Original Article

Occlusal Contact Changes With Journal of Advanced Oral Research

14(2) 134–142, 2023
Traumatic Occlusion After Orthodontic © 2023 Academy of Advanced
Dental Research
Treatment: A Prospective Study Article reuse guidelines:
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DOI: 10.1177/23202068231190202
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Sowmithra Devi S1 and Shantha Sundari1

Abstract
Aim: The aim of this study was to evaluate trauma from occlusion in patients undergoing orthodontic treatment
through assessment of fremitus, pocket depth, gingival biotype, and occlusal contacts pre-orthodontic treatment
(T0) and post-orthodontic treatment (T1).
Materials and Methods: This prospective randomized trial included 40 participants selected based on a simple random
sampling method, of which 27 were women and 13 were men with ages ranging from 25 to 40 years. All the participants
were clinically checked for gingival recession, fremitus, pocket depth, gingival biotype, and occlusal contacts obtained via
digital intraoral scans and fed to 3Shape software to perform the occlusal mapping analysis for pre-orthodontic treatment
(T0) and post-orthodontic treatment (T1). T-Scan occlusal analysis was performed to check the force levels pertaining
to each tooth. A paired t-test was done to find out the changes in fremitus, pocket depth, gingival biotype, and number
of occlusal contacts between T0 and T1.
Results: Results of paired t-tests showed a statistically significant difference for fremitus between T0 and T1 (p < .05).
Gingival biotype and pocket depth did not show any improvement post-orthodontic treatment (T1) (p > .05). Number
of traumatic occlusal contacts reduced at T1 for incisors and canines showing a statistically significant difference between
T0 and T1 (p < .05).
Conclusion: Orthodontic treatment helps in relieving the traumatic occlusal contacts, especially in the incisors and
canine regions. As the teeth are relieved from traumatic occlusal contacts, fremitus also has shown to have drastically
improved at the end of orthodontic treatment. Gingival biotype and pocket depth might take a longer time to regenerate
and improve, which requires long-term observation.

Keywords
Gingival recession, Digital scanning, Periodontal pocket depth, Trauma from occlusion, Orthodontic treatment

Submitted: 22 February 2023; Revised: 03 July 2023; Accepted: 05 July 2023

Introduction where the opposing tooth exhibits a palpable vibration

Trauma from occlusion (TFO) has been defined as perio-
dontal injury resulting from occlusal forces that exceeds the
reparative capacity of the attachment apparatus.1 Traumatic
occlusal forces were considered the preceding cause of
periodontal disease.2 According to Glickman and Smulow,3
excessive occlusal forces, particularly pressure, could be a
factor in the etiology of infrabony pockets and angular bone
loss by an altered path of gingival inflammation and perio-
dontal bone loss. Traumatic occlusal forces can be acute or
chronic depending on the duration of the aberrant occlusal
when subjected to occlusal forces.6 Pain in the masticatory
muscle area and wear facets if noticed should give a sign
of occlusal disharmony leading to the habit of bruxism
and temporomandibular joint problems. Increased probing
pocket depth (PPD), loss of clinical attachment level,
absence or widening of periodontal ligament, discontinua-
tion or absence of lamina dura, bone loss in the region of
1
  Department of Orthodontics, Saveetha Dental College, Saveetha
University, Chennai, Tamil Nadu, India

force imposed onto the teeth.

