‫بسم الله الرحمن الرحيم‬

Occlusal trauma

We know that our teeth are at function

all the time and have attachment
apparatus which is anatomically and
histologically organized in a way to
adapt the forces ( otherwise you cant
work on them like if ankylosed or hard)
but sometimes those teeth with this
.criteria can get injury from occlusion

:In this lec. we want to know

The definition of occlusal trauma -1

? Who is susceptible to it -2
? How to diagnose it -3
What are the effects of it on -4
? periodontium

: Note

1
When we said occlusal trauma this is
the diagnosis , but the etiology is
.""traumatogenic occlusion

:Definition
Injury that is resulting in tissue
changes within the periodontal
attachment apparatus as a result of
occlusal forces (notice not excessive or
. (abnormal just occlusal forces

"‫ واعمل ما شئت فانك مجاز به‬... ‫ وأحبب من شئت فانك مفارقه‬... ‫"عش ما شئت فانك ميت‬

* Attachment apparatus
Consist of : periodontal ligament (the
most affected) +bone(secondly affected
after PDL)+ cementum (may be affected
.(but slowly) + gingiva( not affected

Fremitus
A palpable or visible movement when
.subjected to occlusal forces

Ask the patient to bite while you put your

finger on the tooth that may be have

2
fremitus, and you will feel it move so it's
.called fremitus

It's different from occlusal trauma **

because if tooth has fremitus this tooth
will be a big problem because every
time patient bite, the tooth will shift ,
and we have to do something (take it
out of bite or decrease the force )
because every single time it's moving
from its socket , and will end by coming
out so we must take it in our
.consideration

Fremitus "you feel it and/or see it , it "

happens usually in anterior teeth or
premolars , but in occlusal trauma you
.can't see it move

To differentiate between miller class **

3 (which is mobility index ) from
:fremitus
Fremitus : tooth does not move a lot ,
only when the patient bites you can see
. it and feel it move
‫ بأن همه لن يدوم‬.... ‫قل لمن يحمل هما‬

3
 ‫ هكذا تفنى الهموم‬.... ‫فكما تفنى السعادة‬
Class 3: tooth does not move even if the
patient bites , the only way to detect it is
by hard instrument

not each tooth with class 3 index **

should have fremitus , e.g : there is
tooth- with no opposing tooth- had
supraerupted and moved, when you do
mobility index to it, it will be class 3
index(even there is no opposing tooth)
because there is no attachment
.apparatus

: To detect occlusal trauma

Any patient for the first time has to
run an occlusal evaluation for him
:clinically and radiographiclly

(facets :(clinically -1
( Pic. slide 4 page 1 ( right pic
On the cusp itself or restoration (more
rapid wear) ,everything is very flat,
this is indicating that there is a force
which cause this wear , by the time

4
everyone will have facets so this is more
.applicable for young patients

mostly there are bone loss -2

(vertical) and furcation areas
(involvement (radigrapgically
(Pic. slide 4 page 1 (left pic
All periodontium is good except for the
tooth that has excessive forces , patient
will end with cracked tooth or root (when
it has RCT and leave it without crown so
pocket will have pus and root cracked,
so it's preferable to put crown on the
(tooth after RCT

‫ على كثر ما هي مرة فيها حلوة‬... ‫الحياة التي نعيشها كالقهوة التي نشربها‬

centric relation vs. centric -3

occlusion
.slide 5 page 1 (right pic) Pic
Not all patients have an ideal centric
relation or centric occlusion
but if there is no deviation ,no clicking
you consider it normal , otherwise if
you notice that there is excessive
force…etc ,you have to make sure that
.this patient has trauma from occlusion

5
excursive contacts -4

The common clinical signs of

occlusal trauma
increasing tooth mobility and -1
migration or drifting
fremitus -2
: persistent discomfort on eating -3
Patient says: whenever I chew on this
tooth, it cause pain for me , so we must
.think of excessive force on this tooth

