9A. Occlusal Trauma Flashcards
Occlusal Trauma Clinical Symptoms • Awareness of \_\_\_\_ teeth • Tooth migration or Increased Spaces • \_\_\_\_ of periodontal structures • Sensitive teeth (temperature, pressure pulpitis) • \_\_\_\_ or Myofacial pain • None
loose
soreness
TMJ
Occlusal Trauma Clinical Signs • \_\_\_\_ • Tooth Migration • \_\_\_\_ Wear • Fracture • \_\_\_\_ • Restorative Failure • Implant Failure
mobility
abnormal
abfraction
Checking ____
FREMITUS • \_\_\_\_ patterns of teeth; it is examined by placing \_\_\_\_ finger over maxillary teeth and feeling degree of vibration present during various jaw and glide movements • Classified as Class I - \_\_\_\_ Class II - \_\_\_\_ Class III - \_\_\_\_
mobility index slight moderate visible
Root Fracture
• Root fractures can occur in patients where the teeth undergo trauma
• If a patient has a normal periodontium and you don’t find any ____, but then all of the sudden you fall into a 10mm deep pocket, there is a
high likelihood that it is related to a root fracture
• If it simply a periodontal pocket, we can treat it/correct it
• If it is a root fracture, it is hopeless (no treatment). We must make the correct diagnosis! It is tough bc they don’t show up on ____ well. May need to reflect tissue back to make the diagnosis, then remove the tooth and do bone grafting so we can do an implant in the future
pockets
radiograph
ABFRACTION
• Abfraction are these notches that occur in the ____ area
• These are poorly understood
– thought to be a result of excessive ____ causing flexing at the neck of the tooth, breaking down
the tooth structure
• Thought to be related to ____
CEJ
pressure
bruxism
ROOT RESORPTION
- Root resorption can occur due to orthodontic treatment (note how short the roots are here)
- This can be a result of ____ treatment (too much force, treatment was too prolonged)
- Can get ____ root resorption (shown here), or you can get ____ root resorption (next slide)
too
apical
cervical
Root Resorption
- Root resorption is a process where the bodies own cells start to eat away at the root surface
- Just like with caries, root resorption results in a hole. But it is a completely different process (it is ____, and body cells are eating into the ____ structure)
- We may be able to restore some of these if they are not too bad (we use materials compatible for the ____ environment, we do a flap, and try to place MTA, etc.)
- DIFFICULT to treat!
sterile
root
subgingival
Occlusal Trauma Radiographic Signs • \_\_\_\_ PDL • Vertical Bone Loss • Loss of \_\_\_\_ • Osteosclerosis Buttressing Bone • Altered \_\_\_\_ pattern • Root Resorption
widened
lamina dura
trabecular
Occlusal Trauma Radiographically
- This bridge was hitting hard/high. Note the widened ____, and the dense bone. When astronauts go to space, there is no gravity pressure on the bone. If you put excessive pressure on bone, it builds bone density
- The dense bone is known as ____ bone and is just the bodies response to what is going on
- The neighboring tooth has a well defined ____ around it, whereas the affected tooth does not
PDL
buttressing
lamina dura
Buttressing bone
• The dentist saw what looked like a periapical lesion (red arrow), and referred them to have a root canal. The root canal was done (see right pic) but the patient was still in pain. So they were referred to him (periodontist)
- The problem turned out to be the tooth ____ it (it is hard for patients to determine where the pain is coming from)
- The wide ____/____ indicates it is trauma (as opposed to an endo lesion)
behind
PDL
buttressing bone
Occlusal Trauma Histologically Effects the Attachment Apparatus
• Periodontal Ligament
Wide ____ ,Edema, ____, Hemorrage, fibrosis
• Cementum
____ Resorption, cemental tears
• Alveolar Bone
____, Apposition,
PDL
necrosis
root
resorption
This is a monkey. Note we are looking at two teeth, and shown here (yellow arrow) is the septal bone between two teeth
We will look at NORMAL, and then the changes that occur due to PERIODONTAL DISEASE/OCCLUSAL TRAUMA
There are trans-septal fibers (which cover the septal bone)that go from CEJ to
Root surface
CEJ (they are attached right at or below the CEJ)
• Within the sulcus (with JE) is purple. This purple area is ____ cells (we
will always see these, even in a healthy sulcus). These fight off the bacteria that
get into the sulcus
• Keep this picture in mind…we will then see what happens when there is trauma.
inflammatory
- You apply pressure to the tooth/root, compressing the ligament. Note this is what occurs with ____ treatment (ortho is a controlled form of occlusal trauma)
- Compressing of the PDL, and you start getting ____ that line up and remove the bone, making room for the tooth to move, or to widen the PDL.
