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BRUXISM, AN
OVERVIEW AND
MANAGEMENT.
BY: DR. BAHJAT ABU
HAMDAN
CONSULTANT
PROSTHODONTIST
DDS, CES, DSO
Bruxism.
1. Introduction.
2. Definition.
3. Epidemiology.
4. Etiology.
5. Characteristics.
6. Clinical consequences.
7. Diagnosis.
8. Management.
1. Introduction.
 Before understanding the pathology of
any disorder in the human body, one
should have a good knowledge of the
following elements:
 The anatomy.
 The related physiology.
 The interrelation with the other elements.
 The biochemistry mechanism.
2. Definition.
 Bruxism can be regarded as forcible clenching or
grinding of the dentition, or a combination of both.
 Clenching of the teeth is a forcible closure of the
opposing dentition in a static relationship of the
mandible to the maxilla. In either maximum
intercuspation or an eccentric positions.
 Grinding of the dentition is a forcible closure of the
opposing dentition in a dynamic maxillo-mandibular
relationship as the mandible moves through various
excursive positions.
Definition. AAOFP defined bruxism as “diurnal or nocturnal
parafunctional activity including clenching, bracing,
gnashing and grinding of the teeth.
 Bruxism, diurnal or nocturnal, is considered as a
potential contributing factor to disturbances of the
masticatory system.
 Many individuals are not cognizant of their
parafunctional behaviors, because these activities are
usually subconscious, so obtaining accurate
response regarding his mandibular parafunctional
activity can be challenging.
Definition.
 Bruxism, as disorder of the
neuromuscular activity, may affect any
element of the masticatory system:
 Regional or local pain, it may include one
or more of the muscles of mastication.
The myalgia may worsen during function.
Limitation of mouth opening could be
noticed as well as tenderness on
palpation.
 Wearing of the teeth, and TMJ problems.
In certain cases symptoms may involve
all the precedent elements.
3. Epidemiology.
 Some studies demonstrate that bruxism
occur in up to 90% in the general
population.
 Other studies demonstrate that it affects
8% of the adult, 14% of the children, and
10-12% of the adolescents.
 However some investigations showed
that the incidence is highest in the teens
and the forties, and that behavior
decreases with age.
 Studies indicate that females report
parafunctional clenching more than
males.
Epidemiology.
 However clinical observations
demonstrate approximately an equal
distribution.
 Self reporting of clenching during waking
hours is about 20%.
 Grinding of the teeth during sleeping
hours ranges from 6-12%.
 Parafunctional behavior is performed at
a subconscious level by most individuals
so determination the actual prevalence is
difficult.
4. Etiology.
 The cause of bruxism still controversial.
 The cause is multi factorial and
overlapping, which creates difficulties in
applying comprehensive, effective
management plan for this mandibular
para- functional behavior.
 However, because the parafunctional
mandibular movements concern mainly
the neuromuscular system, so any
situation stimulating this system, at the
subconscious level, would contribute in
starting up bruxism.
Etiology.
 Historically, occlusal interference were thought to be
the precipitating factor for bruxism, the assumption
was that the patient was working a subconscious
attempt at performing a self-equilibration or an
adjustment of his dentition to remove the occlusal
interferences, particularly with nocturnal bruxism.
 Recent studies have refuted this assumption, but
other investigators have reported that patient
response to an occlusal interference, which existed,
is more significant than to an actual presence of
interference
Etiology.
 However, the relationship of the dentition may be a
contributing factor.
 Bruxism is considered as the most destructive
functional disorder to the dentition.
 Emotional or physical stress as well as anticipating of
stress, are related to the mandibular parafunctional
behavior.
 Bruxist activity has been associated with sleep
disorder.
 It is reported that bruxism has been aggravated by
alcohol consumption and certain medication.
Etiology.
 Occlusal interferences act as trigger factors for
nonfunctional movements.
 Both centric and eccentric bruxism are expressions
of increased muscle tonus.
 Its often said that bruxism in centric excursion
involves isotonic muscle contractions, while static
clenching in CO represent isometric activity.
 But even the minute jaw movements include
changes in the muscle length, so that, clenching
involves both isotonic and isometric activity.
Normal function in lateral
movement.
Excursive bilateral joint
strain interferences.
Non working
interference strain.
Canine working intensity
Canine rise becomes
canine clenching
Etiology.
 Any type of occlusal interference may,
when combined with psychic stress,
initiate and maintain bruxism.
 Discrepancy between CR and CO is the
most common trigger factor for bruxism.
 Interference in the balancing side is the
second is the second significant occlusal
trigger factor.
 Interference in the working side or
protrusive excursion may also trigger
bruxism.
CR to CO movement.
Protrusive clenching.
Etiology.
 Since bruxism is an expression of combined psychic
and occlusal factors. Bruxism may be present on the
basis of severe occlusal interference and moderate
degree of psychic or emotional tension, also it can be
the result of very severe psychic stress and very little
occlusal interference.
 A force as little as1.5 gm or less is detectable by the
teeth. ( Munch and schriever ).
 Bodies of 8-20 micron could be detected by some
individuals, and 60 mic were detected by all. (Kraft,
Tryde, Siirila and Lane)
Etiology.
 A state of hyper tonicity muscles might
therefore be due to either :
 CNS influence through the fusimotor
system.
 LOCAL disharmony between the
functional parts of the masticatory
system activity.
 The emotional influences on the muscles
of mastication is well known to clinicians.
 Apprehension of dental procedures
increase muscle tone, and positioning of
the jaw accurately becomes difficult if not
impossible.
