_ j m a _

ARTICLES

Occlusal splints are com m only used for the treatment o f nocturnal bruxism. This study
investigated the effects o f hard and soft occlusal splints on nighttim e muscle activity. The
nocturnal muscle activity o f ten participants was recorded while wearing a hard and then a
soft occlusal splint. The hard occlusal splint significantly reduced muscle activity in eight o f
the ten participants. The soft occlusal splint significantly reduced muscle activity in only
one participant w hile causing a statistically significant increase in muscle activity in five of
the ten participants.

The effects of hard and soft occlusal splints

on nocturnal bruxism

Jeffrey P. O keson, D M D

t is widely accepted that nocturnal had total remission of symptoms, two in T his study compares the effects of wear­

I b ru x ism is often a c o n trib u tin g

causal factor in many temporoman­
dibular disorders .1-6 C ontrolling bruxism,
this group had partial relief, and two were
unchanged. In the group that received the
soft occlusal splint, one had total remission
ing a hard versus a soft occlusal splint on
nocturnal bruxism in the same person and
possibly provides insight on proper splint
therefore, becomes an im portant aspect in of symptoms, six reported additional sore­ selection for the treatment of bruxism or
the treatm ent of such disorders. The use of ness in the m orning, although two of these bruxism-related disorders.
occlusal splints in reducing bruxism has also reported some remission. The rem ain­
been advocated for some time. Only more ing two participants in this group reported Methods and materials
recently, however, have instruments been no change. From these results, Nevarro and
developed to record and document the co-workers concluded that the hard occlu­ T en h ealthy subjects were selected for this study,
five females a n d five m ales. T h e ir ages ranged
effects of occlusal splints on bruxism .7’8 sal splint is more effective in reducing
from 23 to 37 years w ith a m ean age of 27.4 years.
The type of occlusal splint that has received symptoms of m andibular dysfunction. In
All p articip an ts adm itted to som e bruxism , but
the most attention in research studies is the another study, Singh and Berry 16evaluated none was ex p eriencing any m uscle or jo in t
hard acrylic centric relation appliance fab­ the changes in occlusal contacts after wear­ sym ptom s at the tim e of the study. All p a rtici­
ricated for the maxillary arch. Most studies ing a soft appliance, but no attempt was p an ts had a full com plem ent of n a tu ra l teeth
suggest that this appliance significantly made to evaluate symptoms or the appli­ w ith the exception of th ird molars.
reduces nocturnal bruxism .8' 10 ance’s effect on nocturnal bruxism. T h e study was designed to observe the effects
A few citations in the literature suggest
indications for using soft resilient ap p li­
ances . 11"14 A lthough resilient occlusal
splints have gained some popularity, no
studies have evaluated the effect of these
appliances on nocturnal bruxism. Nevarro
and others 15 evaluated the clinical effects of
hard and soft occlusal splints on the symp­
toms of m andibular dysfunction. Twenty
participants aged 20 to 25 years had m an­
dibular dysfunction. Ten were randomly
selected to receive a hard maxillary occlusal
splint and the other ten received a soft max­
illary occlusal splint. After 6 weeks, six of Fig 1 ■ T w o different views of the same hard occlusal sp lin t.
the ten participants with the hard splint