The common radiographic signs of

: occlusal trauma

discontinuity and thickening of lamina -1

dura
widening of periodontal ligament -2
space
radiolucency and condensation of -3
alveolar bone or root
resorption

When there is a strong force the PDL

will spread as much as possible , the
6
bone protect itself by thickening and this
is till a specific stage after it there will be
bone loss (tooth will move from one side
to other, there will be resorption from
where it move and thickening to where it
.”move ),”as the dr said

‫الضمير صوت هاديء يخبرك بان احدا ينظر اليك‬

but in primary ( not chronic ) cases there
will be widening and thickening of
lamina dura (well defined around tooth)
but in worst cases will be bone
resorption and even root resorption will
. happen

(Pic. slide 2 page 2 (left Pic**

There is attrition on incisal edges and bone
loss all over , so this is from occlusal trauma
combined with periodontal disease ( this
. ( called secondary occlusal trauma
in the primary occlusal trauma the bone is)
the same everywhere, only one side will have
(changes,so it's not generalized as secondary
.

: Classification of occlusal trauma

7
primary occlusal trauma **
Injury resulting in tissue changes from
excessive occlusal forces(EOF) applied
to a tooth or teeth with normal support
:There will be
normal bone levels-1
normal attachment levels-2
excessive occlusal force-3

So everything is perfect(normal bone

levels, normal attachment levels) except
excessive forces(could be iatrogenic
.(:high restoration ,or abnormal occlusion

So periodontal ligament tissues can**

respond with traumatic occlusion
changes when a normal periodontium is
affected by increased occlusal loading
due to bruxicing clenching(which is a
habit , not a must to end with signs of
occlusal trauma , may only muscles affected)
or high restoration

secondary occlusal trauma **

8
Injury resulting in tissue changes from
normal or EOF applied to tooth or teeth
with reduced support
:There will be
bone loss-1
attachment loss-2
normal/EOF-3

Not every perio patient must have**

occlusal trauma but they are susceptible
.if there is signs

But if the patient lost his teeth or has

collapsed occlusion , this patient will
never have a good forces on his teeth , it
will hurt him –due to the bite collapse-
because there is no posterior stops, so
the anterior teeth will take excessive
forces so they will procline , move and
.lose bone quickly

But if he had mild chronic periodontitis

this doesn’t mean he is really
susceptible unless you see widenenig
. and other clinical signs

9
Clinical and radiographic signs for**
primary and secondary are very much
the same except that in primary
(periodontium is normal ) but in
secondary (dentition is not healthy and
there is attachment apparatus loss so
the normal forces will act as traumatic
. (forces
:Other classification
: Acute **
from occlusion occurs following an
abrupt increase in occlusal load e.g. As a
result of biting unexpectedly on a hard
. object

: Chronic **
from occlusion is more common and
has greater clinical significance(takes
time to happen ,it represents most of
. (secondary occlusal trauma

In exam classification mean primary and

:secondary note

10
Role of occlusion in the
pathogenesis of periodontal disease
Many animal studies rats , monkeys
and dogs evaluated the effect of occlusal
. forces on periodontium

Periodontal disease is initiated by

plaque which start at sulcus (gingiva
--->supracrestal fibers --->. bone ) this is
.the usual pathway

but Occlusal trauma starts in bone

and periodontal ligament , and if the
sulcus stays intact (no pocket) it can't
.cause gingival inflammation

So the plaque is in Zone of irritation

(coronal part)… but occlusal trauma is in
Traumatic zone (co-destructive zone:
mean both together : forces and
…(periodontal disease

‫ لنجح الجميع باستنشاق رحيقها‬... ‫لو كانت الحياة وردة‬

:Pic. in slide 2 page 4**
Zone of co-destruction occurs when plaque
induced periodontitis, and occurs in a tooth
that also has traumatic occlusion resulting in

