Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

PERIODONTAL SYMPTOMATOLOGY IN CRANIO-MANDIBULARY SYNDROME

Dorina-Cerasella Şincar, Oana Chipirliu, Mioara Decusară*, Dan Ionel Cristian, Gabriel-Valeriu Popa, Cristian Constantin Budacu*, Gabi Topor, Gabriela Popa, Kamel Earar ”Dunărea de Jos” University, Galaţi, Romania Faculty of Medicine and Pharmacy, Department of

* Corresponding author: [email protected] [email protected]

Introduction: The cranio-mandibulary syndromes are pathological entities in which at least one of the components of the dento-maxillary apparatus (jaws) is not structurally or functionally adapted to its own activity. These disorders include manifestations at the temporomandibular joint or neuro-muscular system and occlusal disarmony manifested in the dento-periodontal component of the dento-maxillary apparatus. Unfavorable occlusal relations causes changes to the fundamental positions of the mandible, resulting in non-physiological forces exerting a negative impact on the manifested clinically and radiologically through: dental mobility, gingival retraction, periodontal bags, widening of the desmodontal space. Aim of study: The purpose of this study was to identify periodontal signs produced by occlusal trauma and to remove potentially harmful periodontium factors by obtaining a mandibular-maxillary relationship that maintains the health of the dento- maxillary apparatus. Materials and methods: The study based on the clinical, paraclinical and dental treatment of the patients included in the study group was performed. A group of 20 persons with at least one of the following signs considered to be inherited from cranio-mandibulary disorder: dental mobility, pathogenic dental wear, root resorption, widening of the desmodontal space, Stielmann cracks, occlusal parapuncture (), hypercementhosis, false or true periodontal pockets. Results: During the study, we were able to highlight that primary or secondary occlusal trauma is a cofactor in the production of . In the absence of microbial plaque, occlusal trauma, does not produce or periodontitis, and minor periodontal lesions are reversible. Conclusions: Occlusive trauma occurs when one or more teeth are harmful to excess strain, by intensity, duration, frequency, direction. Occlusal trauma is a cofactor in the production of periodontal disease; therefore, treatment should begin early by correctly identifying the causes of occlusal disharmony and removing them. Key words: cranio-mandibular syndrome, periodontium, occlusal trauma, occlusal disharmony

Introduction. The triggering of cranio- maxillary apparatus are initially taken up by mandibular syndrome is the result of the the dental arcades and then transmitted action of several intra and supra-systemic through the periodontium to the alveolar factors. Although the debut can be achieved bone and to the cranio-facial resistance on a dysfunction of a single element of structures[11-20]. At present, an efficient stomatognathic system, subsequent dental treatment requires the perfect homeostatic disorders attract the other understanding of some of the notions of elements[1-10]. Potentially pathogenic mechanics applied to biological systems occlusal relationships can cause many dento- such as stress analysis, force acquisition and periodontal disorders. Within the distribution in the context of the dento- stomatognathic system dysfunctions occur maxillary appartus, fluid dynamics, energy deviations from occlusal morphology and and mass transfer. When the occlusive force functionality and the normal functionality of acts on a healthy periodontium, occlusal the dento-maxillary apparatus is affected. trauma is called primary occlusal trauma or The forces that are born in the dento- pure occlusal trauma that produces

