Trauma from occlusion

Submitted by
Saumya
Bds 3rd year
59
Contents
•Definition
•Adaptive capacity of periodontium
•Types of trauma from occlusion
•Role of trauma from occlusion in progression of periodontal
disease
•Reversibility of traumatic lesions
•Histologic features
•Pathologic tooth migration
•Pathogenesis
•Clinical features
•Radiographic features
•Treatment
Trauma from occlusion
According to Orban and Glickman et al (1968):
Trauma from occlusion is defined as, when occlusal
forces exceed the adaptive capacity of periodontal
tissues, the tissue injury results. This resultant injury
is termed as trauma from occlusion.
WHO defines trauma from occlusion as
“the damage in the periodontium caused
by stress on the teeth produced
directly or indirectly by the teeth of the
opposing jaw”.
ADAPTIVE CAPACITY
OF THE PERIODONTIUM TO
OCCLUSAL FORCES

The dynamics of the periodontium to

accommodate the forces exerted on the
crown is appreciable and is known as
its adaptive capacity. This varies in
different persons and in the same
person at different times.
Four factors which mainly influence the effect of
occlusal forces on the periodontium:
a. Magnitude: When magnitude is increased the
periodontium responds by
(a) with a thickening of the periodontal ligament.
(b) an increase in the number and width of periodontal
ligament fibers .
(c) an increase in the density of the alveolar bone.
b. Direction: Changes in the direction causes
reorientation of the stresses and strains within the
periodontium. Lateral forces and torque are more likely
to injure the peridontium.
c. Duration: Constant pressure on the
bone is more
injurious than intermittent forces.
d. Frequency: The more frequent the
application of an intermittent force, the
more injurious to the periodontium.
 TYPES OF TRAUMA FROM
OCCLUSION
i. Depending on the cause:
a. Due to the alterations in the occlusal forces.
b. Reduced capacity of the periodontium.
ii. Depending on the
onset and duration:
a. Acute trauma from occlusion
b. Chronic trauma from occlusion .
Acute trauma from occlusion:
Develops from the abrupt changes in the occlusal
forces, such as that produced by biting on a hard
object and due to iatrogenic factors like faulty
restorations/prosthetic appliance.

Chronic trauma from occlusion

It occurs as a result of the gradual changes produced
in the periodontium due to the tooth wear, drifting
movement, extrusion of the teeth combined with
parafunctional habits such as bruxism and clenching.
Primary trauma from occlusion
•When trauma from occlusion is the result of alterations
of occlusal forces , it is called primary trauma from
occlusion .
•It elicited around a tooth with normal height of
periodontium.
•Occurs if:
• occlusion results in only local alterations of tooth.
•Parafunctional habits
Secondary trauma from
occlusion.
When trauma form occlusion occurs when adaptive
capacity of the tissues to withstand occlusal forces
impaired by bone loss resulting in marginal inflammation
,it is known as secondary trauma from occlusion.

It is related to situations in which occlusal forces cause

injury in a periodontium of reduced height. For example
Periodontitis.
 ROLE OF THE TRAUMA
FROM OCCLUSION IN THE
PROGRESSION OF
PERIODONTAL DISEASE
Studies have shown changes produced by the pressure
and tension sides of the tooth, with an increase in the
width of the periodontal ligament and increased tooth
mobility.
None of these methods have caused gingival
inflammation or pocket formation. This can be
explained by :
•Glickman’s concept
•Waerhaug’s concept
1.Glickman’s concept
•Glickman claimed that the pathway of the spread of plaque
associated gingival lesion can be changed if the forces of an
abnormal magnitude are acting on teeth harbouring sub
gingival plaque.

•Itimplies that character of progressive tissue destruction of

periodontium at a “traumatized’ tooth is different from that
in “non-traumatized” tooth.

