TRAUMATOGENIC OCCLUSION IN A PEDIATRIC

DENTAL PATIENT: A CASE REPORT

Shreya Kartha1 , Krishna P Vellore2 , Santhosh K Challa3 , Ramakrishna Vallu4 , Soumya
Pusuluri

Shameena k
Junior Resident
Dept of Pediatric &
Preventive Dentistry
 INTRODUCTION

Periodic monitoring of developing occlusion contributes to preventive care

and encourages the maintenance of a healthy periodontium. Regular restorative care and
careful orthodontic planning can also play a role in the prevention of developing occlusal
abnormalities. Thus, prevention will maintain the vitality of the tooth allowing the clinician to
select noninvasive approaches toward the management of trauma from occlusion.
 DEFINITION
 WHO Definition (1978) : “Damage in the Periodontium caused by stress on the
teeth produced directly or indirectly by the teeth of the opposing jaw”

 Orban and Glickman’s Definition (1968) : “When occlusal forces exceed the
adaptative capacity of the periodontal tissues , the tissue injury results . This
resultant injury is termed as trauma from occlusion”
 CLASSIFICATION OF TRAUMA FROM OCCLUSION

1. Depending on the onset & duration

 Acute
 Chronic
2. Depending on the nature of the cause
 Primary
 Secondary
 Acute trauma from occlusion can result from an abrupt occlusal impact on bitten
objects, restorations or prosthetic appliances that interfere with or alter the
occlusal forces on teeth.

 Chronic trauma from occlusion is more common than acute trauma and
develops from gradual changes in occlusion produced by tooth wear, drifting
movement, extrusion of teeth, combined with parafunctional habits such as
bruxism and clenching.
 Primary trauma from occlusion : It is generally referred to as a condition resulting
from abnormal occlusal forces on relatively sound periodontal structure. In effect, the
traumatic forces acting on teeth with normal support are greater than the forces that can
be withstood without injury to the periodontium.
 Causes :
1. High Fillings
2. Prosthesis which creates excessive forces on abutments & antagonists
3. Supraeruption of teeth
4. Orthodontic movement of teeth into functionally unaccepted positions
 Secondary trauma from occlusion : Applied to a condition resulting from physiologic or
abnormal occlusal forces, which act on a dentition that is seriously weakened by the loss of
supporting alveolar bone. This lack of periodontal support may result not only from effects of
periodontal disease but also from injudicious bone resection during periodontal therapy or oral
surgery, from accidental trauma or from excessive apical resorption associated with orthodontic
or endodontic therapy.
 Causes :
1. Alveolar bone loss due to marginal inflammation
2. Systemic disorders – reduce tissue resistance
 ETIOLOGY

 Inappropriate
 SIGNS & SYMPTOMS
 Excessive tooth pain  Attrition
 Tenderness on percussion  Pathologic tooth migration
 Increased tooth mobility  Fremitus test is positive
 Periodontal abscess  TMJ dysfunction may be seen
formation  Presence of chipped enamel
 Cemental tears  Crown / Root fractures
 Infrabony pockets  Presence of tenderness in muscles
 Furcation Involvement of mastication
 Clinical Indicators of Trauma from Occlusion

 Mobility
 Fremitus test being positive
 Malocclusion
 Wear Facets
 Tooth migration
 Fractured tooth / teeth
 Thermal sensitivity
 Muscle Hypertonicity
 Radiographic Features
 Widening of PDL space
 Thickening of lamina dura at lateral, apical & bifurcated areas of root
 Presence of Angular bone loss
 Vertical destruction of interdental septum
 Disruption of lamina dura
 Presence of radiolucency in the furcation areas & apex of vital teeth
 Presence of root resorption
 Stages of tissue response to excessive occlusal forces

 Stage 1: INJURY:- Soft tissue injury is the immediate result of excessive occlusal forces. The
magnitude of forces varies from slightly excessive, greater than excessive or severely high.

 Stage 2: REPAIR:- Takes place when the damage tissue is replaced by new connective tissue and
cells. This is a well-regulated mechanism and the healing process is directly or indirectly
facilitated by the extracellular matrix and certain inflammatory mediators. The activity is
increased during TFO & the body tries to reinforce the trabeculae within the new bone by a
process known as buttressing bone formation.

 Stage 3: ADAPTIVE REMODELING OF THE PERIODONTIUM:-Establishes a structural

relationship in such a way that the forces of occlusion are no longer harmful to the periodontium,
and the repair process can keep pace with the destructive occlusal forces.
 Is traumatic occlusion reversible?

