Trauma From Occlusion
Question 1. Write short note on radiographic changes in TFO.
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Define trauma from occlusion. Give its clinical, histological and radiographic features. Describe its role in pathogenesis of periodontal disease.
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Describe clinical and radiological features of trauma from occlusion.
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Write short note on trauma from occlusion.
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Write short note on TFO.
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What is trauma from occlusion. Discuss tissue response to increased occlusal forces.
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Write short note on stages in trauma from occlusion.
Answer. When occlusal forces exceeds the adaptive capacity of tissues, tissue injury results which is called as trauma from occlusion or occlusal trauma.Orban and Glickman et al (1968)
It is defined as “damage in the periodontium caused by stress on the teeth produced directly or indirectly by the teeth of the opposing jaw”.
Classification of Trauma from Occlusion
Depending on Mode of Onset
- Acute trauma from occlusion
- Chronic trauma from occlusion
Read And Learn More: Periodontics Question And Answers
Depending on Capacity of Periodontium to Resist Occlusal Forces
- Primary trauma from occlusion
- Secondary trauma from occlusion
Clinical Features
- Presence of hypermobility of tooth is the most common clinical sign.
- Presence of tooth migration
- Presence of tenderness of tooth while chewing or percussion.
- Presence of tenderness in muscles of mastication.
- Temporomandibular dysfunction is seen.
- Presence of chipped enamel or crown/root fractures.
- Wear facets are seen beyond the level of age of patient’s and diet consistency.
- Presence of fremitus.
- In severe cases, periodontal abscess formation and cemental tears are seen.
Histopathological Features or Tissue Response to Increased Occlusal Forces
The response of tissues is explained under three stages, i.e.
- Stage 1—Injury
- Stage 2—Repair
- Stage 3—Adaptive remodeling of periodontium.
Stage : Injury
- Tissue injury occurs due to excessive occlusal forces.
- Body then attempts to repair the injury and restore the periodontium.
- This may occur if the forces are diminished or if the tooth drift away from them.
- If the offending force is chronic, the periodontium is remodeled to cushion its impact. The ligament is widened at the expense of the bone, which results in angular bone defects without periodontal pockets, and the tooth becomes loose.
- Slightly excessive pressure stimulates the resorption of alveolar bone along with the resultant widening of the periodontal ligament space.
- Slightly excessive tension leads to elongation of periodontal ligament fibers and apposition of alveolar bone.
- In areas of increased pressure, blood vessels are numerous and reduced in size; in areas of increased tension, they get enlarged.
- Greater pressure leads to the gradation of changes inside periodontal ligament, starting with compression of the fibers, which produces areas of hyalinization.
- Subsequent injury to firoblasts and other connective tissue cells leads to necrosis of areas of the ligament.
- Vascular changes are also seen within 30 minutes, impairment and stasis of blood flw occur at 2 to 3 hours, blood vessels appear to be packed with erythrocytes, which start to fragment; and between 1 and 7 days, disintegration of the blood vessel walls and release of the contents into the surrounding tissue occur.
- In addition there is increased resorption of alveolar bone and resorption of the tooth surface occurs.
- Severe tension leads to widening of periodontal ligament, thrombosis, hemorrhage, tearing of the periodontal ligament, and resorption of alveolar bone.
- Pressure, which is severe enough to force the root against bone leads to necrosis of the periodontal ligament and bone.
- Bone gets resorbed from viable periodontal ligament adjacent to necrotic areas and from marrow spaces, this process is known as undermining resorption.
Stage 2: Repair
- Repair goes on constantly inside the normal periodontium, and trauma from occlusion stimulates increased reparative activity.
- Damaged tissues are removed, and new connective tissue cells and fibers, bone, and cementum are formed in an attempt to restore the injured periodontium.
- Forces remain traumatic only as long as damage produced exceeds the reparative capacity of tissues.
- When bone gets resorbed by excessive occlusal forces, the body attempts to reinforce the thinned bony trabeculae with new bone. This attmpt to compensate for lost bone is known as buttressing bone formation which is an important feature of the reparative process associated with trauma from occlusion.