Schematic representation of the
relationship of local and environmental
factors to dysfunctional disturbances of
the masticatory system.
Etiology.
 Occlusal habits are all outlets for
emotional and psychic tension and have
no relation with occlusal disharmony as
in the case of bruxism.
 The only indirect effect of occlusal
interferences is possibly an increase of
muscle tonicity.
 The precipitating factors of these habits (
lip, tong, cheek and fingernail biting) may
be overwork, worry, and premenstural or
other tensions having frustrations as the
common background.
5. Characteristics.
 Studies are focused on the nature of
nocturnal bruxism because of practical
limitations of investigating diurnal bruxist
behavior.
 Mandibular para functional behavior
during the sleeping hours:
 RHYTHMIC, and forceful GRINDING.
 PROLONGED CLENCHING; sustained
clenching can occur either in maximum
intercuspation, and /or eccentric
intercuspation anterior or lateral position.
Characteristics.
 Masticatory system is more prone to deleterious
ramification from forces generated by bruxism than
forces generated by functional tooth contact.
 Duration, Frequency, and Intensity of the
mandibular parafunctional activity is of paramount
significance in contributing to the resulting effect.
Bruxist forces affect the structures of the masticatory
system:
 Dentition and their supporting tissues.
 The associated musculature.
 The TMJ
Characteristics.
 The mandibular rhythmic movements of
nocturnal bruxism reflect episodic
patterns that can occur at intermittent
intervals.
 25 bruxist episode per night each
episode may have duration of 8-9 sec.
 Other study reported episode of 5
minutes.
 Total average bruxing time per period 42
sec. Other study reported 162 mint. With
different behavior from night to night.
Characteristics.
 Functional tooth contact during 24 hours
is approximately 20 minutes.
 The excessive forces generated by
bruxism extends for more than 20
minutes.
 Nocturnal bruxism can generate greater
occlusal forces (subconscious) than
conscious effort during working hours.
 One study demonstrated that 65% of
nocturnal bruxing episodes exceeded
forces generated by mastication.
Characteristics.
 The average working force that can be
delivered to a natural tooth is about 175
PSI (80 KG), 50 KG for FPD, and 10 Kg
for CD, wherever nocturnal bruxist can
increase this force 300 PSI with reported
cases of 100,000 to 175,000 PSI
(intensity).
 Functional activity can generate tooth
contact forces about 17,200 lb/sec/day.
 Para functional activity generate about
57,000 lb/sec/day.
Characteristics.
 It is possible that cortical inhibitions
normally operational during the working
hours are suppressed during sleeping
hours, thereby allowing the masticatory
muscles to exert greater occlusal forces
during sleeping hours.
 Forces delivered in the axe of the tooth
are better tolerated than lateral forces,
because stimulating the whole
periodontal tissues of the teeth as well
as the whole alveolar bone is less
traumatic than the lateral forces
stimulate just 1/17 of the periodontal
tissues and the alveolar bone.
Characteristics.
 Forces generated by functional tooth
contact has no pathologic effects on the
components of the masticatory system,
but forces generated by bruxism may
affect one element or more of the
masticatory system.
 Results are affected by resistance of the
host, duration, frequency and intensity of
the para functional activity.
6. Clinical
Consequences.
 In every individual there is a limit for
physiologic adaptation to imperfection or
disharmony in occlusal relationships.
 When this limit is surpassed, either
because of increased occlusal
disharmony or increased CNS tension a
hypertonic response in the masticatory
muscles follows.
 The hypertonic response may be on the
basis of facilitation of nervous impulses
of occlusal origin and/or lowered
threshold of neuron excitability from
nervous tension or pain.
Effect of trauma on the
masticatory system.
Clinical Consequences.
 An increase in neuromuscular activity
may lead to injury to the periodontiumperiodontium or
the TMJTMJ, or may produce pain and
discomfort within the tense muscles.muscles.
 Such injury or discomfort will result in
increased afferent stimuli to the nerve
center of the reflex system, with
subsequent tendency for increased
efferent activity and increased injurious
impact.
Clinical Consequences.
 It appears that there is no acceptable
evidence to show that there is
adaptability of the TMJ in adults or even
children more than 10 years of age
beyond physiologic internal remodeling
that occurs in all living bones.
 Although the joint where changed
temporarily because of the trauma from
occlusally induced displacement,
adaptive repositioning of the teeth
continued until the TMJs returned to their
previous relationships.
Clinical Consequences.
 Results of several studies indicate the
need for adapting the occlusion to the
joints rather than hoping for the joints to
adapt to the occlusion, at least when
considering the old TMJ.
 It appears that changes which
occasionally take place in the TMJ are
the result of pathologic processes rather
than physiologic adaptation.
 The entire dentition undergoes a
continuous adaptation to functional wear.
Clinical Consequences.
 Adjustment of tooth position occurs
throughout a person’s lifetime in
response to naturally induced changed
of occlusal forces associated with wear,
in response to pathologic changes in the
support mechanism or muscle tonicity,
and following placement of restorations
and other dental procedures.
 However, within the adaptive capacity of
the masticatory system, a balance of
forces is maintained.
Clinical Consequences.
 The most clinical consequences of
trauma from bruxism is tooth wear as
reflected by localized or generalized
occlusal or incisal facets or both.
 Excessive wear of the anterior teeth
result in esthetic concern and restorative
challenge.
 Severe wear of posterior teeth may
cause reduced vertical dimension,
mandible over-closure combined with
food impaction.
Tooth wear.
Clinical Consequences.