Corresponding author:
TFO deteriorating periodontium shows various signs Sowmithradevi S, Department of Orthodontics, Saveetha Dental
that help in early diagnosis. The most common sign of College, Saveetha University, Chennai, Tamil Nadu 600077, India.
TFO is tooth mobility.4,5 Fremitus is another symptom E-mail: sowmithrasaravanan@gmail.com
Devi S and Sundari
trauma, and gingival recession are the radiographic signs
of TFO.7–9
TFO in orthodontics should be diagnosed and treated
as early as possible to prevent further deterioration of the
periodontium. Orthodontic treatment results in changing
the positions of teeth by tipping or by bodily movement,
which can give rise to occlusal discrepancies that are only
temporary. Lighter orthodontic forces when applied and
dissipated slowly cause no harm to the affected tooth from
TFO.10 A case report by Thierens et al.11 showed that a max-
illary central incisor that was periodontally affected by
TFO was reversed to normal with reduced PPD and reces-
sion decreased after 12 months of orthodontic treatment.
This gives an insight on orthodontic treatment also being
therapeutic to eliminate symptoms of TFO.
This study focuses on the orthodontic treatment in
decreasing the harmful effects of TFO by comparing the
signs such as fremitus, PPD, gingival biotype, and occlusal
contact changes pre-orthodontic treatment (T0) and post-
orthodontic treatment (T1). The null hypothesis of the study
is that there is an improvement in the signs of TFO post-
orthodontic treatment (T1). An alternate hypothesis of the
study is that there is no difference between T0 and T1
regarding the signs of TFO.
Materials and Methods
Setting and Design
The study was approved by the Institutional Human
Ethical Committee of Saveetha University with the approval
number of IHEC/SDC/ORTHO-2001/20/575. A total of
40 participants were included in the study 27 women and
13 men of age 25–40 years reporting to the outpatient
department of orthodontics of Saveetha Dental College,
Chennai. The study was started in September–October 2020
and completed in March–April 2022.
Sampling Criteria
The participants reported to the department were screened
for signs and symptoms of TFO in the upper and lower ante-
riors by the primary investigator. Patients with debilitating
disease, progressive periodontal disease, gingival recession
or periodontal conditions, tooth mobility due to periodontal
disease, anterior or lateral open bite conditions, and tempo-
romandibular joint disorder (TMD) not pertaining to trau-
matic occlusion such as stress or psychological problems
as a cause for TMD, systemic conditions leading to perio-
dontal problems, postmenopausal women were excluded
135
from the study. Participants of age 18–45 years, both men
and women, with gingival recession, deep bite, and anterior
crossbite due to traumatic occlusion were included in the
study.
Abiding to the inclusion criteria, initially 42 participants
were selected. On the calculation of sample size with
G*Power 3.1.9.4 software (Germany) with a significance of
less than 5% (<0.05) and a power of 90%, we arrived at a
sample size of 40. Finally, 40 participants were recruited to
take part in the study by random selection process. Written
and informed consent was obtained from all the participants
of the study.
Methodology
Clinical examination of all the participants was done by the
clinician (primary investigator). Eligible participants were
provided orthodontic treatment by an orthodontist who was
not a part of the trial. Of the 40 patients, 23 underwent non-
extraction treatment 17 underwent extraction treatment
and all of them were either average or high-angle patients.
With regard to bracket prescription, all the patients were
given Mclaughlin Bennet and Trevisi (MBT) prescription,
and only friction mechanics were used to avoid bias. All
the first and second molars were bonded as molar bands
would interfere with T-scan recordings. Fremitus, gingival
biotype, PPD, gingival recession, and occlusal contacts
were recorded for each participant before starting orthodon-
tic treatment (T0) and after completion of orthodontic treat-
ment (T1) with the mean orthodontic treatment duration
of 12–18 months. The obtained values were recorded in
Excel spreadsheets.
Fremitus was checked in the upper anterior region by
placing the index finger on the facial surfaces of maxillary
anterior teeth during repeated habitual centric closure.12
This helped to evaluate the functional mobility of the teeth
during mastication. Fremitus if present was recorded as
“yes” and if absent was given as “no” while entering in the
spreadsheet.
Classification of gingival biotypes by Fu et al.13 was
applied in this study categorizing the gingival biotypes
