8.TFO.pptx

trauma from occlusion- classification, clinical and radiographic features
pathologic tooth migration

1. 1 Trauma From Occlusion

2. To understand the role of trauma from occlusion in periodontal disease, it is necessary to understand the relationship of occlusion to periodontal health. Occlusion is the lifeline of the periodontium. 2 Role of occlusion in the etiology and treatment of periodontal disease IRVING GLICKMAN J Dent Res Supplement No. 2 Vol 50, 1971 INTRODUCTION

3. 3 When there is increased functional demand, the periodontium tries to accommodate it. The periodontal ligament thickens and becomes more dense; the bone trabeculae are reinforced. If the periodontium cannot adapt to the force , the tissues are injured,Injury in the periodontium produced by occlusal forces is "TRAUMA FROM OCCLUSION“ Role of occlusion in the etiology and treatment of periodontal disease IRVING GLICKMAN J Dent Res Supplement No. 2 Vol 50,1971

4. Definitions 4 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition “An injury to the attachment apparatus as a result of excessive occlusal force.” American Academy of periodontology -1986 Glickman 1972 , “ When occlusal forces exceed the adaptive capacity of the tissues, tissue injury results. The resultant injury is termed trauma from occlusion.”

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6. Trauma from Occlusion is defined as an injury resulting in tissue changes within the periodontal attachment apparatus as a result of occlusal force. Such an occlusion is called truamatic occlusion. 6 Ann Periodontol 199 9( 4);102-107. Ann Periodontol 199 9( 4);102-107.

7. SYNONYMS Traumatic occlusion Traumatizing occlusion Occlusal trauma Traumatogenic occlusion Periodontal traumatism Overload Occlusal dystrophy/disharmony 7 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

8. Historical perspective Karolyi (1901) – postulated interaction between TFO & “alveolar pyrrohea ” Stillman (1917 & 1926) – advocated use of occlusal adjustment for treatment of TFO Box & Stones (1938’s ) - animal experiments TFO etiologic factor in periodontal disease 8 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

9. Effect of occlusal forces on the periodontium is influenced by their :- Magnitude Direction Duration Frequency 9 Carranza’s Clinical Periodontology –10 th edition

10. TYPES 10 Carranza’s Clinical Periodontology –10 th edition

11. Acute TFO Results from an abrupt change in the occlusal forces, such as - that produced by biting on a hard object or - by restorations or prosthetic appliance. Teeth exhibit signs of acute trauma - tooth pain, - sensitivity to percussion, - tooth mobility etc. 11 Carranza’s Clinical Periodontology –10 th edition

12. If the force is dissipated the injury heals and the symptoms subside. If untreated or unresolved it may worsen leading to necrosis, pdl abscess formation or persist as a symptom free chronic condition. Sometimes cemental tears may occur as a result of occlusal trauma. 12 Carranza’s Clinical Periodontology –10 th edition

13. Chronic TFO - more common than acute TFO - greater clinical significance. develops from gradual changes in occlusion produced by - tooth wear, - drifting movement, and - extrusion of teeth, - combined with parafunctional habits such as bruxism and clenching 13 Carranza’s Clinical Periodontology –10 th edition

14. 14 Primary TFO occurs if TFO is the primary etiologic factor in periodontal destruction Local alteration to which a tooth is subjected is from occlusion Causes - Insertion of high filling Insertion of a prosthetic replacement Drifting / extrusion of teeth into spaces Orthodontic movement Primary TFO Carranza’s Clinical Periodontology –10 th edition

15. Primary trauma does not alter the level of connective tissue attachment and does not initiate pocket formation. Supracrestal gingival fibers are not affected ,therefore prevent apical migration of the Junctional epithelium. (Polson et al – JPR 1976; 279 ) 15 Carranza’s Clinical Periodontology –10 th edition

16. Secondary TFO 16 When the adaptive capacity of the tissues to withstand occlusal forces is impaired by bone loss resulting from marginal inflammation.   Periodontium becomes vulnerable to injury Previously well tolerated forces become traumatic. Marginal inflammation reduces the periodontal attachment area Carranza’s Clinical Periodontology –10 th edition