788 ■ JADA, Vol. If4 , June 1987


of tw o different types of occlusal splints on noc­
tu rn al bruxism . T h e first sp lin t was a hard
acrylic occlusal sp lin t fabricated for the m ax il­
lary arch (F ig 1). T h is sp lin t covered all the
m axillary teeth. T h e condyles were located in an
a nterosuperior position by use of a n anterior
stop on the in itial structure of the a p p lian ce.17
O nce the m usculoskeletally stable position was
achieved, the sp lin t was finalized by providing
even and sim ultaneous contacts for all m an d ib u ­
lar buccal cusps and incisal edges on flat su r­
F ig 2 ■ T w o different views o f the sam e soft occlusal sp lin t.
faces. D u rin g eccentric m ovem ents the m an d ib ­
u lar canines discluded all posterior teeth.
T h e soft occlusal sp lin t was fabricated from
4-m m thick soft vinyl sheets adapted to a m axil­
lary cast w ith a vacuum adapter. T h e soft
ap p lian ce was cut from the cast w ith a labora­
tory knife, the edges sm oothed, and the appliance
placed in the m outh. T h e p a la tal area was
removed so th at it duplicated the same tissue
coverage as the h ard appliance. T h e soft occlusal
sp lin t was adjusted intraorally u n til the p atien t
reported that d u rin g light closure a ll m an d ib u ­
lar teeth contacted the splint evenly. N o attem pt
was m ade to control eccentric contacts as this
was nearly im possible (Fig 2).
All 20 occlusal sp lin ts were fabricated by the
same operato r in an attem pt to control variation
of ap p lian ce construction and adjustm ent. T he
goal of the ap p lian ce therapy was n o t to greatly
increase the vertical dim ension of occlusion.
T h e hard appliance altered the vertical d im en ­
sion a pproxim ately 4 m m in the incisal area.
T h e soft appliance was adjusted to a p p ro x i­
m ately the same vertical dim ension of the hard
sp lin t so that vertical d im ension w ould not be a
factor in the study.
T h e design of this study was A-B-A-C-A
in tra p articip a n t design. Period A represents con­
trol periods w hen n o ctu rn al bruxism was m o n i­
tored w ith o u t influence of any treatm ent. Period
B represents th at period w hen the h ard occlusal
sp lin t was w orn by the p a rticip a n t and period C
represents th at period w hen the soft occlusal
sp lin t was w orn. Each control p eriod was m ade
u p of 5 consecutive n ig h ts a n d each treatm ent
period (B and C) was 7 consecutive nights.
Each n ig h t of the study, nocturnal bruxism
was recorded w ith an AL-200B m uscle activity
integ rato r7 using a technique described in detail
by R u g h .18’19 T h is technique uses surface elec­
trodes placed over a single m asseter m uscle and
EM G activity above 20 mV (route m ean square)
was integrated d u rin g the nig h t, p ro v id in g a
num erical value that is a function of the d u ra ­
tio n a n d am p litu d e of the m yoelectric activity.
T h is m easurem ent provides an index of both
clenching and g rin d in g behavior a n d is sensitive
to treatm ent effects and correlated w ith sym p­
tom s of dysfunction.8'1920 Each p a tie n t was
instructed about placem ent of electrodes and
general use of the instrum ent. Each m o rn in g the
m illivolts of activity produced by the m asseter
d u rin g the previous night were recorded along
w ith the n um ber of hours to the nearest 15 m in ­
utes the p a tie n t slept. T h e total m illivolts of
activity per n ig h t was divided by the n u m b er of
ho u rs slept to acquire the average m illiv o lt of
activity per hour, per night.
P articipants were asked to record any changes
in reg u lar daily ro u tin e or level of em otional
stress in an attem pt to identify o ther factors that
m ig h t have influenced the level of bruxism other
th an the occlusal splint. P articipants were also
asked to record any m asticatory sym ptom s of
p a in or tenderness.
Each p a rticip a n t was instructed to w ear the
in stru m e n t for 3 to 5 consecutive nights before
the study began. T h is time was provided so p a r­
ticip an ts could becom e accom m odated to the
presence of the instrum ent. After this trial period,
5 consecutive nights w ith no occlusal sp lin t were
recorded. If the results of these 5 nig h ts were
relatively constant in m illivolt activity per hour,
these recordings were used for the first control
period (A). If consistency was n o t achieved, m ore
recordings were m ade until a relatively consis­
tent baseline level was achieved. After 5 nights
were recorded, the h ard occlusal sp lin t was
inserted. T h is ap p lian ce was w orn for the next 7
n ig h ts a n d the m illiv o lt activity recorded. After 7
nights, the hard occlusal sp lin t was discon­
tinued and no appliance was used for the next
Table 1 ■ A comparison of the total data for all ten participants. (The mean trans­
formed log values are presented for each control period as well as for the periods when
the hard and soft appliances were worn.)
C o n tro l 1 H ard C ontrol 2
7.261 6.5261*
*i = Significant decrease, P > .001.
f t = Significant increase, P > .01.
Okeson : EFFECTS OF SPLINTS O N BRUXISM ■ 789
ARTICLES
five nights. After the baseline was reestablished
(5 days), the soft occlusal sp lin t was w orn for the
next 7 consecutive nights. After these 7 nights,
the soft ap p lian ce was disco n tin u ed and again
no appliance was w orn for the next 5 nights.
Results
A one-w ay analysis of variance w ith repeated
m easures was com puted. L og transform ations
were m ade to satisfy the assu m p tio n of h om oge­
neity of variance. T ab le 1 com pares the m ean
transform ed log value totals for a ll p a rtic ip a n ts
in the study. T h e analysis revealed th a t the m ean
activity for the tim e the h ard occlusal sp lin t was
w orn was significantly low er th an each of the
three control periods (F = 33.86, d f = 1.36; P <
.001). T h e m ean activity for the tim e the soft
occlusal sp lin t was w orn was significantly h igher
th an each of the three control p eriods (F = 11.42,
d f = 1.36; P < .01). T h ere was n o statistically
sig n ifican t difference betw een any of the control
periods.
T ab le 2 com pares the m ean transform ed log
values for each p a rtic ip a n t for b oth the h a rd and
soft occlusal sp lin ts as well as for the control
periods. T h e control period in T ab le 2 repre­
sents the m ean transform ed totals for all three
control periods. W hen com pared w ith the c o n ­
trol period, eight of the ten p a rticip a n ts had
significant decrease in m uscle activity w hile
w earing the h ard occlusal splint. T w o p a rtic i­
pants had no significant change. W hen the soft
occlusal sp lin t was w orn, five of the ten subjects
show ed significant increases in m uscle activity
b u t only one show ed significant decrease. F our
patients show ed no significant change in m uscle
activity from the control period w ith the soft
occlusal splint.
T o further analyze the data, the percent change
of arith m etic m ean m illiv o lt activity was com ­
p u ted for each person (T able 3). It is d ifficult to
predict w hat percentage of change could m ake a
significant difference in sym ptom s for each
patient. T h is is likely to be an individual factor.
How ever, if a 25% increase or decrease in activity
is assum ed significant, th en the follow ing c o n ­
c lusions can be m ade: e ig h t of ten p a rticip a n ts
had a 25% o r greater decrease in n o c tu rn a l m u s­
cle activity w ith a h a rd occlusal appliance. No
p a rticip a n ts had a 25% o r greater increase w ith
the hard appliance. Seven of the ten p articip an ts
had a 25% or greater increase in n o c tu rn a l m u s­
cle activity w ith the soft occlusal splint. O nly
one person had a 25% o r greater decrease in m u s­
cle activity w ith the soft appliance.
Soft C on tro l S
7.296 7.640Î f 7.135
ARTICLES

