Trauma from Occlusion
Question 1. Define trauma from occlusion and discuss the types of trauma from occlusion and its features.
Answer:
Trauma from occlusion is defined as the tissue injury that results to the supporting periodontium of teeth from occlusal forces that are in excess of the reparative/adaptive capacity of the attachment apparatus.
Read And Learn More: Periodontology Important Question And Answers
Acute And Chronic Trauma From Occlusion
Acute trauma from occlusion arises from a sudden increase in occlusal forces that act on the periodontium, such as that produced by biting a hard object.
- Chronic trauma is the result of slow changes in the occlusion over some time such as the drifting of teeth or as a result of parafunctional habits such as clenching or bruxism.
Primary And Secondary Trauma From Occlusion
Primary trauma from occlusion results when the healthy periodontium is subjected to an increase in occlusal force.
- Such trauma does not lead to pocket formation or the loss of attachment though hypermobility of the teeth may be a significant feature.
- It is usually observed following a high point in a restoration, drift into edentulous spaces, or orthodontic tooth movement.
- Secondary trauma from occlusion occurs due to the inability of the compromised periodontium (reduced periodontal support as a result of disease) to withstand normal occlusal forces as a result of reduced periodontal support.
Question 2. What Are The Clinical And Radiographic Signs Of Trauma From Occlusion?
Answer:
Radiographic Signs Of Trauma From Occlusion Clinical Features
A positive diagnosis of occlusal traumatism can be made if some of the signs and symptoms of an injury can be located in some part of the masticatory system.
The following represent clinical features of such an injury, but are not pathognomonic for the condition:
- Hypermobility is the single most important and prevalent clinician sign of trauma from occlusion that is not complicated by pre-existing periodontitis.
- The hypermobility is due to the destruction of the periodontium during the injury stage of TFO and the widening of the periodontal ligament space as a result of the accommodation of the periodontal ligament to the increased forces in the later stages.
- Tooth migration.
- Tooth pain or discomfort on chewing or percussion.
- Tenderness of the muscles of mastication or other signs or symptoms of temporomandibular dysfunction.
- Presence of wear facets beyond expected levels for the patient’s age and diet consistency.
- Chipped enamel or crown/root fractures.
- Fremitus.
Radiographic Signs
The radiographic features of trauma from occlusion are:
- Widening of marginal periodontal ligament space along with thickening of the lamina dura along the lateral, apical, and bifurcation areas of the root.
- Angular bone loss (without the clinical feature of a periodontal pocket), vertical destruction of the interdental septum.
- Disruption of the lamina dura.
- Radiolucencies in the furcation or at the apex of a tooth that is vital
- Condensation of the alveolar bone. A narrowing of the interproximal alveolar bone and shelflike thickening of the marginal bone occurs.
- Root resorption.
These clinical signs and symptoms may be indicative of other pathoses. Therefore, differential diagnoses may be established. Use of supplementary diagnostic procedures may be helpful; e.g. pulp vitality tests and evaluation of parafunctional habits.
Question 3. What Are The Responses Of The Tissues To Increased Occlusal Forces?
Answer:
The response of the periodontal tissues follows through the three phases of injury, repair, and adaptive remodeling of the periodontium.
Tissues To Increased Occlusal Forces Radiographic Injury
This stage is characterized by bone resorption, hyalinization, necrosis of periodontal ligament, and occasionally cemental tear.
The microvasculature of the periodontium shows changes that lead to the above-mentioned phenomena.
Radiographic Repair
- The injury that occurs is repaired either completely or partially during this phase, provided the source of trauma is removed.
- The necrotic tissues are slowly removed and replaced by the formation of new connective tissue cells, fibers, alveolar bone, and cellular cementum.
- With persistent low-grade trauma, there may be buttressing bone formation. Peripheral buttressing bone formation usually observed on the labial aspect is called lipping.
Adaptive Remodeling
The periodontal ligament due to its capacity for tissue formation and remodeling can result in the formation of a periodontal structure that is necessary to cope with occlusal trauma. A funnel-shaped widening of the crystal bone is an example of adaptive remodeling.
What Is Trauma From Occlusion And Its Relationship To Progression Of Periodontitis?
Trauma from occlusion does not affect the gingiva as long as the inflammatory process is confined to the gingiva, as its blood supply is sufficient to maintain it.
- Trauma from occlusion does not cause periodontal pocket formation. However, in the presence of pre-existing inflammation trauma from occlusion can change bone loss patterns from horizontal to vertical and result in infra bony pockets.
Question 4. What Are The Theories Proposed To Explain The Interaction Of Trauma From Occlusion And Inflammation?
Answer:
Glickman’s concept (1965, 1967): He divided the periodontal structure into two zones; (a) the zone of irritation and (b) the zone of co-destruction.
- The zone of irritation includes the marginal and inter-dental gingiva which is not affected by the occlusal forces.
- The irritation is the result of microbial plaque. The information in a non-traumatized tooth propagates apical direction by first involving the alveolar bone and later the periodontal ligament.
- The progression of this lesion results in horizontal bone loss.
- The zone of co-destruction includes the periodontal ligament, the root cementum, and the alveolar bone and is coronally demarcated by the gingival collagen fiber bundles.
