SLEEP APNEA

The Use of a BruxChecker in the Evaluation of

Different Grinding Patterns During Sleep Bruxism
Kanji Onodera, D.D.S.; Toshimi Kawagoe, D.D.S.; Kenichi Sasaguri, D.D.S.;
Cynthia Protacio-Quismundo, D.D.S.; Sadao Sato, D.D.S.

ABSTRACT: A variety of problems involving the masticatory system can be partially attributed to para-
functional habits such as bruxism. These include occlusal trauma, abfractions, tooth migration, as well
0886-9634/2404- as temporomandibular dysfunction. Since bruxism is considered a contributing factor to the above-men-
292$05.00/0, THE
JOURNAL OF tioned dental problems, it is essential to consider parafunctional habits in the diagnosis and treatment
CRANIOMANDIBULAR planning before doing any occlusal reconstruction. However, the problem lies in the lack or absence of
PRACTICE,
Copyright © 2006 a simple device or gauge useful to be able to diagnose and evaluate the occlusal schemes in the
by CHROMA, Inc. patient’s grinding pattern. In this study, we have developed a very simple device (BruxChecker) for eval-
uating the grinding patterns in sleep bruxism. Using the BruxChecker, it was possible to visualize real or
Manuscript received
December 13, 2004;
actual interferences during sleep bruxism. Therefore, examination of the grinding pattern using this
revised device is necessary and crucial for making the proper treatment plan for each patient.
manuscript received
June 27, 2006; accepted
June 30, 2006
Address for reprint
requests:
Dr. Sadao Sato
Department of Craniofacial
Growth and Development
Dentistry
Kanagawa Dental College
82 Inaoka-Cho, Yokosuka,

Kanagawa, Japan
E-mail: satos@kdcnet.ac.jp
Dr. Kanji Onodera received his D.D.S.
from Tokyo Dental College in 1995 and
had a clinical practice in the Department
of Conservative Dentistry at the same
school from 1996-1999. He received a
certificate in orthodontics in 2001 from
Kanagawa Dental College. His major
research interest is the interrelation of
craniomandibular dysfunction with
bruxism.
B
ruxism is generally defined as a diurnal or noctur-
nal parafunctional activity involving: clenching,
grinding, bracing and gnashing of the teeth. 1
During bruxism, excessive forces can be generated for
extended periods of time that exceed the approximately
20-minute tooth contact. Some literature even reported a
case of bruxism involving more than two hours of tooth
contact.2 Sleep bruxism can generate tremendous biome-
chanical occlusal forces, which at times can be signifi-
cantly greater than bruxing with conscious effort by an
individual during the waking hours.3-5 As a result, signif-
icant load can be distributed to the dentition, the alveolar
and periodontal supporting structures, and the temporo-
mandibular (TM) joints. Simultaneously, hyperactivity of
masticatory muscles occurs, thus compromising the
health of these muscles.
Several types of degenerative occlusal conditions such
as occlusal trauma, abfractions, dental compression syn-
dromes, tooth migration, as well as temporomandibular
dysfunction have long been described in dentistry.
Stresses from active bruxism appear to cause a physical
or physiochemical loss of cervical tooth structure and
may result in dentin hypersensitivity in these regions due
to the progressive exposure of dentinal tubules.6 A high

