The document discusses bruxism, which is the involuntary clenching or grinding of teeth, including definitions, classifications, causes, symptoms, risk factors, diagnosis methods, and management options. Bruxism can be diagnosed through questionnaires, clinical exams assessing tooth wear, and polysomnography; and is managed primarily through behavioral changes, occlusal splints, pharmacotherapy, and biofeedback.

1. BRUXISM AND IT’S
MANAGEMENT
PRESENTER-DR MEGHA SABHARWAL
PRECEPTOR-DR KASHINATHA SHETTYDate- 17/04/2020

2. CONTENTS
1. Introduction.
2. Definition.
3. Classification
4. Etiology.
5. Clinical Implications.
6. Risk factors
7. Diagnosis.
8. Investigations
9. Management
10. Case Studies

3. • According to GPT 9, bruxism is defined as “the
parafunctional grinding of the teeth; an oral habit
consisting of involuntary rhythmic or spasmodic
non-functional gnashing, grinding, or clenching of
teeth, in other than chewing movements of the
mandible, which may lead to occlusal trauma”
• It is noted as the commonest of the many
parafunctional habits of dento facial system.
• Bruxism activity is of major concern for the dentists as
it leads to tooth wear and damage, restoration
fractures, temporal headache and other
temporomandibular disorders.
• The prevalence range is from 8-31% in the general
population and 14-20% in children

4. INTRODUCTION
• Activities of the masticatory system can be
divided into two types: Functional, which
includes chewing, speaking, and parafunctional,
which includes clenching or grinding of the
teeth (referred to as bruxism).
• Parafunctional activity is also known as muscle
hyperactivity.
• ‘Bruxism’ originates from the Greek word
brychein,meaning to ‘gnash the teeth’. An
early and common definitionof bruxism was
thus ‘‘gnashing and grinding of the teeth for
non-functional purposes’’

5. CLASSIFICATION
Bruxism is classified based on:
1) Time of occurrence
a. Awake bruxism
b. Sleep bruxism (SB)
c. Combined bruxism
2) Aetiology
a. Primary, essential or idiopathic bruxism: For which no apparent cause is known.
b. Secondary bruxism: Secondary to diseases (coma, icterus, cerebral palsy),
medication (e.g., antipsychotic and cardioactive medication) and drugs (e.g.,
amphetamines, cocaine).

6. 3) Motor activity type
a. Tonic: Muscular contraction sustained for more than two seconds.
b. Phasic: Brief, repeated contractions of the masticatory musculature with three or
more consecutive bursts of electromyographic activity that last between 0.25 and
two seconds apart.
c. Combined: Alternating appearance of tonic and phasic episodes. Approximately
90% of the episodes of SB are phasic or combined, unlike in awake bruxism, where
episodes are predominantly tonic.
4) Status of bruxism
a. Past
b. Current or present

7. ETIOLOGY
The etiology of bruxism is uncertain, but the hypotheses fall into four major
categories:
1. Local factors
2. Neurological factors
3. Medications
4. Psychosocial factors
Local factors
Bruxism has been interpreted as an automatic reaction of the body to occlusal
interferences with the purpose of eliminating them by grinding. Even though there
are some data suggesting that occlusion affects muscle activity leading to
parafunctions, most of the studies seem to deny this correlation.
Neurological factors
Some neurological pathologies may be associated with parafunctional oral activity
such as -Dyskinesias, Parkinson’s disease, and other extrapyramidal disorders.

8. Medications
Several medications that have been shown to elicit bruxism: Amphetamines, L-
dopa, fenfluramine, phenothiazine, neuroleptics, selective serotonin reuptake
inhibitors (SSRls), Antipsychotic agents which frequently cause dyskinesias:
fluphenazine, haloperidol loxapine, molindone, perphenazine, pimozide,
thiothixene, trifluoperazine and Recreational drugs (heroin, cocaine, ecstasy,
marijuana, (“crack”, LSD, methadone).
Psychosocial factors
This includes anxiety, stress and characteristics of personality.

10. CLINICAL IMPLICATIONS
ACTIVITIES NORMAL PARAFUNCTION
DIRECTION OF APPLIED
FORCE
VERTICAL HORIZONTAL/LATERAL
MANDIBULAR POSITION STABLE /CENTRIC
OCCLUSAL POSITION
UNSTABLE/ECCENTRIC
POSITION
MUSCLE ACTIVITY RYTHMIC
CONTRACTION AND
RELAXATION
SUSTAINED MUSCLE
CONTRACTION
NEUROMUSCULAR
REFLEXES
PROTECTION FROM
REFLEXES PRESENT
ABSENT OR
THRESHOLDS ARE
Reddy SV, Kumar MP, Sravanthi D, Mohsin AH, Anuhya V. Bruxism: a literature review. J Int Oral
Health. 2014; 6(6):105-9.

