Vol. 26, No.

1 January 2004
Trauma from occlusion: a review
Commander R. Dave Rupprecht, DC, !N
Introduction
"cclu#$on and $t# relat$on#h$p to per$odontal d$#ea#e ha# %een and rema$n#
an area o& con#$dera%le controver#y. "ver the year#, there have %een a
num%er o& human and an$mal #tud$e# $nve#t$'at$n' th$# relat$on#h$p. (he
purpo#e o& th$# Cl$n$cal pdate $# to #ummar$)e prev$ou# re#earch,
de#cr$%e the #$'n# and #ymptom# o& trauma &rom occlu#$on, and d$#cu##
treatment con#$derat$on#.
Definitions
*e&ore d$#cu##$n' trauma &rom occlu#$on, a rev$e+ o& commonly u#ed
de&$n$t$on# +$ll help &ac$l$tate under#tand$n' o& th$# #u%,ect.
Occlusal Trauma: -n $n,ury to the attachment apparatu# a# a re#ult o&
e.ce##$ve occlu#al &orce /10. "cclu#al trauma $# the t$##ue $n,ury, and not
the occlu#al &orce. "cclu#al trauma can %e d$v$ded $nto 1 'eneral
cate'or$e#2
10 Primary Occlusal Trauma: 3n,ury re#ult$n' &rom e.ce##$ve occlu#al
&orce# appl$ed to a tooth or teeth +$th normal #upport /10. 4.ample#
$nclude h$'h re#torat$on#, %ru.$#m, dr$&t$n' or e.tru#$on $nto edentulou#
#pace#, and orthodont$c movement.
20 Secondary Occlusal Trauma: 3n,ury re#ult$n' &rom normal occlu#al
&orce# appl$ed to a tooth or teeth +$th $nade5uate #upport /10.
10 Combined Occlusal Trauma: 3n,ury &rom an e.ce##$ve occlu#al &orce
on a d$#ea#ed per$odont$um /20. 3n th$# ca#e, there $# '$n'$val
$n&lammat$on, #ome poc6et &ormat$on, and the e.ce##$ve occlu#al &orce#
are 'enerally &rom para&unct$onal movement#.
Traumatogenic Occlusion: -ny occlu#$on that produce# &orce# that cau#e
an $n,ury to the attachment apparatu# /10.
Occlusal Traumatism: (he overall proce## %y +h$ch a traumato'en$c
occlu#$on produce# $n,ury $n the per$odontal attachment apparatu# /10.
Background
-# &ar %ac6 a# 100 year# a'o, $t +a# &elt that occlu#$on played a #$'n$&$cant
part $n per$odontal d$#ea#e /40 and the &ormat$on o& vert$cal cle&t# /7,60.
8l$c6man /9,:0 propo#ed the Theory of Codestruction to e.pla$n the
relat$on#h$p %et+een occlu#$on and per$odontal d$#ea#e. ;e de#cr$%ed t+o
re'$on# $n the per$odont$um2 the zone of irritation /mar'$nal and
$nterdental '$n'$va and '$n'$val and tran#eptal &$%er#0 and the zone of
codestruction /per$odontal l$'ament, alveolar %one, cementum, tran#eptal
and alveolar cre#t &$%er#0. ;e &elt that pla5ue $nduced '$n'$val
$n&lammat$on +a# con&$ned to the )one o& $rr$tat$on. "cclu#al &orce# or
traumato'en$c occlu#$on e&&ected the )one o& code#truct$on %ut d$d not
cau#e '$n'$val $n&lammat$on. ;o+ever, occlu#al trauma to'ether +$th
pla5ue $nduced $n&lammat$on acted a# code#truct$ve &orce# re#ult$n' $n an
alterat$on o& the normal path+ay o& $n&lammat$on and the &ormat$on o&
an'ular %ony de&ect# and $n&ra%ony poc6et#.