292
ONODERA ET AL.
correlation between patients with active bruxism and the
development of abfractive lesions was also reported.7 It
is suggested that repetitive overloading of the temporo-
mandibular joint via dentition causes parafunctional
activities such as bruxism and clenching can be consid-
ered as significant contributors to repetitive overloading
of the temporomandibular joint structures.8-10 Bruxism,
which is a common source of microtrauma, usually
results in the elongation of the capsular and diskal liga-
ments coupled with thinning of the articular disk as well
as muscle incoordination.
Almost all of the above-mentioned problems regarding
the dental, oral, and masticatory system are closely
related to bruxism. Thus, every dentist must have suffi-
cient knowledge of the fundamental aspects of occlusion
as affected by the strong biomechanical load created by
bruxism and treat these conditions on a routine basis in
their practice. However, the problem lies in the absence
of a simple device or gauge usable for diagnosing and
evaluating the occlusal schemes in the patient’s grinding
pattern. The purpose of this study is to introduce a very
simple method for evaluating grinding patterns and
examining the individual occlusal schemes during sleep
bruxism.
Materials and Methods
Fabrication of the BruxChecker
The BruxChecker is a thin plate, 0.1 mm thick, clear
transparent sheet, composed of polyvinyl chloride (Scheu-
Dental, Germany). The BruxChecker was fabricated in a
vacuum press in which the 0.1 mm thick transparent sheet
was heated at 230º C for 15 seconds and sucked over a
maxillary plaster cast using Biostar (Scheu-Dental,
Germany). The device was then trimmed along the gingi-
val margins, and the occlusal surface was painted with a
red dye (Acid Red 51, Morimoto Chemical Co. Ltd,
Tokyo, Japan) dissolved in shellac-ethanol solution
(Shellac Co. Ltd, Tokyo, Japan) in order to visualize the
grinding facets. Acid red 51, also known as Red No. 3 or
erythrosine B, is a dye used in artificial food coloring.
Figure 1 shows the BruxChecker on the upper dentition
of the patient.
Subjects
Thirty-six (36) volunteers (16 males and 20 females,
aged 23 to 24, mean age: 24 years 8 months) and fifty
patients (9 males and 41 females, aged 15 to 58, mean
age: 26 years 2 months) from the orthodontic department
of the Kanagawa Dental College, who complained of
temporomandibular joint (TMJ) symptoms such as joint
noise and limitation of mouth opening, accompanied by
OCTOBER 2006, VOL. 24, NO. 4
EVALUATION OF GRINDING PATTERNS DURING SLEEP
Figure 1
BruxChecker on the upper dentition of the patient. The device was
fabricated using a 0.1 mm thick transparent sheet dyed using Acid Red
51 dissolved in shellac-ethanol solution.
pain, were selected and instructed to use the BruxChecker
for the evaluation of their grinding patterns during sleep
bruxism. Thirty-six (36) volunteers with no TMJ symp-
toms presenting with a full set of dentition from central
incisor to second molar with no severe malocclusion or
major prosthodontic treatment were also evaluated as a
comparison group. All subjects were instructed to wear
the BruxChecker at night during sleep for two consecu-
tive nights.
Effect of the BruxChecker Wearing on the EMG Activities
In order to examine the effect on the masticatory mus-
cles of wearing the BruxChecker , the activity of the mas-
seter and temporalis muscles were recorded using
electromyography (EMG) with surface electrodes. The
subject was instructed to grind initially without the
BruxChecker for a few seconds and then repeat the same
procedure with the BruxChecker on. Then the corre-
sponding EMG recording was made. This procedure was
necessary prior to the study in order to determine whether
the BruxChecker induces masticatory muscle activity.
Evaluation of Tooth Contacts on the Articulators
All maxillary dental casts were mounted in a SAM 2
articulator (SAM prazisionstechnik, Munich, Germany)
as referenced to the axis orbital plane (AOP) by means of
an anatomical face bow transfer (SAM prazisionstechnik,
Munich, Germany). The lower casts were mounted in the
unstrained border position of the TMJ (reference posi-
tion, RP) achieved using chin point guidance. Tooth con-
tacts of the maxillary and mandibular casts were evaluated
by manually moving the casts, using the subject’s actual
sagittal condylar inclination (SCI) value during excursive
movements of the condylar hinge axis, to imitate the
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 293
EVALUATION OF GRINDING PATTERNS DURING SLEEP
parafunctional movement. Classification of the tooth
grinding contacts on the laterotrusive side of the upper
and lower dentition during excursive movement were
separated into four groups: 1. incisor-canine, 2. incisor-
canine-premolar, 3. incisor-canine-premolar-molar, and
4. no contact. The mediotrusive side tooth contacts were
also classified into three groups: 1. mediotrusion-contact,
2. mediotrusion-grinding, and 3. no mediotrusion con-
tact. In the evaluation of mediotrusive tooth contacts,
tooth contact and tooth grinding were differentiated.
Tooth contact was defined as a cusp contact during
mediotrusive movement of the condyle, while tooth
grinding was defined as a wider and expanded facet
around the cusp and oblique surface of the cusp rather
than cusp contact seen on the articulator.
Statistical Analysis
In order to evaluate the significance of the difference in
frequency of grinding pattern between no-TMJ symptom
and TMJ symptom groups, we applied the Chi-square
test. Statistical significance was evaluated at the p=0.05
level.
294 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
ONODERA ET AL.
Results
Applicability of the BruxChecker Device to Evaluate
Bruxism Activity
There was no significant difference between the activ-
ity of the masseter and temporalis muscles with and with-
out the BruxChecker in the mouth during grinding as seen
in the EMG results (Figure 2). After wearing the
BruxChecker for two consecutive nights, the grinding
pattern of the subjects was transferred to the surface of
the BruxChecker as marked by the painted areas, which
were ground off by tooth grinding. The grinding site, as
well as the grinding pattern, could then be evaluated and
observed easily by putting the BruxChecker onto the
original cast (Figure 3). The BruxChecker presented dif-
ferent grinding patterns in sleep bruxism that could be
classified into four groups: canine-dominance grinding
(CG), canine-dominance grinding with mediotrusion
grinding (CG+MG), canine-premolar-molar grinding
(group grinding, GG) without mediotrusion grinding, and
canine-premolar-molar grinding (group grinding) with
mediotrusion grinding (GG+MG). Figure 4 shows differ-
ent grinding patterns of the BruxChecker.
Figure 2
Effect of subject wearing the
BruxChecker on the masticatory
muscle activity. No significant differ-
ence between the activity of the mas-
seter and temporalis muscles with and
without wearing the BruxChecker was
noted.
OCTOBER 2006, VOL. 24, NO. 4
ONODERA ET AL. EVALUATION OF GRINDING PATTERNS DURING SLEEP