11. SIGNS
1. Abnormal tooth wear and
occlusal trauma
2. Tongue & cheek indentation
3. Linea alba along the biting
pane
4. Gum recession
5. Increase in muscle activity (this
is recorded by the
polysomnography)
6.Presence of masseter muscle
hypertrophy on voluntary
contraction
SYMPTOMS
1. Grinding of the teeth accompanied
by a characteristics sound that may
even awaken the bruxers bed
partner
2. Headache (especially in the
temporal zone when the patient
wakes up in the morning)
3. Pain, Clicking or locking of
temporomandibular joint
4. Pain in the masticatory and cervical
muscles
5. Tooth or teeth hypersensitive to cold
air or liquid
6. Excessive tooth mobility
7. Poor sleep quality ,tiredness

12. Risk Factors
• Age: Bruxism is more common in young children and noted to decrease by
adulthood.
• Stress: Increased stress and anxiety can cause bruxism.
• Personality: Aggressive, competitive and hyperactive type of behaviour
and personality can increase the chance of teeth grinding.
• Family history: Sleep bruxism tends to give a family history, other
members also may have teeth grinding or a history of it.
• Medications and habits: Certain antidepressants can result in bruxism as
an uncommon side effect. Habits like smoking, tobacco chewing, drinking
caffeinated beverages may increase the risk of bruxism.
• Other factors- Bruxism can be associated with medical problems like
epilepsy, sleep related disorders, dementia, parkinson’s disease and
gastroesophageal reflux disorder.

13. DIAGNOSIS
• Diagnosis of bruxism is based particularly on case
history, clinical evaluation followed by investigations.
• Icludes questionnaires
• Self reports to assess presence and absence of bruxism is
convenient for both clinicians and researchers.

14. OTHER METHODS
1. Clinical evaluation Tooth Wear
2. Facets of Intra-oral Appliance
3. Assessment of bruxism activity
4. Measurement of bite force

15. Clinical evaluation Tooth Wear
• Tooth wear is considered to be analogous to bruxism. Tooth wear is a
cumulative record of both functional and parafunctional activities and
various factors such as age, gender, diet and bruxism are associated with
tooth wear. Several studies have demonstrated a positive relationship
between tooth wear and bruxism.
• Major disadvantage with tooth wear is that it neither proves ongoing
bruxism nor static tooth clenching. Tooth-Wear Index is used to the rank
persons with regard to incisal and occlusal wear.

16. Facets of Intra-oral Appliance
• Repetitive wear pattern on the occlusal splint has been reported with wear
facets on full-arch acrylic resin splints, which reappeared in the same
location with a similar pattern and direction, even after adjustment of the
splints.
• Hence intra oral appliances may be used to detect bruxism.

17. Assessment of bruxism activity
• The Bruxcore Bruxism-Monitoring Device (BBMD) is an intra-oral
appliance that was introduced as a device for measuring sleep bruxism
activity objectively and the Bruxcore plate evaluates bruxism activity by
counting the number of abraded microdots on its surface and by scoring
the volumetric magnitude of abrasion.
• The major disadvantage with this method is that it is difficult to count the
number of missing dots with good precision

18. Measurement of bite force
• Takeuchi et al. developed a recording device for sleep bruxism, an intra-
splint force detector (ISFD), which uses an intra-oral appliance to
measure the force being produced by tooth contact onto the appliance. The
force is detected using a thin deformation-sensitive piezoelectric film,
which is embedded 1-2 mm below the occlusal surface of the appliance.

19. Investigations
Polysomnography (sleep laboratory)
• This offers a highly controlled recording environment
wherein sleep disorders can be ruled out and sleep
bruxism can be discriminated from other orofacial
activities that occur during sleep. Physiological
changes related to sleep bruxism (e.g tachycardia and
sleep-stage shift) can also be monitored.
These recordings for sleep bruxism generally
include
• electroencephalogram,
• electromyography
• electrocardiogram and
• thermally sensitive resistor (monitoring air flow)
signals along with simultaneous audio-video
recordings.

20. • One major limitation is that a change in the environment for sleep may influence
the actual behaviour of bruxism. Another is the expense as multiple night recording
is to be taken for the occurrence of sleep bruxism as it varies over a number of
nights.

