occlusal trauma by xiaohuicaicai


									                          Occlusal Trauma

     As a difinition ,, occlusal trauma is injury resulting in tissue changes
within the attachment apparatus ,, and it results when the occlusal
forces exceeding the PDL adaptive capacity. So basically ,, the two key
words in this definition are occlusal forces and exceeding the adaptive
capacity of the PDL. We know that the PDL with its fibers are
responsible to transmit the forces to the alveloar bone , so the PDL acts
like a cushion ,, tamta9 l 9admat , without causing any damage . That's
why when there is ankylosed tooth directly attached to the bone without
PDL , it will not tolerate any forces.
     To certain limits , the occlusal forces are acceptable and we need
them coz the PDL lose its function in the absence of these forces. Once
these forces start to exceed certain limits , E.g . patient with
parafunctional habits , patient has functions beyond the normal
functions like biting ,chewing .. etc then these forces exceeding the
adaptive capacity of the PDL and start causing problems.

    Now , it's very important to differentiate btween 2 types of occlusal
trauma ,, Primary occlusal trauma and Secondary occlusal trauma

    Primry occlusal trauma : injury resulting in tissue changes from
excessive occlusal forces applied to a tooth with normal support. So
there is healthy tooth with normal support , normal PDL , normal bone
level , normal cementum , normal peridontium but there is excessive
occlusal forces SO excessive forces on healthy normal apparatus. again
the 3 key words are normal attachment levels , normal bone level but
excessive occlusal forces.

    Secondary occlusal trauma : injury resulting in tissue changes from
normal or excessive occlusal forces applied to tooth with reduced
supprot ( lost some of the peridontium ) . So normal or excessive forces
on tooth with reduced support and reduced attachment apparatus.
Again the 3 key words are bone loss , attachment loss , normal or
excessive occlusal forces.

    The center of rotation in both primary and secondary occlusal
trauma is different coz the bone level is different in both of them so
the tension side and the pressure side are also different.
** The center of rotation is importnat in trems of determining where
the tension side and the pressure side will be once the froces are

  Next step is to understand what the occlusal truma or excessive
occlusal forces can cause to the periodontium ?!

Effect of occlusal trauma on periodontium :

     At early 60s , scientists start looking at occlusal trauma. At certain
stage ,, Glickman ,, the big father of the concept that ( Ok , i found out
one of the major predisposing factors of the periodental destruction,,
trauma from occlusion is a co-factor in the pathogenesis of periodental
disease . Occlusal trauma together with the plaque can cause periodontal
destruction and alters the pattern in rate of progression of the
periodental disease. That's was in 1963.

    In 1965 : there was a concept by Glickmen that : the presence of
occlusal truma or excessive occlusal forces changes the response of the
tissue to the plaque. He was saying that in the absence of occlusal
trauma , the plaque has lateral effect on the bone and basically cause
horizontal bone loss and in the presence of excessive occlusal forces ,
the effect of the plaque is into the PDL and thus it resluts in angular
bone defect .

   Then came another scientist ,, Waerhaug ,, in 1979 . He looked at
autopsy material ( dead bodies) . He catched the mandible of dead
bodies and tried to find any indications of occlusal forces and looked at
the alveolar defects elli kanat 3andhom and tried to find the link.
   But the accuracy of that is questionable coz the judgement clinically
for the occlusal froces distribution is different to what we see in
autopsy material .
    So in 1979 there was 2 studies . the first one was on autopsy
material and the second one was on extracted teeth . He looked at
extracted teeth and the distribution of plaque on these extracted

   Waerhaug was against Glickman ( 5alafo fe l ra2e ). When he looked
on the distribution of plaque , he found that angular bone defect is
related to the way the plaque is on the tooth surface rather than if
there is occlusal forces or not. Y3ni the way of the distribution of the
plaque on the tooth surface or the root surface is the determinant of
the shape of the defect.

