2. 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
HKES S.N. Dental college
3. 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.
HKES S.N. Dental college
4. 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
HKES S.N. Dental college
5. 2. Secondary TFO
Tissue injury resulting from
normal or excessive
occlusal forces applied to a
tooth or teeth with reduced
periodontal support
HKES S.N. Dental college
8. 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
9. 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
HKES S.N. Dental college
10. 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
HKES S.N. Dental college
11. 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
HKES S.N. Dental college
12. 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
HKES S.N. Dental college
13. 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
HKES S.N. Dental college
14. 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
HKES S.N. Dental college
16. 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)
HKES S.N. Dental college
17. 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”
HKES S.N. Dental college
18. 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
HKES S.N. Dental college
20. 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
HKES S.N. Dental college
21. 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
HKES S.N. Dental college
22. 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
27. 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
HKES S.N. Dental college
28. 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
HKES S.N. Dental college
34. 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
HKES S.N. Dental college
35. 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
36. Results and conclusion :
Functional loading of implants may enhance
osseointegrationHKES S.N. Dental college
37. 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
HKES S.N. Dental college
39. TFO occurs in the supporting tissues and
does not affect the gingiva
HKES S.N. Dental college
40. When TFO is eliminated, reversal of bone loss occurs,
except in the presence of periodontitis. (inflammation
inhibits the potential for regeneration )
HKES S.N. Dental college
41. 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.
HKES S.N. Dental college
42. 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.
HKES S.N. Dental college
43. 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.
HKES S.N. Dental college