into two types as “thin” (probe seen through the gingiva)
and “thick” (probe not seen through the gingiva). This probe
transparency method is minimally invasive and has good
accuracy. William’s Periodontal probe (Polodent, India) is
inserted into the sulcus of the midfacial aspect of the tooth
and checked for transparency of the probe and identified as
thin or thick biotypes.
PPD according to the Community Periodontal Index of
Treatment Needs (CPITN) is categorized as pocket depth
of 0–3 mm as no/mild periodontitis, at least one pocket
136 Journal of Advanced Oral Research 14(2)
(a) (b)
Figure 1. (a) Intraoral Scanning Using 3Shape Scanner System. (b) Digitally Scanned Occlusion Obtained from the Patient Will
Appear on the Viewer Screen. (c) Obtained Occlusion Is Transferred to 3Shape OrthoAnalyzer Software to Perform the Occlusal
Mapping. (d) Digital Models Undergo Occlusal Mapping Analysis.
≥4 mm and <6 mm as moderate, and with at least one pocket
≥6 mm as severe periodontitis.14 William’s periodontal
probe with markings 1, 2, 3, 5, 7, 8, 9, and 10 mm markings
were used to record the PPD. The probe was inserted into
the sulcus in the mesial, distal, midfacial, and lingual/pala-
tal sides of the traumatized tooth. The greatest pocket depth
recorded from all four regions is taken as the average PPD
value for that particular tooth. The PPD recorded is entered
in the Excel spreadsheet.
To evaluate the occlusal contacts, intraoral scans at
T0 and T1 were recorded, using TRIOS 3Shape intraoral
scanners, in Copenhagen, Denmark. The intraoral scanning
of the teeth was done starting from the second molar on the
left to the second molar on the right covering the labial,
buccal, and palatal/lingual sides of the upper and lower
arches. Finally, the patient is instructed to bite and the left
and right-side occlusion is recorded. Any incomplete por-
tion is rescanned to avoid any errors in the models. The
scanned models were imported to 3Shape OrthoAnalyzer
dental system software to perform the occlusal mapping
analysis (Figure 1). There is an option in the software to
perform the occlusal mapping analysis which has an
occlusal map available in a scale of different spectrum of
colors amounting to the distance from the surface of the
tooth to the opposing tooth in the opposing arch. This helps
to find the teeth in traumatic contact represented by the red
color spectrum of the scale to the teeth with the least trau-
matic contact that is shown as the gray to white scale
spectrum in the map. To measure the red-colored occlusal
contact areas manually on digital models, the image analy-
sis software Image J (version 1.52a for Macintosh, National
Institutes of Health, Bethesda, MD, USA) was used. The
images were taken from 3Shape separately for all teeth
and calibrated to the imaging software Image J with the
distance measured between two points in mm dimensions.
The outlines of the occlusal contact areas were traced using
the freehand preselection tool using the computer mouse,
and the Image J program will automatically calculate the
traced area in mm2 dimensions. The occlusal contact areas
(c) (d)
averaged for incisors, canines, premolars, and molars were
tabulated.
Observational Parameters
After occlusal mapping of the digital scans, participants
underwent T-scan Digital Occlusal analysis to quantify the
extent and timing of forces acting on distinct teeth as well
as the stability of the occlusal contact of the overall bite.
Digital quantification of bite forces was recorded using
T-scan Novus sensors (TEKSCAN, Inc., Boston, MA,
USA). Recent investigations on articulating paper have
shown that the markings on the paper are not accurate
markers of different occlusal force levels.15,16 Using the
T-scan system both static and dynamic movements of the
jaw can be recorded. The participant was seated upright
in the dental chair chicagosoftware package with real-time
data on occlusal contact and force. These data are shown as
a continuous force “movie” of the whole acquired occlusal
contact event in both two and three dimensions.
Statistical Analysis
All the recorded values were entered in an Excel spread-
sheet and imported to SPSS software version 23.0 (IBM,
Chicago, IL, USA) with a significance of 5% (0.05), a
confidence interval, and power (1 – β) of 95%. A paired
t-test was done to find the difference in fremitus, gingival
biotype, PPD, and occlusal contact changes between T0
and T1.
Results
A paired t-test done for determining the changes in the
gingival and occlusal parameters assessed at T0 and T1
showed a statistically significant difference for fremitus
(p < .05) which decreased at T1 in most of the participants
Devi S and Sundari 137

