The Egyptian Journal of Hospital Medicine (Jan. 2017) Vol.

66, Page 261- 268

A Critical Review on the Relation and Impact of

Bruxism and Prosthetic Treatment
1
Haitham Ehab Y Jan, 1Hamza Abdulkareem Al Zahidy, 1Rahaf Essam O Yousef, 1Ranad
Abdulkareem K Alghamdi, 1Abrar Aqeel A Jefri , 1Lamis Khalid M Albakri , 1Wejdan Ibrahim
Alzahrani, 1Ghayda Saud S Mandili, 1Ameera Khalid M Alrasheed , 2Mohammed Khalid Y.
Alzamzami, 3Sawsan Badr Eshaq,
1
Ibn Sina National College, 2 King Fahad General Hospital, 3 battarjee college, Saudi Arabia

ABSTRACT
Background: Bruxism is defined as the medical term for clenching and grinding of teeth. It‟s one of
the most common parafunctional habit, occurring both during sleep “Eccentric Bruxism” and wakefulness
“Centric Bruxism”. Bruxism can result in tooth wear and damage, jaw disorders, headaches and dental
restoration damage.
Bruxism is usually a subconscious reflex that is often not recognized by the patient. As a consequence, one
of the most difficult aspects of this treatable problem is convincing the patient of this disorder. The early
diagnosis and management can prevent the breakdown of the dentition and pain in the orofacial region.
Although various treatment modalities are present, the successful management of bruxism lies in the
precise diagnosis and isolation of the etiology.
Aim of the Study: raw conclusions about the existence of a possible relationship between the two, and its
clinical relevance. Study selection: dental literature in bibliographic database like PubMed/Medline was
searched for the terms „bruxism‟ and „prosthetic treatment‟, relevant studies were critically reviewed were
conducted using, as well as combinations of these and related terms.
Results: there is no known treatment to stop bruxism, including prosthetic treatment. The role of bruxism
is considered as a major cause in the tooth wear process and as informed by the present critical review, the
relationship between bruxism and prosthetic treatment is one that relates mainly to the effect of the former
on the latter
Conclusion: Bruxism may be included among the risk factors, and is associated with increased mechanical
and/or technical complications in prosthodontic rehabilitation, although it seems not to affect implant
survival. When prosthetic intervention is indicated in a patient with bruxism, efforts should be made to
reduce the effects of likely heavy occlusal loading on all the components that contribute to prosthetic
structural integrity. Failure to do so may indicate earlier failure than is the norm.
Keywords: Bruxism, Sleep bruxism, Awake bruxism, Current concepts in bruxism, Review of bruxism.

INTRODUCTION
Bruxism, which can be considered an umbrella 'Sleep Bruxism' (SB). Awake bruxism is linked to
term for clenching and grinding of the teeth, is life
the commonest of the many parafunctional stress caused by familial responsibility or work
activities of the masticatory system. Opinions on pressure. Sleep Bruxism is an oromandibular
the cause of bruxism are numerous and widely behaviour that is defined as a stereotyped
varying. Current reviews indicate that the movement disorder occurring during sleep and
(3)
etiology is not fully known but that it is probably . characterized by tooth grinding and/or
multifactorial (1). clenching. Sleep bruxism was recently classified
Bruxism can occur during wakefulness or during as sleep related movement disorder according to
sleep. The American Academy of Sleeping recent classification of Sleep Disorders(3).
Disorders proposed the terms Sleep and Awake Prevalence rate of Awake and Sleep Bruxism is
Bruxism. Bruxism during daytime is commonly a about 20% and 8–16% respectively in adult
(4)
semi-voluntary 'clenching' activity and is also population . Awake bruxism occurs
known as 'Awake Bruxism' (AB) or Diurnal predominantly among females while no gender
Bruxism (DB) (2). Bruxism during sleep either difference is seen for sleep bruxism (5). Onset of
during daytime or during night is termed as Sleep Bruxism is about 1 year of age soon after
261
Received: 15 / 12 /2016 DOI : 10.12816/0034662
Accepted: 20 / 12 /2016
 A Critical Review on the Relation and Impact…

