Trauma from occlusion and Pathologic migration in periodontics

TFO, definition,types,stages,C/F, R/F, diagnosis, treatment
Pathologic migration

1. DR.T.ARTHIIE TRAUMA FROM OCCLUSION

2. CONTENTS DEFINITION PHYSIOLOGIC ADAPTIVE CAPACITY OF THE PERIODONTIUM TO OCCLUSAL FORCES TYPES STAGES CLINICAL SYMPTOMS CLINICAL FEATURES RADIOGRAPHIC FEATURES DIAGNOSIS TREATMENT

3. DEFINITION A condition where injury results to the supporting structures of the teeth by the act of bringing the jaws into a closed position When occlusal forces exceed the adaptive capacity of periodontal tissues, the tissue injury results. This resultant injury is termed as a trauma from occlusion

4. PHYSIOLOGIC ADAPTIVE CAPACITY OF THE PERIODONTIUM TO OCCLUSAL FORCES Varies in different persons and in the same person at different times and is influenced by the: magnitude, direction, duration and frequency of the force

5. MAGNITUDE             Widening of periodontal ligament space, Increase in width of PDL fibres Increase in density of alveolar bone.

6. Reorientation of stresses within periodontium The principal Fibers of PDL are rearranged to best accommodate occlusal forces Lateral forces & torque are more likely to injure the periodontium DIRECTION ↓

7. DURATION AND FREQUENCY OF OCCLUSAL FORCES   Constant pressure on the bone is more injurious than intermittent forces. Frequent the application of intermittent force, the more injurious is the force to periodontium

8. Acute trauma from occlusion     Abrupt occlusal impact , such as that produced by biting on a hard object (e.g., an olive pit). Restorations or prosthetic appliances that interfere with the direction of occlusal forces on the teeth may induce acute trauma.

9. Chronic TFO More common & significant   Gradual changes by: tooth wears drifting movement extrusion parafunctional habits - bruxism and clenching ,

10. Primary trauma from occlusion   When trauma from occlusion is the result of alterations in occlusal forces, it is called “ primary trauma from occlusion .” Caused by: alterations in occlusal forces, reduced capacity of the periodontium to withstand occlusal forces, or both .  Changes produced by primary trauma do not alter the level of connective tissue attachment and do not initiate pocket formation

11. Periodontal injury produced around teeth with a previously healthy periodontium after Insertion of a “high filling” Insertion of a prosthetic replacement that creates excessive forces on abutment and antagonist teeth. Drifting movement or extension of teeth into spaces created by unreplaced missing teeth , Orthodontic movement of teeth into functionally unacceptable positions.

12. Secondary trauma from occlusion When it results from reduced ability of the tissues to resist the occlusal forces, it is known as “ secondary trauma from occlusion .” Develops from gradual changes in   occlusion produced by tooth wear, drifting movement, extrusion of teeth, combined with parafunctional habits such as bruxism and clenching Periodontitis

13. Extension of gingival inflammation to alveolar bone Gingival inflammation -collagen fiber bundles - blood vessels - alveolar bone Interproximally , through the vessels perforating the crest of the interdental septum Directly into the PDL & from there into the interdental septum Destroys the transeptal & gingival fibers on the course

14. Once bone is reached: Spreads Into the marrow spaces & replaces marrow with exudate. Bone resorption proceeds from within the marrow spaces Thinning of bony trabeculae & enlargement of the marrow spaces Bone destruction & a reduction in bone height Fatty bone marrow replaced with fibrous marrow

15. GLICKMAN’S CONCEPT The pathway of the spread of a plaque-associated gingival lesion can be changed if forces of an abnormal magnitude are acting on teeth harboring subgingival plaque   Sites which are also exposed to abnormal occlusal force will develop angular bony defects and infrabony pockets than Sites with uncomplicated plaque-associated lesions

16. Periodontal structures divided into two zones: Zone of Irritation Zone of co-destruction

17. Zone of irritation Includes the marginal and interdental gingiva. The soft tissue of this zone is bordered by hard tissue (the tooth) only on one side and is not affected by forces of occlusion. The gingival inflammation cannot be induced by trauma from occlusion The plaque-associated lesion at a “non- traumatized” tooth propagates in the apical direction by first involving the alveolar bone and only later the periodontal ligament area.

