Volume 4 • Number 1 • December 1999

Occlusal Trauma: Effect and Impact on the Periodontium

William W. Hallmon*

* Baylor College of Dentistry, Dallas, Texas.

This focused review is limited to a number of investigations in

an attempt to specifically address the histological and clinical
effects of excessive occlusal forces on the teeth and periodon-
tium and to provide a basis of classification for this interaction.
This review does not include the effects of occlusal forces on
dental implants or dental prostheses/appliances. Ann Periodontol

F
1999;4:102-107. or many years the role of occlusion
KEY WORDS and its dynamic interactive impact
on the periodontium has been an
Occlusion, histology; occlusion, trauma.
issue of controversy and extensive
debate.1-37 Although a variety of occlusal
conditions have purportedly been related
to this interaction (e.g., bruxism, maloc-
clusion, abfraction, etc.), the central
focus has been on occlusal trauma (pri-
mary and secondary) resulting from
excessive force(s) applied to the peri-
odontium. Occlusal trauma is defined as
an injury of the attachment apparatus
or tooth as a result of excessive occlusal
forces.38 In an attempt to clarify and
better understand this condition, early
investigators used human necropsy spec-
imens7,12,15,19,39 and a variety of animal
models as a basis for clinical and histo-
logical studies.3-6,8-11,14,20-37 Findings
were often diverse and somewhat con-
tradictory. In the animal studies, factors
of concern included differences among
animals, forces applied, and lack of con-
trols.16 Retrospective descriptive obser-
vations of the effect of excessive forces on
the periodontium were derived from
human necropsy materials.7,12,15,19,39
The selection of study sites was based on
occlusal wear, patterns of pocket forma-
tion, and the presence of attachment loss,
leaving some question as to the presence
of ongoing occlusal trauma.40,41 Despite
the foregoing concerns, the majority of
these early studies agreed that occlusal
trauma, in and of itself, failed to result in
pocket formation or loss of connective
tissue attachment.16,40 It is apparent that

