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
term for clenching and grinding of the teeth, is
the commonest of the many parafunctional
activities of the masticatory system. Opinions on
the cause of bruxism are numerous and widely
varying. Current reviews indicate that the
etiology is not fully known but that it is probably
multifactorial (1).
Bruxism can occur during wakefulness or during
sleep. The American Academy of Sleeping
Disorders proposed the terms Sleep and Awake
Bruxism. Bruxism during daytime is commonly a
semi-voluntary 'clenching' activity and is also
known as 'Awake Bruxism' (AB) or Diurnal
Bruxism (DB) (2). Bruxism during sleep either
during daytime or during night is termed as
261
Received: 15 / 12 /2016
Accepted: 20 / 12 /2016
'Sleep Bruxism' (SB). Awake bruxism is linked to
life
stress caused by familial responsibility or work
pressure. Sleep Bruxism is an oromandibular
behaviour that is defined as a stereotyped
movement disorder occurring during sleep and
(3)
. characterized by tooth grinding and/or
clenching. Sleep bruxism was recently classified
as sleep related movement disorder according to
recent classification of Sleep Disorders(3).
Prevalence rate of Awake and Sleep Bruxism is
about 20% and 8–16% respectively in adult
(4)
population . Awake bruxism occurs
predominantly among females while no gender
difference is seen for sleep bruxism (5). Onset of
Sleep Bruxism is about 1 year of age soon after
DOI : 10.12816/0034662
 A Critical Review on the Relation and Impact…
the eruption of 7 deciduous incisors. The disorder
appears more frequently in the younger
population (6). The prevalence in children is
between 14 to 20%.
Meanwhile, suggested solution to manage
bruxism can result in problems that are as
frustrating for the patient as for the treating
dentist. Sequelae of bruxism that have been
proposed include tooth wear, signs and symptoms
of temporomandibular disorders (TMD),
headaches, toothache, mobile teeth, and various
problems with dental restorations as well as with
fixed and removable prostheses (7,8).
MATERIALS AND METHODS
The study team searched Medline (via PubMed),
for the terms „bruxism‟ and „prosthetic
treatment‟. The results were filtered out to
include articles focusing on the relationship
between bruxism and prosthetic treatment,
implant-supported and implant-retained
prostheses and including fixed and removable
prostheses. A manual search of the reference lists
and textbooks referred to in the included PubMed
listed articles was also performed in parallel. This
additional search identified 10 relevant studies
and reviews. Some articles were excluded due to
inability of retrieval , sharing the same cohort or
aiming at irrelevant study endpoints.
Finally , a total of 49 relevant papers remained,
and are discussed in the review that follows.
Etiology of Sleep Bruxism
The exact etiology of SB is still not known and
probably multifactorial in nature. Central issues
can be categorized into pathophysiological and
psychosocial factors such as stress , frustration ,
poor social support , and personality issues as
well as pathophysiological factors including sleep
disturbance , use of certain medications or drugs ,
smoking , allergies, genetic factors and nutrition
deficiencies ( calcium, magnesium,) and other
medical conditions(9).
The link between SB and psychosocial factors
such as emotional stress was supported by the
studies reporting elevated levels of urinary
catecholamine in patients with SB (9). In addition,
SB activity had been related to higher levels of
perceived psychological stress and salivary
cortisol (10). A controlled laboratory study
reported that SB patients were more competitive
262
and felt more anxious than normal subjects (11).
Patients with both AB and SB, also showed
significant differences in anxiety, depression,
hostility, phobic anxiety, and paranoid ideation
when compared to non-bruxers(12).
Tooth wear
Bruxism was for long considered a major cause
of tooth wear. A systematic review concluded
that “attrition seems to be co-existent with self-
reported bruxism” (13). Tooth attrition coupled
with Gum recession and abfraction is a common
condition for profound Buxism (see figure 1 and
2 for illustration) – also , Wear facets (small
circular indentations mainly in the back teeth) can
be as well noticed as a sign of Buxism on a
grinder ( Figure 3 ).
