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Periodontology 2000, Vol.

34, 2004, 151±164 Copyright # Blackwell Munksgaard 2004


Printed in Denmark. All rights reserved PERIODONTOLOGY 2000

Occlusal analysis, diagnosis and


management in the practice of
periodontics
William W. Hallmon & Stephen K. Harrel

Occlusal trauma is de®ned as injury resulting in tissue occlusion on the periodontium and the role that
changes within the periodontal attachment apparatus occlusion may play in periodontal disease. The con-
as a result of occlusal forces (1). The controversy that sensus report of the International Workshop group
surrounds this condition including recognition, diag- evaluating occlusion adopted the following working
nosis, effects, and management, has been widely de®nitions for occlusal trauma. These de®nitions are
debated since the early part of the 20th century (8, critical to the clinical evaluation, diagnosis, and
48, 97, 98). Since occlusal trauma can only be con- treatment of occlusion in periodontal disease (1).
®rmed histologically, the clinician is challenged to Occlusal trauma ± Injury resulting in tissue
use clinical and radiographic surrogate indicators in changes within the attachment apparatus as a result
an attempt to facilitate and assist in its diagnosis. of occlusal force (s).
This chapter will focus on the role of occlusal Primary occlusal trauma ± Injury resulting in tissue
analysis, tooth mobility and occlusal therapy in the changes from excessive occlusal forces applied to a
clinical practice of periodontics. Diagnostic and ther- tooth or teeth with normal support (Fig. 1). It occurs
apeutic approaches and effects on treatment out- in the presence of: 1) normal bone levels, 2) normal
comes will be reviewed and discussed. In an attachment levels, and 3) excessive occlusal force (s)
attempt to facilitate this process, the following ques- (Fig. 1).
tions will be addressed: Secondary occlusal trauma ± Injury resulting in
 What is occlusal trauma? tissue changes from normal or excessive occlusal
 What is the role of occlusion in the pathogenesis of forces applied to a tooth or teeth with reduced sup-
periodontitis? port (Fig. 2). It occurs in the presence of: 1) bone loss,
 How is occlusal trauma detected clinically? 2) attachment loss, and 3) normal/excessive occlusal
 What is abfraction and are there data to support a force (s) (Fig. 2).
role for occlusion in its development?
 What methods are used to detect hypermobility of
teeth? Of what value are assessments of tooth mobi-
lity in the management of periodontitis patients?
What is the role of occlusion in the
 Under what clinical circumstances is occlusal pathogenesis of periodontal
adjustment indicated? Following occlusal adjust- disease?
ment, what clinical outcomes are expected and
how are they evaluated? Occlusal trauma has been associated with periodon-
tal disease for over 100 years. In 1901, Karolyi (48)
reported an apparent association between excessive
What is occlusal trauma? occlusal forces and periodontal destruction. In 1917
and 1926, Stillman (96, 97) indicated that excessive
The International Workshop for a Classi®cation of occlusal force was the primary cause of periodontal
Periodontal Diseases and Conditions in 1999 evalu- disease. Stillman felt that occlusal forces must be
ated the available materials relating to the effects of controlled in order to prevent and treat periodontal