21. Masticatory Muscle Electromyographic Recording
• Sleep bruxism activity is assessed based on EMG (Electromyography) activity in
the masticatory muscles (masseter and/ or temporalis).
• Since 1970s, sleep bruxism episodes were measured over an extended period in
patient’s homes with the use of battery-operated EMG recording devices which can
measure masticatory muscle activity more minutely, i.e. the number, duration and
magnitude of bruxism events.
• A miniature self-contained EMG detector-analyser (Bite-Strip) was developed as
a screening test for moderate to high level bruxers wherein the number of bruxism
events can be objectively estimated by simply attaching it to the skin over the over
the masseter muscle .

22. • Recently, a miniature self-contained EMG detector– analyser with a biofeedback
function (grindcare, medotech, denmark) was developed as a detector and
biofeedback device for sleep bruxism.
• It works by the online recording of EMG activity of the anterior temporalis muscle,
online processing of EMG signals to detect tooth grinding and clenching and also
biofeedback stimulation for reducing sleep bruxism activities.

23. MANAGEMENT

24. Behavioural modification
• Psychoanalysis, hypnosis, meditation, sleep, hygiene measures with relaxation
techniques and self- monitoring have been considered for the treatment of bruxism.
• The treatment of sleep bruxism usually begins with counselling of the patient with
respect to the sleep hygiene.
• It includes to instruct the bruxer to stop smoking and drinking of coffee or alcohol ,
• to limit the physical or mental activity before going to bed,
• and to ensure good bedroom conditions like quiet and dark

25. Pharmacological therapy
• Certain drugs have paralytic effect on the muscles, by inhibiting acetylcholine
release at the neuromuscular junction (NMJ) therby decreasing bruxism activity in
severe cases like coma, brain injury etc.
• In a study, botox injections over a period of 20 weeks showed decrease in bruxism
activity in 18 subjects. This study suggested that botulinum toxin inhibited the
release of acetylcholine at NMJ .
• Shim et al. found that the amplitude of the muscle contraction during bruxism
events was reduced after 4 weeks of injection, but with no changes in the rhythm or
number of bruxism episodes per hour of sleep.
Tan EK, Jankovic J. Treating severe bruxism with botulinum toxin. J Am Dent Assoc.
2000; 131:211-216
Jong Sup Shim et al Effect of muscle activity and botulinum toxin dilution volume on
muscle paralysis Developmental Medicine & Child Neurology 2003, 45: 200–206

26. • Another pharmacologic approach involves the use of botulinum toxins in the
treatment of bruxism.
• The clinician injects botulinum toxins into the masticatory muscles that are
triggered with bruxism, including the temporalis and masseter.
• Study results indicate that the use of this treatment can cause some bruxism-related
muscle pain to subside and may reduce bruxism events
Lang R, White PJ, Machalicek W, et al. Treatment of bruxism in individuals
with developmental disabilities. Res Dev Disabil. 2009;30(5):809-818

27. • Lobbezoo and colleagues conducted a thorough systematic review of the
treatment modalities for both waking and sleeping bruxism.
• They summarized the best approach as the “triple-P” approach: plates, pep talk,
and pills.
• Specifically, they referred to stabilization splints, counseling, and short-term
pharmacotherapy.
Lobbezoo F, van der Zaag J, van Selms MK, Hamburger HL,Naeije M. Principles for the
management of bruxism. J Oral Rehabil. 2008;35(7):509-523.

28. Biofeedback
• Biofeedback works on the principle that “bruxers can unlearn their behaviour when
a stimulus makes them aware of their adverse jaw muscle activities”.
• Mittelman described an EMG technique that provides the daytime bruxer with
auditory feedback from his/her muscle activity letting him know the degree of
muscle activity or relaxation that is happening.
• Nissani used a taste stimulus to awaken the patient, in case of sleep bruxism .

29. • In recent years, contingent electrical stimulation (CES) has appeared in an attempt
to reduce the masticatory muscle activity associated to sleep bruxism. The rationale
during the bruxism episode is
RATIONALE
INHIBITION OF
MUSCLES
ELECTRICAL
STIMULATION

31. • Experimental studies have used CES in patients with signs and symptoms of sleep
bruxism and myofascial pain, and found a reduction of the EMG episodes per hour
of sleep while using CES, but with no changes in pain and muscle tension scores.
Svensson P. Effect of contingent electrical stimulation on jawmuscle activity during sleep: a pilot
study with a randomized controlled trial design. Acta Odontol Scand. 2013; 71(5):1050-62
Conti PC, Stuginski-Barbosa J, Bonjardim LR, Soares S, Svensson P. Contingent electrical
stimulation inhibits jaw muscle activity during sleep but not pain intensity or masticatory muscle
pressure pain threshold in self-reported bruxers: a pilot study. OralSurg Oral Med Oral A review
of current concepts in bruxism-diagnosis and management. Nitte university journal of health
sciences. 2014, 4(4).