A recent review concluded that a number of
published observations strengthen the concept of
the multifactorial etiology of tooth wear. The
review went on to state that it seemed fair to
conclude that the overall significance of bruxism
as a causative factor for tooth wear is not fully
known, but it is even fairer to say that it is
probably overestimated (14).It follows that there
are significant limitations with self-reports to
provide a reliable diagnosis of sleep bruxism.
Therefore, in much of the discussion that follows,
the use of the term bruxism implies an acceptance
of this limitation, and that what it refers to might
equally be just heavy loading through high
biting/chewing forces operating as a direct factor,
rather than it being categorically due to
parafunctional activity.
Irrespective of the etiology, restoration of worn
teeth that will frequently involve prosthetic
treatment will be needed in some patients.
Because such treatment is typically complex and
often extensive, there is a tendency to defer
treatment until the tooth wear is well advanced.
This complicates treatment further, and with
greater mechanical vulnerability to the restoration
provided. There is a scarcity of studies on the
outcome of prosthetic restoration of worn
dentitions, leading to widely differing opinions
among prosthodontists in different countries
about how these complex treatment situations
should be managed (14,15).
Effects of bruxism on the masticatory system
Since bruxism is considered a possible etiological
factor for TMD and tooth wear, its clinical
 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

263
 A Critical Review on the Relation and Impact…
conclusion that the implants can be integrated in
the stomatognathic control circuit (30).
Occlusal Material for the Suprastructure in
Implant Prostheses
Based on biomechanical analyses, acrylic resin
denture teeth were therefore predominantly used
during the initial years of dental implant use
(31)
.However, biomechanical calculations do not
always stand the test in the clinic. In a clinical
study on five subjects using fixed prostheses with
either acrylic resin or porcelain occlusal surfaces,
masticatory forces were recorded while the
subjects chewed various foods. No differences
related to tooth material could be detected in the
load rates (32).In a study covering 6 years, the use
of porcelain instead of composite resin as
occlusal material had no influence on the
marginal bone height around the implants
(33)
.These findings can be interpreted as a support
for the use of porcelain as occlusal material
because no serious biological consequences of
the hard material were reported. Furthermore, the
most common complications of implant
prostheses have been related to fractures of the
acrylic resin of the prostheses (34) . Wear of
acrylic occlusal surfaces increased substantially
with time, according to a 15-year follow up of
fixed implant-supported prostheses in the
edentulous maxilla (35) .
Effects of bruxism on implant restorations
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. Evidently, more
clinical trials are needed to provide evidence for
these recommendations. More recently,
framework or crowns in zirconia was also
developed in this field. However, in a clinical
trial on fractured dental zirconia implants,
Gahlert et al. reported that “the patient with the
fracture of the 4 mm diameter zirconia implant
was adversely affected by strong bruxism” (36)
.Recently, some investigators demonstrated
zirconia as a new dental implant material (37) .The
development of new dental implant material
might change the relationship between fractured
dental implants and bruxism.
264
Effects of bruxism on removable dentures
Due to lack of evidence , systematic studies on
the effects of bruxism on removable dentures are
not available in the literature.
Complete dentures
Textbooks on complete denture fabrication often
mention that clinical experience indicates that
bruxism is a frequent cause of complaint of
soreness of the denture-bearing mucosa. The
relationship between oral parafunctions and
residual ridge resorption has not been
investigated, but it is tempting, even if
anecdotally, to include parafunctions as a
possible factor related to the magnitude of ridge
reduction (38) .
