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Recibido: 7 de septiembre de 2016Revisado: 13 de septiembre de 2017

Aceptado: 24 Septiembre 2017

DOI: 10.1002/JPER.16-0581

2017WORLDWORKSHOP

Trauma oclusal y fuerzas oclusias excesivas: revisin narrativa,

definiciones de casos y consideraciones de diagnstico
Jingyuan Fan Jack G. Caton
Departamento de Periodoncia, Instituto Eastman
para Salud Oral, Universidad de Rochester,
Rochester, NY, Estados Unidos
Correspondencia
Dr. Jingyuan Fan, Departamento dePeriodon-
tics,EastmanInstitutefor Oral Health, 625 Elmwoodperiodontitis, abfracción y recesión gingival. Definiciones de casos, consid-
Avenue,Rochester,NY14620. Email:jingyfan@gmail.com
Los procedimientos del taller fueron
publicado de forma conjunta y simultÆnea en el
Journal of PeriodontologyY Diario de
Periodontolog a cl nica .
Abstracto
Objetivos: Esta revisión narrativa determina los efectos del trauma oclusal y la exc-
fuerzas oclusivas en el periodontium, incluyendo la iniciación y progresión de
las erations, y los efectos de la terapia oclusal también se revisan y discuten.
Importancia:
El papel del trauma oclusal en la iniciación y progresión de la peri-
la odontitis sigue siendo un tema controvertido en la periodontolog a. Porque el trauma oclusal
sólo puede confirmarse histológicamente, su diagnóstico cl nico depende de
indicadores radiogrÆficos sustitutas que dificultan los ensayos
cl nicos. Resultados:
En general, las investigaciones han convenido en que el trauma oclusal y el
Las fuerzas oclusales no inician periodontitis ni pérdida de unión del tejido conectivo.
Cuando la periodontitis inducida por placa y el trauma oclusal estÆn presentes al mismo tiempo,
hay pruebas débiles de que el trauma oclusal puede aumentar la tasa de tis-
sue pérdida. La terapia oclusal estÆ indicada como parte de la terapia periodontal para reducir la m
y aumentar la comodidad del paciente y la función masticatoria. Los datos existentes no admiten
la existencia de la abfracción como causa de la recesión
gingival. Conclusiones:
El trauma oclusal no inicia periodontitis, y existe una evi-
decestar que altera la progresión de la enfermedad. No hay pruebas cre bles para
apoyar la existencia de abfracción o implicarla como causa de recesión gingival.
La reducción de la movilidad dental puede mejorar el efecto de la terapia periodontal.

Palabras clave
pérdida de apego, clasificación, diagnóstico, progresión de la enfermedad, estética, recesión gingival,
biotipo periodontal

La literatura sobre la relación entre periodon- base de datos se realizó para encontrar estudios que coincidieran con la f
se revisan las enfermedades y las fuerzas oclusales. AdemÆs, los espÆrretes-
plazos de baja: (enfermedad periodontal O periodontitis O peri-
que han examinado los efectos de las fuerzas oclusales excesivas,odoncio) Y (oclusión dental traumÆtica O traumÆtica
abfracción y recesión gingival. Finalmente, este oclusiones dentales O fuerza oclusal O fuerzas oclusales O
información se utiliza para considerar la revisión de la clase- discrepancias oclusales O discrepancias oclusales O
interferenciao oclusal O interferencias oclusales O
de enfermedades y condiciones traumatismo oclusal o traumatismo oclusal); (oclusal) Y
periodontales. MATERIALESYM TODOS (lesión cervical no cariosa o lesiones cervicales no cariosas);
(oclusal) Y (abfracción O abracciones); y la recesión
gingival Y oclusal. Las bases de datos se buscaron sin
restric-ciones de idioma utilizando términos MeSH, palabras
clave y otros términos libres,
Para esta revisión narrativa, se llevó a cabo una bœsqueda de literatura
utilizando PubMed y Web of Science. Una estrategia de bœsqueda para el

