EFFECT OF OCCLUSAL TRAUMA ON HEALING OF PERIAPICAL LESION : ( Case Report )

Traumatic injury ofth€ teeth occurs frequently on anterior and posterior teeth. Pulp necrosis is often the ilequent sequ€l oftrauma and it will lead to development ofperiapical esions in the presence ofpathog€nic microorganismTwo cases of periapical esion reported here were caused by occlusal trauma lt is still controversial whether a case of large periapical lesion should be treated conventionally or surgically. This cases was treated non surgically and it was proved that this kind of treatment could promote large apical h€aling successfully. 1t1, nesian Jaumal af Denttstry 2006 | Edisi Khusus KP Pl KG X1Y: 266-27 I


Introduction
Occlusal trauma is defined as a pathologjcal condirion or an adaptive change that involves periodonral tissue as the result. of the strength produced by masticatory muscles.Occlusal trauma can develop into a condition which load strength produced by dre occlusion exceeds the ability of periodontal tissue around the teeth that gets involved.also in nonfun€tional condition and produces a strength without movement.This exc€eding occlusal strength can cause dystrophrc rn periodontal ligament, alveolar bone, cementum and also could induces periapical inflarnmation and root The relalionship between occlusal trauma and periapi€al healing has been reported a lot and well estsblish€d.when rhe periodontal lissue is h€aithy, occlusal lrauma may not cause $e formation of denral poclel or rhe de.rrucrion oi conneclive Ii$ue atrachment.Baclerial infection combined wifh occlusal trauma can cause damage to the periodontal tissue.In lhis case, occlusal lrauma plays ils role as co-factor in destruction process.rEldeeb and Andreason (1991) has reported th€ir research, using rats as trial animals, that hyper and hypo occlusion did not aff€ct periapical healing.' Kumazawa, et al (1995) reported his resedrch which alio used rars as trial animal, the conelation was found between occlusal trauma and periapical pathosis.It was presumed that occlusal nauma could be asso(iated with slow-developrng inflammation in periapical tissue a.
Thes€ two cas€-reports showed the root canal treatm€nts performed in maxillary premolar teeth and ma\illary cenral incisor that experienced occlusal trauma caused by dental disorder.ln one case, the healing took place after occlusal adjustment while in other case healing was not seen Persistent pain occured eventhough the root canal reatment had been well performed.An occlusal adjustmeni on the teeth could nol be performed yet.
Crse Report female paliett, 17 years of age visited dental cln'ic (Conservative Department in Faculty of Denti,(ty.tJniversity of Sumatera Utara) with the need to have the de€ayed right maxillary premolar resiored because she felt discomfort while €ating and somelimes it was throbbing.She also wanted to change her ouilook because lbe dental order was not good.Before this, lhe tootl had been painful fot about past six months but the pain had Eone if she took analgesic.When she visited the denlal €linic, the tooih was nolpaintul anymore.
In a ciinical exarnination, it was seen $at tooth 14 with fracture palatal cusp.and caries with pulp expossure.Ihe rernainiflg tooth structur€s left were buccal and a few in mesial and distal part.Vitaliry test ofthe teeth did not show an) sensitivity but il was sensirive Io percussion and palpation.Radiographic view showed that lhe root had shorlened, and apical root canal natrowed.The periodontal ligament widened, lamrna dum disappeared and wid€ radioluscency viewed at penape\.,lrg lr.foolh l4 $a.foLnd palaroversion in the dental arch (fig 2).The diagnosis oftooth 14 was pulp necrolic wi$ ctuonical apical periodontrtrs-The treaiment perfonned was a non-vital root canal treatmenr with post cor€ and porcelain full crown io restore the dental occlusion into the dental ar€h.lig 2. The posilion ofthe teeth *as pslalotersion Non-vital root canal treatm€nt was performed on tooth 14.After biomechanical rcot canal prepamtion, calcium hydroxide as dressing with glycerin as its vehicie was applied to the tooth.The change of intra-canal dressing was performed every week by observing fie subjective and objectiv€ complaints of the patient.ln the root canal preparation, apical reach was hard to attain.though tbe ch€lating agent and inigation with NaOCI 2.5% had been applied.Buccal root was prepared untrl size/length 35/1 5 and palatal root was 40/ I 3 .
Root canal filling was performed after the third w€ek with gutta-percha by using lateral condensation techniqu€ and Apexit (Ivoclar I/ivadent, Liechstenstein\ as th€ sealer.In control a week after root canal filling, fabricated post was cemented in buccal root and full porcelain crown was prepar€d.Th€ cemenfation of full crown on tooth 14 was compl€t€d after two weeks' cor€ cementation by using luting O?e of Glass Ionom€r Cement (Fig 3).