 If excessive occlusal forces are neutralized, healing takes place. The presence of
plaque may however impair healing so resolution of inflammation should be
first initiated. Injury caused by TFO is reversible but there may or may not be
complete restoration of the supporting structures of the tooth.
 CASE DESCRIPTION
A 13-year-old female patient presented to the Department of Pediatric and Preventive Dentistry with
a chief complaint of “pain and mobility in the lower incisors
 EXTRAORAL EXAMINATION

Extraoral examination showed no signs of any pathological condition or trauma.

However, a deep mentolabial sulcus angle was observed (96°)
 INTRA ORAL EXAMINATION

 Intraoral examination showed plaque deposits on 31, 32, 41, and 42. Erythematous gingiva
and gingival recession were also observed.
 Wear facts were present on 31 and 41. All four lower incisors were tender on percussion
followed by grade I mobility.
 The probing depths were normal indicating a healthy periodontal tissue. However, the labial
mucosa was tender on palpation.
 The patient also had a class I molar relation with increased overbite with retroclined
maxillary and mandibular incisors
 RADIOGRAPHIC INVESTIGATION
 Radiographic investigation revealed a large periapical lesion involving the four
mandibular incisors.
 Vitality testing was done using electric pulp test (EPT) which showed all four incisors to
be nonvital.
 Fremitus test was positive with vibratory movements palpated on occlusion. The patient
also exhibited an increase in overbite along with retroclined incisors.
 The overbite was measured at 6mm on the diagnostic cast.
 Based on clinical findings and investigations, the condition was diagnosed as primary
trauma from occlusion.
 Primary occlusal trauma is an injury that occurs due to excessive occlusal forces to teeth
with healthy periodontal support resulting in tissue changes. It occurs in cases with normal
clinical attachment and bone levels.
 PHASE I
 Following parental consent of the parents, full mouth oral prophylaxis was done and
endodontic treatment was initiated for 31, 32, 41, and 42.
 The patient was also started on a 5-day antibiotic course along with daily chlorhexidine
mouth rinses.
 The occlusal prematurities were identified using articulating paper and selectively removed
by coronoplasty.
 The endodontic treatment was completed in multiple visits. Following the cleaning and
shaping, metapex dressing was given for a period of 3 months. A semirigid wire and
composite splint were given from canine to canine, lingually, to restore masticatory
function and stabilize the teeth.
 A semirigid wire and composite splint were given from canine to canine, lingually, to
restore masticatory function and stabilize the teeth.
 The patient was kept on follow-up visits every 3 weeks.
 The patient was assessed based on clinical and radiographic signs and symptoms.
 Radiographic signs of healing were seen within 3 months following which permanent
obturation was done using gutta-percha and mineral trioxide aggregate (MTA) root canal
sealer.
 The access cavities were sealed with composite resin cement.
 PHASE II
 For correction of the traumatic bite, a removable Hawley’s appliance with anterior bite
plane was prescribed to guide the premolars into occlusion and thus increase the
overbite.
 Full-time wear of the appliance was prescribed for a period of 6 weeks with follow-up
visits every 2 weeks.
 Following 3 months of wear of the appliance, the deep overbite decreased from
6mm to 3mm.
 A radiograph taken at 1 year follow-up showed complete resolution of the lesion apically.
 The periodontal tissue was healthy and the treated teeth showed satisfying esthetics and
function.
 DISCUSSION
 The adaptive capacity of the periodontium varies from person to person as well as the same
person at different times. The periodontium adapts in response to increased functional demand.
Forces that go beyond the adaptive capacity cause injury.

 The injury occurs due to excessive occlusal forces resulting in repair, which is initiated naturally,
to restore the periodontium.

 However, in chronic forces, the periodontium remodels to cushion the impact. The PDL widens,
as a result of bone resorption forming angular bone defects without periodontal pockets.
Eventually, the tooth becomes loose.
The treatment of TFO involves removal of the excessive occlusal forces and bringing the
tooth/teeth in a comfortable position. Many treatment modalities have been advised to treat
TFO. These include,

 Occlusal adjustments and occlusal equilibration

 Management of parafunctional habits.

 Biometric management of trauma from occlusion.

 Orthodontic tooth movement.

 Occlusal reconstruction.

 Extraction of selected teeth.

