OCCLUSAL CONSIDERATIONS IN OCCLUSAL CONSIDERATIONS IN PERIODONTICSPERIODONTICS

Presented By- Dr. Abhishek Gakhar (1st yr. MDS)

Department of PeriodontologyI.T.S Dental College , Hospital & Research Centre

13/9/12

Moderator- Dr Kanwarjit Singh AsiPerceptor- Dr. Rupali Kalsi

INTRODUCTIONINTRODUCTION

KarolyiKarolyi (1901) :(1901) :

Linked trauma from occlusion to periodontalLinked trauma from occlusion to periodontal disease.disease.

WeinmannWeinmann (1941)(1941) : :

No relationship between No relationship between occlusalocclusal forces and forces and periodontal destruction. Gingival inflammation periodontal destruction. Gingival inflammation extending into the supporting bone was the cause of extending into the supporting bone was the cause of periodontal destruction.periodontal destruction.

Glickman et al(1954):Glickman et al(1954):

No initiation of periodontal disease by occlusal No initiation of periodontal disease by occlusal trauma.trauma.

““Altered pathway of destruction”Altered pathway of destruction”

When excessive occlusal forces are present.When excessive occlusal forces are present.

Changed orientation of periodontal and Changed orientation of periodontal and gingival fibers in the presence of gingival fibers in the presence of excessive occlusal forces.excessive occlusal forces.

Allows gingival inflammation to extend Allows gingival inflammation to extend along the periodontal ligament.along the periodontal ligament.

Leads to vertical bony defects.Leads to vertical bony defects.

GlickmanGlickman::Since there were two separate Since there were two separate pathological processes working together pathological processes working together to cause bone loss, the process was to cause bone loss, the process was termed a “co-destructive” effect.termed a “co-destructive” effect.

Waerhaug:Waerhaug:

Bone loss was always associated with Bone loss was always associated with the downgrowth of plaque and there is the downgrowth of plaque and there is no relationship between excessive no relationship between excessive occlusal forces and vertical bone loss.occlusal forces and vertical bone loss.

OCCLUSAL TRAUMAOCCLUSAL TRAUMA

Injury to the periodontium resulting Injury to the periodontium resulting from occlusal forces which exceed the from occlusal forces which exceed the reparative capacity of the attachment reparative capacity of the attachment apparatusapparatus

CLASSIFICATIONCLASSIFICATION

HISTORICALLYHISTORICALLY

PRIMARYPRIMARY SECONDARYSECONDARYOCCLUSAL TRAUMAOCCLUSAL TRAUMA

PRIMARY OCCLUSAL TRAUMAPRIMARY OCCLUSAL TRAUMA

Results from excessive occlusal force Results from excessive occlusal force applied to a tooth or to teeth with normal applied to a tooth or to teeth with normal and healthy supporting tissues.and healthy supporting tissues.

SECONDARY OCCLUSALSECONDARY OCCLUSAL TRAUMATRAUMA

Refers to changes which occur when Refers to changes which occur when normal / abnormal occlusal forces are normal / abnormal occlusal forces are applied to the attachment apparatus of a applied to the attachment apparatus of a tooth / teeth with inadequate / reduced tooth / teeth with inadequate / reduced supporting tissuesupporting tissue

SECONDARY SECONDARY

PRIMARYPRIMARY

ANOTHER CLASSIFICATIONANOTHER CLASSIFICATION

TRAUMA FROM OCCLUSIONTRAUMA FROM OCCLUSION

ACUTEACUTE CHRONICCHRONIC

ACUTE TRAUMA FROM OCCLUSIONACUTE TRAUMA FROM OCCLUSIONOccurs following an abrupt increase in Occurs following an abrupt increase in occlusal load. E.g. as a result of biting occlusal load. E.g. as a result of biting unexpectedly on a hard object.unexpectedly on a hard object.

CHRONIC TRAUMA FROM OCCLUSIONCHRONIC TRAUMA FROM OCCLUSIONMore common. In this paper, occlusal More common. In this paper, occlusal trauma will mean chronic occlusal traumatrauma will mean chronic occlusal trauma..

Does occlusal trauma have a role in the Does occlusal trauma have a role in the etiology of periodontal disease?etiology of periodontal disease?

Do occlusal forces influence the onset of Do occlusal forces influence the onset of plaque induced inflammation?plaque induced inflammation?

