Periodontal Response to

External Forces

EKA FITRIA A
 Adaptive Capacity of the Periodontium to
Occlusal Forces
-The periodontal ligament has a cushioning effect on
forces applied to teeth as means to accommodate forces
exerted on the crown
-Due to the elastic nature of the periodontal ligament, all
teeth with normal bone support present with physiologic
mobility in all directions.
- Physiologic tooth mobility varies among
individuals
- In the absence of excessive occlusal forces or the
absence of reduced bone support induced by
inlammatory periodontal disease, tooth mobility
remains unchanged due to the fact that physiologic
forces are not able to induce changes to the
periodontal tissues
OVERLOAD CHANGES TO
ON OCLUSAL PERIODONTAL

DEPENDS :
CHANGES TO magnitude, direction,
PERIODONTAL duration, and
load increase frequency
occlusal.

PERIODONTAL RESPONSE IF THE PRESSURE IS EXCESSIVE:

widening of the periodontal ligament,
increase in the number of periodontal ligament fibers
increased alveolar bone density.
• Changes in the direction of occlusal loads cause changes in stress
and strain in the periodontal tissues (Fig. 25.1). The main fibers of the
periodontal ligament are arranged to accommodate occlusal forces
along the long axis of the tooth.
 Trauma From Occlusion
Trauma from occlusion is defined as microscopic alterations of
periodontal structures in the area of the periodontal ligament
that become manifest clinically in the elevation of tooth
mobility.
As mentioned earlier, an inherent “margin of safety” that is
common to all tissues permits some variation in occlusion
without adversely affecting the periodontium. However, when
occlusal forces exceed the adaptive capacity of the tissues,
tissue injury results.The resultant injury is termed trauma from
occlusion, which is also known as occlusal trauma.
 Thus, occlusive trauma refers to tissue injury rather than
occlusal forces. An occlusion that produces such an injury is
called a traumatic occlusion.

ONSET/TIME OF INJURY ACUTE / CHRONIC

Occlusive trauma

PERIODONTAL
CAPACITY PRIMARY/SECONDARY
ACCEPT PRESSURE
- Acute trauma from occlusion refers to periodontal changes associated
with an abrupt occlusal impact such as that produced by biting on a hard
object. In addition, restorations or prosthetic appliances that interfere with
or alter the direction of occlusal forces on the teeth may also induce acute
trauma. Acute trauma results in tooth pain, sensitivity to percussion, and
increased tooth mobility
If the trauma continues, it becomes chronic.
Chronic trauma from occlusion refers to periodontal changes associated
with gradual changes in occlusion produced by tooth wear, drifting
movement, and extrusion of the teeth in combination with parafunctional
habits (e.g., bruxism, clenching) rather than as a sequela of acute
periodontal trauma.
Chronic trauma from occlusion is more common than the acute form
- Primary trauma from occlusion occurs if trauma from
occlusion is considered the primary etiologic factor in
periodontal destruction and if the only local alteration to which a
tooth is subjected is a result of occlusion. Occlusal trauma
which is the result of changes in occlusal pressure
-Secondary trauma from occlusion occurs when the adaptive
capacity of the tissues to withstand occlusal forces is impaired
by bone loss that results from marginal inlammation. This
reduces the periodontal attachment area and alters the
leverage on the remaining tissues. The periodontium becomes
more vulnerable to injury, and previously well-tolerated occlusal
forces become traumatic.
three situations in which excessive occlusal forces occur:
1. Normal periodontium with normal bone height
2. Normal periodontium with reduced bone height
3. Marginal periodontitis with decreased bone height
 Stages of Tissue Response to
Increased Occlusal Forces
Tissue response occurs in three stages: injury, repair, and
adaptive remodeling of the periodontium.
• Stage I: Injury
Tissue injury is produced by excessive occlusal forces. The
ligament is widened at the expense of the bone, which results
in angular bone defects without periodontal pockets, and the
tooth becomes loose.
The areas of the periodontium that are most susceptible to
injury from excessive occlusal forces are the furcations.
 • Stage II: Repair
Repair occurs constantly in the normal periodontium, and trauma
from occlusion stimulates increased reparative activity. The
damaged tissues are removed, and new connective tissue cells
and fibers, bone, and cementum are formed in an attempt to
restore the injured periodontium. Forces remain traumatic only
as long as the damage produced exceeds the reparative
capacity of the tissues.
 • Phase III: Adaptive Remodeling of the Periodontal Tissue
If the repair process cannot compensate for the damage caused
by the occlusive forces, the periodontal tissue will repair itself in
an effort to minimize the unfavorable pressure on the
periodontal tissue.
The injury stage showed an increase in the area of resorption
and a decrease in bone formation, while the repair stage
showed a decrease in resorption and an increase in bone
formation. After that, in the stage of adaptive remodeling, a
balance of bone resorption and formation occurs again.
Effects of Insufficient Occlusal Force
Insuficient occlusal force may also be injurious to the supporting
periodontal tissues. Insuficient stimulation causes thinning of the
ligament, atrophy of the fibers, osteoporosis of the alveolar
bone, and a reduction in bone height. Hypofunction can result
from an open-bite relationship, an absence of functional
antagonists, or unilateral chewing habits that neglect one side of
the mouth.
 Reversibility of Traumatic Lesions
Trauma from occlusion is reversible. When trauma is induced in
experimental animals, teeth shift and disturbance occurs. When
the created power is reduced, the tissue undergoes repair.
Although trauma from occlusion is reversible, the periodontal
tissue does not always repair itself. Adverse stresses must be
removed for improvement to occur
Relationship Between Plaque-Induced Periodontal Diseases
and Trauma From Occlusion
Several studies have shown a combination of changes in the
strength of the applied pressure with an increase in ligament
width and an increase in tooth mobility. However, it does not
cause gingival inflammation or periodontal pocket formation.
Bacterial plaque accumulation that causes gingivitis and
periodontal pocket formation affects the marginal gingiva but
trauma from occlusion occurs in the periodontal supporting
tissues and does not affect the gingiva.
Other theories that have been proposed to explain the
interaction of trauma and inlammation include the
following:

