1) There is debate around the role of occlusion in periodontal disease, with some studies finding a relationship between excessive occlusal forces and periodontal destruction, while others finding no such relationship.
2) Animal studies show that occlusal forces can lead to increased tooth mobility and minor bone loss in healthy periodontium, but do not enhance progression of plaque-induced periodontitis.
3) Occlusal adjustment may be indicated when occlusal forces cause trauma, aggravate parafunction, or to aid splint therapy, but its role in periodontal treatment is unclear.
1. OCCLUSAL CONSIDERATIONS INOCCLUSAL CONSIDERATIONS IN
PERIODONTICSPERIODONTICS
Presented By- Dr. Abhishek Gakhar (1st
yr. MDS)
Department of Periodontology
I.T.S Dental College , Hospital & Research Centre
13/9/12
Moderator- Dr Kanwarjit Singh Asi
Perceptor- Dr. Rupali Kalsi
3. KarolyiKarolyi (1901) :(1901) :
Linked trauma from occlusion to periodontalLinked trauma from occlusion to periodontal disease.disease.
WeinmannWeinmann (1941)(1941) ::
No relationship betweenNo relationship between occlusalocclusal forces andforces and
periodontal destruction. Gingival inflammationperiodontal destruction. Gingival inflammation
extending into the supporting bone was the cause ofextending into the supporting bone was the cause of
periodontal destruction.periodontal destruction.
4. Glickman et al(1954):Glickman et al(1954):
No initiation of periodontal disease by occlusalNo 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.
5. Changed orientation of periodontal andChanged orientation of periodontal and
gingival fibers in the presence ofgingival fibers in the presence of
excessive occlusal forces.excessive occlusal forces.
Allows gingival inflammation to extendAllows gingival inflammation to extend
along the periodontal ligament.along the periodontal ligament.
Leads to vertical bony defects.Leads to vertical bony defects.
6. GlickmanGlickman::
Since there were two separateSince there were two separate
pathological processes working togetherpathological processes working together
to cause bone loss, the process wasto cause bone loss, the process was
termed a “co-destructive” effect.termed a “co-destructive” effect.
Waerhaug:Waerhaug:
Bone loss was always associated withBone loss was always associated with
the downgrowth of plaque and there isthe downgrowth of plaque and there is
no relationship between excessiveno relationship between excessive
occlusal forces and vertical bone loss.occlusal forces and vertical bone loss.
7. OCCLUSAL TRAUMAOCCLUSAL TRAUMA
Injury to the periodontium resultingInjury to the periodontium resulting
from occlusal forces which exceed thefrom occlusal forces which exceed the
reparative capacity of the attachmentreparative capacity of the attachment
apparatusapparatus
9. PRIMARY OCCLUSAL TRAUMAPRIMARY OCCLUSAL TRAUMA
Results from excessive occlusal forceResults from excessive occlusal force
applied to a tooth or to teeth with normalapplied 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 whenRefers to changes which occur when
normal / abnormal occlusal forces arenormal / abnormal occlusal forces are
applied to the attachment apparatus of aapplied to the attachment apparatus of a
tooth / teeth with inadequate / reducedtooth / teeth with inadequate / reduced
supporting tissuesupporting tissue
12. ACUTE TRAUMA FROM OCCLUSIONACUTE TRAUMA FROM OCCLUSION
Occurs following an abrupt increase inOccurs following an abrupt increase in
occlusal load. E.g. as a result of bitingocclusal load. E.g. as a result of biting
unexpectedly on a hard object.unexpectedly on a hard object.
CHRONIC TRAUMA FROM OCCLUSIONCHRONIC TRAUMA FROM OCCLUSION
More common. In this paper, occlusalMore common. In this paper, occlusal
trauma will mean chronic occlusal traumatrauma will mean chronic occlusal trauma..
13. Does occlusal trauma have a role in theDoes occlusal trauma have a role in the
etiology of periodontal disease?etiology of periodontal disease?
Do occlusal forces influence the onset ofDo occlusal forces influence the onset of
plaque induced inflammation?plaque induced inflammation?
Do occlusal forces enhance the rate ofDo occlusal forces enhance the rate of
periodontal destruction?periodontal destruction?