the eruption of 7 deciduous incisors. The disorder and felt more anxious than normal subjects (11).
appears more frequently in the younger Patients with both AB and SB, also showed
population (6). The prevalence in children is significant differences in anxiety, depression,
between 14 to 20%. hostility, phobic anxiety, and paranoid ideation
Meanwhile, suggested solution to manage when compared to non-bruxers(12).
bruxism can result in problems that are as
Tooth wear
frustrating for the patient as for the treating
Bruxism was for long considered a major cause
dentist. Sequelae of bruxism that have been
of tooth wear. A systematic review concluded
proposed include tooth wear, signs and symptoms
that “attrition seems to be co-existent with self-
of temporomandibular disorders (TMD),
reported bruxism” (13). Tooth attrition coupled
headaches, toothache, mobile teeth, and various
with Gum recession and abfraction is a common
problems with dental restorations as well as with
condition for profound Buxism (see figure 1 and
fixed and removable prostheses (7,8).
2 for illustration) – also , Wear facets (small
circular indentations mainly in the back teeth) can
MATERIALS AND METHODS
be as well noticed as a sign of Buxism on a
The study team searched Medline (via PubMed),
grinder ( Figure 3 ).
for the terms „bruxism‟ and „prosthetic
A recent review concluded that a number of
treatment‟. The results were filtered out to
published observations strengthen the concept of
include articles focusing on the relationship
the multifactorial etiology of tooth wear. The
between bruxism and prosthetic treatment,
review went on to state that it seemed fair to
implant-supported and implant-retained
conclude that the overall significance of bruxism
prostheses and including fixed and removable
as a causative factor for tooth wear is not fully
prostheses. A manual search of the reference lists
known, but it is even fairer to say that it is
and textbooks referred to in the included PubMed
probably overestimated (14).It follows that there
listed articles was also performed in parallel. This
are significant limitations with self-reports to
additional search identified 10 relevant studies
provide a reliable diagnosis of sleep bruxism.
and reviews. Some articles were excluded due to
Therefore, in much of the discussion that follows,
inability of retrieval , sharing the same cohort or
the use of the term bruxism implies an acceptance
aiming at irrelevant study endpoints.
of this limitation, and that what it refers to might
Finally , a total of 49 relevant papers remained,
equally be just heavy loading through high
and are discussed in the review that follows.
biting/chewing forces operating as a direct factor,
Etiology of Sleep Bruxism rather than it being categorically due to
The exact etiology of SB is still not known and parafunctional activity.
probably multifactorial in nature. Central issues Irrespective of the etiology, restoration of worn
can be categorized into pathophysiological and teeth that will frequently involve prosthetic
psychosocial factors such as stress , frustration , treatment will be needed in some patients.
poor social support , and personality issues as Because such treatment is typically complex and
well as pathophysiological factors including sleep often extensive, there is a tendency to defer
disturbance , use of certain medications or drugs , treatment until the tooth wear is well advanced.
smoking , allergies, genetic factors and nutrition This complicates treatment further, and with
deficiencies ( calcium, magnesium,) and other greater mechanical vulnerability to the restoration
medical conditions(9). provided. There is a scarcity of studies on the
The link between SB and psychosocial factors outcome of prosthetic restoration of worn
such as emotional stress was supported by the dentitions, leading to widely differing opinions
studies reporting elevated levels of urinary among prosthodontists in different countries
catecholamine in patients with SB (9). In addition, about how these complex treatment situations
SB activity had been related to higher levels of should be managed (14,15).
perceived psychological stress and salivary Effects of bruxism on the masticatory system
cortisol (10). A controlled laboratory study Since bruxism is considered a possible etiological
reported that SB patients were more competitive factor for TMD and tooth wear, its clinical

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 Haitham Jan et al

importance is obvious. Other effects of bruxism presents a significantly different environment,

