Abstract
The aim of this study was to investigate the centric occlusal contact pattern in maximum intercuspation and to study the nature of occlusal contacts during maximum intercuspation to protrusive, lateroprotrusive and lateral excursive movements. Fifty subjects having gingival recession and ten subjects having gingival clefts belonging to age group of 18–25 years were selected after obtaining informed consent from the student’s population. The selected subjects were examined and the location and extent of gingival recession, gingival clefts and occlusal wear facets were recorded. The type of occlusion and the nature of occlusal contact in maximum intercuspation and eccentric mandibular movements were also recorded using articulating foil and shimstock. Chi square test, Fisher’s exact test (F) and Z test were used to statistically analyse the data obtained. Among the three occlusal concepts, gingival recession was more commonly related to group function than to canine protected occlusion. Canine protected occlusion was associated with gingival recession on the labial surface while in group function occlusion; the recession was distributed equally on the facial surface of the anterior as well as posterior teeth. Nearly all subjects showed interferences in protrusive, lateroprotrusive and lateral excursive movements on teeth showing gingival recession and gingival clefts. Occlusal wear was seen on all teeth having gingival clefts and on most teeth having gingival recession. These results suggest that occlusal interferences in maximum intercuspation and eccentric movements in one form or the other and absence of mutually protected occlusion can contribute to gingival lesions such as gingival recession and clefts.
Keywords: Gingival recession, Gingival clefts, Occlusal interferences, Group function occlusion, Canine guided occlusion, Mutually protected occlusion
Introduction
A harmonious relationship between occlusion and periodontium is today considered mandatory to maintain a healthy dentition. In a healthy occlusion, there are multiple pin point contacts between the maxillary and mandibular teeth in maximum intercuspation; and during protrusive, lateroprotrusive and lateral excursive movements there is immediate disclusion in the form of anterior guidance, canine guided occlusion or a mutually protected occlusion. In this manner, the teeth and the periodontium are protected from detrimental forces in centric and eccentric occlusions. When occlusion is unfavorable, this mechanism is disturbed and few cusps or a single cusp bear the occlusal forces initially during jaw closure. This affects the periodontal tolerance of the tooth or teeth which exhibit occlusal interferences.
Gingival recession and gingival clefts are two periodontal entities that can occur due to various factors. Stillman [1] in 1921 was the first to associate occlusal trauma in the development of gingival cleft and became known by his name as ‘Stillman’s cleft’. Surprisingly, the relationship between occlusal trauma and gingival cleft has remained unclear till the reports published by Solnit [2] which revealed that gingival clefts apparently underwent spontaneous repair following occlusal analysis and subsequent adjustment. According to Solnit, gingival clefts in the upper jaw are due to working side interferences and in the lower jaw due to the balancing side contacts. Contrary to this, Emslie [3] found no evidence to support the role of occlusal trauma in the formation of gingival clefts.
Parfit and Major [4] observed no occlusal contacts in more than half the mandibular incisors with recession and heavy occlusal contacts in only 15 % of the cases. Trot and Love [5] observed trauma from occlusion in only 10 % of the cases with recession while Gorman [6] found recession in 20 % of the cases.
Inspite of the voluminous nature of studies which relates occlusion to periodontal disease, the role of pathological occlusion to the incidence of gingival recession and gingival clefts has not been adequately investigated. It was thought desirable to find out the association of occlusal trauma in subjects having gingival recession who were otherwise free from the influence of calculus and other etiological factors which cause gingival recession and gingival clefts. Hence, this investigation was conducted on 50 subjects having gingival recession and 10 subjects having gingival clefts with the following objectives:
To study the maximum intercuspal contact pattern in teeth showing gingival recession and gingival clefts
To study the nature of occlusal contacts from maximum intercuspal position to protrusive, lateroprotrusive and lateral excursive movements in the same teeth showing gingival recession and gingival clefts
Materials and Methods
From the screening of 600 dental students comprising of males and females between 18 and 25 years of age group, 50 subjects showing gingival recession and 10 subjects showing gingival clefts were obtained. The following investigation was made for the tooth/teeth showing gingival recession and gingival clefts.