- This buttessing bone formation also occurs when bone is destroyed by inflmmation or osteolytic tumors.
- Buttessing bone formation occurs within the jaw known as central buttessing and on the bone surface known as peripheral buttessing.
- During central buttessing, the endosteal cells deposit new bone, which restores the bony trabeculae and reduces the size of the marrow spaces.
- Peripheral butterssing occurs on the facial and lingual surfaces of the alveolar plate.
- Depending on its severity, peripheral butterssing may produce a shelf like thickening of the alveolar margin, which is referred to as lipping or a pronounced bulge in the contour of the facial and lingual bone.
Stage 3: Adaptive Remodeling of Periodontium
- If repair process cannot keep pace with the destruction produced by the occlusion, the periodontium is remodeled in an effort to create a structural relationship in which the forces are no longer injurious to tissues.
- This result in a widened periodontal ligament, which is funnel shaped at the crest, and angular defects in the bone, with no pocket formation. The involved teeth become loose.
- Increased vascularization has also been observed.
- Injury phase demonstrates an increase in areas of resorption and a decrease in bone formation, whereas the repair phase shows decreased resorption and increased bone formation.
- After adaptive remodeling of the periodontium, resorption and formation return to normal.
Trauma From Occlusion Radiographic Features
- There is increased width of the periodontal space, often with thickening of lamina dura along the lateral aspect of the root, in apical region, and in bifurcation areas.
- A vertical rather than horizontal destruction of the interdental septum.
- Radiolucency and condensation of the alveolar bone.
- Presence of root resorption.
Role of Trauma from Occlusion in Pathogenesis of Periodontal Disease
The role of trauma from occlusion in pathogenesis of periodontal disease is explained by:
Glickman’s Concept
He claimed that the pathway of spread of plaque associated gingival lesion can be changed, if forces of an abnormal magnitude are acting on teeth harboring subgingival plaque. He explained, teeth which are nontraumatized exhibit suprabony pockets and horizontal bone loss, whereas teeth with trauma exhibits, angular bony defects and infrabony pockets:
According to him periodontal structures are divided into two parts:
- Zone of irritation.
- Zone of co-destruction.
Zone of Irritation
- This zone includes marginal and interdental gingiva. Sof tissue of this zone is bordered by hard tissue i.e. tooth is only on one side and is not affcted by forces of occlusion. This means that gingival inflmmation cannot be induced by trauma from occlusion but is the result of irritation from microbial plaque.
- The plaque-associated lesion at a non-traumatized tooth propagates in apical direction by first involving the alveolar bone and later the periodontal ligament area. The progression of this lesion results in an even (horizontal) bone destruction
Zone of Co-destruction
- This includes the periodontal ligament, the root, cementum and alveolar bone and is coronally demarcated by the transseptal (interdental) and the dentoalveolar collagen 0.fiber bundles.
- The tissue in this zone may become the seat of a lesion caused by trauma from occlusion.
- The spread of the inflammatory lesion from the zone of irritation directly down into the periodontal ligament (i.e. not via the interdental bone) may hereby be facilitated.
- This alteration of the normal pathway of spread of the plaque-associated inflammatory lesion results in the development of angular bony defects.
- According to Glickman (1967), trauma from occlusion is the significant causative agent in situations where angular bony defects combined with infrabony pockets are found at one or the several teeth.
Waerhaug’s Concept
The loss of periodontium, according to Waerhaug, was result of inflammatory lesions associated with subgingival plaque. He concluded that angular defects occur when subgingival plaque of one tooth has reached more apical level than microbiota on neighboring tooth, and when volume of alveolar bone surrounding roots is comparatively large.
In conclusion, four possibilities can occur when a tooth with gingival inflmmation is expressed to trauma.
- Trauma from occlusion may alter pathway of extension of gingival inflmmation to underlying tissues inflmmation may proceed to PDL rather than to alveolar bone and resulting bone loss will be angular with infrabony pockets.
- It may favor the environment for formation of attchment of plaque and calculus and may be responsible for development of deeper lesions.