© 2018 Academia Americana de Periodoncia y Federación Europea de Periodoncia

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Periodontol. 2018;89(Suppl 1):S214 S222.
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Ventilador
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y los operadores booleanos (OR, AND) se utilizaron para combinar TABLA 1 Propuesto Cl nica Y RadiogrÆfica IndicadoresDe
Bœsquedas. Ensayos cl nicos controlados aleatorios, pernos- traumaos oclusales
estudios de casos, series de casos, art culos de revisión, 1. Fremitus 7. Sensibilidad térmica
l neas, la investigación animal y la investigación in vitro fueron elegibles para
2. Movilidad 8. Incomodidad/dolor al masticar
inclusión en esta revisión. Se buscaron bases de datos hasta Febru- 3. Discrepancias oclusales 9. Espacio PDL ampliado
ary 2017, sin l mites en el aæo de publicación. 4. Usar facetas 10. Resorción de ra z
Bœsquedas manuales Journal
de of Periodontology, Journal
5. Migración dental 11. Desgarro cicementoal
de Periodoncia Cl nica Periodontolog
, a 2000 Diario
,
6. Diente fracturado
de la Investigaci n Periodontal
Y Revista Internacional de Peri-
PDL, ligamento periodontal.
odontics y odontolog a restaurativatambién se llevaron a cabo. Ini-
tialmente, un cr tico examinó los t tulos y resœmenes de la arti-
Cles. Se obtuvieron art culos que indicaban una posible coincidencia
para una revisión completa para su posible inclusión. Arte histórico importante-
estudio, el estrés del ligamento periodontal aumentó
cles fueron incluidos. Para complementar la bœsqueda, la referencia reduciendo el 60% significativamente después de 5
del soporte óseo.
listas de art culos principales relacionados con esta revisión narrativaDebido fueron
a que el trauma de la oclusión se define y se diagnostica
también evaluado. Debido a la heterogeneidad de los estudios, sobreun la base de cambios histológicos en el periodontium,
metaanÆlisis no se llevó a cabo. Un total de 93 art culos fueron no es posible un diagnóstico definitivo de trauma oclusal
incluido en la revisión e incluyó tanto a los hombres como a los sinanimales
biopsia por sección de bloqueo. En consecuencia, mœltiples clin-
Estudios. indicadores ical y radiogrÆficos se utilizan como sustitutos para
para ayudar al diagnóstico presuntivo de trauma oclusal. Cl nica
diagnóstico de que se ha producido o se estÆ produciendo un traumaoc
CASEDEFINITIONSAND puede incluir movilidad dental progresiva, fremitus, oclusal
DIAGNOSTICACIONES discrepancias/disharmonies, facetas de desgaste (causadas por
molienda), migración de dientes, fractura de dientes, sensi-
Fuerza oclusal excesiva se define como fuerza oclusal que trisia, resorción de la ra z, desgarro cicementoso, y la ampliación de
supera la capacidad reparadora del apego periodontal espacio del ligamento periodontal tras el examen radiogrÆfico
aparato, lo que resulta en traumaos oclusales y/o causa 1 3 (Tabla 1). Estos signos y s 6,7 ntomas cl nicos pueden indicar