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Hallmon & Harrel

disease. These early reports created a background for


controversy that continues to this day:
 Is there an association between excessive occlusal
forces and the progression of periodontal disease?
 How are occlusal forces evaluated in a clinical
setting and at what point does an occlusal force
become ``excessive''?
 When an occlusal force is detected and the deter-
mination is made that it is excessive, when should
treatment be initiated and how should this treat-
ment be accomplished?
To effectively evaluate the role of occlusal trauma
in periodontal disease, it is necessary to review stu-
dies that have used human autopsy material or ani-
mal models. As previously stated, several early
authors felt that occlusal forces were the initiating
factor in periodontal disease and led to the ongoing
progression of the periodontal lesion. The associa-
tion between occlusion and periodontal disease was
based on clinical observation as opposed to scienti®c
evaluation. In an attempt to demonstrate this rela-
tionship, several animal studies on sheep and mon-
Fig. 1. Primary occlusal trauma results from excessive
keys were conducted. These studies were an attempt
occlusal forces applied to a tooth with normal support.
Note that the center of rotation is near the middle of the to determine the response of the periodontium to
root. (From: T. G. Wilson Jr. et al. Advances in periodontics, occlusal forces both clinically and histologically (8,
1992. Printed with permission, Quintessence Publishing 98). The authors of these studies felt that their ®nd-
Co., Inc.). ings showed that excessive occlusal forces were a
contributing factor in the progression of periodontal
disease. By the end of the 1930's, many practitioners
felt that excessive occlusal forces (occlusal trauma)
were a causative factor in periodontal disease, that
occlusal adjustment was a necessary part of period-
ontal treatment, and that occlusal discrepancies
should be prophylactically treated to prevent period-
ontal disease (9, 60).
The role of excessive occlusal forces in the patho-
physiology of periodontal disease has been disputed
by several researchers. Orban & Weinmann in 1933
(70) and Weinmann in 1941 (109), using human
autopsy material, evaluated the effect of excessive
occlusal forces on the periodontium. They concluded
that there was no relationship between occlusal
forces and periodontal destruction and suggested
that occlusal forces played no part in periodontal
destruction. Instead, they indicated that gingival
in¯ammation extending into the supporting bone
was the cause of periodontal destruction.
During the 1950's and 1960's, further animal
Fig. 2. Secondary occlusal trauma results from excessive research using rats, monkeys, and dogs evaluated
occlusal forces applied to a tooth with reduced support.
the effect of occlusal forces on the periodontium
Note that the center of rotation is in the apical third of the
root. (From: T. G. Wilson Jr. et al. Advances in periodontics,
(13, 20, 59, 73, 110). The designs of these studies were
1992. Printed with permission, Quintessence Publishing more controlled than most of the earlier investiga-
Co., Inc.). tions. The results from these studies did not support

152
Occlusal analysis, diagnosis and management in periodontics

the concept that excessive occlusal force was a cau- eous defects and any associations with the presence
sative agent of periodontal destruction. Further, or absence of excessive occlusal forces. He found that
many of the studies showed no obvious association the ``plaque front'' (i.e. the apical border of the sub-
between occlusal forces and periodontal disease. gingival plaque) was always in very close approxima-
In contrast to the above noted studies, at approxi- tion to the epithelial attachment level and always
mately the same time Glickman and co-workers pub- followed the morphology of the bony defect. In addi-
lished studies based on animal models and human tion, the relationship of the plaque level between
autopsy material. Animal studies using a heavy adjacent teeth (either at the same or different apico-
occlusal contact created by placing a ``high'' restora- coronal levels) was associated with either horizontal
tion were performed utilizing dogs and monkeys (30, or vertical interproximal bone loss. He also observed
33). While these studies showed no evidence of initia- that excessive occlusal forces bore no relationship to
tion of periodontal disease by occlusal contacts, the the underlying bony defect and that vertical defects
authors felt that a study using rhesus monkeys were found equally around traumatized and non-
demonstrated a phenomenon described as an traumatized teeth. Waerhaug concluded that bone
``altered pathway of destruction'' when excessive loss was always associated with the downgrowth of
occlusal forces were present (31). This altered path- plaque and there was no relationship between exces-
way of destruction was described as a change in the sive occlusal forces and vertical bone loss.
orientation of the periodontal and gingival ®bers The use of human autopsy material to study the
which occurred in the presence of excessive occlusal effect of occlusal forces has the inherent problem
forces, allowing gingival in¯ammation to extend that rarely if ever is there a true understanding of
along the periodontal ligament. The altered pathway the patient's occlusal relationship that existed in life.
of destruction was postulated to cause vertical bony Some knowledge can be obtained by studying the
defects due to in¯ammation and bony destruction wear patterns on the teeth but there is no assurance
following the periodontal ligament. Another animal that the teeth actually occluded in the assumed man-
study (34) showed that bone in bifurcation areas was ner or that wear facets represent current and active
stressed by excessive occlusal force and that bone occlusal trauma. Therefore, any conclusion or obser-
loss in the furcation area was related to these forces. vations based on autopsy material concerning the
Glickman and coworkers also reported evidence of role that occlusal forces may or may not have on
an altered pathway of destruction in studies utilizing the progression of periodontal disease has to be
human autopsy material (30). questioned. A single histologic study (95) evaluated
From these studies, Glickman and co-workers con- the occlusal relationships of four patients prior to the
cluded that excessive occlusal forces in the presence removal of their jaws for cancer therapy. This study
of plaque-associated in¯ammation caused a change did not show a relationship between occlusal forces
in the alignment of the periodontal ligaments, allow- and periodontal disease. However, it is unclear if
ing an altered pathway of in¯ammation/destruction, excessive occlusal forces existed in these patients.
resulting in vertical bony defects. Because there were Two extensive animal studies were performed in
two separate pathologic processes working together the 1970s. These studies evaluated the effect of pla-
to cause bone loss, the process was termed a ``co- que and excessive occlusal forces in the animal mod-
destructive'' effect. Glickman and coworkers sum- els utilized. Unlike most of the earlier investigations,
marized their work in a series of review articles (25, stringent scienti®c controls and designs were used.
27±29, 32). These papers indicated that excessive One series of studies were conducted by Polson and
occlusal forces (trauma from occlusion) were a co- co-workers (47, 71, 76±83) and a different series of
destructive force in the presence of gingival in¯am- studies was performed by Lindhe and co-workers
mation and could lead to vertical osseous defects. (17±19, 55±57, 67, 68, 100±102). Polson's group used
Based on these observations, the use of occlusal squirrel monkeys and mesial±distal compression
adjustment was advocated as part of the treatment forces comparable to orthodontic forces whereas
for existing periodontal disease. Because no evidence Lindhe's group used beagle dogs and applied buc-
existed that excessive occlusal forces initiated peri- cal±lingual forces using a high occlusal contact and a
odontal disease, occlusal adjustment to prevent per- ®nger spring. Both groups investigated excessive
iodontitis was not advocated. occlusal forces in the presence and absence of pla-
Waerhaug (103±105) evaluated a large number of que.
human autopsy specimens to determine the relation- These studies yielded similar results despite the
ship of subgingival plaque to the morphology of oss- different animal models and the different excessive

