Biomechanical induced dental disease

A Scientific Article
by Assistant. Professor Dr. Muneer Gohar Babar
Jinnah College of Dentistry

Abstract

Biomechanically induced dental disease affects at least 75% of the adult population.
It is likely that more teeth are lost due to biomechanically induced dental disease
than to the effects of caries. Nonetheless, caries has been the main focus of the
preventive dentistry movement since Arnum and Bass' theory of bacteria and
philosophy of preventive dentistry was popularized by Barkley in the early 1970s.

The controversy of occlusal imbalance as a biomechanical etiological agent in dental

disease is due primarily to the fact that it is difficult for many practitioners to
clinically define and then establish a condylar position in which the condyles can
operate in harmony with the biting surfaces of the teeth.' As a result, apples are
compared to oranges and much of the dialogue in the scientific literature cannot
withstand the scrutiny of logical analysis. In order to move forward, first it is
necessary to define rigidly the terms we use every day and then utilize a method to
achieve the biomechanical relationship we have defined easily, predictably, and
consistently.

An examination of the literature reveals that most of the controversy about

occlusion is not the result of scientifically defined and rigorously applied methods
but actually is due to sloppy logic and inconsistently applied biomechanics.

Many people have defined centric relation as the position of the condyles in the
glenoid fossa where they are in a stable nonmuscle braced position. Dawson has
defined this position as the rearmost, uppermost, midmost (RUM) position of the
condyle in the fossa at which the medial pole of the condyle disc assembly is braced
against the bony wall of the emenentia. In this position the condyles are supported
by the bony structures and muscle activity is balanced and minimized (Fig.1) The
teeth, in order to intercuspate fully when swallowing or biting together all the way,
can fit together in only one position, just like a key can fit into a lock in only one
position.

When the teeth can fit together in a position of maximum intercuspation at the
same time the condyles are in the RUM position, they are said to be in a
nonconflicted occlusal condylar relationship. If the cusps cannot fit together when
the condyles are in the RUM position, the occluding cusps of the teeth act like
mechanically inclined planes and actually can force the condyle to deviate from this
RUM position to allow for maximum interdigitation. This occlusally determined
condylar position requires all of the muscles to contract in an unbalanced and
uncoordinated fashion.
It is a testimony to the remarkable adaptability of the temporomandibular joint
(TMJ) that it can attempt to accommodate to this conflict. No other joint in the body
has the capacity to function in a condition of continuous dislocation.

Figure 1 shows that the teeth can intercuspate completely without forcing the
condyles to assume an occlusally determined eccentric condylar position. Figure 2
demonstrates that when the condyles are in the centered RUM position, only one
occluding surface can contact.

Figure 3 shows the effect of the contacting surfaces of the teeth forcing the
condyles into an eccentric, occlusally guided position.

Fig. 1. Teeth fully intercuspated with he condyles in the RUM position. Fig. 2. The
condyle in the RUM position. Due to a conflict between the teeth and the TMJ, only
one tooth can touch its opposing contact. Fig. 3. The teeth in conflict with the
optimal condylar position. Full intercuspation of the teeth results in an eccentric,
occlusally determined condylar position.

Realizing that two condyles must coordinate together, one easily can imagine that a
very complicated series of muscular accommodation are required for the mandible
to move into a position at allows full dental interdigitation Figures 1-3 show only
one condyle in two dimensions. In actuality, the two condyles operate three
dimensions, which requires geometrically more comlpex accommodations.

It is I rare for a patient to have a condylar relationship that is not in conflict with
the occluding surfaces of the teeth. A thorough examination of adult patients
reveals at it is equally rare to find one who does not have any signs of
biomechanically-induced dental . disease that can be proven to result from tooth
clenching and grinding.

Materials and methods

One hundred consecutive patients entering the author's practice for routine or
emergency dental care ere examined clinically and by bitewing and panoramic
radiographs and screened by routine medical and dental histories. In addition to
bacteria-caused decay and periodontal disease, patients were screened for the 12
biomechanically-induced dental problems that follow. A photograph of each of these
dental problems or conditions is provided with a description to illustrate the
condition (Fig. 4-15). Although these problems can and usually do occur in
combination, they are listed separately.