•Teeth which are non-traumatized exhibit

suprabony pockets and horizontal bone loss, whereas teeth
with trauma exhibit angular bony defects and infrabony
pockets.
According to him, the periodontal structures are
divided
into two zones:
1. The zone of irritation and
2. The zone of co-destruction.
The zone of irritation
The zone of irritation includes the marginal and
interdental gingiva, and is affected only by microbial
Plaque not by trauma due to occlusion.
In a plaque associated lesion, at a “non-traumatized”
tooth, the inflammation spreads in an apical direction,
first involving the alveolar bone and later the
periodontal ligament area. Hence progression of this
lesion results in an even (horizontal) bone loss.
 The zone of codestruction
It includes the periodontal ligament, the root
cementum and the alveolar bone, which are coronally
demarcated by the trans-septal and the dentoalveolar
collagen fibers.
The tissue in this region becomes the seat of a lesion
caused by the trauma from occlusion. Here the spread
of inflammation is from the zone
of irritation directly down into the periodontal
ligament and hence angular bony defects with
infrabony pockets are seen
2.Waerhaug’s concept:
He refuted the hypothesis that trauma from occlusion
played a role in the spread of a gingival lesion into the
zone of co-destruction.
According to Waerhaug, the loss of periodontium
was as a result of inflammatory lesions associated
with sub gingival plaque.
He concluded that angular defects occur when the
Sub gingival plaque of one tooth has reached a more
apical level than the microbiota on the neighbouring
tooth, and when the volume of the alveolar bone
surrounding the roots is comparatively large.
Reversibility of traumatic
lesions
•Trauma from occlusion is reversible.
•On removal of the injurious force
the repair occurs.
•The presence of inflammation in the periodontium
because of plaque accumulation may
impair the reversibility of traumatic lesions.
Histologic changes:
The response of tissues to increased occlusal forces is
explained under three stages;
• Stage 1: Injury
• Stage 2: Repair
• Stage 3: Adaptive remodeling of the periodontium.
Stage 1: injury
When a tooth is exposed to excessive occlusal forces, the
periodontal tissues are unable to withstand and hence they
Distribute to maintain the stability of the tooth. This
may lead to certain reactions in the periodontal
ligament and alveolar bone, eventually resulting in
adaptation of the periodontal structures to altered functional
demand. When subjected to horizontal forces
the tooth rotates or tilts in the direction of force. This tilting
results in the pressure and tension zones, within the
marginal
and apical parts of the periodontium
Satge 2 : repair
TFO stimulates increased reparative activity.
When bone is resorbed by excessive occlusal forces,
the body attempts to reinforce the thinned-bony
trabeculae with new bone.
This attempt to compensate for lost bone is called
buttressing bone formation which is an important
feature of reparative process associated with trauma
from occlusion
Stage 3: Adaptive Remodeling of
the Periodontium
If the repair process cannot keep pace with the
destruction caused by occlusion, the periodontium
may get remodelled in order to maintain the structural
relationship. This may result in thickened periodontal
ligament, angular defects in
the bone with no pocket formation, loose teeth and
increased vascularization.
 PATHOLOGIC TOOTH
MIGRATION
•It refers to tooth displacement that results when the
balance among the factors that maintain physiologic
tooth position is disturbed by periodontal disease.
•It is more frequent in
anterior region.
The teeth may move in any
direction and the migration is
usually accompanied by mobility
and rotationPathologic
migration in occlusal or incisal
direction is called as“extrusion”
Pathogenesis

Two major factors play a role in maintaining the normal

position of the teeth.
1. The health and normal height of the periodontium.
2. The forces exerted on the teeth.
The Health and Normal Height
of the Periodontium
•A tooth with weakened periodontal support is unable
to withstand the forces and moves away from the
opposing Force.
•the abnormality inpathologic migration rests with the
weakened periodontium.
•Forces that areacceptable to an intact periodontium
become injurious when periodontal support is
reduced.
Changes in the Forces Exerted on the Teeth

Changes in the forces may occur as a result of

(a) unreplaced missing teeth,
(b) Failure to replace first molars, or
(c) other causes.
Unreplaced missing teeth leads to drifting of teeth
into the spaces created by it. it usually creates
conditions that leads toperiodontal diseases and thus
the initial tooth movement is aggrevated by loss of
periodontal support..
Failure to replace first molars: It consists of the following:
1. The second and third molars tilt resulting in decrease in vertical
dimension.
2. The premolars move distally and the mandibular incisors tilt or drift
lingually.
3. Anterior overbite is increased.
4. The maxillary incisors are pushed labially and laterally.
5. The anterior teeth extrude due to disappearance of incisal
apposition.
6. Diastema is created by the separation of the anterior teeth.

Other causes:
Pressure from the tongue
Pressure from the granulation tissue of periodontal
pocket
Clinical Indicators for Trauma from Occlusion
a. Increased tooth mobility. - hallmark
b. Fremitus test being positive.
c. Malocclusion.
d. Excessive tooth pain
e. Tooth migration.
f. Fractured tooth/teeth.
g. Thermal sensitivity.
h. Muscle hypertonicity.
i,. tenderness on percussion,
j. In severe cases, periodontal abscess formation and
cemental tears can be seen
Radiographic changes
i. Increase in the width of the periodontal ligament
space often with thickening of the lamina dura along
the lateral borders of the root, apical and bifurcation
areas.
ii. “Vertical” rather than horizontal destruction of the
interdental septum.
iii. Radiolucency and condensation
of the alveolar bone.
iv. Root resorption.
Treatment of TFO
The goal of periodontal therapy is in treatment of
occlusal traumatism is to maintain the peridontium in
comfort and function.
proposed by AAP(1996)
1. Reduce/ eliminate tooth mobility
2. Eliminate occlusal prematurities and fremitus
3. Eliminate parafunctional habits
4. Prevent further tooth migration
5. Decrease/ stabilize radiographic changes
Thank you