(Tables 1 and 2). At T0, 23 participants were found to have
fremitus in the upper incisor region which in T1 was
reduced in only 14 participants, so this means 9 partici-
pants did not have fremitus at T1. PPD and gingival
biotypes did not show much of difference at T1 as out of
27 participants who had thin gingival biotypes at T0 in
the tooth which had a gingival recession or a traumatized
tooth, 22 of them still had the same thin gingival biotype at
T1 showing insignificant difference (Table 1). Occlusal
contact changes showed a statistically significant differ-
ence in the reduction of traumatic contacts in the region
of incisors and canines (p < .05). Molars and premolars
did not show a significant difference at T1; however, there
was a reduction of traumatic occlusal contacts although
insignificant (Table 2). Difference in occlusal force distri-
bution shows a statistically significant difference in
occlusal contacts between T0 and T1 for anteriors (p < .05)
(Figure 2 and Table 3).

Table 1. Paired t-Test Depicting the Difference in Gingival Biotype, Fremitus, and PPD with Fremitus Showing a Statistically
Significant Difference Between T0 and T1.

Parameters T0 T1 Sig
Gingival biotype Thin 27 22 0.323
Thick 13 18
Fremitus Yes 23 14 0.002*
No 17 26
Pocket depth Mean 3.13 3.05 0.083
Std. dev. 1.017 1.011
Note: * Signifies (p < .005).

Table 2. Paired t-Test Showing Occlusal Contact Changes Pre- and Post-orthodontic Treatment with Incisors and Canines Showing a
Statistically Significant Reduction in Traumatic Occlusal Contacts at T1.

Occlusal Contacts Mean SD Sig

Incisors T0 2.953 0.968 0.003
T1 1.126 0.786
Canines T0 2.031 0.949 0.015
T1 1.117 0.819
Premolars T0 3.112 1.623 0.163
T1 3.081 0.238
Molars T0 3.525 1.419 0.762
T1 3.235 0.831
Note: * Signifies (p < .05).

(a) (b)

Figure 2. (a) Pre-orthodontic Treatment (T0). (b) Post-orthodontic Treatment (T1) T-scans Showing Reduction in Anterior
Occlusal Forces.
Note: The reduction in red yellow bar in the displayed bar charts in the post treatment scans especially in the anterior region.
138 Journal of Advanced Oral Research 14(2)
Table 3. Paired t-Test Showing Difference in Mean Occlusal
Force Distribution in Percentage Between T0 and T1.
Mean % Force Distribution Sig
T0 T1 P Value
Anteriors 21 ± 3.2 18 ± 1.5 .046*
Posterior (L) 46 ± 2.3 47 ± 2.6 .156
Posterior (R) 44 ± 2.7 46 ± 3.4 .218
Notes: Posterior (L) shows left posteriors and posterior (R) depicts
right posteriors; * signifies (p < .05).
Discussion
TFO being an important factor that is to be focused upon,
especially for an orthodontist is never to be ignored and
should be treated at the earliest with continuous monitoring
during the treatment. According to Saravanan et al.,1 before
debonding of brackets the clinician should make sure
that there are no occlusal interferences both in static and
functional excursions, and also during the retention period,
retainers should be customized according to the initial
malocclusion and periodontal status of the patient.
According to the results of our study, a statistically
significant difference was observed for fremitus account-
ing for approximately nine participants who had been
detected with absence of fremitus post-orthodontic treat-
ment (T1). This shows that orthodontic treatment has
effectively worked in reducing the traumatic occlusion
thus preventing further deterioration of the supporting
structures. Also, in this study not all the 40 participants
were detected with fremitus, it was only 23 participants
who did have fremitus although they had a traumatic
occlusal contact that was proven with further clinical
diagnosis and occlusal mapping. Of the 23 participants,
14 of them still had fremitus at the end of the orthodontic
treatment (Table 1). According to a study by Kundapur
et al.,12 fremitus was associated with gingival recession in
almost 59.1% of patients and was not significantly related
(a)
Figure 3. (a) Pre-orthodontic Treatment (T0). (b) Six Months After Orthodontic Treatment. (c) Post-orthodontic Treatment (T1).
to gingival recession. The results of our study show that the
fremitus may or may not be eliminated after orthodontic
treatment, thus helping in the reduction of TFO and not
completely eliminating it.
Gingival biotype of lower anteriors was thin for almost
27 participants and thick for 13 participants which after
orthodontic treatment showed that five participants had
their gingival biotype reversed to normal from a thin
biotype and the others did not have any difference at T1
(Table 1). A systematic review by Amid et al.17 studied the
effects of orthodontic treatment on the periodontium
and concluded that orthodontic treatment did have some
mild detrimental effects on the periodontium especially in
patients with thin gingival biotype. From Figure 3a–c, it
is observed that the loss of gingival keratinization and
thin gingival biotype with respect to the traumatized left
central incisor has not reversed at the mid as well as post-
orthodontic treatment (T1). Gingival recession with respect
to Table 4 shows a significant reduction in gingival reces-
sion in most of the participants with respect to lower
left and right central and lateral incisors except for lower
right lateral incisor. Although there is a reduction in gingi-
val recession with respect to the elimination or reduction of
traumatic occlusion, the biotype did not improve in most
of the patients. Average gingival recession observed in
included participants with traumatic occlusion in lower
anteriors ranged from 1 mm ± 0.25 to 2 mm ± 0.69. We
could observe only an improvement with respect to reces-
sion of gingiva but it was not completely reversed back to
normal gingival architecture at the end of the treatment in
almost all the participants. The results of this study showed
that it may take a longer time for the reversal of normal
gingival biotype after completion of orthodontic treatment
which requires longer follow-up.
With PPD, no significant difference was observed
between T0 and T1. Although the participants included in
the study had an average or close to average pocket depth
(b) (c)
Devi S and Sundari 139