Sensitive teeth

When you clench or grind your teeth, the nerve inside the tooth may become
inflamed. This inflammation of the nerve, or hyperemia, causes tooth pain. The
tooth may hurt spontaneously but it is more common for the pain to occur during
tooth grinding, normal chewing, and especially when eating or drinking cold foods
or beverages. Some people experience so much cold sensitivity in their teeth that
they avoid very icy beverages entirely or have to drink through a straw. This
inflammation doesn't cause any structural damage to the tooth and generally is
reversible when the clenching or grinding stops. This is similar to what is observed
when a dentist places a restoration that has an occlusal interference. The
symptoms of sensitivity are relieved when the occlusal interference is reduced.

Fractured teeth

Clenching or grinding forces can break a tooth. Breakage is especially common in

teeth with large fillings because decay and fillings can weaken the tooth and make
it more fragile. Usually these teeth can be saved by crowning them but unless the
grinding and clenching forces are controlled it is only a matter of time before
another tooth will break.

Worn teeth As teeth are ground back and forth in a subconscious attempt to wear
down the protruding points, they can become extensively worn. Ironically, though,
grinding won't correct the unevenness that first stimulated it.
Tooth grinding follows a back and forth or side to side pattern. Because of the
shape of the teeth and the bones of the jaw, every tooth along the path of the
grinding experiences some wear.

The 12 dental signs and symptoms caused by excessive occlusal forces.

Percentage of patients exhibiting

Dental condition
symptoms

Abfractures 56

Broken teeth 30

Chipped teeth 73

Cracked teeth 20

Gum recession 60

Internal cracks 53

Loose teeth 16

Lost teeth 6

Root exposure 56

Sensitive teeth 53

Shifting teeth 16

Worn teeth 96

The teeth that wear the most are often the front teeth, even though the offending
uneven points almost always are located on back teeth. The amount of wear varies
from slight to extreme depending on the intensity of the grinding. In extreme
cases, more than half of the tooth structure can be worn away and the patient may
require extensive reconstruction to rebuild the worn tooth structures.
Chipped teeth

Chipped teeth are worn and fractured teeth. Grinding causes tooth loss from wear.
Once teeth are worn down, the tooth structure can become fragile and fracture
easily. These chipped regions are seen often on the biting edges of the anterior
teeth.

Internal cracks

Severe clenching and grinding pressures can cause internal cracks and stress
fractures in the teeth. They are not painful and unless they go deep into the tooth
they do not compromise the strength of the tooth. They look similar to the maze of
crack lines seen in ice cubes that have been hit but not broken. These subsurface
stress cracks sometimes can be nearly invisible unless a light beam is angled to
reveal them.

Cracked tooth syndrome

When clenching or grinding causes an internal crack deep inside the tooth, the
cracked segment can move away from the remaining tooth strucure. The crack is
usually so small and the movement so slight that it is neary imperceptible but biting
on the tooth at just the right angle can cause severe pain. If the crack does not go
all the way down into the nerve canal, the recommended treatment is to put a
crown or onlay on the tooth. That holds the broken tooth fragments tightly together
so they cannot move and the pain goes away. If the immobilization does not ease
the pain, root canal treatment will be necessary. Cracked tooth syndrome usually
strikes the back molars where the force is highest.
Gingival recession

We generally blame brushing too hard for gingival recession but it can be caused by
grinding, too. Pressures on the teeth rock the tooth back and forth in the bone,
damaging it below the gingival margin. When the bone is destroyed, the gingiva
has no support and recedes as well. This grinding-induced gingival recession is
observed most often on the cheek side of the tooth where the bone is normally thin
and most easily damaged. Depending on the degree of recession, it may be
necessary to perform reconstructive gingiva procedures as well as correcting the
bite.

Exposed root surfaces

From gingival recession, the exposed root surface may become sensitive to air
sweets, or cold. These areas also are prone to decay.