284

Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019 periodontal suffering per primam. If the interdental papillae - beheaded papillae, occlusal trauma acts on a periodontium pathological root resorption phenomena, already affected by a marginal periodontitis, dental enlargement. it is called secundary occlusal trauma, per The inclusion criteria in the group were secundam, intervening on the basis of based on the clinical, paraclinical and dental already existing periodontal lesions, which treatment data of the patients included in the no longer allow the affected periodontium to batch. The preliminary examination of each undergo previous physiological patient included a rigorous anamnesis and requirements[21-25]. complementary examinations: face and Occlusive trauma is followed by numerous profile photographs, extraoral and intraoral adaptive modifications of the marginal examinations, study patterns, periodontium. These changes are represented orthopantomography, retro-alveolar by the gradual endangering of functions and radiographies, profile teleradiographies as its support structures, thus abnormal dental well as cephalometric analysis. The mobility, enlarged dento-alveolar space, secondary exam had a very important role in lamina dura thickening, gingival retraction, establishing the diagnosis and developing the diffusion demineralization of the alveolar treatment plan. Treatment planning was done bone, damage of root furcations, dentinal with informed and motivated patient consent. hyperesthesia, and a whole chain of CLINICAL CASE. Patient A.C., aged 30, degenerative phenomena[25-30]. The profession: teacher in urban environment; purpose of the study was to identify the patient presented to the dental practice periodontal signs produced by the occlusal accusing the impossibility of proper trauma found in the patients included in the mastication, aesthetic problems, unilateral batch and to eliminate the potentially mastication, demanding replacing the damaging factors on the parodontium by amalgam dental filling and covering the obtaining a mandibular-maxillary edentulous. The patient is experiencing relationship that would preserve the health of repeated episodes of diffuse pain identified the dento-maxillary apparatus. Given the at the level of the right mandible at the teeth numerous aggressions on tooth and on nearby the toothless gap, mean intensity pain periodontal tissues caused by excessive that increased in intensity during forces, occlusal rebalancing for periodontal mastication. Following the exam, in the health and functionality of the dento- anamnesis, it was found that the general maxillary apparatus is absolutely necessary. personal history and the heredo-collateral Material and method. The group consisted history are irrelevant. Personal dental history of 20 patients, 4 female patients and 16 male revealed that the patient had the 3.6 molar patients aged 18 to 36 years who had at least extractions about 6 years ago due to the one of the following signs considered to be long-term evolution of an untreated carious associated with craniomandibular disorders, process.(Fig.1) The extraoral examination but with one significant clinically or revealed at the TMJ joint, level noises, radiologically character: dental mobility, cracks and crepitations. pathological dental wear, root resorption, In the endobuccal clinical exam in the widening of the desmodontal space, dental-alveolar maxillary arcade, was Stielmann cracks, occlusal parafunctions observed: (bruxism), , early or • a natural dental arcade, uninterrupted moderate periodontal lesions, horizontal and of edentations, the presence of non- / or vertical bone lysis, changing the vertical physiognomic fillings at the level dimension of , diffuse periodontal of several teeth 1.6, 1.7, 1.8, 2.6. pain, traumatic occlusion, , • a U-shaped dental arcade with a diffuse demineralization, abnormal bleeding slight asymmetry of the hemiarcades at brushing and mastication, false or true produced by the tooth erruption in periodontal pockets, affecting of the 2.8 vestibulo-position and 1.8 is

285

Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

rotated, which did not have enough • visible gingival recession at the level space for erruption. of 3.5, distal wall, nearby totthless At the dentoalveolar mandibular arcade was gap, facets 3.5, 3.7 - observed: possibly results of unsatisfactory • absence of 3.6; mastication. • 3.7 shifted to mesial and lingualised, • gingival recession at the canine level, amalgam filling at 4.6, 4.7, 4.8; possibly due to a traumatic physiognomic fillings at level 4.5, occlusion. 4.4.

Fig. 1 The shape of the dental arcades

The following periodontal risk factors have - dental coloring - data from been identified: amalgam fillings and inappropriate Determining Factors: Bacterial plaque – hygiene. Silness-Löe plaque index with values Radiological at the level of teeth found in between 1 and 2; occlusal trauma was observed (Fig. 2) Favors: Dental tartar - supragingival and • the widening of the periodontal space subgingival tartric concrement on the associated with the narrowing of the vestibular and palatal surface of the upper lamina dura to its partial or total molars 1.6, 1.7, 2.6, 2.7, lingual surface of destruction, from where we conclude lower incisors 4.2, 4.1, and lateral areas 3.1, a dental mobility above the normal 3.2, 3.5, 3.7, 4.5, 4.6, 4.7 limits, at 3.7, 3.5, 2.6, 2.7; • carious medium-depth process on the • the periapical bone matrix rarefection distal face the cervix area of 3.5, - hypertransparency - to the vital painful at palpation - food retention teeth 3.7. • edentation 3.6, untreated - migration • possible vertical root fracture, in the of limitrophe teeths - traumatic apical third, at 3.4 - which was not occlusion - teeth in occlusal trauma confirmed by a subsequent 3.5, 3.7, 2.6, 2.7 radiological examination • dental jaw abnormalities - teeth in • the vertical migration of 2.6, 2.7 malpositions - 1.8, 2.8 - blockage of • vertical and horizontal bones lysis of occlusion, lack of terminal contact medium and profound depth in the points. medial wall of 3.7 and the distal wall • damaged amalgam dental fillings, 3.5. especially in the 4.7. some of the obturation is lost.