18. Zone of co-destruction   Includes PDL, Root cementum & alveolar bone Coronally demarcated by the transeptal & the dentoalveolar collagen fiber bundles TFO may cause a lesion here The fiber bundles which separate the zone of codestruction from the zone of irritation can be affected from two different directions: From the inflammatory lesion maintained by plaque in the zone of irritation From trauma-induced changes in the zone of co-destruction .

19. Waerhaug’s Concept (1979) Trauma from occlusion played a role in the spread of a gingival lesion into the "zone of co-destruction ". Waerhaug concluded that angular bony defects and infrabony pockets occur when the subgingival plaque of one tooth has reached a more apical level than the microbiota on the neighboring tooth, and when the volume of the alveolar bone surrounding the roots is comparatively large.  

20. STAGES Stage I: Injury . Stage II: Repair. Stage III: Adaptive Remodeling of periodontium

21. STAGE I : INJURY Caused by Excessive occlusal forces. Forces of occlusion or tooth rotates around a fulcrum - creates pressure and tension on opposite sides of fulcrum. Slightly excessive pressure - stimulates resorption of alveolar bone, with compression of PDL fibres . Slightly excessive tension - elongation of PDL fibers & opposition of alveolar bone .   In areas of increased pressure,- the blood vessels are numerous and reduced in size Increased tension – blood vessels are enlarged .

22. Greater Pressure - Compression of fibres produces hyalinization . Injury to fibroblasts and other connective tissue cells leads to necrosis . Vascular changes: Within 30 min: retardation and stasis of blood flow 2-3 hrs : blood vessels paused with erythrocytes which start to fragment. In 1-7 days disintegration of the blood vessel walls and release of the contents into the surrounding tissue

23. SEVERE TENSION Widening of the periodontal ligament. Thrombosis Hemorrhage Tearing of the periodontal ligament. Resorption of the alveolar bone Osteoclasts appear in marrow spaces within the adjacent bone tissue where the stress concentration is lower than in the periodontal ligament and a process of undermining or “ indirect bone resorption ” is initiated

24. Stage II: Repair Repair is constantly occurring in the normal periodontium and TFO stimulates increased reparative activity.   The damaged tissues are removed and new connective tissue cells, fibers, bone, and cementum are formed in an attempt to restore the injured periodontium .   When bone is resorbed by excessive occlusal forces, the body attempts to reinforce the thinned bone with new bone. This attempt to compensate for lost bone is called buttressing bone formation and is an important feature associated with TFO .

25. Buttressing bone formation occurs within the jaw (central buttressing) and on the bone surface (peripheral buttressing ). In central buttressing the endosteal cells deposit new bone, which restores the bony trabeculae and reduces the size of the marrow spaces . Peripheral buttressing occurs on the facial and lingual surfaces of the alveolar plate . Depending on its severity, peripheral buttressing may produce a shelf like thickening of the alveolar margin, referred to as “lipping”, or a pronounced bulge in the contour of the facial and lingual bone.

26. Stage III: Adaptive remodeling of the periodontium   To react for thr repair process , the periodontium is remodeled to create a structured relationship in which forces are no longer injurious to the tissues. This results in a thickened periodontal ligament, which is funnel- shaped at the crest, angular defects in the bone with no pocket formation, increased mobility increased vascularisation

27. Clinical Symptoms Periodontal pain Localized, sharp pain or soreness to the tooth – severe TFO In chronic TFO- there is little or no pain . Pulpal pain Sensitivity of the teeth, especially to cold   Food impaction The plunger cusp effect of occlusal interference may produce a functional opening of contact between the teeth, leading to food impaction. TMJ pain This is always accompanied by an occlusal disharmony

28. Clinical Signs Tooth mobility - Increasing tooth mobility Pain on chewing or percussion Fremitus - positive Wear facets Tooth migration Chipped or fractured teeth Thermal sensitivity

29.   Radiographic features Increased width of periodontal ligament space . The injury phase : a loss of the lamina dura and results in widening of PDL space. The repair phase : The advanced traumatic lesions result in deep angular bone loss and when combined with marginal inflammation leads to intrabony pocket. The more advanced traumatic lesions may result in funnel shaped deep angular bone loss with vertical destruction of the interdental septum. Root resorption

30. Diagnostic tests Fremitus test Palpation test Percussion test Articulating paper test Miller s tooth mobility test.

31. Fremitus test/Functional Mobility It is the measurement of vibratory patterns of the teeth when teeth are placed in maximum intercuspal position. The index finger is placed partially on the gingiva and partially on teeth and pateient is asked to bite repeatedly . Grading: Class I: Mild vibrations or movements detected Class II: Easily palpable vibrations but no visible movements Class III: Movements visible with the naked eye