desgaste excesivo del diente (pérdida). otros pathoses. Por ejemplo, la pérdida de apego cl nico puede
Trauma oclusal es un término utilizado para describir el daæo resultante
afectan la gravedad de la movilidad. AdemÆs, a menudo es muy dif cil
cambios de tejido dentro del aparato de fijación, incluyendo para determinar si las facetas de desgaste son causadas por
ligamento periodontal, apoyando hueso alveolar y cemen- 4 hÆbitos parafuncionales, como el bruxismo. por lo tanto
El trauma oclusal puede diagnósticos diferenciales. Suplementario
como resultado de la(s) fuerza(s) oclusal(es).
se producen en un periodontium intacto o en un periodontium reducidolos procedimientos de diagnóstico, tales como pruebas de vitalidad de la
causada por la enfermedad periodontal. hÆbitos parafuncionales, puede ser considerado.
Trauma oclusal primario es una lesión que resulta en tejido Lesiones cervicales no cariosas (NCL) implican la pérdida de duro
cambios de fuerzas oclusales excesivas aplicadas a un diente tejido en el tercio cervical de la corona y ra z subjacent e- 8
o 4
dientes con soporte periodontal normal. Se produce en la pres- rostro, a través de procesos no relacionados con Gingival
la caries.
reces-
niveles normales de apego cl nico, niveles óseos normales, sion se define como la ubicación del margen gingival apical
y fuerza(s) oclusal(es) excesiva(s). el cruce cemento-esmalte. a 4Los NCCL suelen ser acompa-
Trauma oclusal secundario es una lesión que resulta en tejido negado por la recesión gingival. 9 Los NCCL son un grupo de
cambios de las fuerzas oclusales normales o excesivas y la etiolog a es multifactorial. lesiones 10
Abfracción, una hipot-
aaplicadas 4 o dientes con soporte periodontal reducido.eso lesión diente-superficie causada por las fuerzas oclusales, es una
un diente
en presencia de pérdida de apego, pérdida ósea y nor- de las etiolog as propuestas para los NCCL, y otras etiolog as
fuerza(s) oclusal(es) mal/excesiva(s). incluyen abrasión, erosión, corrosión o una combinación. 4,8,11
Fremitus es un movimiento palpable o visible de un diente La lesión de la abfracción se ha descrito como
sometidos a cuando
fuerzas 4oclusales. defectos que se producen en la unión cemento-esmalte de los
Bruxismo o molienda de dientes
es un hÆbito de moler, apretar o dientes como resultado de la flexión y la eventual fatiga del
sujetar los dientes. La4fuerza generada puede daæar tanto Dentina. Las fuerzas oclusales excesivas esmalte
hanysido
8,12pro-
14
aparato de dientes y fijación. un factor causal en el desarrollo de la abfracción 2,3,11 16
A pesar del consenso sobre la definición de recesión gingival. Debido a que la abfracción no es cur-
trauma oclusal secundario, criterios espec ficos para distinguirrespaldado en alquiler por pruebas apropiadas, una diagno-
entre el apoyo periodontal "normal" y "reducido" han sis no es posible. Los NCCL pueden ser el resultado de la abrasión, la ero
no se ha identificado a partir de estudios controlados. In an ino corrosión.
vitro Por lo tanto, en los casos de NCCL, el cepillado