- There is also a signal sent within the ____ that causes some undermining resorption.
ortho
osteoclasts
bone marrow
• This is an example of occlusal trauma
• Widening of the PDL, resorption, and you see less of the bone within this area
• Where is the attachment? It is still up at the CEJ. Important to
distinguish that they’ve lost ____, but NOT ____
• If you take a radiograph, you might see the bone is lower, so you assume it’s periodontal disease. But this is NOT ____ disease, it is what you’d expect with ____ trauma
bone
attachment
perio
occlusal
- What happens when you stop the trauma (take braces off, or patient is no longer bruxing, etc.)?
- Bone regrows and ____. You can see it looks like tree rings (note the yellow arrow pointing to ____ where bone is reforming)
- The ligament becomes ____ again, as well as the ____ spaces
- If this did not occur, we could never do braces!
recalcifies
laminar lines
narrow
haversian
• You can create periodontal disease in an experimental animal by tying silk ligatures around the teeth that harbor dense bands of bacteria
- Note the attachment loss on the left, whereas the attachment on the right side is normal
- On the left, if you put a perio probe in, you’d fall really deep, but on the right you have a normal pocket (orange arrows)
- The loss of attachment is due to ____ disease (loss of bone and loss of attachment are not the same thing)
periodontal
- Here we have experimental periodontal disease, but he also put separators between the teeth to displace them. The tooth becomes high, causing occlusal trauma
- This is combining occlusal trauma + periodontal disease
- RIGHT SIDE: Example of normal (normal ligament, attachment is at the CEJ)
- LEFT SIDE: periodontal disease (presence of a ____, as well as a widened ____) as well as ____ loss
- So the bone is being attacked both from ____ as well as the ____ process (cofactors of destruction).
- Occlusal problems do not cause ____ disease. But if you have periodontal disease with trauma, the disease may be more severe
pocket PDL bone trauma disease periodontal
- This patient has both perio disease + occlusal trauma
- It looks like there is no bone at all (yellow arrow), but when he probed it did not feel like he was going all the way down to the apex. So he thought some of what he was dealing with was due to occlusal trauma
- Here is the patient 23 years later (they were able to save the teeth)
- So despite the bone loss/loss of lamina dura, they were able to ____ the teeth
- Formation of ____ indicates that the bone is stable.
- He does not look at the level of bone as much as he does the health. Even if the bone level is low, if it is ____ (no bleeding, no excessive depth, presence of lamina dura) then it can usually be maintained. This case is an example
save
lamina dura
healthy
- You can change the ____ of the periodontal pockets by moving the teeth.
- We haven’t actually grown more bone to fill the pocket, but rather it is an anatomical thing
- If the tooth is at an angle and there is a deep pocket, as the tooth begins to go ____, the point of attachment remains constant (you can level periodontal pockets/defects by changing tooth position)
morphology
upright
- 25 years later the lesions have consolidated and everything is stable
- In this case we may have something called “____” (see arrow) meaning it is not actually reattached to the tooth, but everything is stable and there is no deep ____
long epithelium
probing depth
- Same patient in the lower
- This is pre-treatment – note the lesion (no lamina dura)
• 25 years later we can see a well-defined ____
• So even though we’ve lost a lot of attachment, this is a stable
situation
• Oral surgeons and some dentists will recommend taking teeth out early when there is advanced disease like this so that the bone can stabilize and we can put implants in. But he says that if we were to place an implant, the head of the implant would be really low, and we may not be able to attach the crown.