Recording the location and extent of gingival recession, gingival clefts and occlusal wear facets
Recording the type of occlusion
Recording the nature of occlusal contact in maximum intercuspation and eccentric mandibular movements.
Armamentarium
Arti-fol of 8 micron thickness (blue and red color)
Magnifying mirror
Shimstock of 8 micron thickness
Recording the Extent of Gingival Recession/Gingival Cleft and Occlusal Wear Facets
Gingival recession/gingival cleft were measured from the CEJ (deepest point) to the deepest point of the margin of the gingiva by using a graduated periodontal probe (Fig. 1).
Fig. 1.
Grading the extent of gingival cleft using graduated periodontal probe
The following grade was given depending on the amount of recession.
Grade I-Mild (0–2 mm)
Grade II-Moderate (2–3 mm)
Grade III-Severe (3–6 mm)
The following scale was used for grading the severity of occlusal wear.
0-No visible facets in the enamel
1-Marked wear facets in the enamel
2-Wear into dentine
3-Extensive wear into dentine
Recording the Type of Occlusion
The subject was asked to move the mandible towards the side showing recession till the tip of the mandibular canine touches the tip of the maxillary canine. If the cuspids were the only teeth in contact and disclusion is seen in the posteriors then it is considered as “canine guided occlusion”. Along with the canine if the other posterior teeth also made contacts with its antagonists then it was considered as “group function occlusion”.
Recording the Nature of Occlusion in Maximum Intercuspation
The patient was instructed to “tap his/her back teeth together, both sides at the same time, slow and hard”. After having the patient to repeat this process once or twice, the actual maximum intercuspation (MI) contacts were assessed by using Arti-Fol (blue) of 8 micron thickness which is cut into strips and placed over the teeth to be examined and the patient was asked to open and close the mouth again as before. The number of contacts was noted (Fig. 2). If there were interfering contacts, these were seen as ‘darker marks’ compared to others which were considered as ‘heavy contacts’ in maximum intercuspation.
Fig. 2.
Contacts obtained by articulating film during maximum intercuspation
The firmness of the contact can be detected by using the shimstock placed over the lower anteriors and the patient was asked to clench the teeth in MI. If there was resistance to removal, then it is suggested that there is no anterior disclusion (Fig. 3).
Fig. 3.
Checking anterior disclusion during maximum intercuspation using shimstock
A “two color method” was followed for recording protrusive excursive contacts. The protrusive contacts were first marked after drying and isolating the teeth, by inserting red articulating foil and having the subject to produce several protrusive glides to edge-to-edge position (Fig. 4). The vertical stops are then marked with blue articulating foil by having the patient to tap his or her teeth together in MI. The number of protrusive interferences was noted.
Fig. 4.
Protrusive interferences identified during incisor edge-to-edge position
Recording the Nature of Occlusion in Laterotrusive and Mediotrusive Movements
The patient was trained to move his mandible sideward till the tip of the mandibular canine aligns with the tip of the maxillary canine. The tooth was dried, isolated and red articulating foil was placed between the teeth and the patient was asked to close the mouth in MI and then the mandible is moved slowly, towards the predetermined position. Heavy occlusal contacts were observed as dark red marks on the surface of the affected tooth. A two color method was followed to distinguish the vertical stops. For recoding the mediotrusive contacts, the extent of mediotrusion was guided by the laterotrusion on the opposite side (Fig. 5).
Fig. 5.
Mediotrusive and laterotrusive interferences identified during eccentric movements of the mandible
In this manner, all the subjects were evaluated for the presence of occlusal interferences on the tooth exhibiting gingival recession and gingival clefts.
The data collected from 50 subjects showing gingival recession and 10 subjects showing gingival clefts was analysed statistically by applying Chi square test, Fisher’s exact test and Z test.