Do occlusal forces enhance the rate of Do occlusal forces enhance the rate of periodontal destruction?periodontal destruction?

Human cadaver investigationsHuman cadaver investigations

Animal studiesAnimal studies

Human clinical studiesHuman clinical studies

THREE CATEGORIES OF RESEARCH WERE THREE CATEGORIES OF RESEARCH WERE CARRIED OUTCARRIED OUT

HUMAN CADAVER STUDIESHUMAN CADAVER STUDIES

1960S and 1970s1960S and 1970s

Results inconclusiveResults inconclusive

ANIMAL STUDIESANIMAL STUDIES

Periodontal attachment level is one of 3 Periodontal attachment level is one of 3 types:types: A normal healthy periodontium.A normal healthy periodontium. Healthy periodontal support but a reduced Healthy periodontal support but a reduced

bone height.bone height. An active plaque induced periodontitis.An active plaque induced periodontitis.

TYPE OF FORCES THAT CAN BE APPLIED TYPE OF FORCES THAT CAN BE APPLIED TO THE ANIMAL TOOTHTO THE ANIMAL TOOTH

Jiggling forceJiggling force : :

produced by multidirectional displacement of a produced by multidirectional displacement of a tooth in alternating bucco-lingual / mesio-distal tooth in alternating bucco-lingual / mesio-distal direction by use of supra-occluding onlays.direction by use of supra-occluding onlays.

Orthodontic forceOrthodontic force::

created by the spring. It is a unilateral force that created by the spring. It is a unilateral force that results in deflection of the tooth away from the results in deflection of the tooth away from the force.force.

SUMMARY OF THE RESULTS SUMMARY OF THE RESULTS OF ANIMAL STUDIESOF ANIMAL STUDIES

HEALTHY PERIODONTIUM NORMAL HEALTHY PERIODONTIUM NORMAL BONE HEIGHTBONE HEIGHT

ORTHODONTIC FORCEORTHODONTIC FORCE JIGGLING FORCEJIGGLING FORCEIncreased mobility.Increased mobility.Tooth movement.Tooth movement.No change in position ofNo change in position of

JE or connective tissueJE or connective tissue

attachmentattachment

Increased PDL space.Increased PDL space.Some loss in crestal bone Some loss in crestal bone

height & bone volume.height & bone volume.No loss of attachment.No loss of attachment.Increased tooth mobilityIncreased tooth mobility

reversible on removal ofreversible on removal of

the forcethe force

HEALTHY PERIODONTIUM REDUCED BONE HEALTHY PERIODONTIUM REDUCED BONE HEIGHTHEIGHT

ORTHODONTIC FORCEORTHODONTIC FORCE JIGGLING FORCEJIGGLING FORCE

Increased mobility.Increased mobility.Tooth movement.Tooth movement.No gingival inflammation.No gingival inflammation.No further loss ofNo further loss of

connectiveconnective

tissue attachmenttissue attachment

Increased periodontalIncreased periodontal

ligament space.ligament space.Some loss of crestal boneSome loss of crestal bone

height & bone volume.height & bone volume.No gingival inflammation.No gingival inflammation.No further loss ofNo further loss of

attachmentattachment

PLAQUEPLAQUE--INDUCED PERIODONTITISINDUCED PERIODONTITIS

ORTHODONTIC ORTHODONTIC FORCEFORCE

JIGGLING FORCEJIGGLING FORCE

No progression of No progression of

periodontal diseaseperiodontal disease

Gradual widening of Gradual widening of the the

periodontal ligament periodontal ligament

space.space.Progressive mobility.Progressive mobility.Angular bone loss.Angular bone loss.

HUMAN CLINICAL STUDIESHUMAN CLINICAL STUDIES

Lack of reliable index for measuring the Lack of reliable index for measuring the degree of occlusal trauma to which a degree of occlusal trauma to which a tooth is subjected.tooth is subjected.

There is no such thing as an intrinsically There is no such thing as an intrinsically bad occlusionbad occlusion

The effect is a product of quality of the The effect is a product of quality of the contact and the frequency at which the contact and the frequency at which the contact is made.contact is made.

CLINICAL DIAGNOSIS OF CLINICAL DIAGNOSIS OF TRAUMA FROM OCCLUSIONTRAUMA FROM OCCLUSION

Increasing tooth mobility, migration or Increasing tooth mobility, migration or drifting.drifting.