11
more severe bone loss than that seen with
. periodontitis alone

If zone of irritation goes to co-destruction

zone there will be more bone loss( if go
. (downward--->more destruction

Occlusal trauma is bad because most

people have initial periodontal disease
so if they have excessive force … very
quickly they can have advanced
periodontal disease but never ever
start periodontal disease just by
occlusal trauma it's only enhance
.(accelerate)the changes

So the results of the studies do not

support the concept that occlusal
trauma was a causative agent of
.periodontal destruction

In usual pathway: Infection of pocket**

goes to blood vessels and destructs the
.normal periodontium

12
In trauma it looks for other spaces so
the periodontal ligament spaces open
.and the pathway completely changes

The pathway of inflammation will not

be as simple as when there is no trauma
and there will be vertical bone
loss( study using rhesus monkeys
demonstrated a phenomenon described
as "altered pathway of destruction"
when EOF present, which means there
is change in orientation of periodontal
and gingival fibers which occurred in
presence of EOF allowing gingival
inflammation to extend along the PDL
. (and lead to vertical bone loss

Different schools of study

* Scandinavian studies
Done by Gothenberg on begagles
dogs , excessive jiggling cap bar –
(splint(very high force

American studies *

13
Done by Roxchester on squirrel
monkey , light force(really slow force),
orthodontic lightures

Variable Rochester Gotenberg

Model monkey Dog
periodontit Mild- severe
is tomoderate
defect Supracrestal infrabony
Force Mesio-distal capsplaint
Force Moderate severe
magnitude
time week 10 One year
So Gotenberg said that occlusal trauma
is bad and cause more diceases

Conclusion
in the absence of inflammation , TFO -1
will not cause a loss of
: connective tissue attachment
Occlusal trauma could cause mobility
but not attachment loss which is the
gold standard to measure the
. periodontal disease
‫ وهي قمة أحزانه‬.. ‫ تريح جفن باكيها‬.. ‫غريبة قصة الدمعه‬

in a healthy periodontium , TFO will -2

result in mobility , widened

14
PDL and loss of the crestal bone
.hard tissue and volume

with inflammation , TFO will -3

accelerate bone and connective
tissue loss in the dog but not the
. monkey

bone regeneration and healing will -4

occur in the presence of
tooth hypermobility if inflammation
: is controlled
i.e : Mobility is a bad thing so we
condemn tooth extraction if we notice
, the mobility
E.g. Progressive mobility :If you
notice miller class 2 and after 4 months
it is become class 3 so we must extract
the tooth
E.g. In anterior teeth which have a
single and short root and if we have
bone loss and mobility index class 2 we
.will not extract

15
Mobility ber see is not much really**
big factor in decrease the chances of
this tooth to do surgery , Although
regeneration studies were hate mobility
in teeth, and said they cant put a
membrane or do grafting when there is
excessive forces because one of the
success factors is "no mobility" , but this
does not mean if you have inflammation
. you can not do it

Many clinicians believe that traumatic

occlusion causes intrabony periodontal
defects but this is not so , this defect is
caused by dental plaque with
accentuation due to the open contact (…
sorry the pic cover some of the sentence and Dr.
( not read it all

‫ حتى الحديُد سطا عليه المبَرُد‬... ‫ولكل شئ آفُة من جنسه‬

‫ و من ادعى غير حاله كالمفتخر بغير ماله‬... ‫من وعظك بغير حاله كمن أعطاك من غير ماله‬
** Pic. slide 1 page 4
This bone loss is from this high amalgam
restoration but not from it alone , there is
cratering bone defect not only from occlusal
forces ( it should come with periodontal
.( disease

In summary

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irritating factors are plaque that
induces gingivitis which progresses to
periodontitis , traumatizing factors from
occlusion cause tissue changes in
. periodontal ligament space

It's just a tissue changing

(histologically and on x-ray) but does not
appear on tooth itself (except if there is
only mobility and facets it's only clinical
. pictures) and there is no CAL