17. Glickman’s concept: (1965, 1967), 17 Pathway of spread of plaque associated gingival lesion can be changed if forces of abnormal magnitude are acting on teeth harboring subgingival plaque Character of progressive tissue destruction different in: Traumatized tooth Non – traumatized tooth Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

18. Instead of an even destruction of the periodontium and alveolar bone ( suprabony pockets and horizontal bone loss),sites which are also exposed to abnormal occlusal force will develop angular bony defects and infrabony pockets. 18 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

19. The periodontal structures can be divided into two zones: 1. the zone of irritation and 2. the zone of co-destruction 19 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

20. 20 Zone of irritation Marginal & interdental gingiva Gingival inflammation not induced by TFO It results from microbial plaque Zone of co-destruction PDL Root cementum Alveolar bone Seat of lesion caused by TFO. Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

21. 21 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition Fig. 14-2 The infl ammatory lesion in the zone of irritation can, in teeth not subjected to trauma, propagate into the alveolar bone (open arrow), while in teeth also subjected to trauma from occlusion, the infl ammatory infi ltrate spreads directly into periodontal ligament ( fi lled arrow).

22. Waerhaug’s concept : 1979 Waerhaug (1979) examined autopsy specimens, measured the distance between the subgingival plaque and (1) the periphery of the associated inflammatory cell infiltrate in the gingiva and (2) the surface of the adjacent alveolar bone. 22 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

23. He concluded from his analysis that angular bony defects and infrabony pockets occur equally often at periodontal sites of teeth which are not affected by trauma from occlusion as in traumatized teeth. The loss of connective attachment and the resorption of bone around teeth are, according to Waerhaug , exclusively the result of inflammatory lesions associated with subgingival plaque. 23 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

24. Waerhaug concluded that angular bony defects and infrabony pockets occur when – - the subgingival plaque of one tooth has reached more apical level, and - when the volume of the alveolar bone surrounding the roots is comparatively large. 24 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

25. 25 Waerhaug's observations support findings presented by Prichard (1965) and Manson (1976) which imply that the pattern of loss of supporting structures is the result of interplay between the form and volume of the alveolar bone and the apical extension of the microbial plaque on the adjacent root surfaces. Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

26. Glickman's conclusions that trauma from occlusion is an aggravating factor in periodontal disease Waerhaug's concept, i . e. that there is no relationship between occlusal trauma and the degree of periodontal tissue breakdown 26 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

27. Effect of Periodontal Tissues on Orthodontic Type OF Trauma 27 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

28. JIGGLING TYPE OF TRAUMA Occlusal forces act alternately in one then the opposite direction Such forces – jiggling forces 28 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

29. Healthy periodontium with normal height 29 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

30. Healthy periodontium with reduced height 30 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

31. Plaque-associated periodontal disease 31 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

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33. Stages of Tissue Response Injury Repair Adaptive remodeling of the periodontium. TISSUE RESPONSE TO INCREASED OCCLUSAL FORCES 33 Carranza’s Clinical Periodontology –10 th editions

34. STAGE 1 - INJURY Excessive occlusal forces  tissue injury. Body attempts to repair the injury & restore the periodontium. Occurs if the forces are diminished / tooth drifts away from them. If force is chronic  periodontium is remodeled to cushion its impact. 34 Carranza’s Clinical Periodontology –10 th editions

35. Ligament is widened at the expense of the bone Angular bone defects occur without periodontal pocket formation Tooth becomes loose. Under the forces of occlusion : A tooth rotates around a fulcrum or axis of rotation 35 Carranza’s Clinical Periodontology –10 th editions

36. Areas of pressure and tension on opposite sides of the fulcrum. Different lesions are produced by different degrees of pressure and tension. Slightly excessive pressure  resorption of the alveolar bone  widening of the periodontal ligament space. Slightly excessive tension  elongation of the periodontal ligament fibers  apposition of alveolar bone. 36 Carranza’s Clinical Periodontology –10 th edition

37. Histologically : Greater pressure produces gradation of changes in the pdl Compression..hyalinization Injury to fibroblasts and C.T …necrosis Vascular changes… 30 min. stasis…2-3 hrs B.V packed Disintegration of B.V… increased resorption of alveolar bone and tooth surface 37 Carranza’s Clinical Periodontology –10 th editions