286

Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

Fig.2 Initial Ortopanthomography

The profile teleradiography - highlights the stomatognomatous system altered by the development of the base of the skull - presence of the toothless gap and occlusal normal, as well as the development of the complications produced by it. (Fig.3) A mandibular bone base - normal. Centric hypodivergent profile with a posterior relationship and posture relationship - rotation pattern is revealed. We identified the normal. Homeostasis of the following specific rear-directional signs:

Fig. 3 Profile teleradiography

- thin condyle with upward and backward - the mandible developed downward and growth forward - open mandible angle - pronounced preangular notch According to the cephalometric analysis, the - the right mandible canal patient exhibited an eccentric cranio - increased alveolar dental volume mandibular malrelation, consecutive to the - wide and inclined horizontal ram edentation, caused by the occlusal continuity - short and narrow vertical ram disruption and the movement of the anterior - dental high volume mandible in the sagittal plane. (Fig.4)

287

Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

Fig.4 Cephalometric analysis. Drawing the main plans: 1 – Anterior skull base, 2 – Frankfurt plane, 3 - The basal maxillary plane, 4 - The mandibular basal plan

SNA-82˚ orthognathic jaw • SNB-80˚ normal mandibular position relative to the base of the skull, but with a tendency towards a prognathic position due to traumatic occlusion • ANB -2˚, positive • Right profile slightly concave Gn located ahead of the Orbito-Frontal Plane • Hipo-divergent From a periodontal point of view, there was movement in sagital sense. Thus, there was observed a thin gingival biotype, prominent observed the presence of early contacts in exostosis, localized irritation-induced static, and dynamic occlusal interferences inflammation, reduced depth periodontal caused by the horizontal migration and bags located at 3.5, 2.6, and of average depth lingualization of 3.7 and the vertical 3.7. Chronic marginal periodontitis located migration of 2.6, 2.7, the appearance of at the level of sextant 6, site 3.5, 3.7, abrasion as a result of these destabilizations, medium and deep depth of multi-factorial occlusal contacts in the surface. The plaque etiology, bacterial plaque, scale, treatment followed 3 steps: etiological, edentation, occlusal trauma. This results in corrective, and maintenance and outcome chewing and physiognomy slow-moving control therapy. Etiological therapy disorders, and local complications: consisted in the removal of irritation factors, resorption and bone or loco-regional atrophy corrective therapy aimed at stabilizing the - the starting of dysfunctional syndrome of occlusion, removing the interferences and stomatoghnatic system with good prognosis premature contacts, stopping the evolution of in case of appropriate treatment. From the bone lysis as well as performing a occlusal point of view, a malocclusion was conjunctive prosthetic work with the aim of determined, due to the alteration of static and restoring correct occlusal relations. During dynamic occlusion parameters consecutive the maintenance phase, it will be followed: the edentation and eruption of the maxillary control of plaque and scale accumulation, wisdom teeth in ectopic positions. Eccentric control of gingival status, occlusion, dental mandibulo-cranial malrelation is consecutive mobility, other types of pathological to the edentation, caused by the occlusal changes. continuity disruption and the mandibular