 Occlusal adjustments and occlusal equilibration:- Occlusal equilibration is a minimally invasive
therapy involving reshaping of the teeth when improper biting forces are located.

 Management of parafunctional habits:- Management begins with creating a cognitive and

behavioral awareness. Use of hard acrylic splints which are correctly adjusted for occlusion,
helps protect the teeth and relax the muscles.

 Biometric management of trauma from occlusion:- A biometric approach includes the jaw
vibrational analysis (JVA) of the TMJ, EMG of the muscles and digital occlusal scan of the
teeth. Harmony in the muscle, joint, teeth & restorations are closely interrelated, the biometric
approach gives the critical information needed to create this harmony.
 Orthodontic tooth movement:- Orthodontic therapy has a big role to play in prevention and
treatment of malposition. The teeth should be moved to a position which will improve its
stability and long-term prognosis by eliminating abnormal occlusal forces.

 Occlusal reconstruction:- Redesigning of the complete occlusal scheme is done when no other
means of occlusal equilibration can be achieved. This is done by fabrication, crowns, fixed
partial and implant supported prosthesis and requires a thorough understanding of occlusion.

 Surgical management:- Extraction of tooth that interferes with occlusion is a rarely used option.
In certain situations, extraction of the selective teeth with poor prognosis with extensive
periodontal involvement is done to improve the prognosis of the remaining teeth.
 According to Glickman, increased tooth mobility is the cardinal manifestation of TFO.
Plaque-induced gingivitis along with occlusal trauma act as codestructive forces altering
the normal inflammatory pathway.

 The treatment considerations include occlusal adjustments, stabilization of teeth, and

orthodontic corrections.

 In the current scenario, the patient presented with an otherwise healthy periodontium, and
hence the condition was diagnosed as primary trauma from occlusion.
 Since the involved teeth in this case report were nonvital on presentation, endodontic
therapy was initiated.

 A clinical review by Çalışkan reported successful treatment of large periapical lesions

with nonsurgical treatment using calcium hydroxide as an antibacterial dressing.

 In this case, metapex (calcium hydroxide and iodoform) was used for the antibacterial
dressing and it was successful in promoting healing of the periapical lesion.
 According to the American Academy of Periodontology, the goals and treatment
considerations for traumatic occlusion include occlusal adjustment of teeth which helps
setting up of appropriate functional relationships appropriate for the periodontium.

 This can be done by coronoplasty, restorations, or removal of tooth.

 In this case report, coronoplasty was done for occlusal adjustment.

 Further treatment goals include temporary, provisional, or long-term stabilization of

mobile teeth using a splint. Splinting also provides normal functioning and reduces
patient discomfort. In this case, splinting was done by the means of a wire and composite
splint.
 Deep bite is a common malocclusion seen in most children as well as adults and is most
difficult to treat successfully.

 An excessive overbite of incisors may be traumatic to lower incisors, palatal aspect of upper
incisors, or both. The outcome is marked gingival recession, hypersensitivity, loss of
attachment, and tooth mobility.

 In the current scenario, an anterior bite plane was successful in decreasing the overbite and
eliminating the traumatic masticatory forces. Final correction by fixed orthodontic therapy and
its retention will prevent the recurrence of such an event.
CROSS REFERENCE
Case series presents clinical cases of patients with an oral diagnosis of chronic generalized periodontitis
exacerbated by occlusal discrepancies (primary and secondary trauma from occlusion) analysed using T-
scan and Electromyography.

CONCLUSION
Occlusal therapy definitely reduces the long-term progression of periodontal disease, and should be considered
as an important adjunctive therapy in the treatment of periodontal disease by eliminating occlusal interferences
through selective grinding of teeth during periodontal therapy.
Thus, the analysis of the distribution of occlusal loading forces using TScan III™ system provides diagnostic
aid in treating, as well as managing the periodontal deterioration and preventing further periodontal
breakdown.
Introduction: Normal or excessive occlusal forces exerted on teeth with a reduced periodontal support might
result in a secondary occlusal trauma. This type of injury is diagnosed based on histological changes in the
periodontium.
Multiple clinical and radiographic indicators are, therefore, required as surrogates to assist the presumptive diagnosis of
a
(secondary) occlusal trauma.

Case Presentation: In this case report, the diagnosis, management, and the 1-year follow-up of a secondary
occlusal trauma of a maxillary central incisor are described. The occlusal relationship was rehabilitated with fixed
orthodontic appliances and was further stabilized with both fixed and removable retainers.

