauma-* night guard in case of bruxism to break the habit, *or change the occlusion but it may cause trauma again,

*so you do occlusal adjustment.

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Patients -who received occlusal adjustment as a part of their periodontal therapy- had greater attachment gain than patients who did not receive

occlusal adjustment.

** Que. : Patient came with severe periodontal disease and occlusal trauma, treatment plan includes oral hygiene instructions and scaling and root planning and occclusal adjustment , what is the best time to do occlusal adjustment and why?

The last thing , to give it time to heal --->when you do scaling there is resolution of inflammation and decrease mobility and

اآلوان . . فوات بعد عاقال تكون أن أسهل

increase stability, so you have to wait because nearly 30% willhave complete resolution of inflammation and 50% have half

resolution of mobility.

there is one case you have to do it immediately---> in excessive mobility

and fremitus (severe pain).

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Teeth with occlusal discrepancies had deeper presenting probing depths and worse prognosis than those that did not

have occlusal discrepancies .

“Abfraction” is a type of root loss.

**Pic slide 1+2 page 8It’s a tooth with abfraction. like this has been shown to occur clinically in association with heavy occlusal forces.(but in slides: this has not been shown to occur clinically in association with heavy occlusal forces)

Abfraction and role of occlusion in its development **

Abfraction has been defined as the “pathological loss of hard tooth substance by biomechanical loading

forces ”basically its not mainly due to occlusion.

Treatment The treatment of occlusion usually

involves either a reversible approach: consisting of some type of bite appliance (i.e. “night

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حياتك .. طوال عليه تندم حديث اعظم فستقول غاضب وأنت تكلم

guard”) and / or the selective grinding of the occlusal surfaces

of the teeth or extraction if there is excessive mobility or occlusal

adjustment .

Orthodontic therapy is an effective method of changing occlusal relationships and minimizing occlusal forces between opposing teeth in case of

deep bite and very bad occlusion .

Selective grinding involves the non-reversible reshaping of occlusal surfaces but has the advantage of minimizing

occlusal forces at all times .

Conclusion If occlusal discrepancies exist in the

presence of periodontal disease, the occlusal factors should be controlled by the minimization of the occlusal forces. In other words, occlusal treatment should be performed, where indicated, as a routine part of periodontal therapy so its part of treatment plane but not immediately , you have to wait until get rid of inflammation

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The end

Done by ; RAWN RAHHAL

سره" " مفتاح إنسان كل فليحفظ مفاتيحها واأللسن أقفالها والشفاه أوعية القلوب

قطرات " إلى أنت تتحول أن قبل صيفك عنك تمحو الخشنة الشتاء يد �د�ْع­ ت "ال

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