.slide 4 page 4 **Pic

Histology of intrabony defect due to
plaque induced periodontitis ( arrow
shows subgingival plaque on root surface
which will result in inflammation and
increased vascularity and proliferation of
. (…cells

Host- parasite reaction between **

bacterial plaque and host inflammatory
response is the cause of pocket depth
and attachment loss, the presence of
traumatic occlusion can accentuate the
damage when periodontitis proceeds

17
apically into the periodontal ligament
.space

Tissue changes due to traumatic

occlusion

The first reaction to increased occlusal

loading is increased vascularity in the
periodontal ligament space , and no
changes are seen in gingival tissues
**Pic. slide 2 page 5
Normal periodontal ligament with normal
occlusal forces showing dense collagen fibers
attached to bone and cementum with
. minimal vascularity

.slide 3 page 3 **Pic

With excessive occlusal loading the
collagen fibers lose their connections
between cementum and bone , blood vessels
proliferate, cells increase, and fibroblast cells
. number decreases

Pic. slid 4 page 5**

This initial increased vascularity results in
a more compressible periodontal ligament
. and increased clinical mobility

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Pic. slide 5 page 5**
Changes in apical periodontal ligament
vascular patterns can also result in increased
vasodilation of the pulp with increased
sensitivity and pain to hot and cold stimuli
,secondary to traumatic occlusion
So pulp may be involved without caries ….etc
, and maight end with non vital tooth and
. may need pulp treatment

.slide 6 page 5 **Pic

In traumatic occlusion after initial change
of increased vascularity, there is a
stimulation of osteoclasts which cause bone
loss and a widened periodontal ligament
.space this also causes increased mobility

These changes are called secondary

occlusal trauma or secondary trauma
,from occlusion
In teeth with bone loss due to
periodontal disease, the previously

‫اذا ضبطت نفسك متلبسا بالغيره على انسان فقد تكون في حالة حب وانت ل تعلم‬
well tolerated occlusal loading can
become traumatic and cause
changes in the periodontal ligament
tissues, so all these changes are due to

19
secondary trauma that is why normal
forces can cause more destruction of
periodontal ligament space and more
proliferation of blood vessels once there
. is periodontal disease going on

Pic. slide 3 page 6 **

Radiograph of lower molar with traumatic
occlusion : widened periodontal ligament
space on mesial surface all the way around
the apex (the black line) and lamina dura
thickening ,with beginning of bone loss in
furcation , and this tooth has increased
mobility and pulp may undergo calcification
because of high occlusal forces so hard to do
. RCT to it

** Pic. slide 5 page 6

First molar has traumatic occlusion causing
the bone loss in the furcation , clinically there
is no pocket depth nor periodontitis in the
furcation , so the diagnosis is traumatic
occlusion (Furcation involvement of occlusal
trauma because the bone level does not
decrease in other side -crestal bone level is
not bad- so it will not be due to periodontal
disease) and the treatment is occlusal
. adjustment to reduce occlusal loading

20
So furcation involvement could be due to
.perio or endo or occlusal trauma

** .slide 6 page 6 Pic

Both premolars have traumatic occlusion,
and there is an addition periodontitis related
bone loss and pockets on mesial surface of
the first premolar, this is Secondary trauma
because the support is not enough and he
has extracted teeth, so it couldn’t be
primary, this tooth has bone loss so may
. have recession

When generalized bone density**

decreases so it's secondary not primary,
and 100% there is recession and CAL

If one tooth is involved, it may be**

primary, inflammation of perio is not
localized only in cases of localized
aggressive and involving many teeth so
.there is no disease localized in one area

but many patients have posteriorly 2

crowns with incipient periodontitis, this
may be from occlusal forces but along
with inflammation so it ends up like
secondary but more localized in this site

21
but mainly the forces are heavier, but in
presence of plaque it makes a pocket in
. this site

** .slide 1 page 7 Pic

Gingival recession is not caused by
traumatic occlusion but is related to
inadequate keratinized gingival and
excessive tooth brushing (keratinized gingiva
. (at least must be 2 mm but here it's zero