• “The theory of getting the teeth out early to preserve the bone is not one that I subscribe to”
lamina dura
Preventing Occlusal Trauma
• Basic Occlusion
• Cusp to fossa relationship
• Buccal occlusal line angle of the lower articulates in the
central fossa of the ____
• The lingual occlusal line angle (blue) of the upper in the central fossa of the lower
• The green is the FOA in which all contact should occur when the patient does lateral excursions
upper
Cusp to fossa forces on long axis
- This ____ relationship is important because if it is secure/stable, the forces are directed along the ____ axis of the teeth (or the implant)
- This is the way the system is best designed to receive forces
cusp to fossa
long
BUCCOLINGUAL LANDMARKS
• ____ line angle of mandible will be related to central fossa line of maxillary teeth; ____ line of maxilla will be related to central fossa line of mandibular teeth
• Again, CUSP to FOSSA relationship
• The way we extract teeth is by ____ them off axis (buccal-
lingually). We rotate them, we do not just push the tooth
straight up
bucco-occlusal
linguo-occlusal
wiggling
Non axial loading
- What if we have off-axis loading (rather than cusp to fossa relationship we have a cusp to incline relationship)
- The bottom tooth is being pressed on an ____. This pushes the tooth in this direction (red arrow), ____ the PDL on one side (blue), and ____ the PDL on the other (green)
- On the upper tooth, it is the opposite
incline
compressing
stretching
RESTORATIVELY INCORRECT RELATIONSHIPS
- This person spent lots of money for these crows, and they got a ____ relationship.
- This creates lots of forces that displace the teeth and can cause them to ____
cusp to cusp
break
Restoratively Incorrect
• If you make a partial denture, you can’t just have them biting on the partial denture ____. It causes trauma on these teeth (red arrows)
clasp
Periodontal ligament loading
• We want the forces to be directed along the long axis
• If not we have a ____ rotation on the tooth. We get
compression here and here (red), and stretching of the ligament here and here (green)
• This can result in ____ of the teeth/restorative elements
and enhanced periodontal disease
central
fracturing
Restoratively incorrect relationships
- Go back in time and imagine what the tooth looked like before, and what we have to do to make it look right
- This tooth was lost, and this one started to drift. As teeth drift, they tilt. This causes one cusp to become higher, which is probably what caused this cusp to break.
- There is a plastic denture tooth going against a normal tooth. This wears on the ____, causing the tooth to erupt
* This tooth wear down allowing the one above it to ____ - You have to look at things, know your occlusion and what things should look like. Do what you know is right! The closer you can come to ideal occlusion, the less likely you will have deflecting contacts and trauma to the teeth.
enamel
supererupt
BASIC RULES OF OCCLUSION
____ simultaneous contact
Both sides have to touch at the same time
Compatible ____ dimension and freeway space
Freedom to move out of centric by providing proper ____ guidance
(no ____ interferences)
The jaw has to move to either side without any interferences
bilateral
vertical
anterior
bite
BASIC RULES OF OCCLUSION
Teeth (Implants) and cusps are aligned to direct forces on their ____ axis
Proper ____ cusptofossa relationship
long
buccal-lingual
Mutually Protected Occlusion ____ teeth should support the occlusion on their long axis
Anterior teeth should disarticulate the ____ teeth in all jaw movements
Anything that disrupts this rule can lead to ____ trauma
posterior
posterior
occlusal
Anterior disarticulation
- The functional outer aspect rides down the ____ (left) and you get immediate disarticulation (right)
- How much clearance you get in the back depends on two things: • 1. How steep is your ____?
- How steep is your ____? As you open and the jaw translates/comes down the eminence, you are going to get posterior opening occuring
guiding incline
guidance
condylar inclination
Working side
Side to which ____ has been moved in ____ contacting (glide) movement
• When the jaw is moving you have a working side as well as a non- working side
mandible
lateral
Nonworking side
Side of mandible ____ to the direction to which mandible has been moved in ____ contacting (glide) movement
opposite
lateral
Canine guidance
• You also have guidance. This is canine guidance where the canines hit and ____ everything else
• The canines are the cornerstone of the mouth. Usually long roots and very stable.