102
Ann Periodontol
our understanding of the effects of excessive occlusal
force and the destructive, adaptive, and reparative
response of the periodontium has been complicated by
a relative lack of evidence based on well-controlled
prospective studies in human beings.40-42
This focused review is limited to a number of inves-
tigations in an attempt to specifically address the his-
tological and clinical effects of abnormal occlusal
forces on the teeth and periodontium and to provide
a basis of classification for this interaction. This review
does not include the effects of occlusal forces on den-
tal implants or dental prostheses/appliances.
SIGNIFICANCE OF OCCLUSAL
TRAUMA TO INFLAMMATORY
PERIODONTAL DISEASE
Definitions
To facilitate orientation and understanding of this topic,
the following definitions will apply to the review and dis-
cussion of the relationship between excessive occlusal
forces and the periodontium. Occlusal trauma refers to
a response or effect and is defined as an injury to the
attachment or tooth as a result of excessive occlusal
forces.38 Primary occlusal trauma is injury resulting
from excessive occlusal forces applied to a tooth or
teeth with normal support, while secondary occlusal
trauma is injury resulting from normal occlusal forces
applied to a tooth or teeth with inadequate periodon-
tal support.38 Combined occlusal trauma refers to injury
resulting from abnormal occlusal forces applied to a
tooth or teeth with inadequate (abnormal) periodontal
support.43 Traumatogenic occlusion refers to a cause
and is defined as any occlusion that produces forces
that cause an injury to the attachment apparatus.38
Primary, secondary, and combined occlusal trauma
were originally described in the periodontal literature
in 192844 and serve as a basis of discussion of the
sequellae of occlusal trauma.45,46 Despite continued
acceptance and diagnostic use of these defined con-
ditions,38 this reviewer was unable to find specific sup-
port for these terms based on evidence derived from
controlled studies. In an in vitro stress model study
using finite element analysis to calculate periodontal
ligament stresses in primary and secondary occlusal
trauma, stress values increased as bone support
decreased.47 This was especially notable after reduc-
ing the supporting bone 4 mm or more.47
Histological Studies
The histologic features of occlusal trauma have been
studied extensively in animals and human autopsy
materials.7,11,12,19,21,22,39,48,49 Alterations of the peri-
odontium that have been associated with occlusal
trauma will vary with the magnitude and direction of
applied force, and location (pressure versus tension).
These changes may include widening/compression of
Hallmon
the periodontal ligament, bone remodeling (resorption/
repair), hyalinization-necrosis, increased cellularity,
vascular dilatation/permeability, thrombosis, root
resorption, and cemental tears.2,11,12,39,48,50-53 Col-
lectively, these changes have been interpreted as an
attempt by the periodontium to adapt and undergo
repair in response to traumatogenic occlusion. Despite
isolated reports of apical migration of the junctional
epithelium accompanying excessive occlusal forces,3,17
studies generally have failed to disclose associated
pocket formation while demonstrating remarkable sta-
bility of the Sharpey’s fibers and periodontal fibers
coronal to the alveolar bone.12,14,15,21 In the absence
of existing inflammation, it was noted that bony changes
accompanying occlusal trauma may be reversed by
discontinuing offending occlusal forces.13,30,54
A co-destructive theory55 was proposed based on
a zone of irritation (marginal/interdental gingiva; gin-
gival fibers) and zone of co-destruction (transsep-
tal/alveolar crest fibers, periodontal ligament, cemen-
tum, bone). This theory suggested that occlusal trauma
in the presence of plaque-induced inflammation may
result in alteration of the normal pathway of inflam-
mation, and development of angular bony defects
with intrabony pockets, but that occlusal trauma, in
and of itself, did not cause gingivitis and periodonti-
tis.7,8,55-58 Other studies questioned the role of occlusal
trauma on this process,14,15,54 and one particular inves-
tigation identified the bacterial “plaque front” as the
agent responsible for the severity and sites of attach-
ment loss and associated bony defects.19
Due to difficulties encountered in the design and
implementation of prospective controlled human stud-
ies, alternative development and use of animal mod-
els for prospective clinical and histologic investiga-
tions to study the effects of traumatogenic occlusion
on the periodontium have been pursued.41 While such
studies may provide information and insight into the
trauma-associated response, repair, and the accom-
panying adaptive process,54 they do not duplicate the
dynamics of human masticatory function or rule out
significant differences between animals and man.16
Thus, such studies can serve only as a source of indi-
rect evidence. The most widely recognized animal
models used in recent times to study this topic include
the beagle dog and squirrel monkey.23,49
In a series of studies,20-28 investigators used the
beagle dog model and the presence or absence of con-
tinuous excessive jiggling forces (cap splint; bar-spring
device) in health and experimentally induced peri-
odontitis to study the effect of occlusal forces on the
periodontium. Clinical and histologic findings indicated
that heavy occlusal forces in health and established
gingivitis resulted in tooth hypermobility, increasing
vascularity, vascular dilatation, and bone resorption,
but no apical migration of the junctional epithelium or
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Occlusal Trauma: Effect and Impact on the Periodontium
induction of or influence on tissue inflammation.20,21
When induced-periodontitis was accompanied by
excessive jiggling forces, continued vascular perme-
ability, osteoclastic activity, and polymorphonuclear
leukocyte migration were noted, indicative of failure
to adapt to the injurious force. Apical migration of the
junctional epithelium was more pronounced under
these conditions when compared to periodontitis sites
without excessive occlusal forces.21,23,25 When jiggling
trauma and tooth hypermobility were investigated in
a reduced, non-inflamed periodontium that had
received periodontal therapy, no progressive marginal
destruction or apical migration of the junctional epithe-
lium was observed.58 More recently, this model was
used to investigate periodontal ligament tissue reac-
tions to trauma (orthodontic elastics alternated buc-
cally/lingually twice weekly) and ligature-induced gin-
gival inflammation.57 In teeth exhibiting increased
mobility, the coronal periodontal ligament approach-
ing the inflammatory lesion showed an increased width,
increased volume of vascular structures and leuko-
cytes, and a reduction in the percentage of collagen
per tissue volume. There was also a decrease in the
number of collagen fibers inserting into the alveolar
bone and cementum at these sites. Such changes were
not observed adjacent to teeth with normal mobility.59
Other investigators used the squirrel monkey model
to study the effects of the presence or absence of jig-