153
Hallmon & Harrel

occlusal forces used. Excessive occlusal forces in the It has been reported that patients who have occlu-
absence of plaque were found to cause loss of bone sal discrepancies have no more severe periodontal
density and mobility of the affected tooth but no destruction than do patients without occlusal discre-
evidence was found that the occlusal forces alone pancies (46, 51, 74, 84, 85, 94). However, it has also
could cause attachment loss. When the excessive been reported that molars with furcation invasion
occlusal forces were removed, it was noted that the and mobility have greater probing depths than
loss of bone density was reversible. In the presence of molars that are clinically nonmobile (106). The
plaque, in¯ammation of the gingiva and periodontal increased mobility noted in this study may have been
supporting structures were noted and in the pre- due to occlusal factors or to greater loss of bony
sence of excessive occlusal forces and plaque support associated with the furcation involvement.
together there was an indication that more bone Due to the inability to determine whether occlusal
density was lost in both animal models. In the beagle factors or bone loss was initially present, it is impos-
dog model there was evidence of attachment loss sible to draw a clear relationship between occlusal
when plaque and excessive occlusal forces were both discrepancies, mobility, and probing depths from
present. These results were not observed in the squir- this study. Other studies reported that patients who
rel monkey model. received occlusal adjustment as part of their period-
These two series of studies exhaustively evaluated ontal therapy had greater attachment gain than
the relationship of occlusal forces and plaque in an patients who did not receive occlusal adjustment
animal model. They both concluded that there was (10, 21). These studies suggest that occlusal adjust-
no evidence indicating that excessive occlusal force ment should be performed, where indicated, as a
alone will cause loss of attachment. The studies on part of periodontal treatment. A report on risk factors
beagle dogs showed that under speci®c circum- for periodontal destruction indicated that mobility
stances there may be attachment loss when plaque and parafunctional habits that are not treated with
and excessive occlusal forces are both present. Both a biteguard are associated with increased attachment
studies agreed that the removal of plaque and the loss, worsening prognosis, and tooth loss (61). This
control of in¯ammation will stop the progression of study seems to indicate that untreated (i.e. no bite-
periodontal disease whether or not excessive occlusal guard) parafunctional habits may contribute to
forces are present. increased periodontal breakdown. Another study
has shown that mobile teeth treated with regenera-
tive surgery did not respond as well as nonmobile
Human studies teeth (14). However, no association was drawn
between mobility and occlusal forces.
Only a few studies have evaluated the effects of In a series of retrospective reports, private practice
excessive occlusal forces in humans. There are many patients were evaluated who were diagnosed with
ethical dif®culties associated with the non-treatment advanced periodontal disease and had a comprehen-
of diagnosed periodontal disease that complicate sive treatment plan recommended that included sur-
studying the effect of occlusion on the progression gical treatment. Occlusal adjustment was
of periodontal disease. The gold standard of clinical recommended if signi®cant occlusal discrepancies
research is the randomized controlled clinical trial. were detected. Some of these patients self-selected
These studies require prospective comparisons of to not have any periodontal treatment performed
different treatment methods on treatment outcomes. (untreated group). Other patients had only nonsur-
However, in order to compare the combined effects gical periodontal treatment performed (partially
of excessive occlusal forces and periodontal disease, treated group). Others followed through with all
it would be necessary to treat one group of patients recommended periodontal treatment including sur-
while leaving the other group untreated. This creates gery (fully treated group). The effect of occlusal dis-
an unacceptable ethical dilemma due to the known crepancies was studied in each of these groups using
deleterious effects of the non-treatment of period- the individual tooth as the experimental unit (40, 41,
ontal disease. The World Workshop in Periodontics 66). This means that the progression of periodontal
stated, ``Prospective studies on the effect of occlusal destruction or the improvement of the periodontium
forces on the progression of periodontitis are not for each tooth was followed over time. This study
ethically acceptable in humans'' (23). As a result, design allowed for the evaluation of teeth with occlu-
human studies are limited to retrospective and sal discrepancies versus teeth without occlusal dis-
observational research. crepancies rather than comparing patients with