Figure 3

The BruxChecker presented different

grinding patterns in sleep bruxism:
a. canine-dominated grinding (CG);

b. canine-dominated grinding with

mediotrusion grinding (CG+MG);

b
c. canine-premolar-molar grinding
(group grinding, GG) without mediotru-
sion grinding; and

d. canine-premolar-molar grinding
(group grinding) with mediotrusion
grinding (GG+MG).

Figure 4
Observation of different grinding patterns on
the BruxChecker: a. incisor-canine-premolar
grinding (right side) with mediotrusive grinding
(lingual cusps of 1st and 2nd molar on the left
side); b. canine-premolar grinding (right side)
with mediotrusion grinding in 1st molar (left
side) and incisor-canine-premolar grinding
without mediotrusion grinding; c. no anterior-
canine grinding with strong posterior grinding;
d. faint anterior-canine grinding with strong
posterior grinding.

OCTOBER 2006, VOL. 24, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 295
EVALUATION OF GRINDING PATTERNS DURING SLEEP ONODERA ET AL.

Evaluation of Grinding Movement during Sleep Bruxism

The observation of the grinding pattern during sleep
bruxism seen in the BruxChecker indicated that a wide
oval-shaped retrusive grinding was the predominant pat-
tern shown in Figure 5. Two different patterns were also
observed when the relationship between the grinding area
and intercuspal position (ICP) were compared. The first
pattern involved the ICP being located within the grind-
ing field, which indicated the latero-retrusive movement
of the mandible. The second pattern involved the ICP and
was located outside the grinding field, which indicated
that the mandible jumped into the grinding area from ICP
prior to the bruxism activity (Figure 6).
Most of the cases showed that the ICP was located in
an anterior position relative to the grinding field, indicat-
ing that the bruxism activity of the mandible is basically
latero-retrusive in orientation from ICP. There were no
subjects who showed protrusive grinding from ICP.

Comparison of Tooth Grinding Patterns between the

Articulator Mounted Study Casts and as Seen in the
BruxChecker
The tooth grinding contacts were classified as lat-
erotrusive side and mediotrusive side tooth contacts of
the upper and lower dentition during excursive move-
ment (Table 1). In the no-TMJ symptom group, an
incisor-canine-premolar grinding on the BruxChecker
was predominant (38.9%), while an incisor-canine grind-
ing was predominant (44.4%) on the laterotrusive side of
the articulator. Furthermore, high frequency of mediotru-
Figure 6
The grinding field of bruxism on the BruxChecker and intercuspal
position: a. ICP located within the grinding field; b. ICP located
outside the grinding field. The grinding pattern indicates that funda-
mental grinding during bruxism was latero-retrusive movement.
sive grinding on the BruxChecker was 63.9%, although
on the articulator, the mediotrusive contact was predomi-
nant (58.3%).
The TMJ-symptom group showed that incisor-canine-
premolar-molar grinding was 52.0% on the articulator
and 94.0% on the BruxChecker, which was significantly
different, suggesting more group function type of lat-
erotrusive grinding in the symptomatic group. In addition
to these, more than 80.0% of the symptomatic patients
had mediotrusive grinding on the BruxChecker, while
only 10.0% of mediotrusive grinding was observed on the
articulator.

