Occlusion and Periodontal Disease

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

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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.

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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)

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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

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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.

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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 co-destruction

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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.

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Glickmans Concept
Angular bony defect and infrabony pocket distal
of premolar
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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.
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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

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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.
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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.

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Jiggling Forces 2 P-TfO

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

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Jiggling Forces 3 P-TfO

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

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Reduced Height, Healthy 1 S-TfO

• Zones of combined pressure and tension exhibit
• vascular proliferation,
• exudation,
• thrombosis, and
• bone resorption
• A widened periodontal ligament develops
• Tooth mobility is increasing progressively

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Reduced Height, Healthy 2 S-TfO

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

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Reduced Height, Healthy 3 S-TfO

• 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.

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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

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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

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Reduced and Diseased 3 S-TfO

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

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Reduced and Diseased 4S-TfO

• Presence of infrabony pocket and infiltrated
  connective tissue
• Merging of zones of irritation and
  co-destruction

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Reduced and Diseased 5S-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

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Reduced and Diseased 6S-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

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Reduced and Diseased 7S-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

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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