Results
Among the three occlusal concepts, gingival recession was more commonly related to group function than to canine guided occlusion. Canine guided occlusion was associated with gingival recession on the labial surface while in group function occlusion; the recession was distributed equally on the facial surface of the anterior as well as posterior teeth (Table 1). Occlusal wear was seen on all teeth having gingival clefts and on most teeth having gingival recession (Table 2).Nearly all subjects showed interferences in protrusive, lateroprotrusive and lateral excursive movements on teeth showing gingival recession and gingival clefts (Tables 3 and 4).
Table 1.
Type of occlusion, region wise distribution, location of gingival recession and gingival clefts
| Type of occlusion | Anterior region | Posterior region | |||
|---|---|---|---|---|---|
| Labial (%) | Lingual (%) | Labial (%) | Lingual (%) | ||
| Gingival recession | 20 cases (40 %) canine protected 32 teeth, 7 cases mutually protected | 75 [24] | – | 18.8 [6] | 6.2 [2] |
| 30 cases [60 %] group function 48 teeth, 5 cases mutually protected | 39.6 [19] | 10.4 [5] | 45.8 [22] | 4.2 [2] | |
| Gingival clefts | 2 cases, canine protected 2 teeth | 100 [2] | – | – | – |
| 8 cases, group function 21 teeth | 19 [4] | – | 81 [17] | – | |
Table 2.
Occlusal wear on teeth showing gingival recession and gingival clefts
| Type of occlusion | Anterior region (%) | Posterior region (%) | |
|---|---|---|---|
| Gingival recession | Canine protected | 34.4 [11] | – |
| Group function | 37.5 [18] | 35 [12] | |
| Gingival clefts | Canine protected | 100 [2] | – |
| Group function | 19 [4] | 81 [17] |
Table 3.
Number of teeth showing disclusion and interferences in maximum intercuspation, protrusive and laterotrusive movements in gingival recession
| Gingival recession | Type of occlusion | Disclusion present (%) | No. of teeth with interferences/contacts | |
|---|---|---|---|---|
| Anterior (%) | Posterior (%) | |||
| Canine protected | Centric | 3.1 [1] | 71.9 [23] | 25 [8] |
| Protrusive | 31.3 [29] | 62.5 [20] | 6.2 [2] | |
| Mediotrusive | 90.7 [6] | 6.3 [2] | 3 [1] | |
| Laterotrusive | 71.9 [23] | 28.1 [9] | – | |
| Group function | Centric | 12.5 [6] | 37.5 [18] | 50 [24] |
| Protrusive | 60.4 [29] | 35.5 [17] | 4.1 [2] | |
| Mediotrusive | 79.2 [38] | 12.6 [6] | 8.4 [4] | |
| Laterotrusive | 35.4 [17] | 33.4 [6] | 31.2 [15] | |
Table 4.
Number of teeth showing disclusion and interferences in maximum intercuspation, protrusive and laterotrusive movements in gingival clefts
| Gingival clefts | Type of occlusion | Disclusion present (%) | No.of teeth with interferences/contacts | |
|---|---|---|---|---|
| Anterior (%) | Posterior (%) | |||
| Canine protected | Centric | – | 100 [2] | – |
| Protrusive | 50 [1] | 50 [1] | – | |
| Mediotrusive | 100 [2] | – | – | |
| Laterotrusive | 50 [1] | 50 [1] | – | |
| Group function | Centric | 4.8 [1] | 14.3 [3] | 80.9 [17] |
| Protrusive | 76.2 [16] | 4.8 [1] | 19.1 [4] | |
| Mediotrusive | 85.7 [16] | – | 14.3 [3] | |
| Laterotrusive | 47.6 [10] | 14.3 [3] | 38.1 [8] | |
Discussion
Among the three occlusal concepts, mutually protected, canine guided and group function; gingival recession was more commonly related to group function than to canine guided occlusion. This can be explained by the fact that in canine guided occlusion there was total disclusion of posterior teeth while in group function this was not the case. There is general predilection for the lesions to appear on the facial surface [7–9].