288

Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

Results and discussions. From the data that can be produced by many local factors analysis, occlusal trauma was seen to have a that cause disturbance of occlusion and the higher incidence among patients aged over production of supraliminal forces. It has thus 30 years. In these patients, it was necessary been observed that unprotected edentations to restore a harmonious and effective cause most periodontal disease by the occlusion. Maintaining a traumatic occlusion devastating effects of occlusal trauma. Often, leads to irreversible damage to the alveolar the factors that produce occlusal trauma bone, thus appearing the horizontal or intertwine at the same patient and are vertical bone lysis of superficial, medium or determined mutually. profound depth. Horizontal bone lysis was Conclusions. Primary or secondary the most encontoured common type of bone occlusive trauma is a cofactor in the resorption, reduced in height bone, but production of periodontal disease. overall the bone marrow is perpendicular to Periodontal signs in cranio-mandibulary the dental surface. It was observed that for syndrome occur as a consequence of the same site, the resorption was uneven, overloading of supporting tissues through variable in a different way for interdental articular, muscular or by occlusal trauma septums, vestibular and oral cortical bone dysfunction. The method of adapting and and associated with superficial periodontal defending the teeh periodontium exposed to pockets. The vertical bony lysis, which is the various demands of the masticatory present in a smaller proportion to the studied forces largely depends on the physical cases, presents the base of the defect located properties of the periodontal tissues, the apical to the adjacent bone, frequently number and quality of the collagen fibers as associated with the infra-bony periodontal well as their degree of polymerization, the pocket. The presence of the mixed bony lysis vascularization and the quality of the dental met in 50% of the cases included in the alveoli. The triggering of cranio- group, and as the depth, the medium lysis is mandibullary syndrome is the result of the the most common in 10 cases, followed by action of several intra and supra-systemic the deep one in 6 cases and the superficial in factors. Although the debut may occur on a 4 cases. As far as the etiology of occlusal dysfunction of a single stomatognized trauma is concerned, it has been found to be system, subsequent homeostatic disorders a complex and multifactorial phenomenon attract the other elements.

REFERENCES

1. Bratu D., Românu M.,Muntenu M.„ Aparatul dento-maxilar ”, Editura Helicon, Timisoara, 1997; 2. Burlui, V. , Morarasu, C. - „Gnatologie clinică”, Editura Apollonia, Iași 2012; 3. Caranzza F.A., Newman M.G.- Clinical 12th Edition, WB Saunders Co Philadelphia 2014; 4. Forna N. C.. „Protetică dentară ”, Volumul I,Volumul II, Editura Enciclopedică, 2011; 5. Ioniță S., Petre A. „ Ocluzia dentară ”, Editura Didactică şi Pedagogică R. A., Bucureşti, 1997. 6. Mârțu S., Mocanu C.,– „ Parodontologie clinică ”, Ed. Apollonia, Iași, 2000; 7. Antohe ME, Forna Agop D., Dascalu CG, Implications of digital image processing in the paraclinical assessment of the partially edentated patient, Revista de Chimie, 69(2),2018 pg.521-524 8. Niculescu,O.,Nica,P., Gurlui,S.,et al., Experimental investigations of polymer plasma laser ablation, Materiale Plasice, 46(3), 2009, pg.336-338 9. Vasluianu, E., Popescu,V., Grigoriu,A., et al., Comparative study concening the FIR Analysis and the performances of chitosan –based wrinkle-proofing agents, Revista de Chimie, 64(10), 2013, pg.1104-1115