  There is a zone called ........ zone , here the bone can't be close from
the plaque.So there is no relationship if there is excessive occlusal
forces or not but when there is plaque , the bone will go away.

     When we have thin bone thickness where all the bone will go
away from the plaque ,, here we will have horizontal bone defect. But in
case thick buccal or interproximal plate , when the bone will go away
from the plaque , there will be still thickness so here we will have
angular bone defect.

    So ,Waerhaug take us back to the concept that the plaque is the
initiating factor and any other factor is modifying factor or predisposing
factor rather than having really major role in the initiating of the

   So until now we know that the plaque is the initiating factor but how
the occlusal trauma modify the sort of progression of the periodontal
disease ? To answer this question ,, there were 2 groups of studies , one
in America and another in Scandinavia.
   The first study was on dogs. They create jiggling forces ( bilateral
forces similar to that occur in the mouth ) by making high spots by
covering the crown and place orthodontic appliance on it. . The idea of
this study enno they try to stimulate what happens in the patient mouth
in terms of having sort of Para functional habit. So here bilaterally
applied forces.

   The second study was on monkeies. They placed wedjes in between
the teeth similar to place orthodontic appliance to create unilateral
forces ( tipping forces) so here laterally applied forces.

    In both groups they found similar findings and they looked at the
effect of the excessive occlusal forces in the absence or the presence
of inflammation or plaque.

    The results of the first study were :
* Widening in the PDL space. * Angular bone defect in the marginal
alveolar bone. * Increase in periodontal destruction induced by
periodontitis so there is no apical migration of junctional epithilum only
excessive destruction when there is periodontitis in the presence of
occlusal trauma.

    In the second study there also was mobility and widening of the PDL
space , NO attachment loss or apical migration of junctional epithelium.

   Now we must know that to each study , there is advantages and
disadvantages. The drawbacks of these 2 studies are :
* These are animal studies and the animals don't respond the same way
as humans.
* The forces are creative forces , they try to create similar
parafunctional forces or excessive occlusal forces.
* The periodontitis that happens here is induced periodontitis .
something not natural but induced. In the first study , they put legature
around the tooth to make the plaque accumulate on it and in the second
 one they make defects in the tooth using burs to make the plaque
accumulate there.

  *In health and when inflammation is confined to the supra-alveloar
compartment , occlusal trauma fails to initiate periodontal destruction
and loss of attachment. Y3ni healthy patient without periodontitis or he
has gingivitis ( only inflammation in the supra-alveloar connective tissue )
and we apply occlusal forces ,, there will be widening in the PDL ,
mobility , but this occlusal forces fails to initiate periodontal
destruction and loss of attachment .

* In the presesnce of periodontitis and when the occlusal forces
exceeds the adaptive capacity of the PDL so here occlusal trauma acts
like a co-facter , risk factor for the severity and progression of the
disease. So if we compare 2 patients with peiodontitis , one with occlusal
trauma and the other without it , the severity and the progression in the
one with occlusal trauma is more.

SOOOOO : Occlusal trauma can't initiate periodontal destruction
but it's a risk factor increasing the severity and the progression of
the periodontal disease if already presents.

  So occusal forces alone can't do anything except widening in the PDL
space as a sort of adaptation to the excessive occlusal forces and
mobility of the tooth to a certain degree according to the amount of
these forces so it's stable mobility , once become adapted to these
forces it's not progressive anymore.

   When we apply a force on a tooth , there will be resorption of bone at
the pressure side and deposition at the tension side but this resorption
is confined to the amount of the force that present so the body try to
adapt to this force by changing the position of the tooth to go away
from this force. And it's similar here when there is occlusal forces on a
tooth either unilaterally or bilaterally , there will be widening in the PDL
and little bone resorption but once the tooth become adapted to this
force , the resorption stops.