32. In the posterior teeth TFO can be detected with help of occlusion registration strip/ articulating paper. High pressure points can be detected by pattern of impression made by registration strip/articulating paper

33. treatment A goal of periodontal therapy in the treatment of occlusal traumatism should be to maintain the periodontium in comfort and function.   PROPOSED BY AAP(1996) Reduce /eliminate tooth mobility Eliminate occlusal prematurities and fremitus Eliminate parafunctional habits Prevent further tooth migration Decrease / stablize radiographic changes

34. Coronoplasty Selective grinding is a procedure by which the occlusal surfaces of teeth are precisely altered to improve the overall contact pattern. Tooth structure is selectively removed until the reshaped teeth contact in such a manner as to fulfill the treatment goals . Indications (1989 WORLD WORKSHOP IN PERIODONTICS) To reduce traumatic forces to teeth that exhibit Increasing mobility or fremitus Discomfort during occlusal contact or function. To achieve functional relationships and masticatory efficiency in conjunction with restorative treatment, orthodontic, orthognathic surgery or jaw trauma when indicated. As adjunctive therapy that may reduce the damage from parafunctional habits. To reshape teeth contributing to soft tissue injury To adjust marginal ridge relationships and cusps that are contributing to food impaction

35. splinting INDICATIONS : (1989 WORLD WORKSHOP) Stabilize teeth with increasing mobility that have not responded to occlusal adjustment and periodontal treatment.   Facilitate treatment of extremely mobile teeth by splinting them prior to periodontal instrumentation and occlusal adjustment procedures.   Prevent tipping or drifting of teeth and extrusion of unopposed teeth.   Stabilize teeth, when indicated, following orthodontic movement.   Create adequate occlusal stability when replacing missing teeth. Stabilize teeth following acute trauma

36. ⦿ BRUXISM : night guard

37. PATHOLOGIC MIGRATION

38. contents DEFINITION CAUSES CLINICAL FEATURES TREATMENT PREVENTION

39. DEFINITION Pathologic migration refers to tooth displacement that results when the balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease. Most frequently occurs in the anterior region In the occlusal or incisal direction is termed extrusion

40. FACTORS INFLUENCING TOOTH POSITION

41. Causes 1. Weakened periodontal support: Destruction of transeptal fibres by periodontal diseases causes the tooth to move away from the opposing force till it gets contact. Also increases or modify the forces exerted on the teeth. Pathologic migration is an early sign of localized aggressive periodontitis .

42. unrepalced missing teeth: the failure to replace missing first molars results in Tilting of the second and third molars, resulting in a decrease in vertical dimension. The premolars move distally. The mandibular incisors tilt or drift lingually . Anterior overbite is increased and the mandibular incisors strike the maxillary incisors near the gingiva. The maxillary incisors move labially and laterally with extrusion. Diastema formation between maxillary anterior teeth.

43. 3. Trauma from occlusion: TFO may cause a shift in tooth position either by directly or in combination with periodontal disease. 4. Pressure from the tongue: Tongue thrusting causes drifting of the anterior teeth

44. 5. Pressure from granulation tissue: Granulation tissue pulls the teeth in the direction where less destruction during healing. 6. Habits that have been associated with PTM include lip and tongue habits, finger nail biting, thumb sucking, pipe smoking, and playing wind instruments

45. 7. Occlusal Factors - Posterior bite collapse (PBC) Unfavourable occlusal changes that occur most frequently after first molar teeth are lost and not replaced. Results in flaring of anterior teeth

46. 8. Gingival overgrowth or enlargement

47. Clinical features Migration of teeth Tooth mobility TFO Recession Increased overbite Diastema formation

48. Treatment Treatment of severe PTM often involves orthodontic therapy that is preceded by non-surgical and surgical periodontal therapy and prosthodontic treatment. When PTM is in initial stages and localized, the treatment may be greatly simplified for the patient

49. Spontaneous correction of the early stages of PTM following periodontal therapy Limited or adjunctive orthodontic therapy Conventional orthodontic treatment Extraction and replacement of migrated teeth when migration is very severe

50. PREVENTION Early detection Control of periodontal disease- most effective method to prevent Treatment of occlusal factors Habits correction