3n contra#t to the code#truct$ve theory, <aerhau' /=,100 %el$eved there +a#
no proo& that occlu#al trauma cau#ed or acted a# a co&actor $n the
&ormat$on o& an'ular de&ect#. ;e %el$eved that $n&ra%ony poc6et# +ere
a##oc$ated +$th the advanc$n' plaque front or ap$cal 'ro+th o&
#u%'$n'$val pla5ue and the &ormat$on o& e$ther hor$)ontal or an'ular %one
de&ect# +ere dependent on the +$dth o& the $nterpro.$mal %one. (eeth
+$th narro+ $nterpro.$mal %one develop hor$)ontal de&ect# +h$le teeth
+$th +$de $nterpro.$mal %one +ere more l$6ely to develop an'ular or
vert$cal de&ect#.
- num%er o& an$mal #tud$e# u#$n' the !5u$rrel >on6ey /11,12,11,140 and
*ea'le Do' /17,16,19,1:,1=,200 evaluated the e&&ect# o& e.ce##$ve ,$''l$n'
&orce# $n the pre#ence o& e.per$mentally $nduced per$odont$t$#. (he#e t+o
'roup# d$&&ered $n #ome o& the$r &$nd$n'# +h$ch may have %een due to
d$&&erence# $n #tudy de#$'n and the an$mal model ut$l$)ed.
Clinical Update
Naval Postgraduate Dental School
National Naval Dental Center
8901 Wisconsin Ave
Bethesda, Maryland 0889!"#0
27
(he conclu#$on# o& the#e #tud$e# are a# &ollo+#2
10 "cclu#al trauma doe# not $n$t$ate '$n'$val $n&lammat$on.
20 3n the a%#ence o& $n&lammat$on, a traumato'en$c occlu#$on +$ll re#ult
$n $ncrea#ed mo%$l$ty, +$dened ?D@, lo## o& cre#tal %one he$'ht and %one
volume, %ut no attachment lo##.
10 3n the pre#ence o& '$n'$val $n&lammat$on, e.ce##$ve ,$''l$n' &orce#
d$d not cau#e accelerated attachment lo## $n #5u$rrel mon6ey# %ut
$ncrea#$n' occlu#al &orce# may accelerate attachment lo## $n %ea'le do'#.
40 (reat$n' the '$n'$val $n&lammat$on $n the pre#ence o& cont$nu$n'
mo%$l$ty or ,$''l$n' trauma +$ll re#ult $n decrea#ed mo%$l$ty and $ncrea#ed
%one den#$ty, %ut no chan'e $n attachment level or alveolar %one level.
Signs and Symptoms
<hen evaluat$n' a pat$ent #u#pected o& hav$n' occlu#al trauma there are a
num%er o& cl$n$cal and rad$o'raph$c #ymptom# that may %e pre#ent. (he#e
$nd$cator# o& trauma &rom occlu#$on may $nclude one or more o& the
&ollo+$n' /21,2202
Cl$n$cal
10 >o%$l$ty /pro're##$ve0
20 ?a$n on che+$n' or percu##$on
10 Arem$tu#
40 "cclu#al prematur$t$e#Bd$#crepanc$e#
70 <ear &acet# $n the pre#ence o& other cl$n$cal $nd$cator#
60 (ooth m$'rat$on
90 Ch$pped or &ractured tooth /teeth0
:0 (hermal #en#$t$v$ty
Rad$o'raph$c
10 <$dened ?D@ #pace
20 *one lo## /&urcat$on#C vert$calC c$rcum&erent$al0
10 Root re#orpt$on
Therapeutic goals and treatment considerations
- 'oal o& per$odontal therapy $n the treatment o& occlu#al traumat$#m
#hould %e to ma$nta$n the per$odont$um $n com&ort and &unct$on. 3n order
to ach$eve th$# 'oal a num%er o& treatment con#$derat$on# mu#t %e
con#$dered $nclud$n' one or more o& the &ollo+$n' /2202
10 "cclu#al ad,u#tment
20 >ana'ement o& para&unct$onal ha%$t#
10 (emporary, prov$#$onal or lon'Dterm #ta%$l$)at$on o& mo%$le teeth
+$th remova%le or &$.ed appl$ance#
40 "rthodont$c tooth movement
70 "cclu#al recon#truct$on
60 4.tract$on o& #elected teeth
"cclu#al ad,u#tment or #elect$ve 'r$nd$n' $# de&$ned a# re#hap$n' the
occlud$n' #ur&ace# o& teeth %y 'r$nd$n' to create harmon$ou# contact
relat$on#h$p# %et+een the upper and lo+er teeth /10. Ju#t a# controver#y
#urround# the #u%,ect o& trauma &rom occlu#$on and $t# role $n the
pro're##$on o& per$odontal d$#ea#e, the #ame $# al#o true re'ard$n' the
#u%,ect o& occlu#al ad,u#tment. (he 1=:= <orld <or6#hop $n ?er$odont$c#
l$#ted the &ollo+$n' $nd$cat$on# and contra$nd$cat$on# &or occlu#al
ad,u#tment /210.