1. Trauma from occlusion can cause the extension of the

gingival inflammation to the underlying tissue. This causes a
decrease in collagen density, an increase in the number of
leukocytes, osteoclasts, and coronal blood vessels, resulting in
an increase in tooth mobility. The inflammation continues to the
periodontal ligament and to the bone. Bone resorption that
occurs becomes an angular defect and an infrabony pocket is
formed.
2.Areas of root resorption caused by trauma that are not
covered by apical migration of the inflamed gingival attachment
to an environment that facilitates the formation and attachment
of plaque and calculus and facilitates the development of deeper
lesions.
3. Supragingival plaque can become subgingival if the tooth tilts
due to orthodontic movement or if it moves to an edentulous
area, the suprabony pocket becomes an infrabony pocket
Clinical and Radiographic Signs of Trauma From Occlusion
Alone
• The most common clinical sign of trauma to the periodontium
is increased tooth mobility.This is due to damage to
periodontal fibers and widening of the periodontal ligament
 Radiographic signs of trauma from occlusion

1. Increased width of the periodontal space, often with

thickening of the lamina dura along the lateral aspect of the
root, in the apical region, and in bifurcation areas. These
changes do not necessarily indicate destructive changes,
because they may result from thickening and strengthening of
the periodontal ligament and alveolar bone, thereby
constituting a favorable response to increased occlusal forces.
2. A vertical rather than horizontal destruction of the interdental
septum.
3. Radiolucency and condensation of the alveolar bone.
 Pathologic Tooth Migration
• Pathological migration refers to the displacement of teeth that
occurs when the balance of factors that maintain the
physiological position of the teeth is disturbed by periodontal
disease.
• Pathological migration is relatively common. It may be an
early sign of disease, or it may be associated with gingival
inflammation and pocket formation as disease progresses.
• Most often occurs in the anterior region although in the
posterior can also occur
• Teeth can move in any direction, and migration is usually
accompanied by mobility and rotation
 - Pathological migration in an occlusal or incisal direction is
called extrusion
 PATOGENESIS MIGRASI PATOLOGIS

Dua faktor utama berperan dalam

mempertahankan posisi normal gigi: kesehatan
dan ketinggian normal dari perlekatan jaringan
periodontal dan tekanan yang diberikan pada gigi,
yang meliputi kekuatan oklusi dan tekanan dari
bibir, pipi, dan lidah
 Faktor-faktor yang penting dalam kaitannya dengan
kekuatan oklusi meliputi hal hal berikut ini:
(1)morfologi gigi dan sudut cusp (2) adanya gigi lengkap; (3)
kecenderungan fisiologis ke arah migrasi mesial; (4) sifat dan
lokasi hubungan titik kontak; (5) atrisi proksimal, insisal, dan
oklusal; dan (6) kemiringan sumbu gigi.
Perubahan pada salah satu faktor ini memulai urutan
perubahan yang saling terkait di lingkungan dari satu gigi atau
sekelompok gigi yang dapat menyebabkan patologis migrasi.
Dengan demikian migrasi patologis terjadi dalam kondisi
lemahnya jaringan periodontal, adanya tekanan yang
diberikan pada gigi, atau kedua faktor tersebut.
Perubahan besarnya, arah, atau frekuensi gaya yang
diberikan pada gigi dapat memicu migrasi patologis gigi.
Kekuatan ini tidak harus abnormal untuk menjadi
penyebab migrasi jika jaringan periodontal cukup lemah.
Salah satu penyebabnya adalah gigi hilang yang tidak
diganti
Beberapa perubahan yang terjadi bila kehilangan gigi tidak
digantikan, terutama pada gigi Molar pertama :
1. M2 dan M3 miring ke arah mesial resorbsi vertikal
2. Gigi P bergerak ke distal, gigi I RB miring .
3. Overbite anterior meningkat.
4. Gigi I RA didorong ke labial dan ke lateral
5. Gigi anterior menonjol karena adanya apposisi insisal
sebagian besar menghilang.
6. Diastema yang terjadi karena bergeraknya gigi anterior
Hubungan kontak proksimal yang terganggu

impaksi makanan,
penumpukan plak

inlamasi gingiva,
pembentukan
poket

kehilangan tulang
kegoyangan gigi
• Gangguan oklusal yang disebabkan oleh posisi gigi yang
diubah menyebabkan trauma jaringan pendukung periodontal
dan memperburuk kerusakan yang disebabkan oleh inlamasi.

• Penurunan dukungan periodontal mengarah pada migrasi gigi

lebih lanjut dan gangguan oklusi
• TERIMAKASIH