Wear facetsWear facets FremitusFremitus Persistent discomfort on eatingPersistent discomfort on eating Fractured tooth/teeth.Fractured tooth/teeth. Thermal sensitivity.Thermal sensitivity.

CLINICAL SIGNS:CLINICAL SIGNS:

Discontinuity and thickening of lamina Discontinuity and thickening of lamina dura.dura.

Widening of periodontal ligament space Widening of periodontal ligament space (funneling/saucerisation)(funneling/saucerisation)

Radiolucency and condensation of Radiolucency and condensation of alveolar bone or root resorption.alveolar bone or root resorption.

RADIOGRAPHIC SIGNS:RADIOGRAPHIC SIGNS:

TREATMENTTREATMENT

OCCLUSAL EQUILIBRATIONOCCLUSAL EQUILIBRATION

It is the modification of the occlusal It is the modification of the occlusal contacts of teeth to produce a more ideal contacts of teeth to produce a more ideal occlusionocclusion

IS THERE A NEED FOR IS THERE A NEED FOR OCCLUSAL EQUILIBRATION IN OCCLUSAL EQUILIBRATION IN

THE PERIODONTALLY THE PERIODONTALLY COMPROMISED DENTITION?COMPROMISED DENTITION?

There is no evidence at present, that There is no evidence at present, that trauma from occlusion is an etiological trauma from occlusion is an etiological factor in human periodontal disease.factor in human periodontal disease.

Treatment aimed at reducing occlusal Treatment aimed at reducing occlusal forces must be done to benefit the forces must be done to benefit the patients dental attachment apparatus, patients dental attachment apparatus, particularly those with, or at future risk particularly those with, or at future risk of periodontitis.of periodontitis.

occlusal adjustment to reduce tooth occlusal adjustment to reduce tooth mobility before conventional mobility before conventional periodontal treatment leads to probing periodontal treatment leads to probing attachment gain after therapy.attachment gain after therapy.

Burgett et al:Burgett et al:

is that, if occlusal is that, if occlusal adjustment is needed, it should be adjustment is needed, it should be carried out after treatment.carried out after treatment.

CurrentCurrent viewview

When there are occlusal contact When there are occlusal contact relationships that cause trauma to the relationships that cause trauma to the periodontium, joints, muscles or soft periodontium, joints, muscles or soft tissue.tissue.

When there are interferences that When there are interferences that aggravate parafunction.aggravate parafunction.

As an aid to splint therapy.As an aid to splint therapy.

World workshop in periodontics’ World workshop in periodontics’ guidelines for guidelines for situations when occlusal equilibration may be situations when occlusal equilibration may be indicated:indicated:

Successful stabilization-splint therapy.Successful stabilization-splint therapy.

Study models mounted to centric Study models mounted to centric relation on a semi-adjustable articulator.relation on a semi-adjustable articulator.

Mock equilibration on duplicated study Mock equilibration on duplicated study models.models.

All these stages may be necessary before All these stages may be necessary before equilibration of the patient’s teeth can be equilibration of the patient’s teeth can be completed:completed:

SPLINTINGSPLINTING

To stabilize teeth with increasing mobility To stabilize teeth with increasing mobility that have not responded to occlusal that have not responded to occlusal adjustment and periodontal treatment.adjustment and periodontal treatment.

To prevent tipping or drifting and the over-To prevent tipping or drifting and the over-eruption of unopposed teeth.eruption of unopposed teeth.

To stabilize teeth after orthodontic To stabilize teeth after orthodontic treatment.treatment.

To stabilize teeth following acute trauma.To stabilize teeth following acute trauma.

‘‘World workshop in periodontics’ World workshop in periodontics’ indications:indications:

Where tooth mobility is progressive Where tooth mobility is progressive with increased periodontal ligament with increased periodontal ligament width and reduced bone height.width and reduced bone height.

As an adjunct to periodontal therapy for As an adjunct to periodontal therapy for patients comfort.patients comfort.