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S216 Ventilador
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hÆbitos, dieta, trastornos alimenticios, as como relaciones oclusiales

Esta teor a fue desafiada por otros investigadores. 27 29
y los hÆbitos parafuncionales deben evaluarse a fondo. Usando material de autopsia humana de nuevo, la v a alterada
de strucción fue cuestionado porque la placa bacteriana fue
siempre presente cerca del sitio de periodontal
NARRATIVEREVIEW destrucción, y esto sugirió que la inflamación y el hueso
pérdida se asociaron con la presencia de placa bacteriana
Efectos del trauma oclusal en la iniciacin y en lugar de fuerzas oclusales excesivas. Los estudios históricos utilizado
progresin de la periodontitis material de la autopsia que proporcionó poca o ninguna información sob
condiciones periodontales y condiciones oclusales de estos estudios
Histológicamente, un diente afectado por un trauma oclusal demon-
Temas. Fue después de que se presentó la teor a de la co-destrucción
estratifica zonas distintas de tensión y presión dentro de la ad-
que los investigadores comenzaron a examinar el concepto de riesgo mœl
centenoperiodti. La ubicación y gravedad de las lesiones 2
factores que dieron lugar a la iniciación y progresión de la peri-
var an en función de la magnitud y la dirección de las fuerzas aplicadas.
enfermedades odontales.
En el lado de la presión, estos cambios pueden incluir un aumento
vascularización y permeabilidad, hialinización/necrosis de
el ligamento periodontal, hemorragia, trombosis, hueso
resorción, y en algunos casos, la resorción de la ra z y la cemen- Estudios en animales
lÆgrimas de tal. En el lado de la tensión, estos cambios pueden incluir
Por su naturaleza, las observaciones históricas no probaron
alargamiento de las fibras de ligamento periodontal y relación causal entre el trauma oclusal y la iniciación
hueso alveolar y cemento. aposición 3,17 19
o la progresión de la enfermedad periodontal. En un intento de probar un
Colectivamente, los cambios histológicos reflejan un relación entre oclusión y enfermedad periodontal, mul-
respuesta dentro del periodontium al trauma oclusal. Como los estudios en animales con estrictos controles y diseæos fueron per-
como resultado de un trauma oclusal sostenido, la densidad de la alve- se formó en la década de 1970. Hab a dos grupos
el hueso olar disminuye mientras que la anchura de la liga- significativos,
de Eastman Dental Center en Rochester, NY, uno dey30ela 34
aumentos del espacio, lo que lleva a un aumento de la moviliza-otro de la Universidad de Gotemburgo en Suecia. 35 38
y a menudo un ensanchamiento radiogrÆfico de la liga- Los efectos del trauma oclusal y la inflamación gingival en
espacio mento, ya sea limitado a la cresta alveolar o a través animales fueron investigados. El grupo Eastman utilizó
anchura total del hueso alveolar. de el
AdemÆs, losfremitus,
17,18,21
aplicaciones de fuerzas ortodónticas en los dientes de esquir-
o la movilidad funcional palpable de un diente, es otro monos rel, y el grupo de Gotemburgo utilizó fuerzas oclusales
signo cl nico de trauma oclusal. significa- 22
similares a los de una restauración "alta" en perros beagle. Ambos
los grupos examinaron los efectos de las fuerzas oclusales excesivas en
Estudios histricos el periodontium con una duración de unas pocas semanas
A principios del siglo XX, un informe indicaba una asociaciónhasta 6 meses en presencia y ausencia de periodontitis
inducida por placa bacteriana.
entre las fuerzas oclusales excesivas y la pyorrea alveolaris 1
(es decir, periodontitis).
Fue sugerido ademÆs por otros A pesar de los diferentes modelos animales y los diferentes tipos
investigadores que la fuerza oclusal excesiva fue la causa de de las fuerzas oclusales aplicadas, los resultados de estos dos estudios fu
Periodontitis. 2,3,23,24
Sent an que las fuerzas oclusales ten an similar en muchos aspectos. Cuando se mantuvo la higiene bucal
para tratar con éxito la periodontitis. que ser de 3,17 y la inflamación fue controlada, trauma oclusal dio lugar a
En la década de 1930 a la década de 1940, el papel de la mayor movilidad y pérdida de densidad ósea sin pérdida de
oclusiónseexcesiva
fuerzas en la progresión de la periodontitis discutió.25,26 tejido conectivo, durante la duración del estudio. Si
Utilizando material de autopsia humana, se llegó a la conclusión las fuerzas
de que oclusales
la gin- fueron eliminadas, la pérdida de densidad ósea fue
inflamación gival que se extiende en el hueso de soporte fue Reversible. Por el contrario, en presencia de peri-
la causa de la destrucción periodontal. En un animal posterior odontitis y trauma oclusal, hubo una mayor pérdida de hueso
experimento, se encontró que las fuerzas oclusales excesivas volumen y mayor movilidad, pero la pérdida de tejido conectivo
causaron cambios en la dirección de la membrana periodontal apego era el mismo que en los dientes sometidos a
fibras para que la inflamación gingival pasó directamente a periodontitis
solo 31 ardilla.
en el mono En el modelo de perro beagle, cuando
tales 18
`reas. MÆs tarde, otro estudio basado en material de autopsia humanatrauma oclusal se superpuso a la periodontitis, hab a 35
coincidió en que la inflamación parec a comenzar en la gingiva y una pérdida acelerada de la unión del tejido conectivo.Basado
posteriormente progresó en el per odo adyacente sup- 19,20 sobre los resultados de estos estudios, se llegó a la conclusión de que c
tejido de portabilidad
Se propuso ademÆs que la inflamación inflamación inducida por placa, trauma oclusal no
progresó en una v a alterada en los dientes sometidos a oclusal causar pérdida ósea irreversible o pérdida de tejido conec-
Trauma. El efecto combinado del trauma oclusal y bacteriano Ment. Por lo tanto, el trauma oclusal no es un agente causal de
La inflamación inducida por placa se denotó como "codestrucción". Periodontitis.