Absence of anterior disclusion in maximum intercuspation can have deleterious influence [10]. This may be the reason for the gingival recession seen in 85 % of the subjects where there was no anterior disclusion in maximum intercuspation.
Gingival clefts were generally seen on the maxillary teeth and they had a tendency to be located in the posterior region [11]. The same occlusal interferences which were related to gingival recession were also common to gingival clefts (Fig. 6).
Fig. 6.
Gingival recession seen on the buccal surface of lower molar with cross tooth balance preventing group function occlusion
Nearly all the subjects showed interference either in protrusive or in mediotrusive or laterotrusive movement on the teeth showing gingival recession and gingival clefts (Figs. 7, 8 and 9).
Fig. 7.
Gingival cleft seen on the buccal surface of upper first premolar
Fig. 8.
Protrusive interference seen
Fig. 9.
Laterotrusive interference seen as red marks
Arti-foil of 8 microns thickness is used in the study whose thickness is less than patient’s perception [12, 13].
One of the striking observations of the study was the relation between mutually protected occlusion and the incidence of gingival recession and gingival clefts. When there was no mutually protected occlusion there was no disclusion in the anterior teeth during maximum intercuspation, and during protrusion there was no posterior disclusion [10, 14]. All these situations constituted pathological malocclusion which adversely affects the occlusal surface of the teeth, periodontium, neuromuscular system and the temporomandibular joint [11, 15, 16]. This study relates this form of pathological malocclusion also to gingival recession and gingival clefts.
It is a well known fact that pathological malocclusion in the form of various interferences and prematurities can give rise to occlusal wear facets [17]. To complement this theory, this study showed that occlusal wear was seen on all the teeth having gingival clefts and on most of the teeth having gingival recession. Further it is presumed that occlusal wear was a result of heavy contacts during functional and non-functional movements [17–20]. This perhaps may also have a relation to the incidence of these lesions.
To sum up, this study has been significant to show that occlusal interferences in maximum intercuspation and eccentric movement in one form or the other and the absence of mutually protected occlusion can contribute to these gingival lesions. A longitudinal study with proper occlusal analysis and correction of interferences is necessary to further highlight the importance of occlusion to these lesions.
Conclusion
From the results of the foregoing investigation the following conclusions were drawn. Gingival recession was more commonly related to group function occlusion (60 %) as compared with canine guided occlusion (40 %). In subjects having canine guided occlusion, gingival recession was seen on the labial surface of the anteriors (75 %) whereas in group function occlusion, recession was distributed equally on the facial surfaces of the anterior and posterior teeth. Gingival recession was seen on the labial surface of the mandibular anterior teeth in 85 % when there was an absence of anterior disclusion in maximum intercuspation. Interferences in the form of protrusive, mediotrusive and laterotrusive contacts were associated with gingival recession. Gingival clefts were more commonly seen on the maxillary teeth and the posterior region. Interferences in laterotrusion, mediotrusion or protrusion were observed in the teeth showing gingival clefts. Occlusal wear was observed on the teeth having gingival clefts. There was significance between mutually protected occlusion and the incidence of gingival recession and gingival clefts. In 80 % of the subjects, there was no mutually protected occlusion.
Summary
An investigation was done on a selective sample of 50 subjects having gingival recession and 10 subjects having gingival clefts comprising of both the genders with a mean age of 22 years. The influence of occlusal trauma on gingival recession and gingival clefts in these subjects in protrusive, mediotrusive and laterotrusive movements of the mandible were studied. The interfering contacts in these positions were observed and related to gingival recession and gingival clefts. The method consisted of recording occlusal contacts in these positions by obtaining markings on the interferences with an 8 micron thickness articulating foil.
Further anterior disclusion in maximum intercuspation and the nature of occlusion in excursive movements such as posterior disclusion in the form of canine guidance and mutually protected occlusion and group function were recorded in these patients to find out their influence on gingival recession and gingival clefts.
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