32. Occlusal Therapy
• These splints have different names such as occlusal bite guard, bruxism appliance,
bite plate, night guard, occlusal device.
• They are classified into hard splints and soft splints. Hard splints are preferred over
soft splints because soft splints are difficult to adjust and hard splints are effective
in reducing the bruxism activity .
• A study compared occlusal splints versus a medication doses gabapentin, and
found that both treatments reduced similarly the muscle activity associated with
sleep bruxism after 2 month of therapy.
Okeson JP. The effects of hard and soft occlusal splints on nocturnal bruxism. J Am Dent
Assoc. 1987; 114:788-791.
Madani AS, Abdollahian E, Khiavi HA, Radvar M, Foroughipour M, Asadpour H et al. The
efficacy of gabapentin versus stabilization splint in management of sleep bruxism. J
Prosthodont. 2013; 22(2):126-31.

33. Classification of occlusal splints
Okeson
1) Muscle relaxation appliance/
stabilization appliance used to reduce
muscle activity
2) Anterior repositioning appliances/
orthopedic repositioning appliance
3) Anterior bite plane
4) Pivoting appliance
5) Soft/ resilient appliance
Dawson
1) Permissive splints/ muscle
deprogrammer
2) Directive splints/ non-permissive
splints
3) Pseudo permissive splints (e.g. Soft
splints, Hydrostatic splint)

34. Hard acrylic occlusal splint appliances
• Hard acrylic occlusal splint appliances may be indicated in patients who require
protection of their teeth from the further damage, to reduce tooth grinding
sounds during sleep, or to manage concomitant orofacial pains (example
masticatory muscle myalgia).
• Many authors recommend canine- protected occlusion to disocclude the
posterior teeth during eccentric movements.

35. Soft vinyl mouth guards
• Soft mouth guards are generally not durable and are contraindicated for long term
use. More than 50% of patients with soft mouth guards show increased masseter
EMG activity during sleep.
A third variation of material known as dual laminated, as its occlusal surface consists of
hard acrylic resin and the tooth-borne surface consist of a soft material. This produces an
occlusal appliances with advantages of a soft material (fitting well and providing comfort
for the supporting teeth),and an adjustable occlusal surface of the hard acrylic resin.

36. Studies on efficacy of hard splint
versus soft splint
• Hard acrylic resin occlusal appliances have several advantages over the soft
appliances; hardness and resistance of the acrylic resin enable
• Easy and quick adjustments, easy repair, the fit of a hard acrylic resin is more
accurate, methods of fabrication is more reliable and greater longevity, more color
stable, less food debris accumulation and more durable than that of the soft
version.
• In contrary, the adjustment of soft material is more difficult and often results in a
less adequate occlusal scheme. And these appliances are more susceptible to
wearing that in turn result in occlusal changes.

37. FABRICATION OF OCCLUSAL SPLINT
• Clinical Steps 1:• An impression of both the maxillary and mandibular arches
were made with irreversible hydrocolloid material and poured with type III
dental stone to obtain diagnostic casts to be mounted using type II dental
plaster in a semi adjustable articulator following a face bow transfer and
centric relation bite record .
• A preexisting record of centric relation and centric occlusion of the patient
need to be made before treatment to avoid change in occlusion after therapy

38. • Laboratory steps: • The face bow record helps in mounting of the maxillary cast
where as the centric relation bite record help in mounting of the mandibular cast
in relation to the maxillary cast in the articulator [Fig-1].
• This relates exactly to that of the patient’s existing jaw occlusion relation.
• After mounting, the maxillary cast was detached from the articulator to do
surveying procedure using a dental surveyor in order to determine the height of
contour of the teeth and reattached back.
• The vertical height of the articulator with mounted casts was increased by 1mm
and locked in this new incisal guide position to provide interocclusal space
between the posterior teeth .
• The undercuts are blocked out around the maxillary teeth below the survey line
exposing about 2mm on buccal surface and 3-4mm on palatal surface [Fig-2].

39. • Separating media is applied on the maxillary teeth up to the block out, followed by
dispensing of self cure clear acrylic polymer-monomer slowly by sprinkle on
method to get adequate thickness of the splint [Fig-4]
• In between, the articulator is closed often to ensure firm seating of the incisal guide
pin on the incisal guide table.
• Once set, the acrylic splint is removed carefully from the maxillary cast, finished
and polished in a regular manner.
• Rechecking of finished and polished occlusal acrylic splint was done by closing the
articulator to verify whether the mandibular centric (functional) cusp tips made
contact with the occlusal surface of the splint.

