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Periodontal lesions associated with deep traumatic overbiteH. A. Nasry1 and S. C. Barclay2

Certain aspects of malocclusion, particularly deep overbite, can be related to periodontal pathology, especially in thepresence of poor oral hygiene. The authors have noted an association between deep overbite and unusual periodontallesions. These lesions often appear on radiographs as circumscribed radiolucencies, remote from the alveolar crest andsometimes close to the apex. Gingival surface injury and food impaction may be important aetiological factors. This isillustrated in this article by a number of case studies.

1*Specialist Registrar in Restorative Dentistry, NewcastleDental Hospital, Richardson Road, Newcastle Upon Tyne,NE2 4AZ; 2Consultant in Restorative Dentistry, NewcastleDental Hospital, Richardson Road, Newcastle Upon Tyne,NE2 4AZ*Corresondence to: Dr Hany A. NasryEmail: hani.nasry@nuth.nhs.uk

Refereed PaperAccepted 28 September 05doi: 10.1038/sj.bdj.4813587© British Dental Journal 2006; 200: 557–561

INTRODUCTIONIt is believed that destructive periodontallesions similar to chronic periodontalabscesses may result from trauma to theperiodontal tissues already affected bychronic inflammatory periodontal disease,resulting in extension of the infection.Clinical symptoms usually include pain,swelling of the gingiva, erythema and dis-charge through a fistula or through thepocket orifice.

Non-periodontitis related lesions mayoccur in the absence of chronic inflamma-tory periodontal disease due to impactionof a foreign body or food particles into theperiodontal pocket or gingival sulcus, lead-ing to inflammation. This impaction maybe caused acutely by inappropriate use oforal hygiene devices such as toothbrushesor tooth picks,1,2 or more chronically bythe opposing dentition as in the case ofdeep traumatic overbite.

Deep traumatic overbite is mostly asso-ciated with a class II incisor relationship(either division i or ii), usually with anassociated skeletal class II component.

This manifests as trauma to the palatalgingiva behind the upper incisors or thelabial gingiva of the lower incisors (gumstripping). Deep traumatic overbite isdetailed in Akerly’s classification3 which issummarised below.

Akerly IThe skeletal base for this overbite is class IIand the incisal relationship is Angle’s classII div. i; this causes the lower incisors topush against the palatal mucosa and mani-fests as mucosal trauma of the palate awayfrom the palatal gingival margins of theupper incisors.

Akerly IIThe skeletal base is class I or II and the inci-sor relationship is Angle’s class II div. i orii; this overbite causes trauma to the palatalgingival margin of the upper incisors. It isthis relationship that has been implicatedin impacting food or foreign bodies intothe gingival crevice of the upper incisors.

Akerly IIIThe skeletal base is class II and the incisorrelationship is Angle’s class II div. ii. Thiscauses the upper and lower incisors to

shear past each other in contact leading tostripping of the lower labial gingiva andthe upper palatal gingiva surrounding theincisor teeth. This can also lead to foodimpaction into the gingival crevices.

Akerly IVThe skeletal base for this overbite is class Ior II and the incisor relationship is Angle’sclass I or class II div. i. There are often wearfacets on the palatal aspects of the upperincisors and wear may also affect the labialaspect of the lower incisors. This may bedue to loss of posterior support, displace-ment of the mandible and/or a parafunc-tional habit.

The occlusal trauma which is describedin this paper is ‘gingival surface injury’,caused by the direct impingement of atooth on the gingival margin and peri-odontal tissues of an opposing tooth, andas such is different to ‘trauma from occlu-sion’ mentioned in the literature. The lattertype of occlusal trauma has been definedby the American Academy of Periodontol-ogy as ‘An injury to the attachment appa-ratus as a result of excessive occlusal force’.The manner in which the roots are orientat-ed in relation to the forces to which theyare exposed may have an effect on the peri-odontal health of these teeth. Axiallyinclined forces are better tolerated thannon-axially inclined forces; when teeth are

Deep traumatic overbite may be associated with lateral periodontal lesions. Physical impaction of debris or plaque into the periodontal pocket aggravated by deep

traumatic overbite may lead to formation of bony defects. Treatment of these lesions should address the deep traumatic overbite as well as the

periodontal element. Deep traumatic overbite is detailed in Akerly’s classification.

