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Bruxism—a rationale of therapy
Bruxism — a rationale of therapy
Leon M . Gecker, D .D .S ., and Ralph B. W eil, D .D .S ., N ew York
Bruxism is a prevalent and pernicious habit
which
the
dentist
can
control.
Three control appliances are described which test the frequency, duration and severity of the bruxistic habit. These ap pliances do not eliminate the bruxistic habit; the patient must do so of his own volition. T h e y do, however, prevent breakage of teeth and act as shock ab sorbers.
During the past 20 years the prevalence of bruxism and its damaging effects on the periodontium, alveolar bone and teeth have become increasingly apparent. Brux ism is defined as “ the inaudible gnashing or audible grinding of teeth or cuspal interferences during unsuspected move ments of the mandible.” 1 This pernicious habit affects the dental mechanism in two basic ways. It causes abnormal attrition of the teeth, its most commonly recog nized symptom (Fig. 1 ), and it may cause periodontal difficulties with subsequent loosening and migration of teeth (Fig. 2 ) . Leof2 maintains that pressure habits are the initial or contributing cause of the majority of periodontal disturbances. In fact, many reconstructions and rehabilita tions are damaged by this excessive and abusive habit. Nadler3 classified the causes of bruxism in four groups:
1. Local causes: occlusal traumas, missing teeth, anatomical defects and oc clusal disharmonies. 2. Systemic causes: gastrointestinal disturbances, subclinical nutritional defi ciencies, endocrine imbalance and allergies. 3. Psychological emotional tensions.
causes:
release
of
4. Occupational causes: physical, such as the athlete’s clenching of teeth; mental, those engaged in painstaking work, for example, watchmakers and diemakers. T h e majority of workers in the field1,4-6 express the belief that emotional factors are the most significant etiologically. T h e treaments for bruxism are as var ied as its causes.
Fig. I • Bruxism causing severe a ttritio n o f tee th
GECKER—WEIL . . . VOLUME 66, JANUARY 1963 • 29/15
peutic treatments, but it is within the dentist’ s province to control these in stances. T h e fabrication of a bruxism ap pliance that is durable, easy to construct and repair, readily retained and accept able to the patient has been a perplexing problem. T h e apparatus should not, un wittingly, serve as an orthodontic mech anism. Anterior bite plates or posterior bite-blocks are unsatisfactory because they cause occlusal changes. T h e appliance should be made of a resilient, shock ab sorbent material. M etal or hard acrylic appliances either cause wearing of the opposing teeth (Fig. 3) or transmit the pressures of the habit to the periodon tium. This article will describe a method for the management of bruxism that tests its frequency, duration and severity, using Fig. 2 * Periodontal d iffic u ltie s w ith loosening and m ig ration o f te e th due to bruxism
1.
Local: occlusal equilibration, peri
odontal care, replacement of missing teeth, and possibly rehabilitation. 2. Systemic: nutritional care and elim ination of organic deficiencies. 3. Psychological: autosuggestion, psy chotherapy, and even psychoanalysis. T h e majority of instances of bruxism do not respond to the foregoing thera-
three control appliances. T h e appliances made of either latex or soft, self-curing acrylic resin absorb the tension and grinding stress of bruxism without affecting the underlying teeth and reconstructions. They require remak ing or “ resoling” at intervals, depending on the nature and degree of abuse. Some times this “ resoling” or recovering is done at six month intervals. Some patients need the appliances repaired more often; others, only after several years. It is a personal situation involving the patient and the degree of control he may or may
Fig. 3 • L e ft: Im p ro p e r use o f m etal b ite -b lo c k constructed to p revent a ttritio n o f a n te rio r te e th . R ight: M e ta l caused w ear o f te e th opposing b ite -block. The a p pliance appears beneath models
30/16 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
Fig. 4 • Latex a p pliance on stone model covering all tee th on occlusal, labial, buccal and lingual surfaces to I o r 2 mm. past necklines o f all teeth
Fig. 5 • Latex appliance worn on low er tee th. Lower lip re tra cte d to show pe riphe ral lim it o f appliance
not exert in checking this habit. T h e appliances do not help to elimi nate the bruxistic habit unless the patient does so of his own volition. They do, however, prevent a great deal of trouble and breakage and serve as shock absorb ers, much as helmets do for football play ers. T h e prescription of these control devices constitutes a major health service to those patients who need them.
buccal and lingual surfaces (Fig. 4 ) .