40. • Clinical step 2:• Insertion of customized self cure clear acrylic maxillary occlusal
splint is completed with minor intraoral adjustments . Post-insertion instructions
are given and the follow-up visits till total satisfactory results with reduced
symptoms are found in the patient.
• The recommended protocol after insertion of the splint is that the patient need to
visit the prosthodontist for adjustments at 24 hrs, 3 days, 7 days, 14 days, 21 days
and 1 month intervals .

41. Improvement Due to Splint
1) Occlusion on the splint changes, with absence of contacts especially at
the anterior region
2) after removal of the splint at morning, there is difficulty to achieve occlusion in
MI(The difficulty of occlusion demonstrates the difference between the arc of
closure in MI and the arc of closure in the neuromuscular balanced position.)
3 ) The splint increasedthe awareness of parafunction.(theory of cognitive
perception.Occlusalcoverage and the dental contacts on the splint seem to be
important factors that, combined to the change in tonguepositioning, increase the
patient’s awareness)
4) Improved pain relief (the efficacy of occlusal splint to reduce the
electromyographic activity at rest,maximum clenching and during nighttime
parafunctional activity)
5) The absence of anterior contacts on the splint at the follow-up visits suggests
mandibular retrusion, which occurs due to relaxation of the inferior lateral
pterygoid muscles, which are responsible for anterior condylar movement.
Raphael KG, Marbach JJ, Klausner JJ, Teaford MF, Fischoff DK. Is bruxism severity a predictior of oral
splint efficacy in patients with myofascial face pain? J Oral Rehabil. 2003;30(1):17-29.
Roark AL, Glaros AG, O’Mahony AM. Effects of interocclusal appliances on EMG activity during
parafuncional tooth contact. J Oral Rehabil. 2003;30(6):573-7.

42. • This study compared occlusal splints fabricated in centric relationand
maximum intercuspation in muscle pain reduction of TMD patients.
Twenty patients with TMD of myogenous origin andbruxism were
divided into 2 groups treated with splints in maximum intercuspation
(I) or centric relation (II).
• electrognathographic and electromyographic examinations were
performed before and 3 months after therapy.
• There was a remarkable reduction in pain symptomatology, without
statistically significant differences (p>0.05) between the groups.

43. • There were no significant differences (p>0.05) in the electromyographic activities
at rest after utilization of both splints.
• In conclusion,both occlusal splints were effective for pain control and presented
similar action. The results suggest that maximum intercuspation may be used for
fabrication of occlusal splints in patients with occlusal stability without large
discrepancies between centric relation and maximum intercuspation.

44. • In this report, computer-based design and production of occlusal splints was
described .
• In order to eliminate the inherent variabilities associated with current splint-
fabrication methods.
• The digital process provides –
o quantitative control over articulation and splint design, and produces splints with
continuously smooth occlusal surfaces.
o Stone casts are laser scanned, and custom software is used to articulate and
design flat-plane and full-coverage splints with guidance ramps. Splints are
produced by milling excess acrylic placed over stone casts.
 Clinically, digital splints reduce the average time needed for placement because
intraoral equilibration is minimized.
American Journal of Orthodontics and Dentofacial Orthopedics Volume 133, Number 4,
Supplement 1

45. CAD/CAM splints for the functional and esthetic evaluation
of newly defined occlusal dimensions
• Modern production technologies now allow the use of tooth-colored occlusal
splints made of polycarbonate, whose quality and material properties are quite
distinct from those of conventionally manufactured splints made of transparent
polymethyl methacrylate (PMMA).
• These materials, produced under standardized polymerization conditions, are
extremely homogenous, which provides benefits such as a greater accuracy of
fit by eliminating the polymerization shrinkage, greater long-term stability of
shapes and shades, better biocompatibility, less wear, and a more favorable
esthetic appearance.
• In addition, tooth-colored polycarbonate splints can be fabricated very thin
without significantly increasing the fracture risk, thanks to the flexibility of the
material. The improved wearing comfort combined with acceptable esthetics result
in significantly improved patient compliance in terms of a "23-hour splint.”

46. Effect of bruxism on prosthetic
restorations
• The most common mechanical failures reported in case of prosthetic restorations on
natural teeth included loss of retention and fracture of material and the
occurrence of such failures is greatest in patients with bruxing habits.
• Metal or metal–ceramic restorations(or restorations with high nobel content)
seem to be the safest choice in cases of high load conditions, although under
extreme conditions, there is no material that will last for too long.
• Due to the risk of chipping of ceramic veneers in metal–ceramic restorations,
gold– acrylic FDPs for heavy bruxers were preferred.