- Supragingival plaque can become subgingival, if the tooth is tilted orthodontically migrates into an edentulous area, resulting in transformation of suprabony pocket into an infrabony pockets.
- Increase tooth mobility associated with trauma to periodontium may have pumping effct of plaque metabolites increasing their diffusion.
Question 2. Write short note on pathological migration of tooth.
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Write short note on pathological migration.
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Write short note on pathological tooth migration.
Answer. Pathologic tooth migration refers to the tooth displacement that results when balance among the factors that maintain physiologic tooth position is disturbed by periodontal disease.
- It occurs most frequently in the anterior region, but posterior teeth may also be affected.
- The teeth may move in any direction and migration is accompanied by mobility and rotation.
- Pathological migration in occlusal or incisal direction is called as extrusion.
- It is important to detect in its early stages and prevent more serious involvement by eliminating the causative factors.
Pathological Migration of Tooth Pathogenesis
The two major factors play an important role in maintaining normal position of teeth:
The Health and Normal Height of Periodontium
- A tooth with weakened periodontal support is able to withstand the forces and moves away from opposing force.
- It is important to understand that abnormality rests with the weakened periodontium. Forces that are acceptable to an intact periodontium become injurious when periodontals upport is reduced. Pathologic migration may continue even after a tooth no longer contacts its antagonist.
Changes in the Force Exerted on Teeth
May occur as a result of:
- Unreplaced missing teeth.
- Failure to replace first molars.
- Others.
- Unreplaced missing teeth: This leads to driftng of teeth into the spaces created by unreplaced missing teeth, driftng results from pathologic migration, in that, it does not results from destruction of periodontal tissues. However, it usually creates conditions that lead to periodontal disease and thus initial tooth movement is aggravated by loss of periodontal support.
- Failure to replace first molars:
- The second and third molars tilt resulting in decrease in vertical dimension.
- The premolars move distally and mandibular incisors tilt or drift lingually.
- Anterior overbite is increased.
- Maxillary incisors are put labially and laterally.
- Anterior teeth extrude due to disappearance of incisal apposition.
- Diastema is created by separation of anterior teeth.
- Other causes:
- Trauma from occlusion may cause a shif in tooth position either by itself or in combination with inflammatory periodontal disease. Direction of movement depends on occlusal force.
- Pressure from tongue may cause driftng of teeth with reduced periodontal support.
- In tooth support weakened by periodontal destruction, pressure from granulation tissue of periodontal pockets has been mentioned as contributing to pathologic migration.
Question 3. Write short note on secondary trauma from occlusion.
Answer. When tissue injury occurs due to normal or excessive occlusal forces applied to teeth with a reduced support it is called as secondary trauma from occlusion.
In secondary type of trauma from occlusion adaptive capacity of periodontium to withstand occlusal forces is impaired.
Periodontium is susceptible to injury and previously well-tolerated occlusal forces become traumatic, so that is why trauma from occlusion is considered as secondary cause of periodontal destruction.
Secondary Trauma From Occlusion Etiology
- Loss of alveolar bone because of marginal inflammation, which reduces periodontal attachment area.
- Systemic disorders reduce the resistance of tissue and forces previously tolerable increases.
Secondary Trauma From Occlusion Features
- Marginal periodontitis is present with reduced height of bone.
- When secondary trauma from occlusion superimposed with plaque-induced inflammation, it causes angular bone loss and infrabony pocket formation.
Question 4. Write short note on types of TFO.
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Classify TFO (Trauma from occlusion).
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Write short note on acute trauma from occlusion.
Answer. Following are the types of TFO:
Depending on mode of onset:
- Acute trauma from occlusion
- Chronic trauma from occlusion.
Depending on capacity of periodontium to resist occlusal forces:
- Primary trauma from occlusion
- Secondary trauma from occlusion.
Acute Trauma from Occlusion
- Acute trauma from occlusion refers to periodontal changes associated with an abrupt occlusal impact such as that produced by biting on a hard object.
- In addition, restorations or prosthetic appliances that interfere with or alter the direction of occlusal forces on the teeth may also induce acute trauma.