Control was carried out after the sixth month, it $a( seen rhdr rhe parienl had no complainls.Ediogaphic vi€w show€d the dirninution ot periapical lesion-C.tse 2 A female patient.36 y€ars of age was referred with pain and swelling of ma\illary anterior teeth.The swelling had occurred for a week and tlis condilion had occurred seveml times.Teeih had ever received root canal treatment. Clinical exanination showed teeth ll and 2l with Composite Resin filling on the palatal side.Teeth showed grayish-browr discoloradon.Palpation on region ll and 2l showed hpersensitivily ro pcrcusstun, iooth I I was more sensitive than tooth 21.Radiographic view showed widening of ndioluscency in the apical of tooth ll with non' hermetic roor canal filling on both teeth (fig 5).The occiusal relation of maxillar,v and mandibular anterio.leeth was not good (Fig 6).Non-surgical endodontic retrealment was p€rformed on both i€elh.Biomechanical preparation and injgation with NaOCI 2.5% were performed on teeth ll and 21.Calcium hydroxide was applied after drainage had been completed-Oral pre_medications such as analgesic, anti-inflammation, antibiotic and vitarnin were given to ihe patient.
Four days after the first visit.patienr returned with pain on tooth I L Treaiment was contlrued wfth biomechanical preparation.iffigation and calcium hydroxide as dressing.ln this second visit, maxillary The relaiion between tee1hl1,21 od matdibuld t€elh was not goo0, and mandibular impressions were taken to observe the patient's occlusal relation.Occlusal adjustment was made on teedr ll and 2l with antagonist teeth by reducing the occlusal trauma.After this second visit, two da-vs later pati€nt r€ported that it was better than the first visit.Ten days later, patient was back with swollen on maxillary anterior leeth especjally on tooth I l.In this th;td visii, root canal was opened up and drainage on tooth I I was completed through its rooi canal.Biomechanical preparation was performed on loulh ll and d'e*ing wilh cdl.ilm hydroxid€ was applied.Tooth was th€n restored with t€rnporary filling.Pre-medications such as perfbrmed to observe the patienas o€clusal relation Occlusal adjustrnent was made on te€lh ll and 21 wirl antagonist teeth by reducing the occlusal tmuma.After this secod visit, 1\ro days later patient repo.ted that it wa5 tetter than the first visit.Ten days later, paiient was back with slvelling on na.illary anler;or teeth especially on tooth 11-In this third visit.root canal was openecl up and drainage on iooth l l was completed through its root canal.Biomechanical prepamlion was performed on tooth 2l and dressing with calcium hydroxide was applied.Tooth was then restored wilh temporaryfilling.Pre-rnedications such as Analgesic, antiint'lammation and antibiotic were given again with patients approval.Sugical endodontic treatment (apical curetrage) was planned to be perfbrmed provided the swelling disappear.
In this founh visit i-e. a week after the ihird visit, surgical endodontic ireatmetu was pertormed Trapezoidal flap opening and apical curettage w€re perfofined in the periapex of tooth I I (Fig 7).After the p€riapical cleaning of tooth I l, flap was sutur€d to its position.Fie 7. Surgical endodonlic trcatnrenl on rooth ll (apical curetrase) (15-ll-2005) ln control that was in the fi1lh visit, patient reported that she felt discomfbri on tooth ll especially against percussion.Clinical examinatron slrcwed good healing on surgical area.l'ilingthrough th€ root canal showed pus and ganulation thsues.After the suture was opened.it was decided that the foot canal of iooth ll was lefl open.The examination on tooth 2 I showed no syrnptoms.
The sixth visit i-e.two weeks after surgery.patient returned with permanent discomfon feeling on toorh 11.Tooth 2l showed no synptoms thercfore root canal filling of tooth 2 I was performed with sealer conlaining calcium hydroxide and guttapercha usidg condensation technique.Th€ root canal of tooth ll was siill open because pus was still found.
Five days later, conaol was held again on tooth 1l and apical inflammation disappeared.Filing of the tooih showed no pus but becaus€ patient had ever shoM the discomfort feeling, root canal was left open, Tlree weeks afier surgery.root canal treatment wds performed on roorh ll.Dressind qith calcium hydroxide w&r applied and tooth was iestor€d wrth t€mporary filling.
A month later.patieni retumed with complaint of discomfon feeling, though no sensitivity to pdlpolion hul a klrle seniilitit\ lu percu\!ion.Endodontic reatment was continued by applying calcium hydroxide and with rddiographic control.There was a repair s€en in periapex of looth I I (Fig 8).l-ig 8 Radiogaph of post su.gical .ndodoDri.trearment of pcrialical l@lh I l.(?-2-2006) Trealr:nent was conlinued 1en days later as well as roor !dral filling $i'h 'ealer conlaining crlcium hydroxide and gutta-p€rcha by using lateml condensation tecbnique because patielr! had no complainls shown as the former visits had.