 Other consequences from bruxism to the
dentition and supporting tissues include:
 1- Thermal hypersensitivity.
 2- Hyper mobility.
 4- Injury to periodontal ligament.
 5- Hyper cementosis.
 6- Pulpitis an pulp necrosis.
 Resorption of alveolar ridge has been
observed in denture wearer who
exhibited bruxist behavior.
Clinical Consequences.
 Effect on the supporting tissues have
intimate relation with the quality of the
periodontal structure.
 Tooth supra eruption can be noticed with
its alveolar bone, which create
restorative problem.
 Severe trauma may lead to resorption of
the cementum and it may extend to the
dentin.
 Patients with steep cusps may have
greater periodontal damage when lateral
stress was applied.
Clinical Consequences.
 Escher and others claimed that
periodontal disease predispose an
individual to bruxism by increasing the
tonus of jaw muscles.
 Movement of the teeth associated with
gingival and periodontal inflammation
may initiate occlusal interferences.
 Discomfort associated with inflammation
may increase muscle tonus.
Clinical Consequences.
 Repetitive overloading of the TMJ via the
dentition has been suggested as a factor
in osteoarthrosis of the TMJ.
 Mandibular parafunctional activity is a
significant contributor to repetitive
overloading.
 This activity may cause pain in the TMJ
area if the health of the related tissues is
compromised. Elements may be involved
are retrodiscal, synovial, membranes of
the joint capsule and collateral ligaments
of the disc-condyle complex.
Clinical Consequences.
 It’s suggested that clenching involving
the anterior dentition cause internal
derangement of the TMJ.
 But with cusp to cusp contact during
eccentric clenching, the articular disk in
the ipsilateral TMJ concomitantly is
braced by the superior belly of the lateral
pterygoid muscle, the head of the
condyle moves into latero-trusive
direction these excessive forces on the
related ligaments of the disk-condyle
complex may compromise their structure
and cause disk displacement.
Clenching and its effects
on the TMJ.
Clinical Consequences.
 Tenderness to palpation of the
masticatory muscles.
 Patient may experience masticatory
muscle tightnessmuscle tightness and limited musclelimited muscle
movement on awaking.movement on awaking.
 These muscle dysfunctions may create
muscular contraction so that they may
create vascular contraction, which
develops into possible inflammation,or
biochemical changes.
Clinical Consequences.
 Because oxygen decreases in circulation it causeBecause oxygen decreases in circulation it cause
changes of pyruvic acid to lactic acid instead of citricchanges of pyruvic acid to lactic acid instead of citric
acid which will not allow ADP to go to ATP for energyacid which will not allow ADP to go to ATP for energy
formation; thus, the muscular system becomesformation; thus, the muscular system becomes
weaker and may end in possible necrosis of tissueweaker and may end in possible necrosis of tissue.
 Excessive occlusion overloading, tension will
increase and accumulate in the muscles.
 A fatigued muscle showed a loss of irritability due to
an accumulation of lactic acid.
 Constant working of muscles, even when fatigueConstant working of muscles, even when fatigue
does not occur, may result in hypertrophydoes not occur, may result in hypertrophy.
Clinical Consequences.
 It has been showed by Berlin and
Dessner and Monica that bruxism may
lead to chronic headache. Also the
correlation is not entirely clear, it has
been postulated by Wolff and others that
the basis for the pain or ache is the
disturbed circulation in the muscles.
 Various type of headache pose very
difficult problems in differential diagnosis,
since some patients experience
headaches associated with muscle
tension in the masticatory system.
7. Diagnosis.
 Patient arrives complaining of the
following symptoms:
 A tight sensation of the masticatoryA tight sensation of the masticatory
musclesmuscles that usually occurs onon
awakingawaking.
 MyalgiaMyalgia of the masticatory muscles and
myofacial pain.
 Hypersensitive teethHypersensitive teeth
 Sounds generated from grinding the
teeth during sleeping hours reported by a
roommate.
Diagnosis.
 Clinical signs that the practitioner can
observe:
 Occlusal and incisal wear of theOcclusal and incisal wear of the
dentitiondentition.
 Mobility of the teeth that are
periodontally compromised.
 Fracture of teeth as well as restorations.
 Hypertrophy of the superfacial belly ofHypertrophy of the superfacial belly of
the masseter musclesthe masseter muscles as well as the
anterior temporalis muscles.temporalis muscles.
 X ray shows widening of the periodontal
ligament space.
Diagnosis.
 TendernessTenderness to palpation of the
masticatory muscles.
 The most obvious sign of nocturnal
bruxism is attrition of the incisal edges of
the anterior teeth and the occlusal
surface of the posterior teeth.
 Abrasion during normal mastication or
oral habits characterized by facets of
opposing teeth that does not align with
each other whereas grinding of opposing
teeth during bruxism has wear facets
that do align.
8. Management.
 One investigator suggested that the
objectives for management of bruxism
should include:
 Reduction of psychological stress.
 Reduction of occlusal irritations.
 Cessation of neuromuscular habits.
 Treatment of signs and symptoms of
mandibular parafunction.
 Because the cause may be multifactorial,
a thorough medical and dental history
should be performed.
Management.
 Stress management strategy
include:
 Biofeedback counseling.
 Relaxation.
 Hypnosis.
 Occupational and lifestyle change.
Management.
 Direct therapeutic approach to the
dentition, musculature and
supporting structures include:
 Occlusal adjustment.
 Intra oral orthosis.
 Pharmacotherapeutic.
 Physical therapy.
Management.
 Occlusal adjustmentOcclusal adjustment is indicated
only when there is obvious
deflective interference such as:
 Supra erupted or mal positioned
third molar.