14. Human cadaver investigationsHuman cadaver investigations
Animal studiesAnimal studies
Human clinical studiesHuman clinical studies
THREE CATEGORIES OF RESEARCH WERETHREE CATEGORIES OF RESEARCH WERE
CARRIED OUTCARRIED OUT
15. HUMAN CADAVER STUDIESHUMAN CADAVER STUDIES
1960S and 1970s1960S and 1970s
Results inconclusiveResults inconclusive
16. ANIMAL STUDIESANIMAL STUDIES
Periodontal attachment level is one of 3Periodontal attachment level is one of 3
types:types:
A normal healthy periodontium.A normal healthy periodontium.
Healthy periodontal support but a reducedHealthy periodontal support but a reduced
bone height.bone height.
An active plaque induced periodontitis.An active plaque induced periodontitis.
17. TYPE OF FORCES THAT CAN BE APPLIEDTYPE OF FORCES THAT CAN BE APPLIED
TO THE ANIMAL TOOTHTO THE ANIMAL TOOTH
Jiggling forceJiggling force ::
produced by multidirectional displacement of aproduced by multidirectional displacement of a
tooth in alternating bucco-lingual / mesio-distaltooth 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 thatcreated by the spring. It is a unilateral force that
results in deflection of the tooth away from theresults in deflection of the tooth away from the
force.force.
18. SUMMARY OF THE RESULTSSUMMARY OF THE RESULTS
OF ANIMAL STUDIESOF ANIMAL STUDIES
19. HEALTHY PERIODONTIUM NORMALHEALTHY PERIODONTIUM NORMAL
BONE HEIGHTBONE HEIGHT
ORTHODONTIC FORCEORTHODONTIC FORCE JIGGLING FORCEJIGGLING FORCE
Increased 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 boneSome 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
20. HEALTHY PERIODONTIUM REDUCED BONEHEALTHY 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
22. HUMAN CLINICAL STUDIESHUMAN CLINICAL STUDIES
Lack of reliable index for measuring theLack of reliable index for measuring the
degree of occlusal trauma to which adegree of occlusal trauma to which a
tooth is subjected.tooth is subjected.
There is no such thing as an intrinsicallyThere is no such thing as an intrinsically
bad occlusionbad occlusion
The effect is a product of quality of theThe effect is a product of quality of the
contact and the frequency at which thecontact and the frequency at which the
contact is made.contact is made.
28. Discontinuity and thickening of laminaDiscontinuity and thickening of lamina
dura.dura.
Widening of periodontal ligament spaceWidening of periodontal ligament space
(funneling/saucerisation)(funneling/saucerisation)
Radiolucency and condensation ofRadiolucency and condensation of
alveolar bone or root resorption.alveolar bone or root resorption.
RADIOGRAPHIC SIGNS:RADIOGRAPHIC SIGNS:
31. OCCLUSAL EQUILIBRATIONOCCLUSAL EQUILIBRATION
It is the modification of the occlusalIt is the modification of the occlusal
contacts of teeth to produce a more idealcontacts of teeth to produce a more ideal
occlusionocclusion
32. IS THERE A NEED FORIS THERE A NEED FOR
OCCLUSAL EQUILIBRATION INOCCLUSAL EQUILIBRATION IN
THE PERIODONTALLYTHE PERIODONTALLY
COMPROMISED DENTITION?COMPROMISED DENTITION?
33. There is no evidence at present, thatThere is no evidence at present, that
trauma from occlusion is an etiologicaltrauma from occlusion is an etiological
factor in human periodontal disease.factor in human periodontal disease.
Treatment aimed at reducing occlusalTreatment aimed at reducing occlusal
forces must be done to benefit theforces must be done to benefit the
patients dental attachment apparatus,patients dental attachment apparatus,
particularly those with, or at future riskparticularly those with, or at future risk
of periodontitis.of periodontitis.
34. occlusal adjustment to reduce toothocclusal adjustment to reduce tooth
mobility before conventionalmobility before conventional
periodontal treatment leads to probingperiodontal treatment leads to probing
attachment gain after therapy.attachment gain after therapy.
Burgett et al:Burgett et al:
is that, if occlusalis that, if occlusal
adjustment is needed, it should beadjustment is needed, it should be
carried out after treatment.carried out after treatment.