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Occlusal analysis, diagnosis and management in periodontics

occlusal discrepancies vs. patients without occlusal risk factor may slow the progression of periodontal
discrepancies. This experimental approach differs destruction and improve the results of periodontal
from most past studies where the patient was the treatment outcomes. As is the case with all risk factors
experimental unit and the changes in probing depth such as smoking, oral hygiene, and systemic factors,
or attachment levels were expressed as the ``patient the effect of occlusion on periodontal disease needs
mean.'' Using the patient mean may tend to mask to be minimized by recognizing the risk, diagnosing
changes that are occurring at the more active sites the existence of the risk factor, and minimizing the
and, thereby, give results that do not re¯ect what is risk by the use of various treatment modalities such
actually occurring during localized disease progres- as selective grinding, orthodontics, and/or occlusal
sion. appliances.
These studies found that teeth with occlusal dis-
crepancies had deeper presenting probing depths
and worse prognoses than those teeth that did not How is occlusal trauma detected
have occlusal discrepancies. Further, when teeth clinically?
with occlusal discrepancies were followed over time,
a signi®cant increase in probing depth and a worsen- Because trauma from occlusion is de®ned and diag-
ing of prognosis was noted when compared to teeth nosed on the basis of histologic changes in the per-
without occlusal discrepancies. Additionally, teeth in iodontal supporting structure, a diagnosis of occlusal
the partially treated group that had received occlusal trauma is impossible without block section biopsy.
adjustment showed a slowing of the progression of Because this is clearly impractical for the clinical
periodontal destruction when compared to teeth practice of periodontics, the clinician must rely on
with occlusal discrepancies from the same group that the clinical signs of potential occlusal trauma. The
had not had occlusal adjustment. It was concluded following discussion is based for the most part on
that occlusal discrepancies appear to be a signi®cant clinical experience due to the extreme paucity of
risk factor that contribute to more rapid periodontal written material on the subject.
destruction and that treatment of occlusal discrepan- Most periodontal training programs and the Amer-
cies seemed to slow periodontal destruction. The ican Board of Periodontology require an analysis of
authors postulated that the reason for the difference the patient's occlusal relationship as part of a com-
in their ®ndings and those of previous studies was prehensive periodontal examination. Often the Angle
the use of the individual tooth as the experimental classi®cation is part of this analysis (5). However, the
unit, which they felt yielded a more accurate assess- Angle classi®cation was designed to quantify the ske-
ment of the effect of occlusal discrepancies on the letal relationship between the maxilla and the mand-
periodontium (40, 41, 66). ible. While important in determining the growth
In summary, animal and human studies have indi- pattern of adolescents and recording a starting point
cated some association between occlusal discrepan- for orthodontic treatment, the Angle classi®cation
cies/occlusal trauma and changes in the periodontal has little bearing on the occlusal relationship that
supporting structures. Extensive animal studies have exists between various cusp surfaces. The relation-
shown that occlusal trauma does have an effect on ship between cusps is the most important factor in
the periodontal supporting structure but does not the transmittal of occlusal forces to the periodontal
initiate breakdown of the attachment apparatus with supporting structures. Therefore, it is the relation-
resulting measurable attachment loss. The human ship between opposing cusps that is the most impor-
studies have indicated that treating occlusal discre- tant aspect of occlusion and any role it may play in
pancies may lead to better results following period- the progression of periodontal destruction or the
ontal treatment. A study using a more contemporary outcomes of periodontal treatment.
statistical analysis and utilizing individual sites as the The relationship of opposing cusps is usually deter-
basis for comparison, has shown a strong association mined by using a composite of means that generate a
between occlusal discrepancies and deeper pockets list of data that must be correlated by the practitioner.
(66). The compiling of data on the relationship of opposing
Furthermore, existing research does not establish a cusps usually starts with the detection of occlusal
cause-and-effect relationship between occlusion and discrepancies. Typically, the initial contact between
periodontal disease. However, there are strong data the teeth is detected by gently manipulating the
to indicate that occlusion is a potential risk factor patient's mandible into a ``retruded'' position (15,
for periodontal breakdown and that controlling this 26). There is little agreement as to what is meant by