- Acute trauma results in tooth pain, sensitivity to percussion, and increased tooth mobility.
- If the force is dissipated by a shift in the position of the tooth or by the wearing away or correction of the restoration, then the injury heals, and the symptoms subside. Otherwise, periodontal injury may worsen and develop into necrosis accompanied by periodontal abscess formation, or it may persist as a symptom-free chronic condition.
- Acute trauma can also produce cementum tears
Chronic Trauma from Occlusion
- Chronic trauma from occlusion refers to periodontal changes which are associated with gradual changes in occlusion caused by tooth wear, drifting movement, and extrusion of the teeth in combination with parafunctional habits (e.g., bruxism, clenching) rather than as a sequela of acute periodontal trauma.
- Chronic trauma from occlusion is more common than the acute form and of greater clinical signifiance.
- It can be primary or secondary.
Primary Trauma from Occlusion
- When trauma from occlusion is the result of alterations in occlusal forces, it is known as primary trauma from occlusion.
- Primary trauma from occlusion happens if trauma from occlusion is considered the primary etiologic factor in periodontal destruction and if only local alteration to which a tooth is subjected is a result of occlusion.
- Examples include periodontal injury produced around teeth with a previously healthy periodontium after the following:
- High filling surfaces
- Prosthetic replacement that creates excessive forces on abutment and antagonistic teeth
- Drifting movement or extrusion of teeth into spaces created by unreplaced missing teeth
- Orthodontic movement of teeth into functionally unacceptable positions.
- Changes produced by primary trauma do not alter the level of connective tissue attchment and do not initiate pocket formation because the supracrestal gingival fibers are not affected and therefore prevent the apical migration of the junctional epithelium.
Secondary Trauma from Occlusion
- Secondary trauma from occlusion occurs when the adaptive capacity of the tissues to withstand occlusal forces is impaired by bone loss that results from marginal inflammation.
- This decreases periodontal attachment area and alters the leverage on the remaining tissues.
- The periodontium becomes more vulnerable to injury and previously well-tolerated occlusal forces become traumatic.
Question 5. Define trauma from occlusion and give its Classification. Describe clinical and radiographical features of trauma from occlusion in detail.
Answer.
Trauma from Occlusion Clinical Features
Symptoms of Trauma from Occlusion
- Thermal sensitivity: Trauma from occlusion leads to pressure on venous return which causes venous hyperplasia and increase blood pressure in pulp and pain. When teeth are pushed together scratching or squeaky sound is heared.
- Habits: Occlusal prematurities can lead to the habit pattrn which is injurious to periodontium. Due to tension, patient grinds or clenches the teeth.
- Muscle hypertonicity: Occlusal interferences lead to muscle spasm or discomfort. Subluxation and crepitus in TMJ associated with muscle spasm occur by cuspal interferences.
- Loosening teeth: In advanced cases, patient is aware of loosening of teeth and complains of soreness and tenderness in some of the areas.
- Effect of excessive occlusal forces on dental pulp: Complete calcification of pulpal canal occur in cases of long standing severe trauma or following single serious traumatic accident to tooth resulting in gross disturbances of circulation.
- Effect of insufficient occlusal forces: They causes thinning of periodontal ligament, atrophy of fibers, osteoporosis of alveolar bone and reduction in bone height.
Signs of Trauma from Occlusion
- Visual signs: Signs that can be seen in wear registration, as transparencies are points of contact and not broad areas. Excessively large areas of contact can also be detected by using a variety of marketing materials such as carton paper, tape, ribbon or a dye.
- Auditory sign: In centric relation, there is a distinct ringing sound; in maximum tooth contact with deflections present, the sound is dull or perceptible.
- Tactile sign: In centric relation and in normal excessive movements, response to figer contact is smooth, with deflection present, a roughness can be detected.
- Migration of teeth: Loss of inter – proximal contacts and migration of teeth may be the sequela of traumatic occlusal relations. Unusual habit pattrn may lead to tooth migration and trauma from occlusion beyond the functional range of normal occlusal contacts.