47. • Clinical studies published on wear of materials in bruxism patients indicate
minimal differences in wear resistance of gold and ceramic materials,
whereas resin-based materials showed times more substance loss than gold
or ceramics.
• Zirconia, which is the present material of esthetics and strength, have
demonstrated improved mechanical properties in laboratory studies and hence
may be promising in the treatment of bruxism related tooth wear .
• However, a systematic review of zirconia FDPs has shown that there are
complications when the material is used clinically.

49. Effect of bruxism on implant
restorations
• In a prospective 15- year follow-up study of
mandibular implant-supported fixed
prostheses, smoking and poor oral hygiene had
a significant influence on bone loss, whereas
occlusal loading factors such as bruxism,
maximal bite force and length of cantilevers
were of minor importance.
• Although bruxism was included among risk
factors, and was associated with increased
mechanical and/or technical complications, it
had no effect on implant survival.
• Several studies have indicated that patients
with bruxism have a higher incidence of
complications on the superstructures of both
of fixed and removable implant-supported
restorations .

50. The effect of bruxism on treatment
planning for dental implants
• Excessive force is the primary cause of late implant complications.
• One viable approach is to increase the implant-bone surface area.
• Additional implants can be placed to decrease stress on any one implant, and
implants in molar region should have an increased width.
• Use of more and wider implants decreases the strain on the prosthesis and also
dissipates stress to the bone, especially at the crest.
• The additional implants should be positioned with intent to eliminate cantilevers
when possible.
.
Misch CE. The effect of bruxism on treatment planning for dental implants. Dent
Today. 2002 Sep;21(9):76-81.

51. • Greater surface area implant designs made of titanium alloy and with an
external hex design can also prove advantageous.
• Proper established anterior guidance in mandibular excursions further
decreases force and eliminates or reduces lateral posterior force.
• Metal occlusal surfaces decrease the risk of porcelain fracture and do not
require as much abutment reduction, which in turn enhances prosthesis
retention.
• Night guards designed with specific features also are a benefit to initially
diagnose the influence of occlusal factors for the patient, and as
importantly, to reduce the influence of extraneous stress on implants and
implant-retained restorations.

52. •The consequences of nocturnal
parafunctional habits may be prevented
by acrylic resin night guards
• A hard stabilization splint for nightly
use (night guard) contributes to
optimally distributing and vertically
redirecting forces that go with
nocturnal teeth grinding and
clenching .
• A night guard that promotes even
occlusal contacts around the arch in
centric-related occlusion can be helpful
to prevent fractures of implant
prostheses.

53. • In current clinical practice, porcelain has become the primary occlusal material for
single-tooth and partial fixed implant prostheses . It is generally agreed that ceramic
occlusal surfaces provide superior esthetics and wear resistance
• Regarding full-arch fixed prostheses on implants, metal ceramic prostheses are
sometimes presented in clinical reports, but in many centers acrylic resin teeth
continue to be the material of choice.
• Although there is no evidence regarding the preferred restorative materials in
implant prosthesis for patients with bruxism, some clinicians prefer metal
restorations and not porcelain to protect the implant prostheses in patients
with bruxism, especially for second molar teeth in the maxilla.
• Recently, investigators demonstrated zirconia as a new dental implant material .
Osamu Komiyama,Frank Lobbezoo, Antoon De Laat Clinical Management of Implant
Prostheses inPatients with Bruxism International Journal of Biomaterials volume 2012

54. Effect of bruxism on dentures
• It is considered, clinical experience indicates that bruxism is a frequent cause of
complaint of soreness of the denture-bearing mucosa.
• In a similar way, heavy bruxism may have deleterious effects on the residual
dentition and the denture-bearing tissues in patients with RPDs, although this has
not been systematically studied.

56. • A study mentioned the management of four patients with severe sleep bruxism, and who were
using conventional RPDs.
• Each patient was provided with a splint-like RPD, called a night denture, and followed-up for
2–6 years using the night denture. The study concluded that the night denture appeared to be
effective in managing problems related to sleep bruxism in patients with RPDs.
• Delivery of an inexpensive acrylic night denture is a practical approach to minimize the
unfavorable effects of sleep bruxism in these patients, which include progression of tooth
attrition, uncomfortable feeling or pain inthe remaining teeth upon waking, and increased
tooth mobility.
Baba K, Aridome K, Pallegama RW. Management of bruxism-induced complications in removable
partial denture wearers using specially designed dentures: A clinical report. Cranio. 2008; 26:71-
6.

57. resin occlusal coverage over the remaining anterior teeth with a resin base
and increased the vertical dimension, resulting in a gap of 3 mm
between the upper and lower incisal edges.

60. Clinical examination revealed that the tooth contact occurred only at the left
premolar region between the copings and the opposite teeth in the absence of the
denture.