155
Hallmon & Harrel

Fig. 3. (a) Initial contact in centric relation. (b) Centric habitual) occlusion, demonstrating maximum intercus-
slide between centric relation and centric (acquired cen- pation or contact of the teeth of the opposing arches.
tric; habitual) occlusion. (c) Centric (acquired centric; (Courtesy Dr. J. Y. Cho).

a retruded position of the mandible but on a clinical in¯ammation and bone rarefaction in the presence
basis, an attempt is made to guide the mandible into of experimental occlusal stress and, in beagle dogs,
a position where both right and left condyles are the loss of attachment when plaque is present in
®rmly placed in the fossa of the temporomandibular addition to the experimental occlusal stress, there
joint. This position is one that is felt by the practi- is a likelihood that a similar process is occurring in
tioner rather than con®rmed by any type of device or humans as in the beagle dog model. If this assump-
instrument and is therefore subjective in nature. tion is true, then at least in certain cases the histo-
Once the practitioner feels that a retruded position logic lesion of occlusal trauma is likely to be present
has been achieved, the patient is asked to close until in periodontal patients who have occlusal interfer-
the patient feels the ®rst contact between the teeth ences.
(Fig. 3a). This contact point is veri®ed by the exam- Other clinical ®ndings that have been associated
iner either by eye, inked marking paper or ribbon, or with trauma from occlusion are tooth mobility and
both. This initial contact in a retruded position has wear patterns on the occlusal surface of the teeth
been described as contact in ``centric relation''. Fol- (Table 1). These clinical ®ndings are extremely dif®-
lowing the establishment of the initial contact, the cult to correlate with occlusal contacts. In the case of
patient is asked to continue to close the jaws together mobility, many other factors such as loss of attach-
until maximum contact between the teeth is ment can affect the presence and severity of the mobi-
achieved. The jaw position of maximum tooth con- lity. In the case of occlusal wear patterns, it is often
tact is often termed ``centric occlusion''. The position impossible to determine whether they are caused by
of maximum tooth contact is assumed to be the functional or parafunctional habits that are occur-
position that the patient will naturally move to as ring at present or whether they may be associated
the most comfortable or habitual position (Fig. 3b,c). with episodes of bruxism that have occurred in the
The distance that the patient moves between the past. If bruxism has occurred in the past, what if any
retruded initial contact and the point of maximal part did it play in the current clinical evidence of
tooth contact is termed the slide between the posi- periodontal breakdown? The practitioner must eval-
tions of centric relation and centric occlusion. This uate and record all of these ®ndings so that a picture
slide is often described as the ``centric relation/cen- of the occlusal stresses being placed on the period-
tric occlusion slide'' or ``CR/CO shift''. This slide is ontium can be assessed and to help form an assump-
usually recorded as the length of the slide in the tion of the occurrence of trauma from occlusion.
anterior, vertical, and lateral planes (26).
No direct correlation with histologic evidence of Table 1. Clinical indicators of occlusal trauma
trauma from occlusion has been shown between the Clinical indicators of occlusal trauma may include one
presence of a slide between the contacts in centric or more of the following:
1. Fremitus
relation and the contacts in centric occlusion. How-
2. Mobility (progressive)
ever, indirect clinical evidence of a more rapid pro- 3. Occlusal discrepancies
gression of periodontal destruction as evidenced by 4. Wear facets in presence of other indicators
increased probing depths has been shown to occur in 5. Tooth migration
patients with untreated periodontal disease (40, 41, 6. Fractured tooth/teeth
7. Thermal sensitivity
66). While this ®nding cannot be directly correlated
with animal research showing histologic evidence of