Abfractured root surfaces

just as the wind can cause tall buildings to lean, powerful clenching and grinding
forces can bend teeth. When this happens, the enamel near the gingival margin can
break off, causing notches in the teeth. These notches are smooth and may or may
not be sensitive. Abfractures also can occur on the biting surfaces of back teeth, It
is important to realize that these holes are not caries; rather, they are symptoms of
grinding or clenching.
Shifting teeth

When an orthodontist moves a tooth, the braces exert forces so small they are
measured in ounces. On the other hand, grinding or clenching can create forces of
500 pounds per square inch. Forces of that magnitude can cause considerable
undesirable tooth movement. Movement usually is noticed first when spaces
develop between the top front teeth or where the lower front teeth begin to
overlap.

This problem once was blamed on third molars pushing the other teeth. But the
third molar buried in the back of the jaw could never exert enough force to affect a
front tooth. When you park your car, it can't move seven cars in front of you to
create extra space. In the same way, third molars can't move all of your teeth from
the back up to the front to shift the front ones. Any time teeth shift, a problem in
the bite should be suspected and investigated.

Loose teeth

If the bone that holds the teeth in place is damaged, the teeth can become loose.
Usually bone damage is associated with plaque and periodontal disease. However, it
is evident that prolonged grinding or clenching also can damage the bone.

A tooth that is held by healthy strong bone is never perceptibly loose. At the first
sign of loose teeth, the dentist must carefully examine the gums for symptoms of
infection and the bite for signs of unevenness, occlusal trauma, and fremitus. Often
all are present.

Lost teeth

Except for decay or accidents, tooth loss usually is caused by bone loss or tooth
breakage beyond the point of repair. Both of these conditions, loosening and tooth
breakage, often are caused by tooth clenching and grinding.
The same excessive biting force that can cause pain in one tooth or break another
tooth can loosen another tooth painlessly. The cause is the same. The resulting
damage depends on the resistive capacity of the individual.

Results

Of the 100 patients, all were found to have one or more of the 12 listed
biomechanically induced dental signs and symptoms.

The table shows the 12 dental signs and symptoms and the number of times that
each one was found. If a patient had one or more abfractures, for example, they
were counted as one even if there were six teeth with abfractures, so the maximum
reportable number of any of the signs was 100.

In order to substantiate the use and effect between the dental sign and
biomechancial forces of tooth clenching and grinding, the following requirements
were established. In every situation in which trauma was thought to be a causative
agent, such as gingival recession, it had to be clear that the patient in fact was
grinding his or her teeth based on supporting physical evidence such as ear,
hypermobility, and objective evidence such as obvious heavy markings using
occlusal indicator ribbon on the affected tooth. The twelfth sign, missing teeth, is
highly subjective and is included as a consequence even though the criteria actually
are unreliable and impossible to count.

It was observed that most reported biomechanically induced dental signs occurred
in multiple situations. For example, most people who exhibited abfracture lesions
also had gingival recession, bone loss, and often tooth sensitivity in the same area.

Discussion

The field of medicine and dentistry has come to associate tooth clenching and
grinding with the controversial field of head, neck, and facial pain while ignoring the
obvious effect of biomechanically induced dental disease. Despite the fact that
structural engineers have studied and quantified the effect of stress in mechanical
systems and their response, many dentists seem to believe that the teeth and
dental structure somehow are immune to the laws of physics.

There are three basic forces that physical objects can be subjected to, based on the
direction of the application of the load. They are compression, tension, and shear
Compression force occurs when force is applied in the long axis of the system, such
as when a carpenter hits a nail straight into a piece of wood. Tensile force occurs
when the direction of the force is between 180 degrees and 90 degrees of the long
axis. Shear force occurs when force is directed perpendicular to the long axis.
Experience tells you that no matter how hard a nail is struck and regardless of the
weight of the hammer, a nail that is hit with the force directed in the long axis of
the nail will never bend.

