Occlusion and Periodontal Disease

This series of slides is based on Lindhe et al.s textbook Clinical Periodontology and Implant Dentistry, chapter 8.

Definition
Trauma from Occlusion:
Pathologic or adaptive changes which develop in the periodontium as a result of undue force produced by the masticatory muscles. Stillman (1917): A condition where injury results to the supporting structures of the teeth by the act of bringing the jaws into a closed position WHO (1978): Damage in the periodontium caused by stress on the teeth produced by the teeth of the opposing jaw. AAP (1986): An injury to the attachment apparatus as a result of excessive occlusal force.

Definition
Trauma from Occlusion
Primary TfO:
A tissue reaction, which is elicited around a tooth with normal height of the periodontium (no attachment loss!)

Secondary TfO:
Related to situations in which occlusal forces cause damage in a periodontium of reduced height (attachment loss present)

TfO and Plaque-Associated Periodontal Disease

Karolyis (1901) Hypothesis
An interaction exists between TfO and alveolar pyorrhea.

Stones (1938)
TfO is an etiologic factor in the production of that variety of periodontal disease in which there is vertical pocket formation associated with one or a varying number of teeth

Glickmans Concept
Pathway of spread of a plaque-associated gingival lesion can be changed if abnormally strong forces are acting on teeth with subgingival plaque Zone of irritation includes marginal and interproximal gingiva. Not affected by occlusal forces. Lesion propagates apically first by involving the bone then the periodontal ligament.

Glickmans Concept
Zone of co-destruction includes the ligament, cementum, bone, and the transseptal and dentoalveolar fibers Fibers can be affected from the lesion in the zone of irritation, or from trauma-induced changes in the zone of codestruction

Glickmans Concept
In teeth not affected by TfO, inflammatory lesion can spread into alveolar bone In teeth affected by TFO, inflammatory lesion spreads into periodontal ligament. This will create an angular bony lesion combined with an infrabony pocket.

Glickmans Concept

Angular bony defect and infrabony pocket distal of premolar

Waerhaugs Concept

Apical cells of the JE and the subgingival plaque are at different levels. Crest of marginal bone is slanting. It follows the location of the JE and plaque.

Waerhaugs Concept
Waerhaug measured distance between the subgingival plaque and
The perimeter of the associated inflammatory infiltrate The surface of the adjacent alveolar bone

He concluded that angular defects and infrabony pockets occurred equally frequently in teeth with TfO and in teeth without TfO Waerhaug postulated that loss of attachment and bone are the result of inflammation induced by subgingival plaque

Orthodontic Movements

T: tension zone

P: pressure zone

Recession or AL can occur at sites of gingivitis when tooth is moved through the envelope of the alveolar process.

Jiggling Forces 1: P-TfO

Combined pressure and tension zones result from jiggling Zones are characterized by collagen resorption, bone resorption, and cementum resorption. Signs of increased vascularity or exudation. Tooth shows progressive mobility.

Jiggling Forces 2 : P-TfO

Ligament space gradually adjusts to new situation. No attachment loss! Increased tooth mobility

Jiggling Forces 3 : P-TfO

Occlusal adjustment normalizes the width of the periodontal ligament. Teeth are stabilized and regain normal mobility.

Reduced Height, Healthy 1 : STfO

Zones of combined pressure and tension exhibit
vascular proliferation, exudation, thrombosis, and bone resorption

A widened periodontal ligament develops Tooth mobility is increasing progressively

Reduced Height, Healthy 2 : STfO

Ligament space gradually adjusts to new situation. No attachment loss! Increased tooth mobility Ligament tissue regains normal composition

Reduced Height, Healthy 3 : STfO

Supra-alveolar tissue unaffected No further loss of attachment Teeth hyper mobile, surrounded by tissue that adapted to the new functional situation Occlusal adjustment will allow the periodontal ligament to regain its normal width.

Reduced and Diseased 1 : S-TfO

Can abnormal occlusal forces influence the spread of the plaque-associated periodontal lesion and/or enhance tissue breakdown? In the case presented here, there is a healthy zone between inflamed CT and PL

Reduced and Diseased 2 : S-TfO

Pathologic and adaptive reactions occur in the PL A widened periodontal ligament and increased tooth mobility will result No further loss of attachment is observed

Reduced and Diseased 3 : S-TfO

Occlusal adjustment will result in reduction of periodontal ligament width and Reduced (not normal!) tooth mobility

Reduced and Diseased 4: S-TfO

Presence of infrabony pocket and infiltrated connective tissue Merging of zones of irritation and codestruction

Reduced and Diseased 5: S-TfO

Jiggling forces lead to typical vascular and exudative reaction in ligament space Pathologic reaction may occur within a zone that also contains (plaque-induced) inflammatory cell infiltrate

Reduced and Diseased 6: S-TfO

In this situation, increasing tooth mobility may also be associated with an enhanced loss of attachment and further down growth of the most apical portion of the PE

Reduced and Diseased 7: S-TfO

Occlusal adjustment will result in narrowing of the ligament space, less tooth mobility Regeneration of attachment cannot be expected Loss of attachment is permanent If plaque-induced inflammation persists, more attachment loss may occur

Conclusions
In a healthy periodontium, neither unilateral nor jiggling forces can result in attachment loss or pocket formation TfO alone cannot induce periodontal tissue breakdown Bone resorption in TfO should be interpreted as an adaptation of the ligament and bone to the altered functional requirements In plaque-induced inflammation, TfO may enhance the disease progression