1. Occlusion and Periodontal Disease

2. This series of slides is based on Lindhe et al
This series of slides is based on Lindhe et al.’s textbook “Clinical Periodontology and Implant Dentistry”, chapter 8.

3. 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.

4. Definition Trauma from Occlusion Primary TfO: Secondary 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)

5. TfO and Plaque-Associated Periodontal Disease
Karolyi’s (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

6. Glickman’s 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.

7. Glickman’s 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

8. Glickman’s 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.

9. Glickman’s Concept Angular bony defect and infrabony pocket
distal of premolar

10. Waerhaug’s 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.

11. Waerhaug’s 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

12. 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.

13. 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.

14. Jiggling Forces 2 : P-TfO
Ligament space gradually adjusts to new situation.
No attachment loss!
Increased tooth mobility

15. Jiggling Forces 3 : P-TfO
Occlusal adjustment normalizes the width of the periodontal ligament.
Teeth are stabilized and regain normal mobility.

16. 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

17. Reduced Height, Healthy 2 : S-TfO
Ligament space gradually adjusts to new situation.
No attachment loss!
Increased tooth mobility
Ligament tissue regains normal composition

18. 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.

19. 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

20. 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

21. Reduced and Diseased 3 : S-TfO
Occlusal adjustment will result in reduction of periodontal ligament width and
Reduced (not normal!) tooth mobility

22. Reduced and Diseased 4: S-TfO
Presence of infrabony pocket and infiltrated connective tissue
Merging of zones of “irritation” and “co-destruction”

23. Reduced and Diseased 5: S-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

24. Reduced and Diseased 6: S-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

25. Reduced and Diseased 7: S-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

26. 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