38. Severe tension: widening of the periodontal ligament Thrombosis Hemorrhage Tearing of the PDL Resorption of alveolar bone. Severe pressure : Force the root against bone Necrosis of PDL and bone (undermining resorption ) 38 Clinical Periodontology and Implant dentistry - Jan Lindhe – 5 th edition

39. The damaged tissues are removed New connective tissue cells and fibers, bone and cementum are formed  attempt to restore the injured periodontium. Forces remain traumatic as long as the damage produced exceeds the reparative capacity of the tissues. STAGE II: REPAIR 39 Carranza’s Clinical Periodontology –10 th edition

40. Thinned bony trabaculae reinforced with new bone Important feature of the reparative process associated with TFO Central buttressing ( within the jaws ) and peripheral buttressing (bone surface). Lipping Peripheral buttressing  produce a shelf-like thickening of the alveolar margin Buttressing Bone Formation 40 Carranza’s Clinical Periodontology –10 th edition

41. Results in thickened PDL  funnel shaped at the crest Angular defects in the bone with no pocket formation. Involved teeth become loose .  ed vascularization also reported. STAGE III: ADAPTIVE REMODELING OF THE PERIODONTIUM 41 Carranza’s Clinical Periodontology –10 th edition

42. Effect of insufficient force Insufficient occlusal force may also be injurious to the supporting periodontal tissues (Cohn 1961). Hypofunction can result from - open bite relationships, - absence of functional antagonists - unilateral chewing habits. 42 Carranza’s Clinical Periodontology –10 th edition

43. Insufficient stimulation causes Thinning of PDL Atrophy of fibers Osteoporosis of alveolar bone Reduction in bone height 43 Carranza’s Clinical Periodontology –10 th editions

44. REVERSIBILITY OF TRAUMATIC LESIONS Trauma from occlusion is reversible. The injurious force must be relieved for repair to occur. If conditions do not permit the teeth to escape from or adapt to excessive occlusal force, periodontal damage persists and worsens. 44 Carranza’s Clinical Periodontology –10 th editions

45. If periodontal structures could adapt to the applied force Progressive mobility – terminated in few weeks Active resorption ceased Angular bone destruction persisted 45 Carranza’s Clinical Periodontology –10 th editions

46. If the tissues couldn’t adapt – Angular bone destruction was continuous & mobility remained progressive Zone of irritation & co-destruction merged, dentogingival epithelium proliferated in apical direction Increase in width of PDL on both sides Teeth hypermobile ( Progressive mobility ) Angular bony defects – radiographs 46 Carranza’s Clinical Periodontology –10 th editions

47. CHANGES IN OTHER TISSUE 1. Gingiva: No evidence of gingival changes . The accumulation of bacterial plaque that initiates gingivitis and results in periodontal pocket formation affects the marginal gingiva, but TFO occurs in the supporting tissues and does not affect the gingiva. 47 Vascular reactions in the periodontal ligament incident to trauma from occlusion . journal of clinical periodontology : 1974: 1: 58

48. 48 Vascular reactions in the periodontal ligament incident to trauma from occlusion . journal of clinical periodontology : 1974: 1: 58 The marginal gingiva is unaffected by TFO as its blood supply is sufficient to maintain it, even when the vessels of the periodontal ligament are obliterated by excessive occlusal forces.

49. 2.Cementum: In acute phase , cemental tears and fractures. In the chronic phase reparative changes such as cementum hyperplasia and formation of cementum spurs may occur. In some cases cementum resorption may follow. 49 Significance of occlusion in the etiology and treatment is early,moderate and advanced periodontitis.Sigurd P.Ramfjord and Major M.Ash.J Periodontol 1981,511

50. 3. Pulp: Odontoblastic activity may be stimulated and secondary dentin may be formed. Pulp chamber and canal may become narrower and even obliterated. Pulp stones may be formed. In such cases there may be even pulpitis and loss of pulp vitality. 50 Carranza’s Clinical Periodontology – 10 th edition

51. Clinical Signs Increase tooth mobility Migration Wear facets Vertical impaction of food and wear facets. Hypersensitivity Abfraction 51 Jin LJ and Cao CF: Clinical diagnosis of trauma from occlusion and its relation with severity of periodonitis . J Clin Periodontol 1992: 19: 92-97