may include tooth movement and tooth mobility, and this needs consideration. A natural tooth can
as well as changes in oral soft tissues and be intruded about 50 μm by a light force (20 N)
jawbone (16). compared to only 2 μm for an osseointegrated
implant (22).In an animal study, Miyata et al.
Treatment of bruxism
investigated the relationship between occlusal
The absence of a definitive treatment to
overload and peri-implant tissue and suggested
permanently eliminate bruxism has led tcc o the
that peri-implant bone resorption occurred under
`213422t xdevelopment of strategies to reduce its
occlusal overload (23).On the other hand, Heitz-
deleterious effects. The most common method
Mayfield et al. demonstrated that a period of 8
used to prevent the destructive effects of bruxism
months of excessive occlusal load on titanium
is through different types of interocclusal
implants did not result in loss of osseointegration
appliances (e.g. occlusal splints, nightguards,
or marginal bone loss when compared with
etc.). Recent reviews have concluded that
nonloaded implants in animal study (24).However,
interocclusal appliances are useful adjuncts in the
much of oral and masticatory function seems to
management of sleep bruxism but do not offer a
be similar in natural and implant-supported
definitive or “curative” treatment of bruxism, or
dentitions (25).The periodontal ligament is lost
the signs and symptoms of TMD (17).Similarly,
after tooth extraction, but most of its functional
their efficacy in reducing nocturnal muscle
role as related to occlusion and mastication seems
activity and craniofacial pain is unclear (18).
to be taken over by other mechanisms, such as,
Occlusal splints are commonly used to prevent
muscle spindles, mechanoreceptors in the
tooth wear caused by bruxism and/or heavy
temporomandibular joints (26).Since successful
loading. A survey among general dental
long-term results of implant prostheses have been
practitioners in Sweden showed that they
reported repeatedly, it may be concluded that the
considered the first indication for hard
variety of methods related to occlusal
interocclusal appliances was for protecting the
morphology used in fixed prosthodontics on
dentition from wear, followed by for managing
natural teeth are equally acceptable for
TMD problems (19).An earlier long-term study of
rehabilitation on dental implants. The simple
patients with extensive tooth wear provided with
principles described for conventional
stabilization splints showed that usage patterns by
prosthodontics may therefore be followed also for
patients varied widely . Only a few patients
implant prostheses (22).A literature review
continued to use the splints for the whole follow-
concluded that the occlusal scheme for an implant
up period and the mean period of usage was
prosthesis should be designed to decrease cuspal
approximately 2 years. In most patients, tooth
interferences, centralize forces along the long
wear progression rate over 6–10 years was slow
axis, and minimize lateral forces; that is, it should
and the amount was small. The role of the splints
be like that of a similar prosthesis on a natural
in the minimal continuing tooth wear observed
dentition (27).
was not conclusive: in general, the splints were
Since the occlusal perception level is higher for
used for less than a third of the follow-up period
implant prostheses than for natural teeth,
and, besides bruxism, several other possible
complaints of implant patients should be
causes of tooth wear were
carefully considered when checking their
evident (20).Nevertheless, in spite of the paucity of
occlusion. It is established that the lack of
strong evidence, a recent book on bruxism states
periodontal receptors leads to impaired fine
that there is “total consensus that bruxism splints
motor control of the mandible in implant patients
play a positive role in protecting dental hard (28)
.However, early studies concluded that the
tissues” (21).
functional clinical capacity of patients with
Effects of bruxism on prosthetic restorations on
implant prostheses was almost equal to or
natural teeth
approaching that of dentate subjects (29).A study
The attachment of natural teeth through
showing that the tactile sensibility of single-tooth
periodontal ligaments and osseointegrated
implants opposing natural teeth was similar to
implants with a rigid bone contact in the jaw
that of pairs of opposing natural teeth led to the

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 A Critical Review on the Relation and Impact…

conclusion that the implants can be integrated in Effects of bruxism on removable dentures
the stomatognathic control circuit (30). Due to lack of evidence , systematic studies on
Occlusal Material for the Suprastructure in the effects of bruxism on removable dentures are
Implant Prostheses not available in the literature.
Based on biomechanical analyses, acrylic resin
Complete dentures
denture teeth were therefore predominantly used
Textbooks on complete denture fabrication often
during the initial years of dental implant use
(31) mention that clinical experience indicates that
.However, biomechanical calculations do not
bruxism is a frequent cause of complaint of
always stand the test in the clinic. In a clinical
soreness of the denture-bearing mucosa. The
study on five subjects using fixed prostheses with
relationship between oral parafunctions and
either acrylic resin or porcelain occlusal surfaces,
residual ridge resorption has not been
masticatory forces were recorded while the
investigated, but it is tempting, even if
subjects chewed various foods. No differences
anecdotally, to include parafunctions as a
related to tooth material could be detected in the
possible factor related to the magnitude of ridge
load rates (32).In a study covering 6 years, the use
reduction (38) .
of porcelain instead of composite resin as
occlusal material had no influence on the Removable partial dentures
marginal bone height around the implants The question of restoring lost posterior support
(33)
.These findings can be interpreted as a support by means of mandibular distal extension
for the use of porcelain as occlusal material removable partial dentures (RPDs) in moderately
because no serious biological consequences of shortened dental arches remains controversial (39)
the hard material were reported. Furthermore, the .However, systematic reviews have concluded
most common complications of implant that shortened dental arches comprising anterior
prostheses have been related to fractures of the and premolar teeth generally fulfill the
acrylic resin of the prostheses (34) . Wear of requirements of a functional dentition without the
acrylic occlusal surfaces increased substantially need for prosthodontic extension, especially in
with time, according to a 15-year follow up of older patients (40) and (41) .In this regard, the
fixed implant-supported prostheses in the findings of a study of occlusal activity, including
edentulous maxilla (35) . bruxism, in subjects with moderately shortened
dental arches with or without mandibular distal
Effects of bruxism on implant restorations
extension removable partial dentures and subjects
Although there is no evidence regarding the
with complete dentitions which reported Similar
preferred restorative materials in implant
awareness of bruxism , Similar occlusal wear of
prosthesis for patients with bruxism, some
lower anterior teeth; in contrast, premolars had
clinicians prefer metal restorations and not
significantly more occlusal tooth wear , Similar
porcelain to protect the implant prostheses in
frequencies of signs and symptoms related to
patients with bruxism, especially for second
TMD (42) .
molar teeth in the maxilla. Evidently, more
clinical trials are needed to provide evidence for Night Guard and Pharmacological Approach
these recommendations. More recently, for Bruxism
framework or crowns in zirconia was also A night guard fabricated for the maxillary teeth
developed in this field. However, in a clinical can be a useful tool to evaluate the influence of
trial on fractured dental zirconia implants, the occlusion scheme and its relationship to
Gahlert et al. reported that “the patient with the nocturnal bruxism (43) .Occlusal schemes and
fracture of the 4 mm diameter zirconia implant designs of fixed and removable implant
was adversely affected by strong bruxism” (36) prostheses must satisfy the requirements for an
.Recently, some investigators demonstrated innocuous vertical loading of dental implants.
zirconia as a new dental implant material (37) .The Parafunctional habits (clenching or grinding) can
development of new dental implant material transmit forces to the supporting bone that may
might change the relationship between fractured result in destructive lateral stresses and
dental implants and bruxism. overloading. The consequences of nocturnal