A P P L IA N C E N O . 1
T h e latex appliance is the first appliance used to test the severity, frequency and duration of the bruxistic habit. W hen it is worn during waking hours, the sound of chewing on many rubber bands is evi dent to the patient when he grinds his teeth against this rubber dental glove. Th e appliance covers the entire denti tion within the freeway space so that all opposing cusps meet without interceptive contact. This appliance is made by building a latex glove on the occlusal surfaces of the teeth, preferably those of the lower jaw, after a model had been prepared from a well-balanced occlusion. T h e latex is gradually built up to fill the interdental freeway space. T h e periphery extends to a line 1 or 2 mm . past the necklines of all the teeth covering them on their labial,
This rubber appliance is practically in visible when constructed for the lower jaw. It can be worn at any time during the day or night, except when eating. The patient can speak, sing and perform the necessary chores of a day’ s work while wearing it (Fig. 5 ) . T h e only objections to the appliance arise when the amount of material is excessive or when the occlusion has not been properly built to meet all the cuspal contacts of the opposing teeth. Th e care of the appliance consists of washing it with soap and water, and oc casionally dabbing the internal contacting surfaces with a swab immersed in milk of magnesia. T h e appliance is placed on the teeth after they have been cleaned thoroughly so that no carious lesions can develop. I f this appliance is worn through or torn excessively in too short a time, the patient knows that he grinds or clenches his teeth inordinately, and he is ready for the next appliance, the soft acrylic night splint. A P P L IA N C E
n o
. 2
T h e night splint is constructed on a model using Mortite (Fig. 6) as a peripheral boxing material to outline the gingival extent of the appliance. T h e soft, self curing acrylic resin is placed over the
GECKER—WEIL . . . VOLUME 66, JANUARY 1963 • 31/17
i » O i X > V l OH
M any patients who wore the night splint found that they were more relaxed when they went to sleep knowing that during the night no damage would occur, as had been occurring before wearing the appliance. In our experience, no objec tion has ever been raised to wearing this soft acrylic appliance no. 2. It usually is the only one necessary to control the bruxistic habit (Fig. 8 ) . A P P L IA N C E N O .
Fig. 6 * C o nstruction o f s o ft a crylic appliance. M o rtite is em ployed as pe riphe ral boxing m aterial
teeth to a predetermined thickness and tried in the patient’s mouth at the next visit (Fig. 7 ) . T h e acrylic resin is ground so that the opposing teeth meet the oc clusal surface of the appliance with an even distribution of pressure. It should be built up until it is comfortable to wear and polished to a smooth surface. This can be accomplished at the chair or in the laboratory.
Fig. 7 • S elf-cu ring s o ft a c ry lic appliance being constructed on stone m odel. A c ry lic resin is placed over tee th to predeterm in ed thickness
3
Some patients not only clench their teeth but grind them excessively. For these pa tients a thin layer of hard, self-curing acrylic resin is superimposed on the entire occlusal surface of the soft acrylic appli ance. This modification of appliance no. 2 to appliance no. 3 is accomplished at the chair. After the patient has occluded into this acrylic resin with the teeth in centric relation and the resin has hard ened, the appliance and excessive portions of the hard acrylic resin are removed, leaving slight indentations of the oppos ing cusps on the occlusal aspect of the appliance (Fig. 9 ) . These indentations prevent the jaws from sliding or grinding against each other. W hen wearing this appliance, the patient must relax and slightly unlock his jaws before he can achieve a grinding movement. Therefore,
Fig. 8 • up per jaw A p p lia n c e
Bruxism ap pliance no. 2 in m outh on a fte r occlusion has been e q u ilib ra te d , trim m e d and polished to smooth surface
32/18 • THE JOURNAL,OF THE AMERICAN DENTAL ASSOCIATION
2. A rationale of control has been pre sented. 3. The fabrication and use of three appliances for bruxists have been de scribed. 4. T h e control of bruxism is the den tist’s responsibility. 3 0 5 W est Seventy-second Street
Fig. 9 • Bruxism ap pliance no. 3 dem onstrating s lig h t in d e n ta tio n o f opposing cusps made in thin veneer o f hard a crylic resin placed over acrylic bruxism a p pliance no. 2
the appliance prevents him from grinding his teeth unconsciously and converts the impulse to grind into a simple clench. Appliances no. 2 and no. 3 should be immersed in hot water for several min utes before use to make them pliable and easy to insert. They are designed for night use only. These appliances should be used after reconstruction or rehabilitation, especially if the patients are bruxists or have severe attrition of the teeth. SUMMARY