- Mobility: Most common clinical sign of trauma to periodontium is increased tooth mobility. In injury stage of trauma from occlusion, there is destruction of periodontal fibers, which will increase the mobility of the tooth. In the final stage, the accommodation of the periodontium to increased forces entails a widening of periodontal ligament, which also leads to increased tooth mobility.
- Fremitus: This is an important tool. Fremitus means palpable vibration or movements. A tooth with fremitus has excess contact, possibly related to a premature contact.
- Wear patterns: Facets and abnormal wear patterns must be differentiated from attrition caused by a coarse diet. Shiny and irregular facets indicate tooth-to-tooth wear that is associated with bruxism. These worn and abraded teeth are invariably fim with no sign of mobility.
- Gingival recession: Gingival recession may be provoked by direct contact of the teeth with the gingiva, as in severe overbite, where the upper incisors damage the buccal gingiva of the lower incisors.
- Gingival clefts: These cleft are a combination of conditions caused by toothbrush abrasion. This initially produces a linear act injury that eventually develops into a gingival cleft
Question 6. Write short note on bruxism.
Answer. Bruxism is defined as clenching/grinding of teeth when the individual is not swallowing or chewing.
Bruxism Etiology
- It occurs due to mild occlusal disturbances.
- Gastrointestinal disturbances or endocrine disturbances.
- Due to emotional tension.
- In occupations like watchmaker.
Bruxism Clinical Features
- Facet patterns are present.
- Bruxism occurring during rapid eye movement sleep is most damaging.
- Chronic bruxism may lead to sensitive worn-out, decayed, fracture, loose or missing teeth.
- Long-term bruxers experience jaw tenderness, jaw pain, fatigue of facial muscles, headache, neck ache, ear ache and hearing loss.
- Bruxism may damage the TMJ.
- Malocclusion or deep bite is most common among bruxers.
- There may be loss of integrity in periodontal structures resulting in loosening or drifting of teeth and even gingival recession occurs.
Bruxism Management
- Maxillary stabilization appliance is advised, which is most effective means of treating bruxism.
- Drugs such as anti-anxiety and muscle relaxants are given.
Question 7. Write short note on occlusal neurosis.
Answer. It is also known as parafunctional habits. The parafunctional habits or occlusal neurosis are bruxism and clenching
Occlusal Neurosis Clenching
- It is defined as closure of jaws under vertical pressure.
- Clenching is the force exerted from one occlusal surface to other without any movement.
- Forces are directed more vertically to plane of occlusion in posterior region and wearing of teeth is unlikely.
- In clenching, a person holds the teeth fimly together with significant amount of force.
- Clenching is associated with masticatory system disorders.
- Tooth mobility, greater temperature sensitivity, muscle tenderness, deviation on opening, stress lines in enamel cervical abfraction is associated with clinical signs of clenching.
Question 8. Define and classify trauma from occlusion (TFO). Write in detail about its management.
Answer.
Definition of Trauma from Occlusion
When occlusal forces exceeds the adaptive capacity of tissues, tissue injury results which is called as trauma from occlusion or occlusal trauma.
It is defined as “damage in the periodontium caused by stress on the teeth produced directly or indirectly by the teeth of the opposing jaw”.
Management of Trauma from Occlusion
- Management of symptoms of occlusal traumatism is appropriate during any phase of periodontal therapy.
- Except in case of acute conditions, treatment is usually first addressed during initial therapy following efforts to reduce or minimize the inflmmatory lesion. Evaluation of occlusal symptoms should continue throughout the course of therapy.
- Management should be needed to repeated or revised.
- Occlusal therapy should be accomplished via various different approaches. Choice of these therapies depends on the various factors such as characteristics of forces, underlying cause of these forces, amount of periodontal support to remaining teeth and functioning of remaining teeth.
- Treatment considerations for trauma from occlusion are:
- Occlusal adjustments
- Management of parafunctional habits
- Coronoplasty
- Temporary, provisional or long-term stabilization of mobile teeth by removable or fied appliances
- Orthodontic tooth movement
- Occlusal reconstruction
- Extraction of selected teeth
- Occlusal bite planes
- Permanent or temporary splint application.
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