Table 2 ■ A comparison of data for each participant. (Mean transformed log values are presented with standard deviations and
T values.) ________________________________________________________________________________________________________
C ontrol
P atients (n o treatm ent) H ard sp lin t Soft sp lin t
and
gender M ean SD Mean SD T value Mean SD T value

1F 7.286 .3129 6.293 .4727 5.8971* 7.437 .3329 -1 .0 2

2M 7.055 .2430 5.785 .4691 8.4681* 7.094 .8160 -.1 7 2 0
3M 8.140 .2309 7.692 .3049 3.4811* 8.360 .2192 -1 .8 6 9
4F 5.910 .3139 5.926 .4288 -.1 1 1 6.457 .2315 —4.107Î+
5M 6.393 .2437 6.638 .3794 -1 .8 3 8 6.978 .2190 —5.4041+
6M 5.548 .3420 4.364 .6762 5.5281* 5.747 .3865 -1 .2 2 3
7F 7.032 .1985 5.152 .1410 22.4151* 6.655 .4342 2.8351*
8F 7.331 .1565 6.712 .0856 9.7291* 7.852 .1767 —6.9841+
9F 8.006 .256 7.708 .2949 2.4291* 9.215 .8023 -5.4011+
10 M 9.301 .1857 8.301 .4213 7.8521* 9.672 .0454 -5.1471+

*1 = Significant decrease, P > .05.

f t = Significant increase, P > .05.