*In unilateral forces , there will be pressure side and tension side from
one side but in bilateral forces there will be pressure side and tension
side all around the tooth .*

 Now we will talk about two things ,, the 1st one is the assessment to see
whether the patient has occlusal trauma or not and the 2 nd one is how to
manage this occlusal trauma if present.

Assessment of trauma from Occlusion :

Clinical assessment :
    Extraoral examination : we look if there is myofacial pain or TMJ
problems as a result of parafunctional habits , assess muscles of
mastication and TMJ.

  Intraoral examination : if we are doubt that the patient has occlusal
truama , we ask him to manipulate his mandible to the most retruded
position and then we ask him to finish up his clousre so move from RCP to
ICP so there will be sliding movement from RCP to ICP. We need to
detect if there is any interferences between these 2 movements :
Sort of homogenous distribution of load on the teeth.       .1

Asses the relationship of the teeth themselves in the presence           .2
of crowding.

* In protrusive movement we need to see that the force is distributed
on all of the incisors and if the force is localized on one tooth , the
chance that this tooth has occlusal trauma will be more.
                                                          * In lateral forces
we ask the patient to move the mandible laterally and see in the working
side if the load is distributed on the whole teeth or on one tooth and in
the non-working side we see if there is interferences or not .
    * We need to asses the number of the teeth present and the size of
the occlusal plane . When there is loss of the posterior teeth so all the
force will be on the anterior teeth so there will be more wideniing in the
PDL space in those patients more than if the posterior teeth present.

* Plunger cusp relationship : we see this relationship when an upper tooth
occlude at the contact point of 2 lower teeth . So if there is open
contact , once the patient bite there will be food impaction . It's not
occlusal trauma but it's sort of occlusal discrepancy , sort of local
factor contribute to food impaction w enno y9eer 3anna destruction in
the presence of plaque.

                                                          * Tooth mobility :
not every mobility indicate occlusal trauma coz there are other factors
that cause mobility like tumor , loss of periodontuim ,, etc etc.
                                                             * Tooth wear –
                       * fremitus : means movement on function , We
asses that by put our finger facially from one molar to the other side
and ask the patient to bite , and in every time the patient eat or bite ,
there will be jeggling forces and movement.
                                                              * Tooth
                              * Pain or discomfort on biting : more
common when the patient has new filling and high spot so here we have
mobility and widening of the PDL and the patient feels very acute pain.
Once we make selective gringing , the patient is relieved.

* Fractured tooth or teeth.

Radiographic assessment :

Radiographically we see :
* Widening of PDL space.
* Distruption of lamina dura , maybe thickening or loss of lamina dura
according to the degree of forces.
* Radiolucencies in furcation area or apex of vital tooth without any
pulpal pathosis ( not common ).
* Root resorption and hypercementosis ( not common but maybe seen
with excessive excessive occlusal trauma) .
Pic slide 16 : here we have healthy patient without periodontitis , and
the occlusal trauma appears radiogarphically as funnel shape widening
coronally ( funnel shape widening coronally is characteristic to Occlusal
trauma ) .
More common this appearance occur in the coronal part but generally
the appearance depends on the direction of the forces , the
relationship between the center of rotation and the tooth , which tooth
in the mouth affected by this forces and many other factors. So maybe
this appearance not confined to the coronal part only but extend
further down or generally distributed.

Histological assessment :

  Probably if wee need to confirm if there is Occlusal trauma or not , we
go for histological examination but this isn't realstic coz we don't want
to take biopsy from each patient and make histological examination !!
Basicaly what seen in histiological assessment are :
*Widening / compression of PDL fibers ad vessels according to the
direction of the froces.
* Bone remolding according to how the froce is directed or the degree
of the forces.
* Increased cellularity.
* Hyalinization necrosis : excessive force in one direction so there will
be necrosis and decomposition of the vessels and the fibers and the
cells .
* Root resorption : we start to see resorption lacune in the root.