156
Occlusal analysis, diagnosis and management in periodontics

What's abfraction and are there data


to support a role of occlusion in its
development?
Abfraction has been de®ned as the ``pathological loss
of hard tooth substance by biomechanical loading
forces'' (37). The lesions have been described as angu-
lar or wedge-shaped defects that occur at the cemen-
toenamel junction of affected teeth as a result of
¯exure and eventual fatigue of enamel and dentin
(7) (Fig. 4). The prismatic structure of enamel is strong
Fig. 5. Note the generalized loss of cervical tooth sub-
in compression, but vulnerable in areas of tension, stance and accompanying marginal tissue recession. The
accounting for the resultant morphology of the pro- patient admitted (and demonstrated) aggressive horizon-
posed lesion (52). It is further noted that occlusal tal toothbrushing.
loads which generate cervical ¯exure may disrupt
hydroxyapatite crystal bonds, and result in micro-
fracture and eventual loss of associated enamel (53).
Noncarious hard-tissue cervical lesions (NCLs)
have been classi®ed as abrasive, erosive, corrosive,
abfractive or combined (38). In contrast to abfrac-
tion, abrasion represents a pathologic loss of tooth
substance resulting from biomechanical wear and is
exempli®ed by improper or overzealous toothbrush-
ing. This condition is generally accompanied by mar-
ginal tissue recession and may affect one or more
teeth (75) (Fig. 5). Erosion is a chemically induced
loss of tooth substance that occurs primarily through
acid dissolution (44) (Fig. 6). Attrition is de®ned as
the physiologic wearing away of a substance or struc- Fig. 6. The maxillary right central incisor shows erosion as
a result of chemically induced loss of enamel. (Courtesy
ture, such as the teeth (3). This typically affects the
Dr. Terry D. Rees).
occlusal and incisal surfaces of the teeth and may
result from functional or parafunctional wear, man-
ifesting as facets (7). These highly polished surfaces
may appear on marginal, transverse and oblique
Is there evidence for a role of
ridges, and on cusps and restored surfaces (Fig. 7). occlusal loading in the genesis of
noncarious cervical tooth loss?
The presence of lesions consistent with those
described as abfraction have been reported to
increase in size and depth with age of affected indi-
viduals (54). In a study of 913 subjects, 23% pre-
sented with such defects. Sixty-®ve percent of the
affected individuals had con®rmed parafunction as
compared to 35% who did not (35). Another study
reported that 96% of teeth with noncarious cervical
lesions also presented evidence of occlusal discre-
pancies (86). In comparing canine-guidance with
group-function occlusal relationships, abfraction-
like lesions were observed six times more often in
Fig. 4. Maxillary right ®rst premolar presents a well-deli-
the latter group, suggesting that increased occlusal
neated noncarious hard-tissue cervical lesion consistent tooth contact during lateral excursion favored the
with abfraction. occurrence of these lesions (87).

157
Hallmon & Harrel

evaluated for occlusal correction or bite-splint ther-


apy to address interferences that may contribute to
tooth ¯exure (75). In a separate case study of 52
modern human skulls, occlusal ®ndings failed to
provide evidence for abfraction (43).
There is a strong contention that NCLs represent a
multifactorial phenomenon. It has been proposed that
the presence of occlusal stresses in combination with
acidic substances may result in greater damage than
either alone (39). However, one clinical question
remains ± Why does abfraction occur on the buccal/
facial surfaces, with only rare reports of lingual lesions?
In summary, available evidence suggests a plausi-
ble explanation for abfraction. It is equally apparent
that this diagnosis is not absolute. In cases where the
therapist is confronted with NCLs, toothbrushing
habits and occlusal relationships should be thor-
oughly evaluated. Restorative and/or periodontal
plastic surgical intervention should be preceded by
Fig. 7. The mandibular ®rst molar presents facets on the
mesiobuccal and distobuccal cusps and on the amalgam control of any habits and/or untoward occlusal load-
restoration at the mesiolingual surface. ing which may adversely affect predictable long-term
treatment outcome.
In addition to clinical observations, evidence sug-
gesting a role of occlusal loading in development of
abfraction-like lesions comes from various stress and What methods are used to detect
strain studies. These include articulated study mod- hypermobility of teeth?
els, strain-gauge studies, ®nite element stress analy-
sis and photoelastic stress analysis (88). Such studies Assessment of tooth mobility constitutes a basic part
have shown that controlled loading (500 N) applied of the comprehensive periodontal examination (2, 4).
to inner inclines of the buccal and lingual cusps of Hypermobility occurs in response to applied force
mandibular premolars resulted in stress values and is dependent upon its direction, frequency, mag-
exceeding the failure stress of enamel (89). This load- nitude, distribution and type (2, 90, 107). The mobi-
ing corresponds to that anticipated during excursive lity status of the dentition has traditionally been
contacts in group-function occlusal relationships. evaluated by visual assessment, using two instrument
These studies are principally in vitro investigations handles to apply alternating luxating force orofacially
that fail to take into account the role of the period- (Fig. 8). In 1950, Miller (63) described a mobility index
ontal ligament and bone during the course of occlusal based on this approach (Table 2). Variations and modi-
loading. It is important to note that in a strain gauge
study of maxillary incisors in healthy volunteers,
large cervical surface strains were observed (65).
In a clinical investigation of the characteristics and
prevalence of abfraction-like lesions in a U.S. popu-
lation with 103 noncarious cervical lesions, the vast
majority of the lesions were strongly suspected as
being the result of toothbrush abrasion. A small sub-
set (i.e. 15 lesions) was deemed the result of some
other phenomenon. Six (40%) of these teeth mani-
fested premature occlusal contacts. Compared to
control teeth without NCLs, affected teeth did not
signi®cantly differ in terms of wear facets or occlusal
contacts. No NCLs were reported on lingual surfaces. Fig. 8. One way to assess tooth mobility is by using two
However, the authors cautioned that teeth with non- instrument handles applied to the tooth and applying
carious wedge-shaped lesions should be carefully alternating luxating force orofacially.