 Supra erupted of teeth opposed
edentulous area.
 Obvious working and non working
interferences.
Management.
 Inter occlusal appliance includes
many types, but with use limitation.
 A study reported significant decrease in
nocturnal masseter activity after
appliance use.
 Other study showed; reduced masseter
activity in 52%, increased in 20%,
unchanged in 28%.
 Some other studies showed 80-90%
improvement in symptoms despite 50%
reduction in bruxing activity.
Management.
 The purpose of the intra oral appliance is
a simple redistribution of the
masticatory forces.
 Unloading the TMJ when the retrodiscal
tissues are inflamed, therefore, reducing
the pressure on the edematous and
injured tissues distal to the condyle.
 The effectiveness of the orthosis can be
enhanced with concomitant use of
pharmaceuticals such as NSAIDs.
Effect of different types
of splints.
Management.
 The inherent design of the
appliance should provide:
 Redistribution of occlusal forces.
 Relaxation of the elevator
masticatory muscles.
 Stabilization of the TMJ.
 Protection of the dentition.
 Decrease in symptoms.
 Reduction of bruxism.
Management.
 The design of of stabilization orthosisThe design of of stabilization orthosis
isis:
 A full arch.
 Acrylic resin.
 Flat plane orthosis.
 Can be maxillary or mandibular.
 Undulation dictated by the occlusal
plane.
 Flat but if indentations exist it should in
centric bearing cusp and incisal edge of
anterior teeth.
Even redistribution of
occlusal forces.
Effect of limited anterior
bite plane on the TMJ.
Occlusal splint.
Maxillary stabilization
bite plane splint.
Management.
 Maxillary appliance has the
advantages to achieve occlusal
contact with the opposing teeth
regardless of the maxillo-
mandibular relationship which is
not possible with the lower
appliance, despite that the
mandibular appliance is more
esthetic and does not affect the
phonetics.
Management.
 Design of the maxillary appliance;
 It should be horseshoe shape.
 Should have clasp on both sides.
 Acrylic should overlap buccal and labial of the
teeth to prevent any movement.
 Flat occlusal surface with even contact in
centric-bearing cusp of the posterior teeth as
well as the incisal edge of the lower anterior
teeth.
 Anterior acrylic ramp is to provide disclusion of
posterior teeth in the lateral movements.
Management.
 In an effort to minimize the adjustment
time, an interocclusal record at the
desired vertical dimension should be
done and which will be used for
mounting the opposing cast, so that the
appliance will be fabricated at a jaw
relationship within the physiologic
parameters of the patient.
 The clearance between the tow jawsclearance between the tow jaws
should never exceed the freewayshould never exceed the freeway
spacespace, if not the muscle tone, which is
the passive resistance to stretch, will be
affected concomitant with fatigue
feelings.
Management.
 Also adjustment is needed to
perform an even contact during
habitual closure as well as inhabitual closure as well as in
occlusion in CRocclusion in CR so the patient
can use it during sleeping time and
awaking hours.
 It is important to remind that the
inerocclusal record should be
performed in reclined positionreclined position
( occlusion in CR ).
Management.
 The healing phase that follows the
appliance therapy shows:
 Reduction of pain.
 Reduction of edema and inflamed
tissues.
 Reduction of muscle activity.
 Clinical examination suggests that this
improvement is on a psychology basis.
However, these results are on the basis
of the even contact in CR occlusion as in
CO position.
Management.
 Stabilization orthosis is generally worn
during increase of muscle activityduring increase of muscle activity,
normally at nightnormally at night, but it could be use
during waking hours.
 Duration of wearing the orthosis can be
reduced as signs and symptomsreduced as signs and symptoms
resolveresolve.
 If the disorder affect just the muscles,
using the orthosis during sleeping is to
be considered.
 If the TMJ is affected (intracapsular
disorder) full time wearing the orthosis
during the initial stage may be indicated.
Management.
 When symptoms are overWhen symptoms are over, using the
orthosis is not necessary anymore, but
intermittent wearing may be necessary
during stressful life events.
 At this stage, the muscles are well
relaxed, so guiding the mandible in
occlusion in different positions will be
helpful in finding out the important
interferences in a clear way.
 Adjustment of these interferences is
helpful in the treatment of the signs and
the symptoms of bruxism.
Management.
 One month useOne month use is enough to expectis enough to expect
positive patient responsepositive patient response.
 In case where symptoms affect the
myofacial and temporal muscles, the
anterior flat biteplane is indicated, it is
fabricated by hard acrylic and come in
contact with just the lower anterior teeth.
 It affects brux. and parafunctional
behavior.
 It is effective when the chief complain is
limited to muscle pain. Its use limited on
sleeping hours to avoid posterior teeth
supra eruption.
Management.
 Concerning the appliance material; one study
indicated that hard interocclusal orthosis is likely to
be more successful than soft orthosis in reducing
nocturnal muscle activity as well as myofacial pain
symptoms.
 Also soft material is more difficult to adjust, and
contribute to inadvertent tooth movement and
occlusal changes.
 However, soft orthosis has certain indications as
transitional one for emergency cases and as athletic
mouth guard.
Management.
 Adjunctive physical therapyAdjunctive physical therapy; it is
useful in managing the pain of
masticatory muscles related to bruxism,
it includes:
 Stretch and spray with vapocoolant.
 Masticatory muscle exercises.
 Patient awareness of parafunctional
activity.
 Ultrasound.
 Trans cutaneous electric stimulation.
 Heat application.
Management.