3nd$cat$on# &or "cclu#al -d,u#tment
10 (o reduce traumat$c &orce# to teeth that e.h$%$t2
3ncrea#$n' mo%$l$ty or &rem$tu# to encoura'e repa$r +$th$n the
per$odontal attachment apparatu#.
D$#com&ort dur$n' occlu#al contact or &unct$on.
20 (o ach$eve &unct$onal relat$on#h$p# and ma#t$catory e&&$c$ency $n
con,unct$on +$th re#torat$ve treatment, orthodont$c, ortho'nath$c #ur'ery
or ,a+ trauma +hen $nd$cated.
10 -# ad,unct$ve therapy that may reduce the dama'e &rom
para&unct$onal ha%$t#.
40 (o re#hape teeth contr$%ut$n' to #o&t t$##ue $n,ury.
70 (o ad,u#t mar'$nal r$d'e relat$on#h$p# and cu#p# that are contr$%ut$n'
to &ood $mpact$on.
Contra$nd$cat$on# &or "cclu#al -d,u#tment
10 "cclu#al ad,u#tment +$thout care&ul pretreatment #tudy,
documentat$on, and pat$ent educat$on.
20 ?rophylact$c ad,u#tment +$thout ev$dence o& the #$'n# and #ymptom#
o& occlu#al trauma.
10 -# the pr$mary treatment o& m$cro%$alD$nduced $n&lammatory
per$odontal d$#ea#e.
40 (reatment o& %ru.$#m %a#ed on a pat$ent h$#tory +$thout ev$dence o&
dama'e, patho#$#, or pa$n.
70 <hen the emot$onal #tate o& the pat$ent preclude# a #at$#&actory
re#ult.
60 3n#tance# o& #evere e.tru#$on, mo%$l$ty or malpo#$t$on$n' o& teeth that
+ould not re#pond to occlu#al ad,u#tment alone.
- num%er o& #tud$e# have reported that the pre#ence o& occlu#al
d$#crepanc$e# $# not a##oc$ated +$th $ncrea#ed de#truct$on cau#ed %y
per$odontal d$#ea#e /24,27,260. *ur'ett /290 &ound that pat$ent# +ho
rece$ved occlu#al ad,u#tment a# a part o& per$odontal treatment had a
#tat$#t$cally 'reater 'a$n $n attachment level than tho#e +ho d$d not
rece$ve an occlu#al ad,u#tment. <h$le the#e re#ult# may have %een
#tat$#t$cally #$'n$&$cant, the#e #mall d$&&erence# d$d not have cl$n$cal
#$'n$&$cance. (he 1==6 <orld <or6#hop $n ?er$odont$c# /10 &ound l$ttle
recent re#earch on the role o& occlu#$on $n per$odontal d$#ea#e. 3t al#o
&ound no pro#pect$ve controlled #tud$e# on the role o& occlu#$on on
untreated per$odontal d$#ea#e and that eth$cal con#$derat$on# ma6e $t
unaccepta%le to per&orm #uch #tud$e#. Recently, a pa$r o& human #tud$e#
&ound that teeth +$th $n$t$al occlu#al d$#crepanc$e# had #$'n$&$cantly
deeper $n$t$al pro%$n' depth#, 'reater mo%$l$ty and a +or#e pro'no#$# than
teeth +$thout $n$t$al occlu#al d$#crepanc$e#. (he#e #tud$e# al#o &ound that
treatment o& occlu#al d$#crepanc$e# #$'n$&$cantly reduced the pro're##$on
o& per$odontal d$#ea#e and can %e an $mportant &actor $n the overall
treatment o& per$odontal d$#ea#e /2:,2=0.