289

Romanian Journal of Oral Rehabilitation Vol. 11, No. 2, April - June 2019

10. Nash,D.,Ruotoistenmaki,J., Argentieri,A.et al.,Profil of the oral healhcare team in countries with emerging economies,Conference Global Congress on Dental Education location,Dublin,Ireland, European Journal of Dental Education,12((1), 2008, pg.111-119 11. Popescu,V., Vasluianu,E., Forna,N.C., et al., Comparative study of the FTIR Analysis and the peformances of N,N,N-trimethyl chitosan as wrinke-poofing agent, Revista de Chimie,4(11),2013, pg.1284-1294 12. Botnariu,G., Forna, N., Popa,A., et al., Correlation of glycemic control parameers in non- diabetic pesons with cardiovascular risk scores-results from a cross-sectional study, 8(1),2017, pg.108-110 13. Iliescu-Bulgaru,D., Costea,G., Scripcaru,A., et al., Homicide and alcohol consumption.A medico-legal and psychiatric interdisciplinary appoach.Multivariate analysis,Romanian Journal of legal medicine, 23(2),2015, pg.137-142 14. Ifteni,G., Apostu,A., Tanculescu,O., Dental occlusion and the importance of is proper investigation-partII, Romanian Journal of Oral Rehabilitation, 8(4),2016,pg.17-22 15. Golovcenco,L., Scripcaru,C., Zegan, G., Thid molar development in relation to chronological age in Romanian children and young adults,Romanian Journal o legal medicine,17(4), 2009, pg.277-282 16. Jumanca D., Galuscan,A., Podariu,A.C., et al.,Anti-inflammatory action of oothpastes conaining betulin nanocapsules, Revista de Chimie,65(12),2014,pg.1473-1476 17. Balan G., Grigore, C.A., Budacu,C.C., et al., Antisepsis, Desinfection Sterilization -mehods used in dentistry, Revista de chimie, 68(1), 2017, pg.186-191 18. Zegan, G., Dascalu, C.G., Mavru, R.B., Cephalometric, features of Class III malocclusion, Medical-surgical journal,119(4), ,2015, 1153-1160; 19. Gradinaru, I. , Ignat ,L., Dascalu, C.G., Soroaga, L.V., Antohe,M.E., Studies regarding the architectural design of various composites and nanofibres used in dental medicine, Revista de Chimie,69(2),2018, p.328-331 20. Ancuta ,C., Pomirleanu, C., Iordache,C., et al., Serum lipid profile in diffuse versus limited systemic sclerosis data from the SASS cohort, Revista de Chimie, ,69(2),2018, pg.403-406 21. Budacu, C., Nemtoi, A., Constantin, M., Biomaterials used in Reduction and Fixation of Unstable Fractures of the Zygomaticomaxillary Complex,Rev. Materiale Plastice, 54(4),2017, pg.773-776 22. Nitescu D., Mihai C., Oanta C., Evaluation of cumulative effects of chemotherapy and bevacizumab (avastin) in oncological patients with periodontal disease, Revista de chimie; 68(3),2017, p. 549 23. Budacu, C.C., Cioranu,S.V.,Chiscop,I.,e al., Glucocoricoids and postoperative disease in oral- maxillofacial surgery, Revista de Chimie, 68(11),2017,pg.2716-271 24. Taranu , T., Constantin, M.M., Toader, M.P,et al., The benefits of using the Iodine solution in the treatment of acne at pregnant women, Revista de Chimie, 69(9), 2018, pg.2343-2345 25. Grigore, M., Furnica, C., Esanu, I., et al., Pentalogy of Cantrell associated with unilateral anophthalmia .Case report and literature review, Medicine, 97(31),2018 26. Nemtoi, A., Danila ,V., Dragan, E., et al., The effecs of insulin and strontium ranelate on guided bone regeration in diabetic rats, Revista de Chimie, 68(4), 2017,pg.693-697 27. Plesoianu C.E., Andriescu G., Salaru,D., e al., The relationship beween biochemical variables and the quality of life in paiens with chronic heart failure, Revista de Chimie, 68(10), 2017, pg.2452-2458; 28. Salaru,D., Macovei,L., Statescu, C., Assessment of microalbuminuria in hypertensive patients wih established coronar artery disease, Revista Romana de Medicina de Laborator, 21(4), 2013, pg.407-414 29. Martu,I., Luchian,I., Diaconu-Popa, D. et.al., Clinical and technological particularities regarding unidental restoration using ceramic crwns with a zirconia infrastructure.a case report.,Romanian Journal of Oral Rehabilitation,9(1),2017, pg.27-31. 30. Ancuta,C., Pomarleanu,C., Iordache C., Periodontal disease and lipid profile in systemic sclerosis: an EUSTAR Cohot Expeience, Revista de Chimie, 68(4), 2017,pg.890-893

290