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badly aligned the effect of excessive forcescan be exaggerated.4,5

Experimental data suggest that maloc-clusion alone does not cause periodontalproblems. However, some authors havefound a correlation between periodontaldisease and malocclusion6,7 while othersfailed to show a relationship.8,9

A recent study has indicated thatocclusal trauma may play a significant rolein the progression of periodontal disease in humans.10

The effect of trauma from a deep over-bite has been mentioned scarcely in the lit-erature. Deep traumatic overbite can leadto enhanced levels of inflammation andperiodontal deterioration in the presence ofplaque.5 Individuals with a high overbite tooverjet ratio were reported to have a morefavourable periodontal condition thanthose with lower ratios.11

The authors suggest that in certain deepoverbite cases, physical impaction of fooddebris or plaque into the periodontal pocketaggravated by the contact of opposingteeth with the gingival margin in a class IIAkerly relationship may lead to the forma-tion of apparent ‘lateral periodontalabscesses’ or bony defects. These changeswere noted on radiographs and in somecases clinically as sinuses on the labial gin-giva which could be deemed erroneously tobe suggestive of periradicular pathology ofendodontic origin, in situations where theteeth were found to be vital. Radiographi-cally, this is associated with the appearanceof very discrete and specific lateral peri-radicular radiolucencies.

The need to recognise the potential for adeep traumatic occlusion to precipitate thisunusual clinical and radiographic appear-ance is highlighted.

CASE REPORTSCase 1A 54-year-old female patient was initiallyreferred to a dental teaching hospital withregard to a recurring sinus associated with11 and 21, in addition to looseness and labialdrifting of these teeth; she was also aware ofbleeding on brushing.

Clinical examination showed a poor levelof oral hygiene, bleeding on probing and 6 mm pocketing on 11 and 21; otherwisepocketing was less than 4 mm.

There was evidence of recession and adegree of root surface loss associated withthe deep traumatic overbite on the palatalaspect of 11 and 21. The patient was awareof regular bouts of trauma to this area. Shehad a class II division i occlusal relationshipwith reduced posterior support.

As seen from the radiographs (Fig. 1),there was 20-30% of bone loss in this areaand apical pathology on tooth 12. Radi-ographic evidence of a lateral radiolucencyrelated to tooth 11 was noted; this was con-sistent with an apparent sinus tract passingmesially around the root of the tooth to dis-charge labially, probably arising from thedeep traumatic overbite.

The patient had tooth 12 root treated. Tooth11 underwent non-surgical management in thefirst instance. A replaced flap procedure around11 and 21 was carried out subsequently.

Partial upper and lower dentures com-bined with milled crowns on strategic teethto increase vertical dimension were used,providing stable occlusal/incisal contactsand reducing the extent of the deep trau-matic overbite. Regular hygiene visits weremaintained with noticeable improvement inthe oral hygiene and resolution of the peri-odontal pocket associated with 11 and heal-ing of the labial sinus.

Case 2A 50-year-old female patient was origi-nally referred to a dental teaching hospitalregarding gingival recession labial to theupper incisors. Examination revealed acomplete anterior overbite with associatedgingival trauma palatal to the upper inci-sors. 11 was post-crowned and root filled.

The oral hygiene was fair with localisedplaque deposits and generalised pocketingof 2-3 mm. However, a 7 mm pocket wasnoted disto-palatal to 11 and a 4 mmpocket mesial to 21. Gingival recession of3 mm was noted on the palatal aspect of11. This was associated with a deep traumatic overbite and lack of posteriorsupport.

As seen from the radiograph (Fig. 2) adeep infra-bony defect was noted mesialto 11. A differential diagnosis of root frac-ture, root perforation or of a lateral peri-odontal abscess was reached.

The patient had three visits for rootplaning of 11 and 21 under local anaes-thesia and oral hygiene instruction by ahygienist.

The lesion associated with 11 respond-ed well to non-surgical periodontal man-agement and provision of partial upperand lower dentures, with reduction of thepocket depth. The partial upper dentureincluded an anterior bite plane to increasethe face height and to reduce depth of theoverbite and the adverse effect on theperiodontium.

Fig. 2 Case 2, showing a deep infra-bony defect

Fig. 3 Case 3, showing a lateral radiolucency

Fig. 4 Case 4, showing lateral radiolucency

Fig. 1 Case 1, anterior bone loss

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Case 3A 42-year-old female patient presented toa dental teaching hospital complaining ofpain related to 13 which had a disto-palatalpocket of 6 mm, bleeding on probing andgrade I mobility. The patient also had adeep overbite and radiographs showed alateral radiolucency mesially (Fig. 3). Thetooth was vital.

This lesion was thought to be aggravatedby the deep overbite and debris impaction.The patient was referred to the school ofdental hygiene for root planing of this area,oral hygiene instruction and full mouthscaling. The patient responded well to non-surgical management with resolution ofthe pocket and associated pain from 13 andgeneral improvement of the oral hygiene.The maintenance regime was continued atthe hospital and the patient was referredback to her general dental practitioner forconstruction of a partial upper denturewith a bite plane and a lower partial den-ture to protect against the recurrence of thetraumatic overbite.

Case 4A 33-year-old female patient was referredto a dental teaching hospital with regard

to a painful gingival swelling in the 12region following food impaction. Thepatient was aware of her lower incisorsimpinging on the gingiva behind the upperanterior teeth.

