Lecture Occlusal Trauma And Occlusal Adjustment

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					       Lecture 5: Occlusal Trauma And Occlusal Adjustment

I. Introduction
       Over the years, no other aspect of dentistry has been more controversial
       than occlusion, especially as it relates to periodontal disease. As a dentist,
       you will encounter extremes in opinion varying from those who believe
       occlusion is the primary etiologic factor in periodontal disease to those
       who believe it plays no role. The purpose of this lecture is to discuss the
       role of occlusal trauma and the need for occlusal therapy as an integral
       part of periodontal therapy.

II. Definitions (Review)
   A) Occlusal Trauma (trauma from occlusion) - An injury to the attachment
   apparatus as a result of excessive occlusal force. Synonyms: Periodontal
   occlusal trauma, trauma from occlusion

 B) Primary Occlusal Trauma- Trauma resulting from excessive occlusal forces
 applied to a tooth or teeth with normal supporting structure.

 C) Secondary Occlusal Trauma- Normal occlusal forces which may cause
 trauma to the attachment apparatus of a tooth or teeth with inadequate support.

 D) Co-destruction theory: A theory promoted by Glickman that proposed
 occlusal trauma was a co-destructive factor, which alters the severity and
 pattern of inflammatory periodontal disease.

 E) Adaptation following occlusal trauma: remodeled but healthy periodontium
 with a widened PDL, and clinical mobility but no additional injury.

III. Clinical Signs of Occlusal Trauma or Adaptation (Review)
    A) Mobility

   B) Fremitis or functional mobility

   B) Pathologic tooth migration

   C) Infrabony pockets (controversial)

   E) Buttressing bone (exostosis) (controversial)
IV. Radiographic Signs of Trauma from Occlusion or Adaptation (Review)

  A) Widened PDL

  B) Increased thickness of radicular lamina dura

  C) Increased bony trabeculations (may line up perpendicular to the tooth)

  D) Furcations (controversial)

  E) Angular bone loss (controversial)

  F) Root changes including resorption and cemental tears

   A) Does occlusal trauma cause periodontal disease? What are the possible
      mechanisms for occlusal trauma affecting periodontal disease?

            1) Normal periodontium

            2) Occlusal trauma alone
                  a) Widened PDL

                   b) Increased mobility

                   c) Essentially reversible bone Loss if trauma removed

                   d) No pocket formation or loss of connective tissue
                      attachment to tooth

            3) Periodontitis alone

            4) Occlusal trauma and Periodontitis
                  a) Separate processes- each entity progresses independent
                  of the other

                   b) Co-destructive effect
                         1) Conditions:
                            a) both processes must be active at the same time.

                             b) The occlusal trauma lesion and periodontitis
                                (inflammatory cell infiltrate are occurring at the
                                 same location).
      B) If a tooth wiggles it is bad? Can regeneration take place on a mobile
              1) Principal of adaptation
              2) The response following periodontal therapy on mobile teeth
              3) Problems in trying to achieve new bone and attachment on teeth
              in occlusal trauma

      C) Bottom line: does occlusal adjustment have a role in periodontal

      A) Reversible:
           1) bite planes (night guards)

             2) extracoronal splints

             3) muscle relaxants, muscle exercises and biofeedback

      B) Irreversible:
             1) intracoronal splints

             2) occlusal adjustment

             3) orthodontic treatment

             4) orthognathic surgery

             5) full mouth rehabilitation

           1) Indications: periodontal occlusal trauma, post-orthodontics, pre-
           restoratively, certain cases of temoporomandibular joint
           dysfunction, certain wear patterns cases of temporomandibular
           dysfunction (TMD), certain wear patterns.

             2) Contraindications: severe malocclusion; non-ideal but well
             tolerated occlusion; severe wear; patient in pain; if suitable end
             point cannot be reached.

             3) Goals:
                   a) stability
                   b) axial loading of forces
                   c) anterior guidance in working & protrusive that is smooth,
                   gliding & unrestrained

Can regeneration take place on a mobile tooth?
•Although there is no proof, it is generally thought that when regeneration is
attempted on mobile teeth, the clot & graft material may become displaced and
•Most clinicians adjust the occlusion or splint mobile teeth prior to regeneration.
•An exclusion criterion for clinical trails on regenerative materials is when mobility
of “2” or more exists.

Support for occlusal trauma relating to attachment loss
•Lindhe and Swanberg (74) and Ericsson and Lindhe („82) applied “jiggling-type
forces and found that under certain conditions occlusal trauma in the presence of
an existing periodontitis may cause an acceleration in bone loss and attachment
•Burgett, et al („92) found that periodontal patients who received prophylactic
occlusal adjustment prior to periodontal therapy had a significant gain in mean
probing attachment compared with those who received no occlusal adjustment.
•Wang , et al („94) found molars with mobility and furcation invasion had more
attachment loss than molars with furcations but no mobility.
    1. followed attachment levels 8 years after periodontal therapy
    2. adverse probing attachment changes related to initial degree of mobility
•Teeth undergoing orthodontic movement have higher levels of cytokines.
(interleukins, TNF, etc.)
•The orthodontic model parallels occlusal trauma in certain ways.
•Nunn and Harrell („02 Part I):
    1. Found strong association between occlusal discrepancies and clinical
        parameters of periodontal disease.
    2. Conclude that there is some evidence that occlusal discrepancy is an
        independent risk factor contributing to periodontal disease.
 Harrell and Nunn („02 Part II) found:
    1. Association between untreated occlusal discrepancies and the
        progression of periodontal disease.
    2. Occlusal therapy significantly reduces progression of periodontal disease
        over time.
    3. Occlusal therapy can be an important adjunct to comprehensive treatment
        of periodontal disease.
Studies Not Correlating Occlusal Trauma With Attachment Loss
•Polson and Zander (1983) used jiggling type forces on the squirrel monkey.
    1. Occlusal trauma alone resulted in bone loss volume but no attachment
    2. Occlusal trauma did not correlate with greater attachment loss even in the
       presence of a pre-existing periodontitis.
    3. Effects generally reversible.
•Lindhe („84), who originally found an accelerated attachment loss under certain
conditions later found no correlation.
•Galler found that 6 months after periodontal surgery, teeth returned to pre-
surgical mobility.
•Teeth that are not splinted do as well as splinted teeth .
•Mobility is frequently associated with other adverse periodontal problems, which
may be the reason for poorer response to periodontal therapy.
•Mobile periodontally involved teeth frequently respond to reduction in
inflammation alone.

Angular bone loss and occlusal trauma
   1. Found no correlation between occlusal trauma and angular bone loss.
   2. Angular defects developed because of an advancing plaque front.
•Tal- using dried skull specimens
   1. Found that for interdental angular bone loss to occur, there must be at
       least 2.6 mm between the roots, otherwise the bone loss will be horizontal.
   2. For 2 angular defects to occur in the same interproximal, there must be at
       least 3,5 mm between the roots.

•Periodontitis (inflammation) must be present for attachment loss to occur.
•Occlusal trauma in the absence of periodontitis may be reversible and result in
•Occlusal trauma superimposed on an existing periodontitis may in certain
conditions accelerate attachment loss.
•No repair can occur unless inflammation is resolved.
•Occlusal therapy in conjunction with periodontal treatment is indicated when
 occlusal trauma is present.
•Occlusal therapy is especially indicated prior to regenerative therapy.
•Occlusal adjustment is not justified in the absence of periodontal disease as a
preventive measure.
•If a tooth can‟t adapt, continued destruction and increased mobility occurs.

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