Conclusions: A combined periodontal-orthodontic approach for a secondary occlusal trauma allows the rehabilitation
of periodontal, occlusal, and esthetic parameters. Twelve months after the end of the active orthodontic treatment,
a combination of fixed and removable retainers showed to be effective in retaining the treatment outcome.
 MANAGEMENT OF MOBILE TEETH CAUSED BY TRAUMA FROM OCCLUSION WITH
CORONOPLASTY
Komala, O.N.,Regina, N.,Tadjoedin, F.M.,Harsas, N.A.,Lessang, R.

 The objective of this study is to evaluate tooth movement after coronoplasty.

 Coronoplasty was carried out for teeth with 2° of mobility. Coronoplasty was done by
reducing the occlusal scheme buccally and lingually.
 Conclusion: Coronoplasty can minimize the mobility of teeth that have suffered trauma
from occlusion.
After 22 months of orthodontic treatment, occlusal trauma resulting from pathologic
tooth migration was relieved, a stable occlusion was achieved, and mutual aggravation of
occlusal trauma and periodontitis was prevented.

This case report shows that resorption of alveolar bone can be prevented and that
multidisciplinary orthodontic treatment of a periodontal patient with pathologic tooth
migration is effective and helpful.
Objectives: This study assessed the survival and maintenance needs of splinted teeth in periodontitis patients.

Methods: Patients receiving active and supportive periodontal treatment involving teeth splinting in a university
setting were retrospectively assessed. Tooth and splint survival and number of splint-repairs were recorded.
Multilevel Cox and generalized-mixed linear regression analyses were performed.

Conclusion: Splinting did not significantly increase the risk of tooth loss; splinted teeth showed long-term surviva
To maintain splints, frequent repairs were needed.

Clinical significance: Splinted teeth were not at significantly higher risk of tooth loss than non-splinted teeth.
While splinting does not improve the prognosis of periodontally affected teeth, it can assist their retention by
reducing their mobility.
 Objective: To evaluate the efficacy of tooth splinting (TS) and occlusal adjustment (OA)
compared to no TS or OA in patients with periodontitis exhibiting masticatory dysfunction.
 Material: The primary outcome criterion was tooth loss (TL), and the secondary outcome
parameters were change in probing pocket depth (PPD), change in clinical attachment level
(CAL), tooth mobility (TM), and patient-reported outcome measures (PROMs). Literature
search was performed on three electronic databases (from 01/1965 to 04/2021) and focused on
clinical studies with at least 12 months follow-up.
 Conclusions: Within the limitations of this review and based on a low level of evidence, it is
concluded that TS does not improve survival of mobile teeth in patients with advanced
periodontitis. OA on teeth with mobility and/or premature contacts may lead to improved
CAL, while the effect of OA on the remaining periodontal parameters remains unclear.
 CONCLUSION
 Early intervention is the key in the diagnosis and management of traumatogenic
occlusion. The selection of treatment options should always be customized to
individual cases while considering a multidisciplinary approach to rehabilitate
them. The elimination of the traumatic forces and stabilization of affected teeth are
the most applicable therapy for TFO. Orthodontic treatment can also be beneficial
for patients with periodontal problems and traumatic bite.
 REFERENCE
 Fan J, Caton JG. Occlusal trauma and excessive occlusal forces: narrative review,
case definitions, and diagnostic considerations. J Periodontol 2018;89(Suppl
1):S214-S222.
 Xie Y, Zhao Q, Tan Z, Yang S. Orthodontic treatment in a periodontal patient with
pathologic migration of anterior teeth. American Journal of Orthodontics and
Dentofacial Orthopedics. 2014 May;145(5):685–93.
 Thierens LAM, Van De Velde T, De Pauw GAM. Orthodontic Management of a
Migrated Maxillary Central Incisor With a Secondary Occlusal Trauma. Clin Adv
Periodontics. 2020 Mar;10(1):23–9.
 Graetz C, Ostermann F, Woeste S, Sälzer S, Dörfer CE, Schwendicke F. Long-term
survival and maintenance efforts of splinted teeth in periodontitis patients. Journal
of Dentistry. 2019 Jan;80:49–54.
 Oh SL. An interdisciplinary treatment to manage pathologic tooth migration: A
clinical report. The Journal of Prosthetic Dentistry. 2011 Sep;106(3):153–8.