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parafunctional habits may be prevented by acrylic finally resulted in a substantial and lasting
resin night guards (44) .A hard stabilization splint reduction in the bruxism outcome measures under
for nightly use (night guard) contributes to study(48).
optimally distributing and vertically redirecting The use of interocclusal appliances is the most
forces that go with nocturnal teeth grinding and common and accepted way to prevent wear of
clenching (45) .A night guard that promotes even teeth and prosthodontic restorations in spite of
occlusal contacts around the arch in centric- lack of strong evidence for its efficacy(49).
related occlusion can be helpful to prevent
fractures of implant prostheses. This device may CONCLUSION
be fabricated with 0.5- to 1-mm colored acrylic The etiology of bruxism is not well known, but it
resin on the occlusal surface. If the patient wears is agreed that it is multifactorial.
this device for 1 month, the consequences or There is no specific treatment available at this
intensity of the bruxism habit may be directly time to stop bruxism, so that the focus has been to
observed. If the colored acrylic is not worn reduce the adverse effects of the habit.
through, the parafunction was not excessive (46) feel that the overload caused by bruxism may
.
As examples, when partial implant prosthesis is result in failure of implant supported prostheses.
present in the maxilla, the night guard is Following the recent developments with the
hollowed out at the implant sites so no occlusal introduction of immediate or early loading, the
force is transmitted to the implant prostheses. clinical management of bruxism will become an
When the partial restoration is in the mandible, important subject for implant prostheses. The
the occluding surface of the guard is relieved lack of well-designed clinical trials regarding the
over the implant prostheses so no occlusal force consequence of bruxism on implant prostheses
is transmitted to the implants. A soft material poses a serious problem. At present, expert
may also be placed around the crowns for stress opinion and cautionary approaches are still
relief and to decrease the impact force on the considered the best available sources for
crowns. suggesting good practice indicators which urges
clinical research centers to dig deeper into the
DISCUSSION matter and provide a strong evidence on whether
Few relevant articles with the search terms used the subjective feeling of clinicians regarding the
were listed in PubMed since Research focusing approach of bruxism in implant patients is correct
on the relationship between bruxism and or not.
prosthetic therapy is scarce, and additional When prosthetic intervention is indicated in a
valuable texts were found by means of manual patient with bruxism, efforts should be made to
searching of the reference lists of articles found reduce the effects of heavy occlusal loading on
and in recent textbooks. all the components that contribute to prosthetic
There is not enough evidence that prosthetic structural integrity.
therapy, or any other available treatment, can
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862

Figure 1: shows a typical manifestation of teeth and gums which is catacterictic to Bruxism.

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 A Critical Review on the Relation and Impact…

Figure 2 : shows abfraction lesions driven by the abnormal load created by bruxing

Abfraction is a mechanical loss of tooth structure that is not caused by tooth decay, located along the gum
line.

Figure 3 : another sign of Bruxism is wear facets (small circular indentations mainly in the back teeth)

268