61. CASE- AWAKE BRUXISM
•COMPLIANCE?
•SPEECH &
SALIVARY FLOW?

62. CASE STUDIES
• A case series survey by Ingerslev ,on a cohort of 366 children aged 6 to 16 over a
period of 4 years documented the efficacy of functional therapy (soft and hard bite-
splints) on reducing the SB signs and symptoms.
• The authors reported that about 60% of the patients presented with symptom
reduction, while 34% were essentially symptom-free at the conclusion of the
treatment.
• It is plausible that SB that is related to a structural problem, including airway
obstruction due to enlarged tonsils, enlarged adenoids, narrow maxillary arches,
mouth breathing, and retrognathic mandible can be managed by treatments that
solve these airway obstructions in the nasopharynx, oropharynx, and hypopharynx
Treatments of sleep bruxism in children: A systematic review and meta-analysis Gaetano
Ierardo, Marta Mazur, Valeria Luzzi, Francesca Calcagnile, Livia Ottolenghi & Antonella
Polimeni Journal of Craniomandibular and sleep practice

63. • The first systematic review with meta-analysis assessing the available evidence of
SB therapy in children, showed that pharmacotherapy with hydroxyzine is the most
effective treatment in reducing both symptoms and signs of SB over a period of
four weeks in a total of 28 subjects.
• Benzodiazepine administration and the usage of Melissa officinalis(lemon balm
/balm mint)showed a lower effect in studies . Although, among the pharmacological
therapies on drugs such as hydroxyzine, flurazepam, and Melissa Officinalis,
hydroxyzine showed the most effective treatment available but still has shown a
weak evidence of a possible efficacy on reducing SB symptoms and signs
Ghanizadeh A,Zare S. A preliminary randomised double-blind placebo-controlled clinical trial of
hydroxyzinefor treating sleep bruxism in children. J Oral Rehabil. 2013;40(6):413–417.
Bortoletto C, Cordeiro Da Silva F, Salgueiro Mda C,et al. Evaluation of electromyographic signals in
childrenwith bruxism before and after therapy with Melissa
officinalis L-a randomized controlled clinical trial.J Phys Ther Sci. 2016;28(3):738–742.

64. Should prosthodontics be a treatment
option for tmd or bruxism?

65. • Correcting dental occlusion and/or repositioning the mandible for TMD treatment
purposes is not medically necessary
• Given these premises, the general practitioner may be perplexed by the apparent
occlusion-related effects of oral appliances (OA) on TMD symptoms.49,50 Oral
appliances may favor reorganization of muscle fiber recruitment patterns51,52 and
a shift in the area of highest joint loading.
• TRANSIENT EFFECTS OF OA ransient shifts in joint and muscle loading.
• Mandibular advancement devices are a option for OSA treatment, may actually
reduce SB as a “side-effect” of OSA decrease induced by jaw advancement
Daniele Manfredini, Carlo E. Poggio, Prosthodontic planning in patients with
temporomandibular disorders and/or bruxism: A systematic review Journal of Prosthetic
Dentistry 2016

66. Can prosthodontics cause tmds and/or
bruxism?

67. • The biological plausibility that a centrally mediated phenomenon such as bruxism
may be induced by a prosthetic treatment is nonexistant.
• The masticatory system has extraordinary powers of adaptation, both to natural
dental-skeletal abnormalities and to iatrogenic modifications.
• However it has been stated that extensive rehabilitation which includes Increases
in the occlusal vertical dimension (OVD) and mandible repositioning treatments
might hold a possibility of being a risk factor.
Daniele Manfredini, Carlo E. Poggio, Prosthodontic planning in patients with
temporomandibular disorders and/or bruxism: A systematic review Journal of Prosthetic
Dentistry 2016

68. • For this reason, the safest prosthodontic strategy against the possible onset
of TMD symptoms is not to plan occlusal modifications that jeopardize the
capacity for accommodation.
• Rehabilitations based on preconceived ideal occlusal schemes or interarch
relations are not advisable, as they fail to account for the muscle engrams
and the functional adaptation that the neuromuscular system of an
asymptomatic patient has developed naturally

69. • For decades centric relation has been a controversial and much debated concept.
• Its definition evolved from a mechanically determined to a physiologically
acceptable position
• This is also due to the absence of an ideal condylar position associated with a
healthy TMJ or jaw musclefunction.
• Based on the wide range of physiologically acceptable centric relation and OVD
values at the inter- and intraindividual level, the habitual position of the interarch
relationship should be used as a reference.
• Whenever possible, and prosthetic treatments required to change it should provide
the minimum shift from that position.

70. • As a general rule, changes must be carried out only for valid prosthetic
reasons and be performed over the longest possible period by testing
adaptation with interim restorations.