Occlusal trauma may cause recession

but you have to have no other factor,
but if there is any other factor it will be
. stronger than occlusal trauma

.slide 2 page 7 ** Pic

Wedge shaped defect in root of lower first
premolar is due to traumatic tooth brushing
. and is not related to traumatic occlusion
‫و اذا ضبطت نفسك متلبسا بالغيره من انسان فقد تكون في حالة اثم و انت تعلم‬

Tooth brushing causes recession and

Abfraction on the neck of teeth due to
excess forces which causes them
.instead of facets

** Pic. slide 3 page 7

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If there is excessive force on tooth and you
open a flap, the bone will be thick
(hyperplastic bone called buttressing bone:
means ledges of bone, its not good, will
. ( create undercut beneath it

Effects of occlusal discrepancies

Patients who have occlusal
discrepancies have no more severe
destruction than patients without
occlusal discrepancies if he not have
.initiating factors

You can do -to patients with occlusal

trauma-* night guard in case of bruxism
to break the habit, *or change the
occlusion but it may cause trauma
. again, *so you do occlusal adjustment

Patients -who received occlusal

adjustment as a part of their periodontal
therapy- had greater attachment gain
than patients who did not receive
. occlusal adjustment

Que. : Patient came with severe **

periodontal disease and occlusal trauma,

23
treatment plan includes oral hygiene
instructions and scaling and root
planning and occclusal adjustment ,
what is the best time to do occlusal
?adjustment and why
The last thing , to give it time to heal
--->when you do scaling there is
resolution of inflammation and decrease
mobility and
‫ بعد فوات الوان‬. . ‫أسهل أن تكون عاقل‬
increase stability, so you have to wait
because nearly 30% will
have complete resolution of
inflammation and 50% have half
. resolution of mobility

there is one case you have to do it

immediately---> in excessive mobility
. (and fremitus (severe pain

Teeth with occlusal discrepancies had

deeper presenting probing depths and
worse prognosis than those that did not
. have occlusal discrepancies

”Abfraction“

24
.is a type of root loss

Pic slide 1+2 page 8**

It’s a tooth with abfraction. like this has
been shown to occur clinically in
association with heavy occlusal forces.
(but in slides: this has not been shown to occur
(clinically in association with heavy occlusal forces

Abfraction and role of occlusion in its

** development
Abfraction has been defined as the
“pathological loss of hard tooth
substance by biomechanical loading
”forces
. basically its not mainly due to occlusion

Treatment
The treatment of occlusion usually
involves either a reversible approach:
consisting of some type of bite appliance
(i.e. “night
‫ فستقول اعظم حديث تندم عليه طوال حياتك‬.. ‫تكلم وأنت غاضب‬
guard”) and / or the selective grinding of
the occlusal surfaces

25
of the teeth or extraction if there is
excessive mobility or occlusal
. adjustment

Orthodontic therapy is an effective

method of changing occlusal
relationships and minimizing occlusal
forces between opposing teeth in case of
.deep bite and very bad occlusion

Selective grinding involves the non-

reversible reshaping of occlusal surfaces
but has the advantage of minimizing
.occlusal forces at all times

Conclusion
If occlusal discrepancies exist in the
presence of periodontal disease, the
occlusal factors should be controlled by
the minimization of the occlusal forces.
In other words, occlusal treatment
should be performed, where indicated,
as a routine part of periodontal therapy
so its part of treatment plane but not
immediately , you have to wait until get
rid of inflammation

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 ‫‪The end‬‬

‫‪;Done by‬‬
‫‪RAWN RAHHAL‬‬
‫" القلوب أوعية والشفاه أقفالها واللسن مفاتيحها فليحفظ كل إنسان مفتاح سره "‬

‫ع يد الشتاء الخشنة تمحو عنك صيفك قبل أن تتحول أنت إلى قطرات "‬
‫" ل َتَد ْ‬

‫‪27‬‬