 For both diagnostic and short
management approach, using a
pharmaceutical anti anxiety agent
is to be considered, diazepam
demonstrated good resultsdemonstrated good results.
 AntidepressantAntidepressant pharmaceutical
agent would suppress the REMREM
stage of sleepstage of sleep which has an
association with bruxism.
THANK
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An overview of bruxism: causes, characteristics and management

  • 1. BRUXISM, AN OVERVIEW AND MANAGEMENT. BY: DR. BAHJAT ABU HAMDAN CONSULTANT PROSTHODONTIST DDS, CES, DSO
  • 2. Bruxism. 1. Introduction. 2. Definition. 3. Epidemiology. 4. Etiology. 5. Characteristics. 6. Clinical consequences. 7. Diagnosis. 8. Management.
  • 3. 1. Introduction.  Before understanding the pathology of any disorder in the human body, one should have a good knowledge of the following elements:  The anatomy.  The related physiology.  The interrelation with the other elements.  The biochemistry mechanism.
  • 4. 2. Definition.  Bruxism can be regarded as forcible clenching or grinding of the dentition, or a combination of both.  Clenching of the teeth is a forcible closure of the opposing dentition in a static relationship of the mandible to the maxilla. In either maximum intercuspation or an eccentric positions.  Grinding of the dentition is a forcible closure of the opposing dentition in a dynamic maxillo-mandibular relationship as the mandible moves through various excursive positions.
  • 5. Definition. AAOFP defined bruxism as “diurnal or nocturnal parafunctional activity including clenching, bracing, gnashing and grinding of the teeth.  Bruxism, diurnal or nocturnal, is considered as a potential contributing factor to disturbances of the masticatory system.  Many individuals are not cognizant of their parafunctional behaviors, because these activities are usually subconscious, so obtaining accurate response regarding his mandibular parafunctional activity can be challenging.
  • 6. Definition.  Bruxism, as disorder of the neuromuscular activity, may affect any element of the masticatory system:  Regional or local pain, it may include one or more of the muscles of mastication. The myalgia may worsen during function. Limitation of mouth opening could be noticed as well as tenderness on palpation.  Wearing of the teeth, and TMJ problems. In certain cases symptoms may involve all the precedent elements.
  • 7. 3. Epidemiology.  Some studies demonstrate that bruxism occur in up to 90% in the general population.  Other studies demonstrate that it affects 8% of the adult, 14% of the children, and 10-12% of the adolescents.  However some investigations showed that the incidence is highest in the teens and the forties, and that behavior decreases with age.  Studies indicate that females report parafunctional clenching more than males.
  • 8. Epidemiology.  However clinical observations demonstrate approximately an equal distribution.  Self reporting of clenching during waking hours is about 20%.  Grinding of the teeth during sleeping hours ranges from 6-12%.  Parafunctional behavior is performed at a subconscious level by most individuals so determination the actual prevalence is difficult.
  • 9. 4. Etiology.  The cause of bruxism still controversial.  The cause is multi factorial and overlapping, which creates difficulties in applying comprehensive, effective management plan for this mandibular para- functional behavior.  However, because the parafunctional mandibular movements concern mainly the neuromuscular system, so any situation stimulating this system, at the subconscious level, would contribute in starting up bruxism.
  • 10. Etiology.  Historically, occlusal interference were thought to be the precipitating factor for bruxism, the assumption was that the patient was working a subconscious attempt at performing a self-equilibration or an adjustment of his dentition to remove the occlusal interferences, particularly with nocturnal bruxism.  Recent studies have refuted this assumption, but other investigators have reported that patient response to an occlusal interference, which existed, is more significant than to an actual presence of interference
  • 11. Etiology.  However, the relationship of the dentition may be a contributing factor.  Bruxism is considered as the most destructive functional disorder to the dentition.  Emotional or physical stress as well as anticipating of stress, are related to the mandibular parafunctional behavior.  Bruxist activity has been associated with sleep disorder.  It is reported that bruxism has been aggravated by alcohol consumption and certain medication.
  • 12. Etiology.  Occlusal interferences act as trigger factors for nonfunctional movements.  Both centric and eccentric bruxism are expressions of increased muscle tonus.  Its often said that bruxism in centric excursion involves isotonic muscle contractions, while static clenching in CO represent isometric activity.  But even the minute jaw movements include changes in the muscle length, so that, clenching involves both isotonic and isometric activity.
  • 13. Normal function in lateral movement.
  • 18. Etiology.  Any type of occlusal interference may, when combined with psychic stress, initiate and maintain bruxism.  Discrepancy between CR and CO is the most common trigger factor for bruxism.  Interference in the balancing side is the second is the second significant occlusal trigger factor.  Interference in the working side or protrusive excursion may also trigger bruxism.
  • 19. CR to CO movement.
  • 21. Etiology.  Since bruxism is an expression of combined psychic and occlusal factors. Bruxism may be present on the basis of severe occlusal interference and moderate degree of psychic or emotional tension, also it can be the result of very severe psychic stress and very little occlusal interference.  A force as little as1.5 gm or less is detectable by the teeth. ( Munch and schriever ).  Bodies of 8-20 micron could be detected by some individuals, and 60 mic were detected by all. (Kraft, Tryde, Siirila and Lane)
  • 22. Etiology.  A state of hyper tonicity muscles might therefore be due to either :  CNS influence through the fusimotor system.  LOCAL disharmony between the functional parts of the masticatory system activity.  The emotional influences on the muscles of mastication is well known to clinicians.  Apprehension of dental procedures increase muscle tone, and positioning of the jaw accurately becomes difficult if not impossible.