71. How should prosthodontics (for prosthetic
reasons)be performed in patients with tmds
and/or bruxism?

72. • The patients with ongoing TMDs, their symptoms should be treated before
starting any prosthetic treatment.
• The absolute contraindications-
 presence of TMJ and/or masticatory muscle pain
 Muscle soreness (temporalis / masseter)
 a limited range of joint movement
Daniele Manfredini, Carlo E. Poggio, Prosthodontic planning in patients with
temporomandibular disorders and/or bruxism: A systematic review Journal of Prosthetic
Dentistry 2016

73. • In addition, a certain freedom of movement is useful around the occlusal contact
areas in maximum intercuspation to create flatter cuspal planes to protect the
prosthesis during eccentric movements.
• As for the restorative material, research does not support any clinical evidence.
• The long-debated dispute on this topic ( high strength anatomic contour ceramics
versus potentially chippable ceramics versus in-mouth restorable composite
resins) has not yet been solved, and the choice of material for an extensive
rehabilitation
in patients with bruxism is often based on the clinician’s predilections and patient
expectations.
• In that respect, restorations with occlusal devices worn at night should be
protected.

74. Conclusion
• Bruxism is a common parafunctional habit, occurring both during sleep and
wakefulness.
• As the etiology is multifactorial, there is no known treatment to stop bruxism,
including prosthetic treatment.
• The management of bruxism should focus to prevent progression of dental wear,
reduce teeth grinding sounds, and improve muscle discomfort and mandibular
dysfunction in the most severe cases

75. References
• Daniele Manfredini, Carlo E. Poggio, Prosthodontic planning in patients with
temporomandibular disorders and/or bruxism: A systematic review Journal of
Prosthetic Dentistry 2016
• Ghanizadeh A,Zare S. A preliminary randomised double-blind placebo-controlled
clinical trial of hydroxyzinefor treating sleep bruxism in children. J Oral Rehabil.
2013;40(6):413–417.
• Bortoletto C, Cordeiro Da Silva F, Salgueiro Mda C,et al. Evaluation of
electromyographic signals in childrenwith bruxism before and after therapy with
Melissa officinalis L-a randomized controlled clinical trial.J Phys Ther Sci.
2016;28(3):738–742
• Treatments of sleep bruxism in children: A systematic review and meta-analysis
Gaetano Ierardo, Marta Mazur, Valeria Luzzi, Francesca Calcagnile, Livia Ottolenghi
& Antonella Polimeni Journal of Craniomandibular and sleep practice
• Baba K, Aridome K, Pallegama RW. Management of bruxism-induced complications
in removable partial denture wearers using specially designed dentures: A clinical
report. Cranio. 2008; 26:71-6.

76. • Misch CE. The effect of bruxism on treatment planning for dental implants. Dent
Today. 2002 Sep;21(9):76-81.
• Okeson JP. The effects of hard and soft occlusal splints on nocturnal bruxism. J Am
Dent Assoc. 1987; 114:788-791.
• Madani AS, Abdollahian E, Khiavi HA, Radvar M, Foroughipour M, Asadpour H et
al. The efficacy of gabapentin versus stabilization splint in management of sleep
bruxism. J Prosthodont. 2013; 22(2):126-31
• Svensson P. Effect of contingent electrical stimulation on jawmuscle activity during
sleep: a pilot study with a randomized controlled trial design. Acta Odontol Scand.
2013; 71(5):1050-62
• Conti PC, Stuginski-Barbosa J, Bonjardim LR, Soares S, Svensson P. Contingent
electrical stimulation inhibits jaw muscle activity during sleep but not pain
intensity or masticatory muscle pressure pain threshold in self-reported bruxers: a
pilot study. OralSurg Oral Med Oral A review of current concepts in bruxism-
diagnosis and management. Nitte university journal of health sciences. 2014, 4(4).

77. • Tan EK, Jankovic J. Treating severe bruxism with botulinum toxin. J Am Dent Assoc.
2000; 131:211-216
• Jong Sup Shim et al Effect of muscle activity and botulinum toxin dilution volume
on muscle paralysis Developmental Medicine & Child Neurology 2003, 45: 200–
206
• Lobbezoo F, van der Zaag J, van Selms MK, Hamburger HL,Naeije M. Principles for
the management of bruxism. J Oral Rehabil. 2008;35(7):509-523
• Lang R, White PJ, Machalicek W, et al. Treatment of bruxism in individuals
with developmental disabilities. Res Dev Disabil. 2009;30(5):809-818
• Reddy SV, Kumar MP, Sravanthi D, Mohsin AH, Anuhya V. Bruxism: a literature
review. J Int Oral Health. 2014; 6(6):105-9.