3t $# 'enerally accepted that occlu#al ad,u#tment d$rected #olely at
e#ta%l$#h$n' an $deal conceptual$)ed pattern $# contra$nd$cated. Rather, $t
#hould only %e per&ormed +hen the o%,ect$ve $# to &ac$l$tate treatment or
$ntercept act$vely de#truct$ve &orce#. <hen occlu#al therapy $# planned a#
part o& per$odontal treatment, $t $# u#ually de&erred unt$l $n$t$al therapy
a$med at m$n$m$)$n' $n&lammat$on throu'hout the per$odont$um ha# %een
completed. (h$# $# %a#ed upon the &act that $n&lammat$on alone can
contr$%ute #$'n$&$cantly to a toothE# mo%$l$ty.
(he &ollo+$n' are $nd$cat$on# and contra$nd$cat$on# &or #pl$nt$n' a# l$#ted
$n the 1=:= <orld <or6#hop $n ?er$odont$c# /210.
3nd$cat$on# &or !pl$nt$n'
10 !ta%$l$)e teeth +$th $ncrea#$n' mo%$l$ty that have not re#ponded to
occlu#al ad,u#tment and per$odontal treatment.
20 !ta%$l$)e teeth +$th advanced mo%$l$ty that have not re#ponded to
occlu#al ad,u#tment and treatment +hen there $# $nter&erence +$th normal
&unct$on and pat$ent com&ort.
10 Aac$l$tate treatment o& e.tremely mo%$le teeth %y #pl$nt$n' them pr$or
to per$odontal $n#trumentat$on and occlu#al ad,u#tment procedure#.
40 ?revent t$pp$n' or dr$&t$n' o& teeth and e.tru#$on o& unoppo#ed teeth.
70 !ta%$l$)e teeth, +hen $nd$cated, &ollo+$n' orthodont$c movement.
60 Create ade5uate occlu#al #ta%$l$ty +hen replac$n' m$##$n' teeth.
90 !pl$nt teeth #o that a root can %e removed and the cro+n reta$ned $n
$t# place.
:0 !ta%$l$)e teeth &ollo+$n' acute trauma.
Contra$nd$cat$on# &or !pl$nt$n'
10 <hen the treatment o& $n&lammatory per$odontal d$#ea#e ha# not %een
addre##ed.
20 <hen occlu#al ad,u#tment to reduce trauma and Bor $nter&erence# ha#
not %een prev$ou#ly addre##ed.
10 <hen the #ole o%,ect$ve o& #pl$nt$n' $# to reduce tooth mo%$l$ty
&ollo+$n' the removal o& the #pl$nt.
!tud$e# have #ho+ed an $ncrea#e $n %one lo## and attachment lo## $n teeth
+$th mo%$l$ty /100 and &rem$tu# /260. (ooth mo%$l$ty can %e cau#ed %y a
num%er o& rea#on# $nclud$n', trauma &rom occlu#$on, lo## o& alveolar %one
and per$odontal attachment and per$odontal $n&lammat$on. 3n &act,
#pl$nt$n' teeth that are $n hyperoclu#$on may %e detr$mental to other teeth
$n the #pl$nt /110. - num%er o& #tud$e# have #ho+ed no d$&&erence $n
teeth that +ere #pl$nted dur$n' or a&ter $n$t$al therapy /#cal$n' and root
plan$n'0, or o##eou# re#ect$ve #ur'ery compared to teeth that +ere not
#pl$nted /12,110. <h$le the data $# l$m$ted, $t may %e prudent to l$m$t a
toothE# mo%$l$ty $n e.ce##$vely mo%$le teeth +hen con#$der$n' re'enerat$ve
procedure# /140.