On examination the patient had a heavi-ly restored dentition with inadequate poste-rior support and a deep traumatic overbiteassociated with a class II div. i malocclu-sion. There was generalised mild gingivitiswith localised pocketing and bleeding onprobing. There was a 6 mm pocket mesial to12. Radiographs taken showed a lateralradiolucency associated with the mesialsurface of tooth 12 (Fig. 4). A diagnosis ofgeneralised periodontitis associated withinadequate oral hygiene and complicatedby a deep traumatic overbite in the upperanterior segment was made.

Oral hygiene instruction and root plan-ing of deep pockets was carried out; thisresulted in a noticeable improvement inpocket depth in relation to 12. A partialupper denture to increase the verticaldimension was constructed to reduce thedeep overbite with occlusal stabilityachieved by provision of an anterior biteplane. The above treatment resulted in res-olution of symptoms and the patient was

placed on a maintenance regime and wassubsequently discharged.

Case 5A 39-year-old female patient was referredto a dental teaching hospital with regard topain from the upper anterior teeth. Thepain occurred on biting and there was den-tine hypersensitivity on the palatal aspectsof 12, 11, 21 and 22. There was increasedmobility of 22 in recent months and anteriorspacing was a concern.

Examination revealed inadequate oralhygiene with bleeding on probing, 3-4 mmpocketing and a 5 mm pocket present on the distal aspect of 22 which had anassociated buccal sinus (Fig. 5). The toothwas vital to electric pulp testing. Thepatient had a class II div. i occlusion with acombination of class II and IV Akerly’sclassification (Fig. 6). Radiographs revealedminimal bone loss but the presence of alocalised peri-radicular defect was seendistal to 22 (Fig. 7).

Initial treatment involved hygiene ther-apy, followed after establishment of goodoral hygiene by a replaced flap procedurefor 12, 22 region (Fig. 8). A post-operativeupper splint was constructed in heat cure acrylic to protect the palatal gingivalmargins of the treated teeth from the trau-matic overbite.

A further open flap curettage procedurewas carried out six months later due to per-sistence of the sinus; this was combinedwith systemic antibiotics.

Ultimately orthodontic treatment toreduce the depth of the overbite as well ascontinuation of hygiene therapy led toeventual resolution of the sinus. Fixedretention using a modified rochette splintto stabilise the occlusion was carried out.12

Fig. 5 Case 5, buccal view

Fig. 6 Case 5, palatal view

Fig. 7 Case 5, radiograph showing peri-radicular

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Case 6In another case, a 45-year-old male wasreferred to a dental teaching hospital withpain and swelling, which had been presentfor three months in the upper incisorregion. There was a small discharging labi-al sinus associated with 11, with mesialpocketing of 6-7 mm. The patient had adeep anterior overbite associated with aclass II incisor relationship.

As seen from the radiographs (Fig. 9) alateral periradicular radiolucency was evi-dent and root planing of 11 was prescribed.The patient failed to attend his appoint-ments and follow up was not possible.

DISCUSSIONAll of the above cases were noted retro-spectively to have a similar history involv-ing a deep traumatic overbite and a charac-teristic radiographic appearance of adiscrete lateral radiolucency with a possi-ble ‘tunnel like’ lesion extending round theroot from the palatal aspect to, in mostcases, a buccal discharging sinus. Thepatients presented with a range of symp-toms, including pain, localised swellingand discharge.

This appearance on radiograph of aradiolucency on the proximal surfaces ofanterior teeth, associated clinically withdeep traumatic overbite, has been high-lighted previously.12 It is suggested that this arises from infection trackinglabially, creating a ‘tunnel’ through theaproximal bone.

Normally pockets develop at right anglesto the gingival margin and progress apically,presumably because anaerobic bacteriathrive at the base of the pocket where theenvironment is most favourable for theirgrowth. In the cases reported, the initiallesion in deep overbite cases is traumaticallyinduced gingival recession, encouragingpocket and sinus tract development at rightangles through the inter-radicular bone

towards the labial plate, with regular fooddebris and plaque impaction, and compres-sion of the palatal gingiva tending to drivethe infection labially.

In most of the cases reported a diagnosisof a chronic lateral peri-radicular peri-odontitis could be considered as a possibleinitial differential diagnosis, attributed tothe traumatic overbite and the presence ofsubgingival plaque.

In the view of the authors, where thecombination of deep overbite and labialsinus formation is identified, periodontaltreatment should be instigated in the firstinstance with a view to starting root canaltreatment only if the associated toothbecomes non-vital. The latter developmentis likely only to arise in these cases if a lat-eral accessory canal is affected by thelesion. However, if the tooth is non-vital onfirst presentation then endodontic treat-ment should be initially instigated.