  • 23. Schematic representation of the relationship of local and environmental factors to dysfunctional disturbances of the masticatory system.
  • 24. Etiology.  Occlusal habits are all outlets for emotional and psychic tension and have no relation with occlusal disharmony as in the case of bruxism.  The only indirect effect of occlusal interferences is possibly an increase of muscle tonicity.  The precipitating factors of these habits ( lip, tong, cheek and fingernail biting) may be overwork, worry, and premenstural or other tensions having frustrations as the common background.
  • 25. 5. Characteristics.  Studies are focused on the nature of nocturnal bruxism because of practical limitations of investigating diurnal bruxist behavior.  Mandibular para functional behavior during the sleeping hours:  RHYTHMIC, and forceful GRINDING.  PROLONGED CLENCHING; sustained clenching can occur either in maximum intercuspation, and /or eccentric intercuspation anterior or lateral position.
  • 26. Characteristics.  Masticatory system is more prone to deleterious ramification from forces generated by bruxism than forces generated by functional tooth contact.  Duration, Frequency, and Intensity of the mandibular parafunctional activity is of paramount significance in contributing to the resulting effect. Bruxist forces affect the structures of the masticatory system:  Dentition and their supporting tissues.  The associated musculature.  The TMJ
  • 27. Characteristics.  The mandibular rhythmic movements of nocturnal bruxism reflect episodic patterns that can occur at intermittent intervals.  25 bruxist episode per night each episode may have duration of 8-9 sec.  Other study reported episode of 5 minutes.  Total average bruxing time per period 42 sec. Other study reported 162 mint. With different behavior from night to night.
  • 28. Characteristics.  Functional tooth contact during 24 hours is approximately 20 minutes.  The excessive forces generated by bruxism extends for more than 20 minutes.  Nocturnal bruxism can generate greater occlusal forces (subconscious) than conscious effort during working hours.  One study demonstrated that 65% of nocturnal bruxing episodes exceeded forces generated by mastication.
  • 29. Characteristics.  The average working force that can be delivered to a natural tooth is about 175 PSI (80 KG), 50 KG for FPD, and 10 Kg for CD, wherever nocturnal bruxist can increase this force 300 PSI with reported cases of 100,000 to 175,000 PSI (intensity).  Functional activity can generate tooth contact forces about 17,200 lb/sec/day.  Para functional activity generate about 57,000 lb/sec/day.
  • 30. Characteristics.  It is possible that cortical inhibitions normally operational during the working hours are suppressed during sleeping hours, thereby allowing the masticatory muscles to exert greater occlusal forces during sleeping hours.  Forces delivered in the axe of the tooth are better tolerated than lateral forces, because stimulating the whole periodontal tissues of the teeth as well as the whole alveolar bone is less traumatic than the lateral forces stimulate just 1/17 of the periodontal tissues and the alveolar bone.
  • 31. Characteristics.  Forces generated by functional tooth contact has no pathologic effects on the components of the masticatory system, but forces generated by bruxism may affect one element or more of the masticatory system.  Results are affected by resistance of the host, duration, frequency and intensity of the para functional activity.
  • 32. 6. Clinical Consequences.  In every individual there is a limit for physiologic adaptation to imperfection or disharmony in occlusal relationships.  When this limit is surpassed, either because of increased occlusal disharmony or increased CNS tension a hypertonic response in the masticatory muscles follows.  The hypertonic response may be on the basis of facilitation of nervous impulses of occlusal origin and/or lowered threshold of neuron excitability from nervous tension or pain.
  • 33.
  • 34. Effect of trauma on the masticatory system.
  • 35. Clinical Consequences.  An increase in neuromuscular activity may lead to injury to the periodontiumperiodontium or the TMJTMJ, or may produce pain and discomfort within the tense muscles.muscles.  Such injury or discomfort will result in increased afferent stimuli to the nerve center of the reflex system, with subsequent tendency for increased efferent activity and increased injurious impact.
  • 36. Clinical Consequences.  It appears that there is no acceptable evidence to show that there is adaptability of the TMJ in adults or even children more than 10 years of age beyond physiologic internal remodeling that occurs in all living bones.  Although the joint where changed temporarily because of the trauma from occlusally induced displacement, adaptive repositioning of the teeth continued until the TMJs returned to their previous relationships.
  • 37. Clinical Consequences.  Results of several studies indicate the need for adapting the occlusion to the joints rather than hoping for the joints to adapt to the occlusion, at least when considering the old TMJ.  It appears that changes which occasionally take place in the TMJ are the result of pathologic processes rather than physiologic adaptation.  The entire dentition undergoes a continuous adaptation to functional wear.
  • 38. Clinical Consequences.  Adjustment of tooth position occurs throughout a person’s lifetime in response to naturally induced changed of occlusal forces associated with wear, in response to pathologic changes in the support mechanism or muscle tonicity, and following placement of restorations and other dental procedures.  However, within the adaptive capacity of the masticatory system, a balance of forces is maintained.
  • 39. Clinical Consequences.  The most clinical consequences of trauma from bruxism is tooth wear as reflected by localized or generalized occlusal or incisal facets or both.  Excessive wear of the anterior teeth result in esthetic concern and restorative challenge.  Severe wear of posterior teeth may cause reduced vertical dimension, mandible over-closure combined with food impaction.
  • 41. Clinical Consequences.  Other consequences from bruxism to the dentition and supporting tissues include:  1- Thermal hypersensitivity.  2- Hyper mobility.  4- Injury to periodontal ligament.  5- Hyper cementosis.  6- Pulpitis an pulp necrosis.  Resorption of alveolar ridge has been observed in denture wearer who exhibited bruxist behavior.