A monlh atcr filling, radiogtaphic view was seen much bettcr but patient still felt disconforr.especially if the tootb was percussed.In the visit after iwo months.the examination of toolh ll showed sensitivity wilh percussion but tooth 2l bad no symploms.Observation was still carried oui on ftis tooth I I

I)iscussion
Occlual trauma can occur due to parafunctional habirs such as bruxism and clenching or due io incorect direciion of occlusal fbrce when bolt) antagonisr of occlusal surfaces encounter.oc€lusal trauma can cause th€ exceeding of oc€lusal use, fracrure ot ma\illa4 reelh cro$n.qrden'ng of and anaphylaclic response (Ig E) such as c)'tokines Droduced by lymphocytes, macrophages' connective iissu€ cells.atachidonic acid metabolites and also kinin Droduced bv other type of c€lls ' The Dossibiiity of immune cells infiltration that releases iheir Droducts may cause periapical bon€ r€sorplion both in $e llrsr and 'econd cases Chronrc inflammation as the result of the occlusal trauma increases bone resorption and bone loss q' In the first cas€, occlusal trauna occured b€cause the dental position was not in the dontal arch {Dalatoversion).As the result of prolonged occlusal ;auma.it was seen that the root shonened with wide periapical lesion.This shortened root showed the ;xtemal rcsorption of tooth 14 The featment that was perform€d in lhis first case was seen to be abl€ to ripair the condition of periapex especiallv by adjusting the dental position with post and crown after non-surgical endodontjc tr€atment was completed.
In the second case, it was se€n that lhere was an exceedina contact relation on teeth 1l and 21 agaanst their anttqonist teeth so ihat periapical lesion might occur.lniiial treatrnent that had been performed by the former clinician showed non-herm€tic root canal filling and when the parient came in the firsr visit there was abscess seen on region ll and 2l Nonsurqical retreatrnent showed that in every cavity sealing on tooth ll patient had swelling and pain again especially on tooth l l Compared to tooth 21, this tooth showed no reactions and treatment could be perforrn€d easily until the root canal filting.
Looking at the condition of tooth ll' it was decided to perform surgical endodontic treatment to eliminate the periapical lesion and reli€ve tbe patieni's pain.In the flap opening, it was seen that the lesion widened fiom mesial of apical tooth ll until mesial of tooth 12. Cavity was left open for several days afier the sugical endodontic aeatmenl until the next examination and was not found any pus or blood in th€ root canals The tr€atment was continued until the mesial of the root canals and the swelling had gone.A few months after the root canal filling.parienr remained d'sLomfon and percrF\ion on tooih I I was more sensitive lhan on teeth 2l and t2.
In radiographic control, it was seen that there rfas a repat in periapical lesion of tooth ll and radiolucent view showed smaller in six months The discomfon feh by ihe patient was presumed caused by maxillary and mandibular anterior teeth that had incorrect relation so that the mechanical irritation could r€main.The continuous trauma could retard healing even though radiographic view showed the diminutjon of the lesion, but the proc€ss that occurred in the apical area could not be explained Spasser and Wendt (1973 cir Boucher, er dl 2000) explained ihis persistent pain phenomenon could be associated with bone defect This case might occur due to th€ prolonged mechanical irritation besjdes the non-hermetic filling r-n the root canal tr€atment that had been performed Both bacterial and mechanical irritation process could occur on tooth l1 3. Yamaguchi and Kasai (2005) also explained that the incident of pain could be associated with the intera€tion of inflammatory m€diators.Hence the control of inflammatory m€diators constituted lhe mainrole in pain relief ' Though the irritation reduction as the result of the trauma had been p€rformed, the repair of patient's dental order in tle second case constrtuted the most essential thing to ihe healing in this case lt was expected that the good rooi canal treahent and hermetic root canal filling as well as th€ elimination of mechanical inilation enabled the healing of periaprcdl le.ron on looth | | dnd .orelie!ed lhe pain or patient's discomfort.

Conclusion
Occlusal trauma can cause inflammatory reaction in periapical tissue that may cause periapical lesion.Non-surgical endodontic treatment can be performed in cases ofinflaned pulp ard periapex as the result ofocclusal trauma and it is seen that there was healing as long asthe traumacan be eliminated.
The findings in these two cases suggest that in some circumstances, occlusal trauma may play a role in the healing ofp€riapical pathosis.