gling trauma (alternating orthodontic elastic wedging
mesial and distal to septum) in health and induced peri-
odontitis.29-37 The authors reported increased tooth
mobility and bone loss (widened periodontal ligament
spaces) with sustained jiggling forces, but observed lit-
tle or no associated attachment loss. Removal of these
forces did not reduce tooth mobility or result in bone
regeneration; however, with control of plaque-associ-
ated inflammation, tooth mobility decreased and
affected bone became more dense. There was, however,
no change in the attachment levels or alveolar bone
levels.31-36 Findings associated with these studies
resulted in decreased attention to occlusal factors and
focused increased therapeutic emphasis on the control
of plaque, and thus, inflammatory periodontal disease.30
Collectively, these studies suggest that occlusal
trauma does not initiate gingivitis or periodontitis. The
beagle dog studies demonstrated accelerated pro-
gression of pocket formation in the presence of on-
going destructive periodontitis,60 while the squirrel
monkey model studies did not.49,54 Although the
importance of the role of bacterial plaque in periodontal
disease is undisputed, the influence of occlusal trauma
on the attachment level remains controversial.
Clinical Studies
Since occlusal trauma is a histologic lesion, clinical
and radiographic indicators are necessary to assist in
104
Volume 4 • Number 1 • December 1999
its diagnosis. Proposed clinical indicators include mobil-
ity, occlusal prematurities, thermal sensitivity, wear
facets, muscle tenderness, fractured teeth, and migra-
tion of teeth. Radiographic indicators may include
altered lamina dura, widened periodontal ligament
space, and evidence of root resorption and/or bone
loss16,43,61-63 (see Table 1).
Although increased tooth mobility is one of the most
widely used indicators of occlusal trauma, it may result
from bone loss independent of occlusal forces. It may
also represent a self-limiting adaptive response of the
host periodontium to the sustained application of
occlusal forces.11,64 Progressive mobility may be sug-
gestive of on-going occlusal trauma, but assessments
and monitoring at differing points in time are neces-
sary to make this determination.16 In a beagle dog
study,65 jiggling occlusal forces in a healthy peri-
odontium were associated with mobility, loss of mar-
ginal bone, and greater clinical probing depths, but
not with changes in the connective tissue attachment
level. The increase in probing depth was attributed to
enlargement and alteration of the supracrestal con-
nective tissue compartment.
Longitudinal and randomized controlled trials have
provided limited insight and evidence related to the
effects of occlusal forces on periodontitis. In studies
investigating the association of occlusal trauma and
periodontitis, teeth in patients with occlusal dishar-
monies (centric relation-centric occlusion, balancing;
or protrusive contacts) did not demonstrate any greater
Table 1.
Clinical and Radiographic Indicators
of Occlusal Trauma
Clinical indicators of occlusal trauma may include one or more of
the following:
1. Mobility (progressive)
2. Fremitus
3. Occlusal prematurities
4.Wear facets in presence of other clinical indicators
5.Tooth migration
6. Fractured tooth (teeth)
7.Thermal sensitivity
Radiographic indicators of occlusal trauma may include one or
more of the following:
1.Widened PDL space
2. Bone loss (furcation; vertical; circumferential)
3. Root resorption
Ann Periodontol
severity of periodontitis when compared to teeth with-
out such contacts.66,67 It is interesting to note how-
ever, that teeth demonstrating signs of occlusal trauma
(e.g., bidigital mobility, functional mobility, widened
periodontal ligament spaces) had greater probing
depths, attachment loss, and less bone support.67,68
It has also been reported that individuals who received
prophylactic occlusal adjustment as part of their treat-
ment for periodontitis had a statistically significant gain
in mean probing attachment (0.42 mm) compared to
those with no occlusal adjustment (0.02 mm). How-
ever, no reduction of tooth mobility was observed
between the groups.69 Data from a similar study which
evaluated the influence of furcation involvement and
tooth mobility on periodontal attachment and tooth
(molar) loss indicated that teeth with furcation invasion
and mobility had greater attachment loss than molars
with furcation involvement and no mobility.70
A longitudinal study71 (28 years) evaluated the
change in attachment level in an adult population and
reported that increased age, smoking, and tooth
mobility were the factors most closely associated with
attachment loss. It should be noted that the occlu-
sion was not specifically evaluated in this study. In
an 8-year study,72 the relationship between tooth
mobility and periodontal therapy was investigated.
Pockets associated with clinically mobile teeth did not
respond as favorably to treatment as firm teeth with
comparable severity of disease. In studies of human
teeth undergoing orthodontic movement, elevated lev-
els of interleukin (IL)-1β, IL-6, tumor necrosis factor-
α, epidermal growth factor, β2-microglobulin, and
prostaglandin E in the gingival crevicular fluid have
been reported, compared to untreated controls.73,74
These findings should not be interpreted as a
“cause-and-effect” association between occlusal
trauma and periodontitis, but do seem to suggest the
clinical relevance of tooth mobility. However, it should
be noted that tooth mobility may also be the result
of numerous other factors, including attachment loss,
loss of alveolar bone, inflammation of the supporting
periodontal structures, widening of the periodontal lig-
ament (physiologic adaption), atrophy of the peri-
odontal ligament, and systemic disease processes
which may impact the supporting periodontal tis-
sues.11,31,41
EFFECTS OF NON-FUNCTION
ON THE PERIODONTIUM
In a study of non-functional teeth, periodontal changes
included a decreased width of periodontal ligaments
(PDL), increased thickness of cementum, inflammation
due to increased plaque and calculus accumulation,
and increased bone loss due to supraeruption.75 These
changes are consistent with those previously defined
as periodontal atrophy or atrophy of disuse.76
Hallmon
SUMMARY AND CONCLUSIONS
A defined lesion and response of the attachment appa-
ratus has been demonstrated in association with exces-
sive occlusal force(s), and has been termed occlusal
trauma. The majority of studies investigating this con-
dition indicate that excessive occlusal forces do not
initiate plaque-induced gingival disease or connective
tissue attachment loss (periodontitis). The effect of
traumatogenic occlusion on the progression of peri-
odontitis has been an area of investigative disagree-
ment, and may represent differences in study design,
model selected for study, nature of the applied
“occlusal” forces, and means of inducing periodontal
disease. These studies also suggest that tooth mobil-
ity may be clinically associated with adverse effects on
the periodontium and affect long-term attachment
response to therapy, but is not necessarily synony-
mous with occlusal trauma.
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