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FAN AND CATON
Using rat models, more recent studies re-examined the
39–41
association of occlusal trauma and periodontal bone loss.
Occlusal trauma was induced by either placing inlay or metal
wire bonding to raise the occlusal surfaces. The receptor
activator of nuclear factor-kappa B ligand (RANKL) is an
important factor in osteoclast differentiation, activation, and
42
survival. RANKL interacts with RANK receptor on osteo-
clasts to initiate bone resorption. During excessive occlusal
loading, the destruction of the periodontal ligament was
observed, and the RANKL associated with osteoclasts and 39
osteoblasts was demonstrated via immunohistochemistry.
In the presence of lipopolysaccharide-induced inflammation,
the expression of RANKL on endothelial cells, inflamma-
tory cells, and periodontal ligament cells was enhanced by 40
occlusal trauma. It was suggested that RANKL expression
on these cells was closely involved in the increase of osteo-
clasts induced by occlusal trauma. Further, loss of connec-
tive tissue attachment at the onset of experimental periodon-
titis was increased when inflammation was combined with 41
occlusal trauma. In addition, estrogen deficiency, nicotine,
and diabetes were all shown to enhance bone loss in rats
with combined with occlusal trauma and ligature-induced
43–45
periodontitis.
None of the animal studies were able to reproduce all
aspects of human periodontitis. In addition, the animal stud-
ies used excessive forces and were conducted for a relatively
short duration (a few weeks to a few months). Nonetheless,
the results from animal studies suggested that occlusal trauma
does not cause periodontitis, but it may be a cofactor that can
accelerate the periodontal breakdown in the presence of peri-
odontitis.
Clinical studies
Tooth mobility has been described as one of the common clin-
3,17,18,20,25,28
ical signs of occlusal trauma. However, increased
tooth mobility may result from inflammation and/or bone loss
or attachment loss alone. Progressive mobility may be sugges-
tive of ongoing occlusal trauma, but assessments at different
46
time points are necessary to make this determination. In an
epidemiologic study, a group of subjects was re-examined for
loss of periodontal clinical attachment after 28 years. It was
found that baseline tooth mobility was a factor related to clini-
47
cal attachment loss. In addition, mobile teeth with a widened
periodontal ligament space had greater probing depth, more
attachment loss, and increased alveolar bone loss than non- 7
mobile teeth. Tooth mobility was also found to affect the
48,49
results following periodontal therapy. It was shown that
teeth with mobility did not gain as much clinical attachment
48
as those without mobility following periodontal treatment.
Further, teeth with increased mobility demonstrated signifi-
cantly more clinical attachment loss during the maintenance
49
period. A recent study on regenerative surgery indicated
S217
that mobile teeth treated with regeneration did not respond as
well as non-mobile teeth. However, no association was drawn
50
between mobility and occlusal forces.
The relationship between cusps is an important factor in 51
the transmission of occlusal forces to the periodontium.
Due to the limitations of clinical diagnosis of occlusal trauma
and ethical considerations, most clinical studies have focused
on teeth with occlusal discrepancies/disharmonies, which
are defined as “contacts of opposing surfaces of teeth that
are not in harmony with each other or with the anatomic and
4
physiologic control of the mandible.” In an early retrospec-
tive study, the relationship between periodontal parameters 52
and molar non-working contacts was examined. It was
found that molar teeth with non-working contacts had greater
probing depths and bone loss compared with those without
non-working contacts. Conversely, other studies looked at
occlusal disharmonies in patients with periodontitis and
failed to find any correlation between abnormal occlusal con-
tacts and periodontal parameters, including probing depth,
6,7,53
clinical attachment level, and bone loss. Nevertheless,
teeth with frank signs of occlusal trauma, including fremitus
and a widened periodontal ligament space, demonstrated
greater probing depth, clinical attachment loss, and bone
loss.7
A series of retrospective studies investigated the asso-
ciation between occlusal discrepancies and the progres- 54,55
sion of periodontitis in a private practice setting. All
patients included had moderate to severe chronic periodonti-
tis. These studies found that teeth with occlusal discrepancies
had significantly deeper initial probing depths, more mobil-
ity, and poorer prognoses than those teeth without occlusal 54
discrepancies. Teeth with occlusal discrepancies demon-
strated a significant increase in probing depth and a wors-
ening prognosis with time. Multiple types of occlusal con-
tacts, including premature contacts in centric relation, pos-
terior protrusive contact, non-working contacts, combined
working and non-working contacts, and the length of slide
between centric relation and centric occlusion were associated
with significantly deeper probing depths and increased
assign- 55
ment to a less favorable prognosis. In a more recent cross-
sectional epidemiologic study, the non-working side contact
was also associated with deeper probing depth and more clin-
56
ical attachment loss.
Based on those observations, if occlusal trauma has any
relationship to the progression of periodontitis, then its
elimination should improve clinical periodontal conditions.
Occlusal adjustment is defined as “reshaping the occluding
surfaces of teeth by grinding to create harmonious contact 4
relationships between the maxillary and mandibular teeth.”
The evidence linking occlusal adjustment to improvement
in periodontal parameters is limited. In an earlier study, the