1. Bruxism is a prevalent and perni cious habit.
1. Bell, D. G. Bruxism. J. Periodont. 18:46 Jan. 1947. 2. Leof, M ilton. Chom ping and grinding habits; their relation to periodontal disease. J.A .D .A. 31:184 Feb. 1944. 3. Nadler, S. C. Bruxism, a classification: c ritical re view. J.A .D .A . 54:615 May 1957. 4. Moore, D. S. Bruxism, diagnosis and treatm ent. J. Periodont. 27:277 O ct. 1956. 5. Summer, C. F. Bruxism; detection and treatm ent. J.D .M ed. 4:58 July 1949. 6. Boyens, P. J. Value o f autosuggestion in the th e r apy o f bruxism and other b itin g habits. J.A .D .A . 27:1773 Nov. 1940. 7. Bober, Heinz. Cause and treatm ent o f bruxism and bruxomania. D.Abs. 3:658 Nov. 1958. 8. Chasins, A . I. Methocarbamal as an adjunct in the treatm ent o f bruxism. J.D .M ed. 14:166 July 1959. 9. Grupe, H. E., and Gromek, J. J. Bruxism splint technique using quick cure acrylic. J. Periodont. 30:156 A p ril 1959. 10. H irt, H. A ., and Muhlemann, H. R. Diagnosis o f bruxism by measurement o f the tooth m obility. D.Abs. 1:356 June 1956. 11. Ingersoll, W . B., and Kerens, E. G. Treatment fo r excessive occlusal traum a or bruxism. J.A .D .A . 44:22 Jan. 1952. 12. M ille r, S. C. Textbook o f periodontia. Philadel phia, P. Blakiston's Son & Co., Inc. 1938, p. 77, 312, 510. 13. Muhlemann, H. R.; H irt, H., and Herzog, H. Tooth m obility, bruxism and selective grinding. D.Abs. 1:544 Sept. 1956. 14. Stahl, D. G. Sim plified _procedure fo r fa bricating a tem porary removable acrylic bite plate. J.Periodont. 27:118 A p ril 1956. 15. Tishler, B. Occlusal habit neuroses. D. Cosmos 70:690 July 1928. _ 16. Wilson, W . E. Common perversions of the func tion of facial muscles, with practical methods of their correction. D. Cosmos 69:351 A p ril 1927.
Leon M . Gecker, D .D .S ., and Ralph B. W eil, D .D .S ., N ew York
Bruxism is a prevalent and pernicious habit
which
the
dentist
can
control.
Three control appliances are described which test the frequency, duration and severity of the bruxistic habit. These ap pliances do not eliminate the bruxistic habit; the patient must do so of his own volition. T h e y do, however, prevent breakage of teeth and act as shock ab sorbers.
During the past 20 years the prevalence of bruxism and its damaging effects on the periodontium, alveolar bone and teeth have become increasingly apparent. Brux ism is defined as “ the inaudible gnashing or audible grinding of teeth or cuspal interferences during unsuspected move ments of the mandible.” 1 This pernicious habit affects the dental mechanism in two basic ways. It causes abnormal attrition of the teeth, its most commonly recog nized symptom (Fig. 1 ), and it may cause periodontal difficulties with subsequent loosening and migration of teeth (Fig. 2 ) . Leof2 maintains that pressure habits are the initial or contributing cause of the majority of periodontal disturbances. In fact, many reconstructions and rehabilita tions are damaged by this excessive and abusive habit. Nadler3 classified the causes of bruxism in four groups:
1. Local causes: occlusal traumas, missing teeth, anatomical defects and oc clusal disharmonies. 2. Systemic causes: gastrointestinal disturbances, subclinical nutritional defi ciencies, endocrine imbalance and allergies. 3. Psychological emotional tensions.
causes:
release
of
4. Occupational causes: physical, such as the athlete’s clenching of teeth; mental, those engaged in painstaking work, for example, watchmakers and diemakers. T h e majority of workers in the field1,4-6 express the belief that emotional factors are the most significant etiologically. T h e treaments for bruxism are as var ied as its causes.