Occlusal Schema Visualized by Grinding Pattern

Figure 5
The BruxChecker presented grinding field of bruxism and intercuspal
position. There were two types of relationships between the grinding
field and ICP: ICP located within the grinding field (a) and ICP
located outside the grinding field (b).
The occlusal schemes were classified into four cate-
gories based on the grinding patterns observed in the
BruxChecker, (Figure 7).
Canine-Dominated Grinding (CG): The canine tooth
on the laterotrusive side provided the predominant guid-
ance during bruxism with signs of slight grinding in the
first and second premolar areas and none in the molars.
Canine-Dominated Grinding with Mediotrusive
Grinding (CG+MG): The canine tooth on the laterotru-
sive side was guided predominantly during bruxism as

296 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE OCTOBER 2006, VOL. 24, NO. 4
ONODERA ET AL. EVALUATION OF GRINDING PATTERNS DURING SLEEP

Table 1
Patterns of Tooth Contact Evaluated on the Articulator or BruxChecker in
No-TMJ Symptom and TMJ Symptomatic Subjects
No-TMJ symptomatic TMJ symptomatic
subjects (n=36) subjects (n=50)
Articulator BruxChecker Articulator BruxChecker
Laterotrusion side
Incisor-canine 16 (44.4) 11 (30.6) 8 (16.0)* 2 (4.0)*
Incisor-canine-premolar 9 (25.0) 14 (38.9) 15 (30.0) 2 (4.0)*
Incisor-canine-premolar-molar 10 (27.8) 11 (30.6) 26 (52.0)* 43 (94.0)*
No-laterotrusion contact 1 (0.03) 0 1 (2.0) 0

Mediotrusion side
Mediotrusion contact† 21 (58.3) 13 (36.1) 28 (56.0) 8 (16.0)*
Mediotrusion grinding‡ 2 (0.06) 23 (63.9) 5 (10.0) 42 (84.0)*
No-mediotrusion contact 13 (36.1) 0 17 (34.0) 0
*Significantly different from No-TMJ symptom group at p<0.05
†Contact: defined as a cusp contact during mediotrusive movement of the condyle
‡Grinding: defined as a wider and expanded facet around the cusp and oblique surface of the cusp than the cusp contact
(): Percent

described previously with grinding facets on the lingual
cusps of the mediotrusive side, mainly first and second
molars.
Group Grinding (GG): The canine tooth up to the
molars on the laterotrusive side are ground off as a group
with no signs of grinding in the molars on the mediotru-
sive side during sleep bruxism.
Group Grinding with Mediotrusive Grinding
(GG+MG): Laterotrusive group guidance up to the molars
with signs of grinding facets in the lingual cusps of the
1st and 2nd molars on the mediotrusive side.

Figure 7
The occlusion scheme based on bruxism
grinding patttern: a. canine-dominated
grinding; b. canine-dominated grinding
with mediotrusion grinding; c. group grind-
ing; d. group grinding with mediotrusion
grinding.