Splinting may be beneficial in 2 situations:Splinting may be beneficial in 2 situations:

TRAUMA FROM OCCLUSION:TRAUMA FROM OCCLUSION:MONITORING EXAMINATION SHEETMONITORING EXAMINATION SHEET

Patient: Date:Patient: Date:

First examined:First examined:

Periodontal status:Periodontal status:

Mobility:Mobility:

Tooth drifting:Tooth drifting:

Fremitus:Fremitus:

Persistent discomfort upon eating:Persistent discomfort upon eating:

Discontinuity in lamina dura:Discontinuity in lamina dura: Thickening of lamina dura:Thickening of lamina dura: Widening or funneling of periodontalWidening or funneling of periodontal

ligament:ligament: Radiolucency of Alveolar bone:Radiolucency of Alveolar bone: Condensation of alveolar bone:Condensation of alveolar bone: Root resorption:Root resorption:

RADIOGRAPHIC CHANGESRADIOGRAPHIC CHANGES

HOW TO DECIDE WHAT MODE HOW TO DECIDE WHAT MODE OF TREATMENT IS REQUIRED?OF TREATMENT IS REQUIRED?

CLINICAL FEATURES:CLINICAL FEATURES:

Increased mobility.Increased mobility.

RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:

width of PDL with width of PDL with bone bone height.height.

TREATMENT REQUIRED:TREATMENT REQUIRED:

Periodontal therapy and occlusal equilibration.Periodontal therapy and occlusal equilibration.

TREATMENT OUTCOME:TREATMENT OUTCOME:

Normalizes PDL width.Normalizes PDL width.

normalnormalIncreasedIncreased

CLINICAL FEATURES:CLINICAL FEATURES:

Increased mobility.Increased mobility.

RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:

width of PDL with width of PDL with bone bone height.height.

TREATMENT REQUIRED:TREATMENT REQUIRED:

Periodontal therapy and occlusal equilibration.Periodontal therapy and occlusal equilibration.

TREATMENT OUTCOME:TREATMENT OUTCOME:

Bone fill of angular defect, bone level Bone fill of angular defect, bone level stabilized, normal PDL width.stabilized, normal PDL width.

reducedreducedIncreasedIncreased

CLINICAL FEATURES:CLINICAL FEATURES:

Increased mobility, patient NOT functioning Increased mobility, patient NOT functioning comfortably.comfortably.

RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:

width of PDL with width of PDL with bone height. bone height.

TREATMENT REQUIRED:TREATMENT REQUIRED:

Periodontal therapy, occlusal equilibration Periodontal therapy, occlusal equilibration ± splinting.± splinting.

TREATMENT OUTCOME:TREATMENT OUTCOME:

Patient’s comfort and function may improve.Patient’s comfort and function may improve.

NormalNormal reducedreduced

CLINICAL FEATURES:CLINICAL FEATURES:

Increased mobility, patient functioning Increased mobility, patient functioning comfortably.comfortably.

RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:

width of PDL, width of PDL, bone height.bone height.

TREATMENT REQUIRED:TREATMENT REQUIRED:

Periodontal therapy alone. No occlusal Periodontal therapy alone. No occlusal adjustment required.adjustment required.

TREATMENT OUTCOME:TREATMENT OUTCOME:

No further deterioration.No further deterioration.

NormalNormal reducedreduced

SUMMARYSUMMARY

No scientific evidence to show that No scientific evidence to show that trauma from occlusion causes gingivitis trauma from occlusion causes gingivitis or periodontitis or accelerates the or periodontitis or accelerates the progression of gingivitis to periodontitis.progression of gingivitis to periodontitis.

PDL physiologically adapts to increased PDL physiologically adapts to increased occlusal loading by resorption of the occlusal loading by resorption of the alveolar crestal bone, resulting in alveolar crestal bone, resulting in increased tooth mobility.increased tooth mobility.

This is This is occlusal traumaocclusal trauma and is reversible and is reversible if the occlusal force is removed.if the occlusal force is removed.

Occlusal trauma may be a co-factor Occlusal trauma may be a co-factor which can increase the rate of which can increase the rate of progression of an existing periodontal progression of an existing periodontal disease.disease.

There is a place for occlusal therapy in There is a place for occlusal therapy in the management of periodontitis, the management of periodontitis, especially when related to the patient’s especially when related to the patient’s comfort and function.comfort and function.

Occlusal therapy is not a substitute for Occlusal therapy is not a substitute for conventional methods of resolving conventional methods of resolving plaque-induced inflammation.plaque-induced inflammation.

THANKS TO ONE AND

ALL