Summary
<h$le the role o& occlu#$on $n the pro're##$on o& per$odontal d$#ea#e ha#
%een d$#cu##ed and #tud$ed &or over 100 year# $t ha# %een and rema$n# a
controver#$al #u%,ect. 3t $# +ell under#tood that trauma &rom occlu#$on
doe# not $n$t$ate or accelerate attachment lo## due to $n&lammatory
26
per$odontal d$#ea#e. ;o+ever, 5ue#t$on# #t$ll rema$n on the relat$on#h$p
%et+een trauma &rom occlu#$on a##oc$ated +$th pro're##$vely $ncrea#$n'
tooth mo%$l$ty cau#$n' an accelerated attachment lo## $n pat$ent# +$th
$n&lammatory per$odontal d$#ea#e. Aor the#e rea#on# +hen treat$n'
per$odontal pat$ent# +$th occlu#al $##ue# the &$r#t a$m o& therapy #hould %e
d$rected at allev$at$n' pla5ueD$nduced $n&lammat$on. "nce th$# ha# %een
accompl$#hed e&&ort# can then %e d$rected at ad,u#t$n' the occlu#$on. (h$#
may re#ult $n a decrea#e $n mo%$l$ty, decrea#e $n the +$dth o& the
per$odontal l$'ament #pace, $ncrea#e $n overall %one volume. A$nally, $n
ca#e# planned &or re'enerat$ve therapy, con#$derat$on to #ta%$l$)$n' mo%$le
teeth #hould al#o %e '$ven pr$or to #ur'$cal $ntervent$on.
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2:. Nunn >4, ;arrel !F. (he e&&ect o& occlu#al d$#crepanc$e# on
?er$odont$t$#. 3. Relat$on#h$p o& $n$t$al occlu#al d$#crepanc$e# to $n$t$al
cl$n$cal parameter#. J ?er$odontol 2001 -prC92/4024:7D=4.
2=. ;arrel !F, Numm >4. (he e&&ect o& occlu#al d$#crepanc$e# on
?er$odont$t$#. 33. Relat$on#h$p o& occlu#al treatment to the pro're##$on o&
per$odontal d$#ea#e. J ?er$odontol 2001 -prC92/4024=7D707.
10. <an' ;@, *ur'ett A8, !hyr H, Ram&,ord !. (he $n&luence o& molar
&urcat$on $nvolvement and mo%$l$ty on &uture cl$n$cal per$odontal
attachment lo##. J ?er$odontol 1==4 JanC67/10227D=.
11. 8l$c6man 3, !te$n R!, !mulo+ J*. (he e&&ect o& $ncrea#ed &unct$onal
&orce# upon the per$odont$um o& #pl$nted and nonD#pl$nted teeth. J
?er$odontol 1=61 JulC12/1022=0D100.
12. Fe'el <, !el$p#6y ;, ?h$ll$p# C. (he e&&ect o& #pl$nt$n' on tooth
mo%$l$ty. 3. Dur$n' $n$t$al therapy. J Cl$n ?er$odontol 1=9= Ae%C6/10247D7:.
11. 8aller C, !el$p#6y ;, ?h$ll$p# C, -mman# <A Jr. (he e&&ect o&
#pl$nt$n' on tooth mo%$l$ty. 33. -&ter o##eou# #ur'ery. J Cl$n ?er$odontol
1=9= "ctC6/702119D11.
14. 8arrett !. ?er$odontal re'enerat$on around natural teeth. -nn
?er$odontol 1==6 NovC1/102621D66.
Commander R. Dave Rupprecht $# a 'raduate o& the ?er$odont$c#
pro'ram at the Naval ?o#t'raduate Dental !chool and $# currently D$rector
o& the 71 -rea Dental Cl$n$c at 1
#t
Dental *attal$on Camp ?endleton, C-.
(he author +$#he# to than6 Capta$n *r$an A. ?aul, !ta&& ?er$odont$#t at !
Naval Dental Center >$dD-tlant$c, Nor&ol6, V-, &or rev$e+$n' th$#
Update &or accuracy and relevancy.
(he op$n$on# or a##ert$on# conta$ned $n th$# art$cle are the pr$vate one# o&
the author# and are not to %e con#trued a# o&&$c$al or re&lect$n' the v$e+# o&
the Department o& the Navy.
29