As the traumatic overbite is a major fac-tor, care should also be taken to address thedeep traumatic overbite element. There isoverwhelming evidence that occlusal trau-ma does not cause periodontitis per se,however the above cases show that deeptraumatic overbite can in certain casescause significant localised periodontalbreakdown.

Reports have been presented in the liter-ature of how to treat the deep traumaticoverbite; the treatment is usually complexand involves different disciplines.13

Conservative treatment of the deeptraumatic overbite starts by achieving agood level of oral hygiene and a stableperiodontal condition. A soft splint to pro-tect both soft and hard tissues from anynocturnal trauma is a simple additionalelement of treatment.

Orthodontic treatment to reduce thedepth of the overbite can be successful butis technically demanding and time con-suming. Where a loss of posterior support

has occurred, partial dentures at increasedface height can protect both hard and softtissues from the effect of the deep overbite.Care to ensure stable occlusal contacts is essential. Additionally they are not with-out the oral hygiene risks inherent in partial dentures. Hard splints or bite planeson their own or as a preliminary step inocclusal reconstruction can also be used in the treatment of deep traumatic overbite.13,14

A more definitive way of correcting thedeep overbite is by increasing the faceheight on existing posterior teeth andachieving a stable contact between theupper and lower anteriors to prevent therecurrence of deep overbite. The use ofcomposite or palatal shims on the palatalsurface of anterior teeth or in certain casescrowns with a palatal ledge for the lowerincisors to occlude against have beenemployed with varying success.15

The initial treatment in the above casesinvolved standard non-surgical periodon-tal therapy: root planing and antibacterialirrigation of the deep pocket with, in somecases, topical applications of antimicro-bials. Root canal treatment was initiatedonly in one case where the tooth was foundto be non vital. Subsequent modification ofthe occlusion was required in most.

The periodontal treatment with associ-ated prosthodontic and endodontic treat-ment as required resulted in resolution ofsymptoms; in one case the tooth was lost asa result of root fracture.

CONCLUSIONSThis report offers a possible diagnosis oflateral root radiolucencies noted in cases with a deep traumatic overbite inAkerly class I and II situations. It also high-lights the potential extent of bony destruc-tion caused by the impaction of foreignbodies in cases with traumatic overbite,especially in the presence of plaque and poor oral hygiene. The infectionappears to track labially, creating a tunnelthrough the bone adjacent to the root sur-face, with the radiographic appearance asdescribed. Methods of management havebeen described.

Fig. 8 Case 5 following initial treatment

Fig. 9 Case 6, radiographs showing lateralperiradicular radiolucency

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1. Gillette W B, Van House R L. Ill effects of improperoral hygiene procedures. JADA 1980; 101: 476-480.

2. Abrams H, Kopczyk R A. Gingival sequela from aretained piece of dental floss. JADA 1992; 106: 57-58.

3. Akerly W B. Prosthodontic treatment overlap of theanterior teeth. J Prosthet Dent 1977; 38: 26-34.

4. Wragg P F, Jenkins W M, Watson I B, Stirrups D R. Thedeep overbite: prevention of trauma. Br Dent J 1990;365-367.

5. Ross I F, D’Onofrio E D, Roman J S. Occlusal contactsand tooth mobility. J Periodontol 1972; 43: 760-764.

6. Poulton D R, Aarson S A. The relationship betweenocclusion and periodontal status. Amer J Orthodont1961; 47: 690-699.

7. McCombie F, Stothard D. Relationship betweengingivitis and other dental conditions. J Canad DentAssoc 1964; 30: 506-513.

8. Geiger A M. Occlusal studies in 188 consecutivecases of periodontal disease. Amer J Orthodont 1962;48: 330-360.

9. Beagrie G S, James G A. The association of posteriortooth irregularities and periodontal disease. Br Dent J1962; 113: 239-243.

10. Harrel S K, Nunn M E. The effect of occlusaldiscrepancies on periodontitis: II. Relationship ofocclusal trauma to progression of periodontaldisease. J Periodontal 2001; 72:495-505.

11. Silness J, Roystrand T. Effect of degree of overbite andoverjet on dental health. J Clin Periodontal 1985;12: 389-399.

12. Barclay S C. Case report: An alternative treatment ofdeep traumatic overbite. Eur J Prosthodont Rest Dent1996; 4: 3-6.

13. Blair F M, Thomason J M, Smith D G. The traumaticanterior overbite. Dent Update 1997; 24: 144-152.

14. Kessler M. The bite plate — an adjunct in periodontic andorthodontic therapy. J Periodontol 1980; 51: 123-135.

15. Treasure P, Jones S A, Treasure B. Resin-bondedpalatal stops for the management of a deeptraumatic overbite — a case report. Restorative Dent1990; 6: 19-21.

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