Fig. I • Bruxism causing severe a ttritio n o f tee th
GECKER—WEIL . . . VOLUME 66, JANUARY 1963 • 29/15
peutic treatments, but it is within the dentist’ s province to control these in stances. T h e fabrication of a bruxism ap pliance that is durable, easy to construct and repair, readily retained and accept able to the patient has been a perplexing problem. T h e apparatus should not, un wittingly, serve as an orthodontic mech anism. Anterior bite plates or posterior bite-blocks are unsatisfactory because they cause occlusal changes. T h e appliance should be made of a resilient, shock ab sorbent material. M etal or hard acrylic appliances either cause wearing of the opposing teeth (Fig. 3) or transmit the pressures of the habit to the periodon tium. This article will describe a method for the management of bruxism that tests its frequency, duration and severity, using Fig. 2 * Periodontal d iffic u ltie s w ith loosening and m ig ration o f te e th due to bruxism
1.
Local: occlusal equilibration, peri
odontal care, replacement of missing teeth, and possibly rehabilitation. 2. Systemic: nutritional care and elim ination of organic deficiencies. 3. Psychological: autosuggestion, psy chotherapy, and even psychoanalysis. T h e majority of instances of bruxism do not respond to the foregoing thera-
three control appliances. T h e appliances made of either latex or soft, self-curing acrylic resin absorb the tension and grinding stress of bruxism without affecting the underlying teeth and reconstructions. They require remak ing or “ resoling” at intervals, depending on the nature and degree of abuse. Some times this “ resoling” or recovering is done at six month intervals. Some patients need the appliances repaired more often; others, only after several years. It is a personal situation involving the patient and the degree of control he may or may
Fig. 3 • L e ft: Im p ro p e r use o f m etal b ite -b lo c k constructed to p revent a ttritio n o f a n te rio r te e th . R ight: M e ta l caused w ear o f te e th opposing b ite -block. The a p pliance appears beneath models
30/16 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
Fig. 4 • Latex a p pliance on stone model covering all tee th on occlusal, labial, buccal and lingual surfaces to I o r 2 mm. past necklines o f all teeth
Fig. 5 • Latex appliance worn on low er tee th. Lower lip re tra cte d to show pe riphe ral lim it o f appliance
not exert in checking this habit. T h e appliances do not help to elimi nate the bruxistic habit unless the patient does so of his own volition. They do, however, prevent a great deal of trouble and breakage and serve as shock absorb ers, much as helmets do for football play ers. T h e prescription of these control devices constitutes a major health service to those patients who need them.
buccal and lingual surfaces (Fig. 4 ) .
A P P L IA N C E N O . 1
T h e latex appliance is the first appliance used to test the severity, frequency and duration of the bruxistic habit. W hen it is worn during waking hours, the sound of chewing on many rubber bands is evi dent to the patient when he grinds his teeth against this rubber dental glove. Th e appliance covers the entire denti tion within the freeway space so that all opposing cusps meet without interceptive contact. This appliance is made by building a latex glove on the occlusal surfaces of the teeth, preferably those of the lower jaw, after a model had been prepared from a well-balanced occlusion. T h e latex is gradually built up to fill the interdental freeway space. T h e periphery extends to a line 1 or 2 mm . past the necklines of all the teeth covering them on their labial,
This rubber appliance is practically in visible when constructed for the lower jaw. It can be worn at any time during the day or night, except when eating. The patient can speak, sing and perform the necessary chores of a day’ s work while wearing it (Fig. 5 ) . T h e only objections to the appliance arise when the amount of material is excessive or when the occlusion has not been properly built to meet all the cuspal contacts of the opposing teeth. Th e care of the appliance consists of washing it with soap and water, and oc casionally dabbing the internal contacting surfaces with a swab immersed in milk of magnesia. T h e appliance is placed on the teeth after they have been cleaned thoroughly so that no carious lesions can develop. I f this appliance is worn through or torn excessively in too short a time, the patient knows that he grinds or clenches his teeth inordinately, and he is ready for the next appliance, the soft acrylic night splint. A P P L IA N C E
n o
. 2
T h e night splint is constructed on a model using Mortite (Fig. 6) as a peripheral boxing material to outline the gingival extent of the appliance. T h e soft, self curing acrylic resin is placed over the
GECKER—WEIL . . . VOLUME 66, JANUARY 1963 • 31/17
i » O i X > V l OH
M any patients who wore the night splint found that they were more relaxed when they went to sleep knowing that during the night no damage would occur, as had been occurring before wearing the appliance. In our experience, no objec tion has ever been raised to wearing this soft acrylic appliance no. 2. It usually is the only one necessary to control the bruxistic habit (Fig. 8 ) . A P P L IA N C E N O .
Fig. 6 * C o nstruction o f s o ft a crylic appliance. M o rtite is em ployed as pe riphe ral boxing m aterial
teeth to a predetermined thickness and tried in the patient’s mouth at the next visit (Fig. 7 ) . T h e acrylic resin is ground so that the opposing teeth meet the oc clusal surface of the appliance with an even distribution of pressure. It should be built up until it is comfortable to wear and polished to a smooth surface. This can be accomplished at the chair or in the laboratory.