which was gauged according to CPITN. An average of
3.13 mm was observed from the mean of 40 participants at
T0 and a decrease in PPD to 3.03 mm was observed at T1,
although there was not a significant difference (p > .05)..
Huang et al.18 conducted a retrospective study of ortho-
dontic treatment on anterior tooth displacement caused by
periodontal disease and concluded that orthodontic treat-
ment proved to be beneficial in reducing pocket depth.
There is a fluctuance within the normal range of pocket
depth in our study, hence future studies should be undertaken
with PPD much more than the average PPD to observe sig-
nificant changes.
When coming to the number of occlusal contacts, a
statistically significant difference was observed only for
incisors and canines (p < .05). Color-coded Occlusal map-
ping of all the xmodels was obtained. The more the redder
areas seen on the models, the greater the traumatic occlusal
contact (Figure 4). The interocclusal distance between the
maxillary and mandibular model corresponds to the color
indicated in the scale (Figure 5). It can be calibrated to

Table 4. Number of Participants with Gingival Recession at T0 and at T1 Respective to Lower Anteriors.

Gingival Recession
T0 T1
Included participants Persisting gingival Reduction in gingival
Lower anteriors with gingival recession recession at T1 recession at T1 Sig.
Left central incisor 9 3 6 0.026*
Left lateral incisor 13 5 8 0.035*
Right central incisor 8 3 5 0.043*
Right lateral incisor 10 6 4 0.128
Note: Paired t-test showing statistically significant difference for left central and lateral incisor and lower right central incisor (p < 0.05).

(a) (b)

(c) (d)