flow rate and quality of gingival crevicular flow (GCF) after
removal of occlusal interferences was examined in patients
S218
with advanced periodontitis.57,58 It was found that occlusal
adjustment reduced the protein content and collagenase activ-
ity without affecting the quantity of GCF. Later, a well-
controlled clinical trial was conducted to evaluate the effect
of the occlusal adjustment on healing outcomes after peri- 59
odontal treatment. In this study, half of the patients received
occlusal adjustment by selective grinding before receiving
surgical or non-surgical periodontal therapy. The other half
did not receive occlusal adjustment. After healing, the group
that received occlusal adjustment before periodontal treat-
ment gained 0.4 mm improvement in mean clinical attachment
levels compared with those without pre-treatment occlusal
adjustment. However, it was noted that the post-treatment
reduction of probing depth and mobility were comparable.
During long-term periodontal maintenance, the parafunc-
tional habits that are not treated with a bite guard and the
presence of mobility were both associated with increased
60,61
clin-con-
ical attachment loss and tooth loss. In another study
ducted in a private practice, the response of patients with peri-
odontitis and occlusal discrepancies to occlusal adjustment
was examined. Regardless of the periodontal treatment sta-
tus, the probing depth of teeth with untreated occlusal dis-
crepancies was increased by a mean of 0.066 mm/year while
a decreased probing depth of 0.122 mm/year was noted on 62
teeth with occlusal adjustment.
Collectively, these clinical studies demonstrated the
added benefit of occlusal therapy in the management of
periodontal disease, but they do not provide strong evidence
to support routine occlusal therapy. Clearly, occlusal therapy
is not a substitute for conventional periodontal treatment for
resolving plaque-induced inflammation. However, it may be
beneficial to perform occlusal therapy in conjunction with
periodontal treatment in the presence of clinical indicators of
occlusal trauma, especially relating to the patient's comfort
and masticatory function. The patient's occlusion should be
carefully examined and recorded before and after treatment.
The occlusion of periodontally compromised teeth should
be designed to reduce the forces to be within the adaptive
capabilities of the reduced periodontal attachment. Overall,
in the presence of occlusal trauma, occlusal therapy may
slow the progression of periodontitis and improve the
prognosis.
Excessive occlusal forces and abfraction
In the late 1970s, excessive occlusal loading was first pro-
posed to cause cervical stress that results in the forma- 15
tion of non-carious cervical lesions (NCCLs). This pur-
ported occlusally generated lesion was termed abfraction.11,13
Although there is theoretic evidence in support of abfrac-
tion, predominantly from finite element analysis (FEA) stud-
ies, caution is advised when interpreting results of these stud-
63–69
ies because FEA does not replicate a clinical situation.
FAN AND CATON
In FEA models, different researchers have assumed signif-
icantly different physical properties of the dental tissues.
Also, arbitrary magnitudes, directions, and durations of forces
have been used, which makes comparison between studies
difficult. Cross-sectional studies have indicated associations
between NCCLs, bruxism, and occlusal factors, such as pres-
ence of occlusal wear facets, group function, and prema-
ture contacts, but these investigations do not confirm causal
9,70–74
relationships. Despite the positive association, the size
9
of NCCLs and the extent of occlusal wear was not correlated.
Only a few studies have sought evidence for a causal rela-
75–77
tionship between occlusion and NCCLs. An increased
incidence of NCCLs was associated with presence of occlusal
wear facets after a 3-year follow-up in a group of den- 75
tal students. To the contrary, in a split-mouth design, it
was shown that the elimination of excursive interferences
by occlusal adjustment did not decrease the progression 76
NCCLs. More recently, a 5-year prospective clinical trial
found that progression of NCCLs was associated with relative
occlusal forces in maximum intercuspation position, but not
diet, toothbrushing, presence of occlusal wear facets, group
77
function, or parafunctional habits. If excessive occlusal
forces were contributing to the etiology of NCCLs, it would
be expected that parafunctional habits, such as bruxism and
clenching, would exacerbate the progression of NCCLs. Two
studies have reported a correlation between self-reported 78,79
bruxism and NCCLs. Although some studies suggested
an association, the causal relationship between excessive
occlusal forces and the progression of NCCLs is still uncer-
tain. Therefore, abfraction is still a biomechanically based the-
oretic concept, and it is not supported by appropriate clinical
evidence.
Effects of excessive occlusal forces on gingival
recession
Historically, it has been suggested that excessive occlusal
force might be a factor in gingival recession and the loss 2,3
of gingiva. The term “Stillman's cleft” is defined as nar-
row, triangular-shaped gingival recession on the facial aspect
of the tooth. It was postulated that excessive occlusal force
caused the Stillman's cleft. However, these historic references
are based on uncontrolled clinical observations.
By examining teeth with gingival recession, no correlation
80
was identified between mobility and gingival recession.
Compared with contralateral teeth without recession, teeth
with recession showed either no or similar mobility. In a
clinical investigation on the etiology of gingival recession, a
positive association between occlusal trauma and gingival
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FAN AND CATON S219

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