Removable partial dentures
The question of restoring lost posterior support
by means of mandibular distal extension
removable partial dentures (RPDs) in moderately
shortened dental arches remains controversial (39)
.However, systematic reviews have concluded
that shortened dental arches comprising anterior
and premolar teeth generally fulfill the
requirements of a functional dentition without the
need for prosthodontic extension, especially in
older patients (40) and (41) .In this regard, the
findings of a study of occlusal activity, including
bruxism, in subjects with moderately shortened
dental arches with or without mandibular distal
extension removable partial dentures and subjects
with complete dentitions which reported Similar
awareness of bruxism , Similar occlusal wear of
lower anterior teeth; in contrast, premolars had
significantly more occlusal tooth wear , Similar
frequencies of signs and symptoms related to
TMD (42) .
Night Guard and Pharmacological Approach
for Bruxism
A night guard fabricated for the maxillary teeth
can be a useful tool to evaluate the influence of
the occlusion scheme and its relationship to
nocturnal bruxism (43) .Occlusal schemes and
designs of fixed and removable implant
prostheses must satisfy the requirements for an
innocuous vertical loading of dental implants.
Parafunctional habits (clenching or grinding) can
transmit forces to the supporting bone that may
result in destructive lateral stresses and
overloading. The consequences of nocturnal
 Haitham Jan et al
parafunctional habits may be prevented by acrylic
resin night guards (44) .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 (45) .A night guard that promotes even
occlusal contacts around the arch in centric-
related occlusion can be helpful to prevent
fractures of implant prostheses. This device may
be fabricated with 0.5- to 1-mm colored acrylic
resin on the occlusal surface. If the patient wears
this device for 1 month, the consequences or
intensity of the bruxism habit may be directly
observed. If the colored acrylic is not worn
through, the parafunction was not excessive (46)
.
As examples, when partial implant prosthesis is
present in the maxilla, the night guard is
hollowed out at the implant sites so no occlusal
force is transmitted to the implant prostheses.
When the partial restoration is in the mandible,
the occluding surface of the guard is relieved
over the implant prostheses so no occlusal force
is transmitted to the implants. A soft material
may also be placed around the crowns for stress
relief and to decrease the impact force on the
crowns.
DISCUSSION
Few relevant articles with the search terms used
were listed in PubMed since Research focusing
on the relationship between bruxism and
prosthetic therapy is scarce, and additional
valuable texts were found by means of manual
searching of the reference lists of articles found
and in recent textbooks.
There is not enough evidence that prosthetic
therapy, or any other available treatment, can
eliminate bruxism. Equally, there is no evidence
that bruxism can be caused by prosthetic therapy.
On the other hand, some few investigators
proposed a pharmacological approach for
bruxism patients with implant prostheses (47,48) ,
especially in cases where oral implants failed as a
probable consequence of severe,
polysomnographically confirmed sleep bruxism.
As the patient had the wish to be reimplanted
after this failure, the operators decided to try
diminishing the frequency of bruxism and
duration first. The selected management
strategies, the administration of low doses of the
dopamine D1/D2 receptor agonist pergolide
265
finally resulted in a substantial and lasting
reduction in the bruxism outcome measures under
study(48).
The use of interocclusal appliances is the most
common and accepted way to prevent wear of
teeth and prosthodontic restorations in spite of
lack of strong evidence for its efficacy(49).
CONCLUSION
The etiology of bruxism is not well known, but it
is agreed that it is multifactorial.
There is no specific treatment available at this
time to stop bruxism, so that the focus has been to
reduce the adverse effects of the habit.
feel that the overload caused by bruxism may
result in failure of implant supported prostheses.
Following the recent developments with the
introduction of immediate or early loading, the
clinical management of bruxism will become an
important subject for implant prostheses. The
lack of well-designed clinical trials regarding the
consequence of bruxism on implant prostheses
poses a serious problem. At present, expert
opinion and cautionary approaches are still
considered the best available sources for
suggesting good practice indicators which urges
clinical research centers to dig deeper into the
matter and provide a strong evidence on whether
the subjective feeling of clinicians regarding the
approach of bruxism in implant patients is correct
or not.
When prosthetic intervention is indicated in a
patient with bruxism, efforts should be made to
reduce the effects of heavy occlusal loading on
all the components that contribute to prosthetic
structural integrity.
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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)

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