Management of trauma from occlusion :

We have 2 approaches : reversible and irreversibal one.
Reversible approach :
Management of parafunctional habits through patient education and use
of occlusal splint. So if the patient has parafunctional habits , we make
for him night guard and give the patient instructions ennu during the day
try to avoid parafunctional habits and during the night to wear the guard

Irreversible approach :
If a patient with periodontal disease comes to u and u see that one of
the predisposing factors or the modifying factors is occlusal trauma. So
first of all we need to remove the initiating factor which is the plaque as
the initial first therapy then we do proper assessment to see the
response to this initial therapy and if this occlusal trauma can still do
problems or not except in smoe cases that cause acute problems so we
don't need to wait until we see the response to the first inital therapy
like when the pateint has plunger cusp relationship or the lower anterior
teeth bite on the palate coz this case causes acute ulceration and for
sure we need to do selective grinding to reverse the predisposing

The irreversible approach includes :
* Selective gringing : ideally to make selective grinding we need to take
impressins and mount the casts using facebow , check if there is high
spots in RCP , ICP , Lateral movements that we should made selective
grinding to them then move to the clinic to do that gringing But
generally we don't use this method except if the problem is generalized
and in most of the case bnektafe bl articulatong paper if the problem is

* Orthodontic therapy : in some cases when it's obvious that the
arrangemnet of the teeth cause problem so we need orthodontic
treatment to arrange them.

* Temporary or provisional splinting of mobile teeth : rarely we do
splinting for the teeth coz the splinting itself doesn't improve the
prognosis of the tooth. If we have 2 periodontally involved teeth with
occlusal trauma and we do periodontal treatment for them , with
splinting and without splintin , there is no difference in the resluts . But
we can do spinting to improve the pateint comfort and overcome some
difficulties .

*Occlusal reconstruction: if the patient had short arch , loss of
posterior teeth , we can think of occlusal reconstruction of post. Teeth
to have longer occlusal table for the forces to be distributed.

* Extraction of selected teeth.

Assessmnet of treatment Outcome :

   We assess the outcome of the treatment by looking at :
* Diminshed mobility : but it isn't a must that we when we done with our
 treatment , there will be no mobility at all , coz when the tooth is
periodontally involved , so it already lose part of its support , so the
mobility occur not because the occlusal trauma alone but because there
is reduced support. So here we look at STABLE mobility over the recall
visits , ennu tdal the degree of mobility nafs-ha and not to become
progressive . But if the tooth with occlusal trauma is healthy , so we
expect that after our treatment , the mobility will reduce until there is
no mobility at all.

* No further migration of teeth: again if the occlusal forces is the cause
for this migration of the teeth , so once we manage the periodontal
problem from on side and the occlusal trauma from the other side , then
the tooth should be stable coz the amount of forces that applied from
different side are equal so it will stay in its place.

((When we have supraerupted ant. tooth because it is periodontally
involved and there is fremitus ( movement on biting ) , many doctors will
do selective grinding for this tooth palatally to stop moving during biting
and this will work but for short period because we don't treat the
source of the problem , which is the periodontal disease) so the
fremitus again will be back so akeed the definite solution is not to make
selective grinding from the palatal side all the times but treat the
periodontal disease))

* Relief of pain and improved patient comfort.            * Relief of
premature contact , fremitus and occlusal interferences.
                          * Satbilization or diminishing of radiographic

Conclusions :

* In the absence of plaque , occlusal trauma can't initaite periodontal

* In the presence of periodontitis , occlusal trauma can act as a risk
factor ( predisposing factor ) for disease severity and progression.

* Careful occlusal assessment and management of the inflammatory
process should be conducted before occlusal adjustment is carried out .
So first we do first phase therapy , then we do proper assessment for
the occlusal froces and the ralationships we have then we do selective
grinding . ( with some exceptions like if we have acute trauma , filling
with high spots , etc etc ).

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                          Done by : Rawan FARASIN

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