Clinical symptoms adm itted to some level of bruxism . T h e results, showed an increase in nocturnal muscle
however, disclosed a great variation in the q u a n ­ activity when wearing the soft appliance.
T h e ten particip an ts selected for this study tity of b ru x in g activity per night. T hree p a rtici­ Therefore, it may be concluded that in
reported n o subjective m uscle or jo in t sym ptom s p ants had low levels of bruxism . T h is supports patients who have symptoms associated
w hen the study began. N one reported any sym p­ the assu m p tio n th a t patients are n o t aware of
with increased nocturnal muscle activity, a
toms associated w ith w earing the hard appliance, their n octurnal bruxism activity and often in ac ­
soft occlusal splint is likely to be contrain­
n o r d u rin g any control periods. However, w hile curately report this activity. Even w ith the low
activity, two of the three p articip an ts reported a
dicated. A hard occlusal splint appears a
w earing the soft appliance four p articip an ts had
m u sc le /jo in t p a in a n d two others had m uscle change in sym ptom s w hile w earing the soft more likely successful treatment. T his study
“ tiredness. ” O f the six p articip an ts w ho reported appliance. did not attem pt to evaluate the indications
a change in sym ptom s, five of the six had a t least of soft appliances for other uses in dentistry
a 25% increase in m uscle activity (p a rticip a n t no. unrelated to nocturnal muscle activity.
1 had only a 17% increase). All of these sym ptom s Discussion
were reported subjectively by the participants. Summary
M uscle a n d jo in t e xam inations were not per­ T he results of this study suggest that hard
formed. acrylic maxillary splints significantly re­ Eight of ten participants showed a statisti­
In all of the analyses, there did not a p p ea r to duce nocturnal muscle activity in the cally significant decrease in nocturnal mus­
be any significant difference in the change of cle activity when wearing a hard occlusal
majority of patients. These results are in
n o c tu rn a l m uscle activity or sym ptom s betw een
accord with similar studies .8' 10 T his is splint. Two patients showed no significant
m ales a n d females. D u rin g the study, no p a rtic i­
p a n t reported any m ajor change in life events or
seemingly the first study that has attempted change. Five of ten participants showed a
em o tio n al stress. T h ere did n o t appear to be any to evaluate the effects of soft occlusal splints statistically significant increase in noctur­
u n u su a l changes in m uscle activity th at could be on nocturnal bruxism, and the results sug­ nal muscle activity when wearing a soft
e x p la in ed by an increase or decrease in the levels gest that a soft occlusal splint will not sig­ occlusal splint. One patient showed signif­
of em o tio n al stress. nificantly decrease bruxism. On the con­ icant decrease and four showed no change.
All ten p a rticip a n ts selected for this study trary, a significant number of participants When wearing the hard occlusal splint,
eight of the ten participants had at least a
25% decrease in nocturnal muscle activity;
Table 3 ■ A comparison of the arithmetic means for each participant. The percentage none had a 25% or greater increase. When
of change from the control created by wearing the hard and soft splint is reported. The wearing the soft occlusal splint, only one
arrows represent an increase or decrease of greater than 25%. Any symptoms reported participant had at least a 25% decrease in
by the participants are also noted.______________________________________________ nocturnal muscle activity. Seven of the ten
C ontrol H a rd sp lin t C hange Soft sp lin t C hange participants, however, showed a 25% or
P a tie n t Age G ender m ean m ean (*) m ean (%) greater increase in nocturnal muscle ac­
1 24 F 1,527 592 161.2 1,781 17 tivity.
2 37 M 1,191 352 170.4 1,484 125* There was no attem pt in this study to
3 24 M 3,690 2,271 138.5 4,355 18 correlate the duration or intensity of a sin­
4 23 F 408 404 0.9 653 Î60+ gle clenching episode. Itis logical to assume
5 33 M 615 737 19.8 1,096 178*
6 31 M 271 94 168.3 361 133
that the symptoms reported by patients
7 29 F 1,155 199 182.8 835 128 vary according to the type of muscle activ­
8 25 F 1,545 825 146.6 2,606 169 ity that is carried out during sleep (isotonic
9 25 F 3,085 2,302 125.3 14,791 1300+ or isometric). Perhaps future studies will
10 23 M 11,129 4,390 160.5 15,879 143+
determine the relationships between var­
•Reported muscle tiredness (no pain). ious types of occlusal splints, types of m us­
fR eported m uscle/joint pain.
cle activities, and the reported symptoms.
----------------------J liO A ----------------------

790 ■ JADA, Vol. 114, June 1987


Dr. O keson is director, d iv isio n o f m asticatory fu n c­
tion, A lbert B. C h an d ler M edical Center, U niversity of
K entucky College o f D entistry, L ex in g to n , KY 40536-
0084. Address requests for rep rin ts to the author.
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