On the other hand, when the nail is struck off axis, the nail will be bent with even
minimal force. That is because any system can withstand compression forces 60
times greater than tensile and shear forces without deformation. The most
destructive application of force is shear force where the force is directed
perpendicular to the long axis of the system. Every mechanical system is designed
to put as much of the load as possible into compression. When that is not possible,
the strength of the design must be enhanced to accept and resist the significantly
greater forces that are delivered in tensile or shear.

Consider the dental system from an engineering point of view. In a typical dentition
with normal overbite and overjet of the anterior teeth, the posterior teeth, in
vertical closure, have the potential to be subjected to nearly vertical compressive
loading. Even though the mandible closes on an arc of rotation, if the biting
surfaces contact in the line of the long axis of the teeth, the potential force is nearly
vertical in the molars and premolars just like the force of the hammer is on the nail
(Fig. 16).

If the teeth hit off axis, the force becomes a combination of tension and shear with
some compression (Fig. 17).

In lateral or protrusive excursions, any forces on the posterior teeth must be

primarily tension and shear (Fig. 18).
In the case of the upper anterior teeth, due to the overbite and overjet, the force
they are subjected to in vertical closure is always a combination of tension and
shear. The same is true in lateral excursions or protrusive excursions (Fig. 19).

In the case of the mandibular anterior teeth, a close examination will reveal that a
great percentage of the force directed at the lower anterior teeth actually is
directed in compressive; during vertical closure and even during excursions much of
the force is in compression (Fig. 20).

The engineering design of the maxilla and mandible is a classical class II lever
system in which the TMJ is the fulcrum, the muscles are the force, and the teeth or
bolus of food acts as the resistance (Fig. 21).
In any lever system, the resultant force is always proportional to the square of the
distance from the fulcrum. Therefore, it would be expected that the force in the
molar area would be considerably greater than in the incisors.

Had the human chewing system been designed by structural engineers, they would
have had to evaluate the strength of the teeth and bones of the jaws as well as the
potential forces that the system would encounter. The two forces to be most
concerned about would have been that required for chewing and tearing food and
the potential parafunctional forces of tooth clenching and grinding. From a chewing
point of view, ripping and tearing foods such as carrots and hard breads and tearing
bites out of meats are more difficult than grinding down foods once they have been
torn off and wetted and softened by saliva.

The design specifications for incisors show one root per tooth. They generally are
conical and the shortest roots in the mouth, with the least surface area. Compare
that to the engineering specifications for molars, which have two to three roots per
tooth. Roots are elliptical in design and the total surface area for molar roots is
typically at least four times that of incisor roots.

Obviously our hypothetical engineers anticipated much more force in the molar area
than in the incisor area. There were two reasons for this. First, despite the potential
for optimal biomechancial loading of the posterior teeth, they recognized that it was
unlikely that the posterior teeth would erupt into an ideal position where vertical
loading would be consistent. Instead, nonvertical occlusal contacts would subject
the molars to far greater tension and shear forces. This would be magnified greatly
because the molars are close to the TMJ.

Second, they recognized the potentially severe destructive forces from

parafunctional tooth clenching and grinding. As a result of off-axis loading,
proximity to the fulcrum, and parafunctional activities, the molars required
strengthening the specifications of the molar roots.

Consider the patients in your practice who are nearly completely edentulous. Which
teeth typically are the last to be lost? Think of your own patients and see if you
don't agree that the mandibular incisors, the ones with the smallest roots, often are
the last to be lost, even if they have significant bone loss and some mobility.

One reason for this is that the molars are so much closer to the fulcrum that they
are subject to much more force than the incisors. The molars can generate forces
up to 500 pounds per square inch, while the incisors can generate barely 150
pounds per square inch. In the natural state of the molars, much of the occlusal
force is in tension and shear despite the potential for transforming that force into
compressive. This explains why there is such a high prevalence of biomechanically-
induced dental disease in the general population.

The clinical dentist has the opportunity to intercede and reengineer the system to
reduce the potentially destructive biomechanical loads on the teeth and the bones
of the jaw through occlusal equilibration and selective reshaping of the biting
surfaces of the teeth. The decision of when to intercede has to be based on clinical
evaluation of the presence of the 12 dental signs and symptoms of biomechanical
dental disease. A patient displaying the damage shown in Fig. 4-15 needs
treatment. Patients without significant signs or symptoms of biomechancial dental
disease should be made aware of their occlusal disharmony and told that since
there does not appear to be any damage, no treatment is indicated at this point.