CurrentCurrent viewview
35. When there are occlusal contactWhen there are occlusal contact
relationships that cause trauma to therelationships that cause trauma to the
periodontium, joints, muscles or softperiodontium, joints, muscles or soft
tissue.tissue.
When there are interferences thatWhen 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 forguidelines for
situations when occlusal equilibration may besituations when occlusal equilibration may be
indicated:indicated:
36. Successful stabilization-splint therapy.Successful stabilization-splint therapy.
Study models mounted to centricStudy models mounted to centric
relation on a semi-adjustable articulator.relation on a semi-adjustable articulator.
Mock equilibration on duplicated studyMock equilibration on duplicated study
models.models.
All these stages may be necessary beforeAll these stages may be necessary before
equilibration of the patient’s teeth can beequilibration of the patient’s teeth can be
completed:completed:
39. To stabilize teeth with increasing mobilityTo stabilize teeth with increasing mobility
that have not responded to occlusalthat 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 orthodonticTo 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:
40. Where tooth mobility is progressiveWhere tooth mobility is progressive
with increased periodontal ligamentwith increased periodontal ligament
width and reduced bone height.width and reduced bone height.
As an adjunct to periodontal therapy forAs an adjunct to periodontal therapy for
patients comfort.patients comfort.
Splinting may be beneficial in 2 situations:Splinting may be beneficial in 2 situations:
41. 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:
42. 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
43. HOW TO DECIDE WHAT MODEHOW TO DECIDE WHAT MODE
OF TREATMENT IS REQUIRED?OF TREATMENT IS REQUIRED?
44. CLINICAL FEATURES:CLINICAL FEATURES:
Increased mobility.Increased mobility.
RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:
width of PDL withwidth of PDL with bonebone
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
45. CLINICAL FEATURES:CLINICAL FEATURES:
Increased mobility.Increased mobility.
RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:
width of PDL withwidth of PDL with bonebone
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 levelBone fill of angular defect, bone level
stabilized, normal PDL width.stabilized, normal PDL width.
reducedreducedIncreasedIncreased
46. CLINICAL FEATURES:CLINICAL FEATURES:
Increased mobility, patient NOT functioningIncreased mobility, patient NOT functioning
comfortably.comfortably.
RADIOGRAPHIC FEATURES:RADIOGRAPHIC FEATURES:
width of PDL withwidth of PDL with bone height.bone height.
TREATMENT REQUIRED:TREATMENT REQUIRED:
Periodontal therapy, occlusal equilibrationPeriodontal 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
47. CLINICAL FEATURES:CLINICAL FEATURES:
Increased mobility, patient functioningIncreased 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 occlusalPeriodontal therapy alone. No occlusal
adjustment required.adjustment required.
TREATMENT OUTCOME:TREATMENT OUTCOME:
No further deterioration.No further deterioration.
NormalNormal reducedreduced
49. No scientific evidence to show thatNo scientific evidence to show that
trauma from occlusion causes gingivitistrauma from occlusion causes gingivitis
or periodontitis or accelerates theor periodontitis or accelerates the
progression of gingivitis to periodontitis.progression of gingivitis to periodontitis.
PDL physiologically adapts to increasedPDL physiologically adapts to increased
occlusal loading by resorption of theocclusal loading by resorption of the
alveolar crestal bone, resulting inalveolar crestal bone, resulting in
increased tooth mobility.increased tooth mobility.
50. This isThis is occlusal traumaocclusal trauma and is reversibleand is reversible
if the occlusal force is removed.if the occlusal force is removed.
Occlusal trauma may be a co-factorOcclusal trauma may be a co-factor
which can increase the rate ofwhich can increase the rate of
progression of an existing periodontalprogression of an existing periodontal
disease.disease.
51. There is a place for occlusal therapy inThere is a place for occlusal therapy in
the management of periodontitis,the management of periodontitis,
especially when related to the patient’sespecially when related to the patient’s
comfort and function.comfort and function.
Occlusal therapy is not a substitute forOcclusal therapy is not a substitute for
conventional methods of resolvingconventional methods of resolving
plaque-induced inflammation.plaque-induced inflammation.