Fig. 7 • S elf-cu ring s o ft a c ry lic appliance being constructed on stone m odel. A c ry lic resin is placed over tee th to predeterm in ed thickness
3
Some patients not only clench their teeth but grind them excessively. For these pa tients a thin layer of hard, self-curing acrylic resin is superimposed on the entire occlusal surface of the soft acrylic appli ance. This modification of appliance no. 2 to appliance no. 3 is accomplished at the chair. After the patient has occluded into this acrylic resin with the teeth in centric relation and the resin has hard ened, the appliance and excessive portions of the hard acrylic resin are removed, leaving slight indentations of the oppos ing cusps on the occlusal aspect of the appliance (Fig. 9 ) . These indentations prevent the jaws from sliding or grinding against each other. W hen wearing this appliance, the patient must relax and slightly unlock his jaws before he can achieve a grinding movement. Therefore,
Fig. 8 • up per jaw A p p lia n c e
Bruxism ap pliance no. 2 in m outh on a fte r occlusion has been e q u ilib ra te d , trim m e d and polished to smooth surface
32/18 • THE JOURNAL,OF THE AMERICAN DENTAL ASSOCIATION
2. A rationale of control has been pre sented. 3. The fabrication and use of three appliances for bruxists have been de scribed. 4. T h e control of bruxism is the den tist’s responsibility. 3 0 5 W est Seventy-second Street
Fig. 9 • Bruxism ap pliance no. 3 dem onstrating s lig h t in d e n ta tio n o f opposing cusps made in thin veneer o f hard a crylic resin placed over acrylic bruxism a p pliance no. 2
the appliance prevents him from grinding his teeth unconsciously and converts the impulse to grind into a simple clench. Appliances no. 2 and no. 3 should be immersed in hot water for several min utes before use to make them pliable and easy to insert. They are designed for night use only. These appliances should be used after reconstruction or rehabilitation, especially if the patients are bruxists or have severe attrition of the teeth. SUMMARY
1. Bruxism is a prevalent and perni cious habit.
1. Bell, D. G. Bruxism. J. Periodont. 18:46 Jan. 1947. 2. Leof, M ilton. Chom ping and grinding habits; their relation to periodontal disease. J.A .D .A. 31:184 Feb. 1944. 3. Nadler, S. C. Bruxism, a classification: c ritical re view. J.A .D .A . 54:615 May 1957. 4. Moore, D. S. Bruxism, diagnosis and treatm ent. J. Periodont. 27:277 O ct. 1956. 5. Summer, C. F. Bruxism; detection and treatm ent. J.D .M ed. 4:58 July 1949. 6. Boyens, P. J. Value o f autosuggestion in the th e r apy o f bruxism and other b itin g habits. J.A .D .A . 27:1773 Nov. 1940. 7. Bober, Heinz. Cause and treatm ent o f bruxism and bruxomania. D.Abs. 3:658 Nov. 1958. 8. Chasins, A . I. Methocarbamal as an adjunct in the treatm ent o f bruxism. J.D .M ed. 14:166 July 1959. 9. Grupe, H. E., and Gromek, J. J. Bruxism splint technique using quick cure acrylic. J. Periodont. 30:156 A p ril 1959. 10. H irt, H. A ., and Muhlemann, H. R. Diagnosis o f bruxism by measurement o f the tooth m obility. D.Abs. 1:356 June 1956. 11. Ingersoll, W . B., and Kerens, E. G. Treatment fo r excessive occlusal traum a or bruxism. J.A .D .A . 44:22 Jan. 1952. 12. M ille r, S. C. Textbook o f periodontia. Philadel phia, P. Blakiston's Son & Co., Inc. 1938, p. 77, 312, 510. 13. Muhlemann, H. R.; H irt, H., and Herzog, H. Tooth m obility, bruxism and selective grinding. D.Abs. 1:544 Sept. 1956. 14. Stahl, D. G. Sim plified _procedure fo r fa bricating a tem porary removable acrylic bite plate. J.Periodont. 27:118 A p ril 1956. 15. Tishler, B. Occlusal habit neuroses. D. Cosmos 70:690 July 1928. _ 16. Wilson, W . E. Common perversions of the func tion of facial muscles, with practical methods of their correction. D. Cosmos 69:351 A p ril 1927.