Step 1 - Assist the condyle to assume the RUM position and perform selective
reshaping of the teeth (in general, primarily the posterior teeth) to eliminate any
deflective contacts until the posterior teeth can contact equally and simultaneously
on both sides without pulling the condyles out of their centered RUM position. Make
sure that all contacts are on flat surfaces and cusp tips so that forces are directed
primarily in the long axis of the tooth roots to create primarily compressive loads on
the posterior teeth.

Step 2 - Slightly relieve anterior teeth in vertical closure so that the off-axis loads
do not cause the teeth to move with hard vertical closure. This can be tested by
feeling for vibration with your finger or looking for movement of the maxillary
anterior teeth with hard vertical closure. This reduces the tension and shear forces
on the anterior teeth.

Step 3 - Reshape the posterior tooth inclines so that there is no contact in lateral or
protrusive excursions. Allow the canines to bear the load during lateral excursions
and the incisors to share the load during protrusive. If the canines are missing, if
their bone support is compromised, or if they are out of ideal position, it may be
necessary for the premolars to share the load during lateral excursions. This takes
the most potentially destructive tension and shear forces off the molars and moves
them as far from the fulcrum as possible.

Step 4 - Let the patient tap, clench, and grind his or her teeth in all directions and
relieve any posterior tooth inclined plane contacts and reduce any anterior teeth
contacts that move the teeth.

Step 1, creating a condylar directed occlusal pattern rather than letting the teeth
establish the condylar position, is critical in achieving a harmonious relationship
between the biting surfaces of the teeth, the TMJ, and the neuromuscular system.
Unfortunately, the average patient has been forced to accommodate to a tooth-
directed condylar position for so long that the muscles become cramped and resist
the condyles seating to the RUM position.
There are several methods that can be used by the clinician to assist the patient.
The first and most difficult for most clinicians is to manipulate the mandible into the
RUM position. Stuart called this "romancing the condyle," while Dawson has
described a two-handed technique Both of these and other similar methods, while
excellent and highly predictable for a very experienced clinician, are very technique
sensitive and are prone to cause errors by the less experienced clinician. These
manipulative errors may lead many clinicians to the incorrect conclusion that
condylar directed occlusion is not correct, effective, or necessary when the real
problem is that this position was not achieved in the first place.

To assist the clinician in positioning the mandible to achieve the RUM position, there
are many methods of discluding the posterior teeth so that the condyle is freed to
move into the RUM position. This method has been advocated in dentistry for many
years. just to name a few of the options, there is the anterior leaf gauge and the
central bearing point on custom designed clutches as well as laboratory fabricated
splints and custom fabricated splints. All of these, when used correctly, can be very
successful in allowing the condyles to achieve the RUM position.

The problem with these systems is that they require a learning curve, they can be
cumbersome to use, many cannot be used unassisted by the patient prior to the
visit, and some cannot be put on and removed from the teeth easily during
equilibration procedures. The biggest barrier to effective treatment and greatest
source of controversy in this area is the difficulty of positioning the condyles in
centric relation position. For this reason, more effective methods must be
developed that are simple to use and easy to learn.

Conclusion

The human stomatognathic system functions like any mechanical system. If the
biomechanical forces it is subjected to can be controlled, damage to the system can
be minimized. If the biomechanical forces it is exposed to exceed its resistive
capacity, damage will occur in the weakest element. Because the damage may
show up as broken, sensitive, worn, or abfractured teeth; gum recession; bone
loss; mobile, migrating, or ultimately lost teeth; or head, neck, and facial pain, the
dentist must be aware of the many potential manifestations of biomechanically-
induced dental disease. Further, it is the responsibility of the dentist to discover
these signs and symptoms as early as possible and then take action to control
these biomechanical forces to minimize their potential consequences.

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