52. Radiographic Changes Increased width of periodontal space Thickening of lamina dura Vertical rather than horizontal bone loss Radioluscence and condensation of alveolar bone Root resorption increased radiodensity due to change in axial forces or decreased trabecular pattern on side of pressure. 52 Carranza’s Clinical Periodontology – 10 th edition

53. ETIOLOGy Malocclusion TMJ dysfunction Faulty restoration Faulty orthodontic treatment Parafucntional habits Drifting/Extrusion of teeth Dental caries Occupational Bruxism Restricted unilateral mastication. 53 Jin LJ and Cao CF: Clinical diagnosis of trauma from occlusion and its relation with severity of periodonitis . J Clin Periodontol 1992: 19: 92-97

54. Neuromuscular irritation Faulty proprioception Altered adaptive capacity of PDL Alveolar Bone loss Psychic disturbance 54 Jin LJ and Cao CF: Clinical diagnosis of trauma from occlusion and its relation with severity of periodonitis . J Clin Periodontol 1992: 19: 92-97

55. How to Detect Clinically Fremitus . Mobility (progressive). Occlusal Discrepancies. Wear facets in the presence of other indicators. Tooth migration. Fractured tooth/teeth. Thermal sensitivity. Clinical diagnosis of trauma from occlusion and its relation with severity of periodonitis . J Clin Periodontol 1992: 19: 92-97

56. Fremitus test Classified into 3 classes Class I : Mild vibration or movements detected. Class II : Easily palpable vibration but no visible movements. Class III : Movements visible with naked eye. DIAGNOSIS OF OCCLUSAL TRAUMA 2/6/2023 56 Occlusal strips Auditory test for TFO Tactile Method Histologic studies Radiographs Clinical diagnosis of trauma from occlusion and its relation with severity of periodonitis . J Clin Periodontol 1992: 19: 92-97

57. Hall –Critical decessions in periodontology - 4th edition. 57

58. Hall –Critical decessions in periodontology - 4th edition. 58

59. TREATMENT OF TFO Occlusal equilibration Splinting Orthodontic treatment Restorative options like onlays Prosthetic replacement 59 Significance of occlusion in the etiology and treatment is early,moderate and advanced periodontitis.Sigurd p.Ramfjord and major m.Ash.J periodontol 1981,511

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61. CORONOPLASTY - STEPS Step 1 : Remove retrusive prematurities and eliminate the deflective shift from RCP to ICP 61 Carranza’s Clinical Periodontology – 8 th editiON

62. STEP 2 :adjustment of the ICP To achieve a stable ICP and to refine occlusal anatomic relationships The posterior teeth are adjusted first, followed by conservative adjustment of the anterior teeth if necessary. 62 Carranza’s Clinical Periodontology – 8 th editiON

63. Step 3: test for excessive contact on the incisor teeth in icp The incisor teeth should be slightly out of contact or in light contact over the maximum number of teeth. Mylar occlusal strip should be held with a hemostat and contacts should be checked. Any supracontacts detected are reduced. 63 Carranza’s Clinical Periodontology – 8 th editiON

64. STEP 4: remove posterior protrusive supracontacts and establish contacts that are bilaterally distributed on the anterior teeth. 64 Carranza’s Clinical Periodontology – 8 th editiON

65. Step 5 : remove (or) lessen (balancing) supracontacts MEDIOTRUSIVE SUPRACONTACTS Grooving 65 Carranza’s Clinical Periodontology – 8 th editiON

66. Step 6 : reduce supracontacts on the laterotrusive (working) side 66 Carranza’s Clinical Periodontology – 8 th editiON

67. Step 7: eliminate undesirable gross occlusal features Step 8 : Recheck tooth contact relationship Step 9 : Polish all rough tooth surfaces. 67 Carranza’s Clinical Periodontology – 8 th editiON

68. Rotated, malposed or tilted teeth Plunger cusp Facets Flat Occlusal wear Uneven marginal ridges 68

69. conclusion There is no scientific evidence that TFO causes gingivitis or periodontitis It is reversible if forces reduced leading to a reduction tooth mobility and physiologic adaptation May be a co-factor in pathogenesis of periodontal disease 69

70. 70 Thank you