158
Occlusal analysis, diagnosis and management in periodontics

Table 2. Miller Mobility Index (63) pathologic (abnormal) mobility. Factors that have
1. The first distinguishable sign of movement been associated with tooth mobility include period-
greater than normal (physiologic) ontal status of the teeth (e.g. in¯ammation, loss of
clinical attachment/bone), periodontal surgery,
2. Movement of the tooth which allows the
crown to move 1 mm from its normal position occlusal trauma, pregnancy, and pathologic pro-
in any direction cesses affecting the jaws/teeth (22, 24, 36, 49, 50).
3. Teeth which may be rotated or depressed in More recently, it has been proposed that the desig-
their alveoli nators ``pathologic tooth mobility'' and ``adaptive
tooth mobility'' may be helpful in addressing mobi-
lity status and thus, facilitate management and
®cations of this index are used extensively throughout maintenance approaches in affected patients (4).
dentistry, and especially periodontics (11, 20). Stability of tooth mobility appears acceptable in
Clinical assessments of tooth mobility derived by the absence of confounding variables, but progres-
this means are somewhat arbitrary and dependent sive mobility is a concern and should be addressed
on examiner subjectivity and interpretation. As a by controlling in¯ammation, occlusal adjustment
result, they do not usually discriminate well between and considering a stabilization appliance or splinting
small mobility increments (99). Consequently, a as indicated. The long-term therapeutic objective is
means of more precise and objective measurement to maintain the health, stability, comfort and func-
of tooth mobility has been pursued and includes tion of the patient's natural dentition (or implants).
mechanical, electronic and optical devices, and laser
Doppler vibrometry (12, 64, 69, 72, 92). Despite
objective approaches striving to standardize tooth Of what value are assessments of
mobility evaluation, such devices by and large have tooth mobility in the management
not been well accepted for use in clinical practice. of patients with periodontitis?
More recently, the Periotest1 (Gulden-Medizintech-
nik, Bensheim, Germany), a device resembling a den- A limited number of human studies have suggested
tal handpiece, has gained favor in evaluating and that tooth mobility may be associated with greater
monitoring tooth mobility and clinical success of attachment loss, probing depth and bone loss when
dental implants (6, 93). The instrument is applied compared to nonmobile teeth (45, 46, 106). It is dif-
orthoradially to the center of the anatomic crown, ®cult to determine from these studies whether tooth
delivering a standardized percussive force. Recorded mobility was a result of the associated periodontal
values range from 0 to 100, and correspond to time in disease process or if, in some way, it contributed
milliseconds taken for the supporting structure(s) to etiologically. Two studies reported that teeth exhibit-
respond to impact deceleration, thus assessing ing a combination of furcation invasion and tooth
rebound dynamics and damping characteristics of mobility were at risk of sustaining greater attachment
the periodontium (42, 58, 91, 108). It is interesting loss as compared to nonmobile teeth or teeth with
to note that no signi®cant change in numeric Peri- furcation invasion alone (45, 106). In a longitudinal
otest1 values has been observed when comparing study by McGuire & Nunn (62), tooth mobility was
baseline values with those recorded after the initial associated with non-improving prognoses of affected
phase of periodontal therapy (16). This would sug- teeth. Other studies have examined the effects of
gest that Periotest1 mobility evaluation relates pri- tooth mobility on periodontal treatment outcomes.
marily to the amount of bone loss (i.e. support) about In an 8-year follow-up study in which patients
teeth being evaluated and may not be directly related received scaling, oral hygiene instruction, occlusal
to traditional tooth mobility. Contraindications to adjustment, periodontal surgery (subgingival curet-
use of this instrument include acute in¯ammation, tage, modi®ed Widman ¯ap or pocket elimination)
traumatic subluxation and dental implants in the and 3-month maintenance, baseline and annual
initial phases of healing (91). assessments were made of probing depth, attach-
One of the diagnostic challenges confronting the ment level and tooth mobility. Results indicated that
clinician is to determine the associative cause of pockets associated with mobile teeth did not respond
the observed tooth mobility. It is widely recognized as positively (i.e. clinical attachment level gain) to
that some degree of tooth mobility is always present therapy as ®rm teeth. This in¯uence was observed
in the healthy dentition. This has been termed by the end of the ®rst year and became more
physiologic (normal) tooth mobility, in contrast to pronounced by the second year, with only minor