  • 42. Clinical Consequences.  Effect on the supporting tissues have intimate relation with the quality of the periodontal structure.  Tooth supra eruption can be noticed with its alveolar bone, which create restorative problem.  Severe trauma may lead to resorption of the cementum and it may extend to the dentin.  Patients with steep cusps may have greater periodontal damage when lateral stress was applied.
  • 43. Clinical Consequences.  Escher and others claimed that periodontal disease predispose an individual to bruxism by increasing the tonus of jaw muscles.  Movement of the teeth associated with gingival and periodontal inflammation may initiate occlusal interferences.  Discomfort associated with inflammation may increase muscle tonus.
  • 44. Clinical Consequences.  Repetitive overloading of the TMJ via the dentition has been suggested as a factor in osteoarthrosis of the TMJ.  Mandibular parafunctional activity is a significant contributor to repetitive overloading.  This activity may cause pain in the TMJ area if the health of the related tissues is compromised. Elements may be involved are retrodiscal, synovial, membranes of the joint capsule and collateral ligaments of the disc-condyle complex.
  • 45. Clinical Consequences.  It’s suggested that clenching involving the anterior dentition cause internal derangement of the TMJ.  But with cusp to cusp contact during eccentric clenching, the articular disk in the ipsilateral TMJ concomitantly is braced by the superior belly of the lateral pterygoid muscle, the head of the condyle moves into latero-trusive direction these excessive forces on the related ligaments of the disk-condyle complex may compromise their structure and cause disk displacement.
  • 46. Clenching and its effects on the TMJ.
  • 47. Clinical Consequences.  Tenderness to palpation of the masticatory muscles.  Patient may experience masticatory muscle tightnessmuscle tightness and limited musclelimited muscle movement on awaking.movement on awaking.  These muscle dysfunctions may create muscular contraction so that they may create vascular contraction, which develops into possible inflammation,or biochemical changes.
  • 48. Clinical Consequences.  Because oxygen decreases in circulation it causeBecause oxygen decreases in circulation it cause changes of pyruvic acid to lactic acid instead of citricchanges of pyruvic acid to lactic acid instead of citric acid which will not allow ADP to go to ATP for energyacid which will not allow ADP to go to ATP for energy formation; thus, the muscular system becomesformation; thus, the muscular system becomes weaker and may end in possible necrosis of tissueweaker and may end in possible necrosis of tissue.  Excessive occlusion overloading, tension will increase and accumulate in the muscles.  A fatigued muscle showed a loss of irritability due to an accumulation of lactic acid.  Constant working of muscles, even when fatigueConstant working of muscles, even when fatigue does not occur, may result in hypertrophydoes not occur, may result in hypertrophy.
  • 49. Clinical Consequences.  It has been showed by Berlin and Dessner and Monica that bruxism may lead to chronic headache. Also the correlation is not entirely clear, it has been postulated by Wolff and others that the basis for the pain or ache is the disturbed circulation in the muscles.  Various type of headache pose very difficult problems in differential diagnosis, since some patients experience headaches associated with muscle tension in the masticatory system.
  • 50. 7. Diagnosis.  Patient arrives complaining of the following symptoms:  A tight sensation of the masticatoryA tight sensation of the masticatory musclesmuscles that usually occurs onon awakingawaking.  MyalgiaMyalgia of the masticatory muscles and myofacial pain.  Hypersensitive teethHypersensitive teeth  Sounds generated from grinding the teeth during sleeping hours reported by a roommate.
  • 51. Diagnosis.  Clinical signs that the practitioner can observe:  Occlusal and incisal wear of theOcclusal and incisal wear of the dentitiondentition.  Mobility of the teeth that are periodontally compromised.  Fracture of teeth as well as restorations.  Hypertrophy of the superfacial belly ofHypertrophy of the superfacial belly of the masseter musclesthe masseter muscles as well as the anterior temporalis muscles.temporalis muscles.  X ray shows widening of the periodontal ligament space.
  • 52. Diagnosis.  TendernessTenderness to palpation of the masticatory muscles.  The most obvious sign of nocturnal bruxism is attrition of the incisal edges of the anterior teeth and the occlusal surface of the posterior teeth.  Abrasion during normal mastication or oral habits characterized by facets of opposing teeth that does not align with each other whereas grinding of opposing teeth during bruxism has wear facets that do align.
  • 53. 8. Management.  One investigator suggested that the objectives for management of bruxism should include:  Reduction of psychological stress.  Reduction of occlusal irritations.  Cessation of neuromuscular habits.  Treatment of signs and symptoms of mandibular parafunction.  Because the cause may be multifactorial, a thorough medical and dental history should be performed.
  • 54. Management.  Stress management strategy include:  Biofeedback counseling.  Relaxation.  Hypnosis.  Occupational and lifestyle change.
  • 55. Management.  Direct therapeutic approach to the dentition, musculature and supporting structures include:  Occlusal adjustment.  Intra oral orthosis.  Pharmacotherapeutic.  Physical therapy.
  • 56. Management.  Occlusal adjustmentOcclusal adjustment is indicated only when there is obvious deflective interference such as:  Supra erupted or mal positioned third molar.  Supra erupted of teeth opposed edentulous area.  Obvious working and non working interferences.