Figure 4. Pre-orthodontic Treatment (T0) and Post-orthodontic Treatment (T1) Digital Models with Occlusal Mapping.
Note: The occlusal mapping was done at an interocclusal distance of 0.5 mm in the occlusal mapping calibration scale.
140 Journal of Advanced Oral Research 14(2)
Figure 5. Color Scale Denoting an Array of Color Range from
Red to Blue Indicating Maximal Interocclusal Contacts to Minimal
in Maxillary and Mandibular Teeth.
Note: The calibration in millimeters denotes the interocclusal distances
between maxillary and mandibular teeth.
a distance of 0.5 mm or 1 mm or 2 mm according to the
preference. Figure 4 shows that the red areas observed in
pre-treatment models were reduced in the models obtained
post-treatment (T1). This proved the improvement in the
occlusal contacts obtained after completion of orthodontic
treatment. Also, in the entire pretreatment model scans
obtained almost all the participants were found to have the
highest number of red areas in the incisor and canine region
when compared to that of premolar and molar regions.
This showed that traumatic occlusal contacts quantitatively
reduced at T1, especially in incisors and canine regions.
In a study by Deng et al.,19 there was improvement in
occlusal contacts post-orthodontic treatment which showed
a reduction in the mean number of occlusal contacts result-
ing in orthodontic treatment being effective quantitatively
and quantitatively in TMD patients.
T-scan analysis helps in interpretation of relative
occlusal loading of force at each contact. Each bar’s color
and height quantify the amount of force applied during
each contact. The occlusal load magnitude is color coded;
the greatest force is shown in red, whereas the smallest
force is blue.20 From Figure 2 and Table 3, force distribu-
tion in the anteriors has reduced in T1 when compared to
T0; however, the occlusal force distribution of posteriors
has increased in T1 from T0. But when compared to ante-
riors, the posteriors have greater root surface to withstand
oblique, transverse, and vertical forces if the supporting
periodontium is in good condition to allow the forces to be
dissipated over their occlusal table, taking into considera-
tion the forces not exceeding the tolerance capacity of the
periodontium. From the results of this study, there is only
minimal change in force distribution of posteriors which
may not be considered harmful to the periodontium. The
concern for TFO is the anteriors which showed an improve-
ment in T-scan values thus showing reduction in occlusal
forces overcoming the traumatic occlusal contacts.
According to the combined results of our study, fremi-
tus is eliminated once the traumatic occlusal contacts
are relieved. Although a greater number of participants
did show a negative fremitus at the end of orthodontic
treatment it was not reflected in all the participants. This
indicates that not all patients with TFO will have fremitus
(as few participants did show negative fremitus at T0) and
it is not definite for the patients with TFO to have negative
fremitus after orthodontic treatment, although significant
results were obtained in the study. Gingival biotype and
PPD requires long-term follow-up of participants as rever-
sal of original architecture might take a longer time than
expected and the results might not have been favorable
as our duration of study is shorter (2 years) to expect a
normal periodontal attachment apparatus. The mean gingi-
val recession in relation to lower anteriors showed a
greater improvement at T1 except for right lateral incisors.
TFO deterioration according to T-scan showed a good
reduction in anterior traumatic contacts and increased in
posteriors. In our study, most of the participants who
underwent T-scan at T0 were found to have increased
TFO in anteriors and very minimal TFO in posteriors.
This was vice-versa at the end of T1. This could be attribut-
able to variable mechanics used in orthodontic treatment
arch alignment and corrections in three dimensions.
Efficiency of the orthodontist, orthodontic biomechanics,
and growth pattern of the individual participant does have
an influence over the TFO in posteriors.
Thus, orthodontic treatment greatly improves the occlu-
sion by eliminating or reducing harmful traumatic contacts,
especially in the anteriors. Null hypothesis is accepted for
only certain parameters assessed in the study (fremitus,
TFO occlusal contact analysis, and gingival recession).
Devi S and Sundari
Limitations of the study include a very small sample size to
be generalized to a larger population. Future studies should
focus on a larger population and longer follow-ups for
more stable results.
Conclusion
Orthodontic treatment helps effectively in eliminating or
reducing the fremitus, gingival recession, and traumatic
occlusal contacts qualitatively and quantitatively in the
anterior region. Long-term observation is necessary to
observe changes in PPD and gingival biotype.
Acknowledgments
I would like to acknowledge the effort of my co-author to get
involved in interdisciplinary research topics involving matters of
concern for orthodontic purposes.
Authors’ Contribution
K.K.S.S. contributed to the study design, manuscript correction,
and formatting of the paper. S.D. contributed to study execution,
data collection, data analysis, and manuscript preparation.
K.K.S.S. contributed to data analysis. All authors have made
substantial contributions to this study, and all have reviewed the
final paper before its submission. Finally, all authors have given
approval for publication.
Data Availability Statement
The data that support the findings of this study are available
from the corresponding author (Sowmithradevi S, E-mail:
sowmithrasaravanan@gmail.com) upon reasonable request.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Ethical Approval
The study was approved by the Institutional Human Ethical
Committee of Saveetha University with the approval number of
IHEC/SDC/ORTHO-2001/20/575.
Funding
The authors received no financial support for the research,
authorship, and/or publication of this article.
Informed Consent
The authors had obtained all appropriate patient consent
forms. The patients understand that their names and initials
will not be published and due efforts will be made to conceal
their identity, but anonymity cannot be guaranteed. This study
was held in Saveetha Dental College, Saveetha University,
Chennai, India.
141
ORCID iD
Sowmithra Devi S https://orcid.org/0000-0003-2430-9339
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