159
Hallmon & Harrel

changes occurring throughout the duration of the 8- between centric relation and centric occlusion con-
year clinical trial. It should be noted that although tribute to the progression of periodontal destruction
clinically mobile teeth could be effectively treated and that the presence of mobility will negatively
and maintained, better responses (i.e. clinical attach- affect the outcome of periodontal treatment. What
ment level gain) were generally observed in associa- part each of these actually plays in periodontal
tion with ®rm teeth (21). destruction, whether these ®ndings are related to
In a randomly controlled clinical trial examining each other or play separate roles, and whether either
clinical outcomes and postoperative morbidity in or both of these ®ndings are associated with the
regenerative treatment of deep infrabony defects, classic histologic de®nition of occlusal trauma is
tooth mobility was assessed as a covariate. Among unknown. Furthermore, due to ethical considera-
clinical parameters evaluated in the study were clin- tions, it is unlikely that these questions will ever be
ical attachment level, probing depth, recession, tooth satisfactorily answered. However, when periodontal
mobility, full-mouth plaque scores, and full-mouth disease and destruction are present, the currently
bleeding scores. These were assessed immediately, available evidence appears to support the need for
prior to surgery and at 1-year post-treatment. Tooth occlusal treatment that will minimize occlusal inter-
mobility was evaluated with a purpose-built electro- ferences and help decrease tooth mobility.
nic device (Periotest1). Baseline tooth mobility was The treatment of occlusion usually involves either
signi®cantly associated with a reduction in antici- a reversible approach consisting of some type of bite
pated amounts of clinical attachment level gain. appliance (i.e. ``night guard'') and/or the selective
Based on the results of this study, the authors sug- grinding of the occlusal surfaces of the teeth (Fig. 9).
gested that clinicians may want to consider reducing Orthodontic therapy is also an effective method of
tooth mobility prior to attempting periodontal regen- changing occlusal relationships and minimizing
erative therapy to facilitate therapeutic success (14).
Other studies have examined the effect of splinting
on tooth mobility after initial therapy and after oss-
eous surgery. In the initial therapy study, there was a
reduction in tooth mobility over the 17-week period,
but there was no difference between the splinted and
non-splinted sites. The reduction in mobility
observed in both study groups was attributed to
reduction of in¯ammation and occlusal adjustment
accompanying initial therapy (49). No difference was
observed between splinted and non-splinted teeth
receiving osseous surgery, indicating that splinting
had no lasting effect on tooth mobility. Mobility pre-
dictably increased following surgery, but returned to
baseline presurgical levels after 6 months (22).
In summary, although a signi®cant role has been
suggested regarding the effect of tooth mobility on
treatment results, it is clear that controlled interven-
tion studies will be necessary in order to clarify the
effect of reducing baseline tooth mobility on period-
ontal treatment outcomes. Until such studies are
conducted, it would appear prudent, based on avail-
able data, to consider reduction/control of tooth
mobility as an integral part of periodontal therapy.

Under what clinical conditions is Fig. 9. (a) Hard acrylic occlusal nightguard in place. As the
occlusal adjustment indicated? patient's jaw moves into a left lateral excursion, note the
disclusion of the teeth in the anterior and right side. (b)
Note the smooth, highly polished occlusal surface and the
Based on current knowledge, it seems that research presence of ball clasps between the second premolar and
supports the ®nding that occlusal discrepancies the ®rst molar to facilitate retention.

160
Occlusal analysis, diagnosis and management in periodontics

occlusal forces between opposing teeth. However,


orthodontics is rarely used during the active phase
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