OCTOBER 2006, VOL. 24, NO. 4 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 297
EVALUATION OF GRINDING PATTERNS DURING SLEEP
Discussion
The BruxChecker, a thin vacuum pressed-sheet, is fab-
ricated using a simple and quick method. It’s application
in the patient’s mouth causes no apprehension on the
patient’s part because the device is not invasive. Patients
are simply instructed to wear the device immediately
before going to bed and to remove it upon waking up in
the morning for two consecutive days.
One of the advantages of the Bruxchecker is that it is
very thin (0.1 mm thickness), providing almost no inter-
ferences to occlusion or mandibular movement, and does
not induce unnecessary masticatory muscle activity.
Several investigators 11,12 have used the same type of
vacuum pressed-sheets such as the bruxcore (which is
composed of laminated plastic sheets of different colors
with the surface covered with microdots. However, it is
still difficult to prove whether the thickness of the brux-
core (0.6 mm) has an effect on the bruxism activity (i.e.,
creating interferences or increasing muscle activity), thus
making the quantification of bruxism activity question-
able and inaccurate.
In clinical practice, it is important for the clinician to
examine the position and distance of inclined plane of the
cusps where abrasion facets appear. Quite often, the dis-
crepancy between the interferences on the articulator-
mounted casts and wear facets on the tooth surfaces can
be seen. In other words, although the mounted stone cast
does not show any posterior interference, the wear facets
can be seen in the posterior dentition. This only means
that there is a discrepancy between the clinical observa-
tion of articulation and tooth contacts and in the actual
grinding pattern during actual sleep bruxism. The aim of
this study was to document the individual’s real grinding
pattern during actual sleep bruxism using the BruxChecker.
Clinically, the grinding contact of the upper and lower
teeth in powerful bruxism is quite important. Stability
after any occlusal reconstruction depends upon the effect
of certain craniomandibular functions such as parafunc-
tional activity (i.e., bruxism). With the use of the
BruxChecker, it was possible to visualize actual interfer-
ences that happen during sleep bruxism. Everytime the
patient attempts to grind, particularly during sleep, the
greatest threat to the masticatory system is when the ante-
rior teeth provide a lack of posterior disclusion to reduce
excessive muscle activities and an extremely steep over-
lap resulting in a too steep disclusion angle. In a bruxing
movement, the excessively steep angle allows more fric-
tion and generates more muscle activity with subsequent
wear of the involved surfaces.13 Therefore, in the recon-
struction of occlusion, we must provide dynamic occlu-
sion without posterior interferences. This should follow
298 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
ONODERA ET AL.
the natural rules of dentition, which show sequentially-
arranged inclination of occlusal guidance from posterior
to anterior.
Although dentistry has made numerous exhaustive
attempts to understand occlusion, it has unsuccessfully
treated occlusion without first taking into consideration
the parafunctional activity of the masticatory organ.
During bruxism, condylar movement patterns and occlusal
guiding planes must be harmonized. While grinding
movements during sleep bruxism are still not completely
understood, the use of the BruxChecker may offer impor-
tant information prior to the reconstruction of occlusion.
As shown in this study, the TMJ symptom group had
more posterior tooth contact and mediotrusive contact
during sleep bruxism (Table 1), suggesting that the pos-
terior interferences potentially cause deflective effects on
TMJ function. The most valued benefit of the BruxChecker
for clinicians is that actual tooth contacts during sleep
bruxism are not only visualized using a simple and inex-
pensive method, but is also instructive to the patient.
Treatment planning, based on the grinding pattern of the
BruxChecker, may be possible to reduce the need for
reconstruction treatment. It is also very important to
apply the BruxChecker after reconstruction treatment to
verify treatment results.
Occlusion concepts such as canine guidance, group
function, balanced occlusion, etc. have long been advo-
cated in dentistry. These concepts were observations
based on intraoral or articulator mounted casts. The
results of this investigation offer new occlusion schemes
based on grinding movement. Since bruxism has long
been recognized as a causative factor for abrasion, abfrac-
tion, tooth supporting tissues distraction, temporo-
mandibular dysfunction, head, neck and shoulder pain
syndrome and destruction of the prosthodontic appli-
ances, it is extremely important to reconstruct occlusion
based on strong grinding movement.
Examination of the grinding pattern during bruxism is
necessary and should be incorporated in the diagnosis of
occlusion in order to make the proper treatment plan for
each patient. It is imperative to provide the patient physi-
ologic tooth contacts during sleep bruxism to avoid or
lessen the occurrence of degenerative occlusal condi-
tions. In this study, the BruxChecker is shown to be a
useful tool in examining the grinding pattern during sleep
bruxism.
Acknowledgements
This work was performed in Kanagawa Dental College,
Research Institute of Occlusion Medicine and supported
by grant-in-aid for Open Research from the Japanese
OCTOBER 2006, VOL. 24, NO. 4
ONODERA ET AL.
Ministry of Education, Culture, Sports, Science and
Technology.
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OCTOBER 2006, VOL. 24, NO. 4
EVALUATION OF GRINDING PATTERNS DURING SLEEP
Dr. Toshimi Kawagoe is a postgraduate student in Kanagawa Dental
College. She received her D.D.S. from Kanagawa Dental College in
2003. Her major interest is the epidemiological research for interrelation
of dysfunction of the temporomandibular joint with bruxism activity.
Dr. Kenichi Sasaguri is an assistant professor in the Department of
Craniofacial Growth and Development Dentistry, Kanagawa Dental
College. He received his D.D.S. from Kanagawa Dental College in 1985
and his D.D.Sc in 1989 from the same school. His major research inter-
ests include function and dysfunction of the craniomandibular system and
the molecular mechanisms in stress and masticatory organ functions.
Dr. Cynthia Protacio-Quismundo was a professorial lecturer at the
University of the Philippines from 1992-1998 and is currently a private
practitioner in Manila. She received her D.D.S. at the Centro Escolar
University in 1987 and her certificate in orthodontics at the Kanagawa
Dental College in 1991. She is also the founder of the MEAW Study Club
of the Philippines.
Dr. Sadao Sato is a professor and head of the Department of
Craniofacial Growth and Development Dentistry, Kanagawa Dental
College. He received his D.D.S. from Kanagawa Dental College in 1971
and his D.D.Sc in 1978 from the same school. Since 1992, he is a
member of the EH Angle Society of Orthodontists. His major research
interests include function and dysfunction of the masticatory organ,
emotional role of bruxism activity, and craniofacial growth and maloc-
clusions.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 299