- The tissue in this zone is affected by the traumatic occlusal forces and may show lesions caused by trauma from occlusion.
- The destruction in this zone would be angular with infrabony pockets. He concluded that trauma from occlusion was an aggravating factor in periodontal disease.
- Waerhaug’s concept (1979): Waerhaug refuted the hypothesis that trauma from occlusion played a role in the spread of gingival lesions into the zone of co-destruction as he found angular bone defects in the autopsy specimens of periodontally affected teeth in both teeth that were affected by trauma and those that were not.
- He felt that the defects were exclusively the result of the apical extension of the inflammatory process as the subgingival plaque reached a more apical level.
Question 5. Describe The Influence Of Parafunctional Habits On Periodontium.
Answer:
Parafunctional habits are another potential cause of occlusal trauma. Parafunctional forces on the teeth are characterized by repeated or sustained occlusion and have been recognized as harmful to the stomatognathic system. The parafunction may be categorized as absent, mild, moderate, or severe.
Periodontium Bruxism
- Bruxism is the vertical and horizontal, nonfunctional grinding of the teeth. The forces used are more than normal physiologic masticatory load.
- These forces occur while a patient is awake or asleep and may generate several hours per day of increased force on the teeth.
- Clinical signs of bruxism include occlusal wearing of teeth, increase in size of temporal and masseter muscles, deviation of the lower jaw on opening, limited mouth opening, increased mobility of the teeth, cervical fraction of teeth, and fracture of teeth.
Periodontium Clenching
Clenching is the force exerted from one occlusal surface to the other without any movement.
- The forces are directed more vertically to the plane of occlusion in the posterior regions and wearing of the teeth is unlikely.
- Tooth mobility, greater temperature sensitivity, muscle tenderness, deviation on opening, limited opening, stress lines in enamel cervical abfraction are associated clinical signs of clenching.
Periodontium Tongue Thrust
Parafunctional tongue thrust is the unnatural force of the tongue against the teeth during swallowing. Spacing between the anterior teeth and tooth indentations on the tongue characterize tongue thrust.
Pathological Migration
Question 6. What Is Pathological Migration?
Answer:
Pathological migration is a separate clinical entity that results when the balance of forces determining the functional position of the tooth in the arch is altered by periodontal disease leading to a shift in the position of the teeth in question.
- Common in the anterior segments, pathological migration is accompanied by hypermobility and a widening of the interdental spaces.
- It is associated with gingival inflammation and pocket formation.
- It differs from mesial drift which is physiological and occurs due to missing adjacent teeth.
- The factors that maintain the position of the tooth are the health and height of the periodontium and the forces exerted on the teeth.
- The forces, that determine the position of the teeth, are the forces of occlusion and the muscular pressure of the lips, cheeks, and tongue.
- The dental factors that influence pathological migration are the cuspal relationships of the teeth, edentulous spaces, mesial migration, attrition, and loss of arch dimension as well as the axial inclinations of the teeth that determine whether the forces will be directed axially or tangentially during occlusion.
- In other words, although occlusal forces themselves may not be of an excessive magnitude but rather the reduced periodontium is unable to bear the burden of even normal forces of occlusion.
- Changes in the magnitude, direction, or frequency of occlusal forces also can induce pathological migration of teeth.
- Trauma from occlusion, pressure from the tongue, and pressure from growing granulation tissue in periodontal pockets may all contribute to pathological migration.
- Pathologic migration is an early sign of localized aggressive periodontitis.
Pathological Migration Treatment Considerations
Treatment of the symptoms of occlusal traumatism is appropriate during any phase of periodontal therapy.
- Except in the case of acute conditions, treatment is usually first addressed during initial therapy following efforts to reduce or minimize the inflammatory lesion.
- Evaluation of occlusal symptoms should continue throughout therapy.
- Treatment may need to be repeated or revised. Efforts are directed toward the elimination or minimization of excessive force or stress placed on a tooth or teeth. Occlusal therapy may be accomplished through several different approaches.
- The choice depends on several factors, such as the characteristics of the forces, the underlying cause of these forces, the amount of periodontal support of the remaining teeth, and the function of the remaining dentition.
Treatment considerations for the chronic periodontitis patient with occlusal traumatism may include one or more of the following:
- Occlusal adjustment
- Management of parafunctional habits
- Temporary, provisional, or long-term stabilization of mobile teeth with removable or fixed appliances
- Orthodontic tooth movement
- Occlusal reconstruction
- Extraction of selected teeth.
Pathological Migration Conclusion
The current understanding is that trauma from occlusion has the potential to alter disease severity and prognosis. It does not induce periodontal breakdown.
- Bone loss resulting in mobility of the teeth may occur as a result of excessive forces acting on the supporting structures but it may not initiate pocket formation in the absence of inflammation.
- The control of inflammation is necessary for the healing of the periodontal tissues to occur.
- In the absence of inflammation, the response to trauma from occlusion is hypermobility of the teeth, which is reversible once the trauma is eliminated.
- In the presence of inflammation, the change in the shape of the alveolar crust may facilitate angular bone loss and the existing pockets may become intrabody.
- A treatment directed towards trauma alone (occlusal adjustment or splinting) will only reduce the mobility of the traumatized teeth, but will not arrest the rate of periodontal breakdown initiated by plaque.
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