• Canine protected occlusion
• “I like canine guidance…the canines seem to protect the
____ as you go into movements”
• But what if the canine is periodontally mobile, or it is fragile, it has posts and composites, etc. and you do not trust it to take all the pressure? Then you may want to do ____ (next slide)
disarticulate
posteriors
group function
Group function
• Group Function
• As the patient slides to the side, you have ____ teeth
that will disarticulate
multiple
MALOCCLUSION
Orthodontic variation from the normal occlusion. May be ____ or pathologic. Though not pathologic, we may treat for cosmetic or functional reasons
- Some patients have malocclusions. If you have orthodontic variation (crooked teeth), it is not a ____ (crooked teeth is not a disease).
- It is treated (for cosmetic purposes), but orthodontic treatment does not necessarily make it more healthy. In fact, some evidence suggests there is ____ to ortho treatment (possible root resorption, etc.)
physiologic
pathology
risk
Class II occlusion
• However if you have this class II occlusion, the patient may not have ____ guidance (they are not hitting)
protrusive
Class III occlusion
• Same with class III. Does anyone see the pathology in this occlusion?
• This is ____ wear (red arrows)
• This abnormal wear is because the patient is not coming
____. The lower incisors belong behind the upper incisors, but this patient has a class III relationship causing posterior wear.
So ____ malocclusions
may lead to occlusal trauma, but it is not in and of itself a disease
abnormal
forward
orthodontic
PHYSIOLOGIC OR FUNCTIONAL OCCLUSION
One that is absent of disease and stable over time. May vary significantly from the normal or ____ occlusion. Allows for acceptable chewing, esthetics, phonetics, and periodontal health, is free of caries, excessive ____, tmj or myofacial pain signs or symptoms and there is a ____ occlusal sense. In a state of balance between injury and repair
ideal
wear
negative
Physiologic or functional occlusion
- Physiologic occlusion means it is working for the patient. It may not be ideal or look pretty, but it is absent of disease, it is stable over time, it is acceptable for chewing esthetics, phonetics, and periodontal health. There is not a lot of caries or excessive wear of the teeth, there is no TMJ or myofacial pain. There is ____ (you are not aware of what you teeth are doing/how they are touching, similar to how are not always aware of your breathing)
- A ____ is created when you get a filling and it feels high. Even after you shave it down, there is a small percentage of people that never quite feel right again (you’ve created a positive occlusal sense for them). At some point you have to recognize it may not be the bite, but rather a ____ problem. These patients are often ____ and often have other ____ in their life (divorce, job loss, etc.) and they are now focusing in on their mouth. It may require counseling beyond our scope.
- Physiologic occlusion is a state of balance between ____
negative occlusal sense positive occlusal sense psychological females stresses injury and repair
PATHOLOGIC OCCLUSION
One that does not meet the standards of a physiologic occlusion.
May exhibit:
• ____ symptoms (Pain noises, Trismus, locking
• Signs and symptoms of ____
TMJ or myofacial
occlusal trauma
Occlusal Trauma
• Primary-____ support,excessive force (magnitude,duration
frequency, direction).
• Secondary-____ support
• Primary
• Normal tooth, but there is too much force
• Maybe the crown is ____, or maybe the patient is a bruxer,
and the teeth are hitting harder than normal and now
showing ____
- Secondary
- The forces on the tooth may be completely normal, but the patient has lost ____ so that the normal forces become excessive
- If you look at the PDL histologically, you can’t really tell if it is primary or secondary. You have to look at the big picture and see how much support the tooth has to make that determination
adequate
inadequate
high
mobility
attachment
Predisposing Factors for Occlusal Trauma
- ____, interferences, premature occlusal contacts
- Disharmony of ____ and TMJ relationship
- ____, clenching, parafunctional habits
- ____
- ____ of teeth and subsequent tooth migration
- Faulty ____ on dental restorations and appliances
malocclusion bruxism caries extraction construction
Predisposing Factors for Occlusal Trauma
- Faulty ____ positioning of teeth
- Faulty ____ adjustment
- Displacement of teeth by ____ or neoplasm
- Loss of ____ support
orthodontic
occlusal
inflammation
periodontal
• There are different types of bruxism:
• ____ (coming down hard and squeezing)
• ____ (putting pressure and sliding all around)
• ____ (a nervous habit where they put the tips of their
canines together and make circles/play around)
• ____
clenching
grinding
doodling
mouth to object
Bruxism
• ____ Occurence Males and Females
• Prevalence 80-90%
• Most People ____ at first inquiry
equal
unaware