  • 57. Management.  Inter occlusal appliance includes many types, but with use limitation.  A study reported significant decrease in nocturnal masseter activity after appliance use.  Other study showed; reduced masseter activity in 52%, increased in 20%, unchanged in 28%.  Some other studies showed 80-90% improvement in symptoms despite 50% reduction in bruxing activity.
  • 58. Management.  The purpose of the intra oral appliance is a simple redistribution of the masticatory forces.  Unloading the TMJ when the retrodiscal tissues are inflamed, therefore, reducing the pressure on the edematous and injured tissues distal to the condyle.  The effectiveness of the orthosis can be enhanced with concomitant use of pharmaceuticals such as NSAIDs.
  • 59. Effect of different types of splints.
  • 60. Management.  The inherent design of the appliance should provide:  Redistribution of occlusal forces.  Relaxation of the elevator masticatory muscles.  Stabilization of the TMJ.  Protection of the dentition.  Decrease in symptoms.  Reduction of bruxism.
  • 61. Management.  The design of of stabilization orthosisThe design of of stabilization orthosis isis:  A full arch.  Acrylic resin.  Flat plane orthosis.  Can be maxillary or mandibular.  Undulation dictated by the occlusal plane.  Flat but if indentations exist it should in centric bearing cusp and incisal edge of anterior teeth.
  • 63. Effect of limited anterior bite plane on the TMJ.
  • 66. Management.  Maxillary appliance has the advantages to achieve occlusal contact with the opposing teeth regardless of the maxillo- mandibular relationship which is not possible with the lower appliance, despite that the mandibular appliance is more esthetic and does not affect the phonetics.
  • 67. Management.  Design of the maxillary appliance;  It should be horseshoe shape.  Should have clasp on both sides.  Acrylic should overlap buccal and labial of the teeth to prevent any movement.  Flat occlusal surface with even contact in centric-bearing cusp of the posterior teeth as well as the incisal edge of the lower anterior teeth.  Anterior acrylic ramp is to provide disclusion of posterior teeth in the lateral movements.
  • 68. Management.  In an effort to minimize the adjustment time, an interocclusal record at the desired vertical dimension should be done and which will be used for mounting the opposing cast, so that the appliance will be fabricated at a jaw relationship within the physiologic parameters of the patient.  The clearance between the tow jawsclearance between the tow jaws should never exceed the freewayshould never exceed the freeway spacespace, if not the muscle tone, which is the passive resistance to stretch, will be affected concomitant with fatigue feelings.
  • 69. Management.  Also adjustment is needed to perform an even contact during habitual closure as well as inhabitual closure as well as in occlusion in CRocclusion in CR so the patient can use it during sleeping time and awaking hours.  It is important to remind that the inerocclusal record should be performed in reclined positionreclined position ( occlusion in CR ).
  • 70. Management.  The healing phase that follows the appliance therapy shows:  Reduction of pain.  Reduction of edema and inflamed tissues.  Reduction of muscle activity.  Clinical examination suggests that this improvement is on a psychology basis. However, these results are on the basis of the even contact in CR occlusion as in CO position.
  • 71. Management.  Stabilization orthosis is generally worn during increase of muscle activityduring increase of muscle activity, normally at nightnormally at night, but it could be use during waking hours.  Duration of wearing the orthosis can be reduced as signs and symptomsreduced as signs and symptoms resolveresolve.  If the disorder affect just the muscles, using the orthosis during sleeping is to be considered.  If the TMJ is affected (intracapsular disorder) full time wearing the orthosis during the initial stage may be indicated.
  • 72. Management.  When symptoms are overWhen symptoms are over, using the orthosis is not necessary anymore, but intermittent wearing may be necessary during stressful life events.  At this stage, the muscles are well relaxed, so guiding the mandible in occlusion in different positions will be helpful in finding out the important interferences in a clear way.  Adjustment of these interferences is helpful in the treatment of the signs and the symptoms of bruxism.
  • 73. Management.  One month useOne month use is enough to expectis enough to expect positive patient responsepositive patient response.  In case where symptoms affect the myofacial and temporal muscles, the anterior flat biteplane is indicated, it is fabricated by hard acrylic and come in contact with just the lower anterior teeth.  It affects brux. and parafunctional behavior.  It is effective when the chief complain is limited to muscle pain. Its use limited on sleeping hours to avoid posterior teeth supra eruption.
  • 74. Management.  Concerning the appliance material; one study indicated that hard interocclusal orthosis is likely to be more successful than soft orthosis in reducing nocturnal muscle activity as well as myofacial pain symptoms.  Also soft material is more difficult to adjust, and contribute to inadvertent tooth movement and occlusal changes.  However, soft orthosis has certain indications as transitional one for emergency cases and as athletic mouth guard.
  • 75. Management.  Adjunctive physical therapyAdjunctive physical therapy; it is useful in managing the pain of masticatory muscles related to bruxism, it includes:  Stretch and spray with vapocoolant.  Masticatory muscle exercises.  Patient awareness of parafunctional activity.  Ultrasound.  Trans cutaneous electric stimulation.  Heat application.
  • 76. Management.  For both diagnostic and short management approach, using a pharmaceutical anti anxiety agent is to be considered, diazepam demonstrated good resultsdemonstrated good results.  AntidepressantAntidepressant pharmaceutical agent would suppress the REMREM stage of sleepstage of sleep which has an association with bruxism.

Editor's Notes

  1. AAOFP: AMERICAN ACADEMY OF OROFACIAL PAIN.
  2. Ramfjord page 123, 399
  3. Because there is documentation which indicates that chronic occlusal considerations are not related to mandibular parafunction such as bruxism, so it is not advisable to use irreversible management which may have deleterious effects.