Journal of Oral Rehabilitation 2008 35; 353–360
Palate morphology of bruxist children with mixed dentition.
A pilot study
C . C . R E S T R E P O * , C . S F O R Z A †, A . C O L O M B O †, A . P E L Á E Z - V A R G A S * & V . F .
F E R R A R I O † *CES-LPH Research Group, Medellı́n, CES University, Colombia and †Laboratory of Functional Anatomy of the
Stomatognathic Apparatus, Department of Human Morphology, University of Milan, Milan, Italy
SUMMARY The objective of the study was to analyse
quantitatively palatal morphology in bruxist and
non-bruxist children with mixed dentition. Twenty-
three children with mixed dentition were classified
as bruxist according to their anxiety level, audible
occlusal sounds related by the parents and signs of
temporomandibular disorders; 23 children were
control subjects matched for gender, age, and dental
formula. The maxillary dental arches of all subjects
were reproduced from alginate impressions cast in
dental stone with a standardized technique. The
casts were digitalized and mathematical equations
were used to obtain the form of the palate in the
sagittal, frontal and horizontal planes. Bruxist chil-
dren had a statistically significant longer palate in
the sagittal plane than control children; palatal
Introduction
The aetiology of bruxism has been defined as multi-
factorial (1). It is mainly regulated centrally, but
influenced peripherally (2). Oral habits (3), temporo-
mandibular disorders (TMD) (4–7), malocclusions (8,
9), hypopnoea (10), high anxiety levels (11) and stress
(12) among others (13) could influence the peripheral
occurrence of bruxism. These factors act as a motion
stimulus to the central nervous system, which reacts
with an alteration in the neurotransmission of dopa-
mine (14, 15) and the answer is the clenching or
grinding of the teeth.
The effects of bruxism on teeth (16, 17) as well as on
facial morphology (18–20) have been widely studied,
but its relationship with the function and ⁄ or the shape
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
shape differed especially in correspondence of the
third, fourth and fifth teeth, bruxist children show-
ing a relatively higher palate than control children.
In this pilot study, sagittal plane differences in the
palate between bruxist and non-bruxist children
matched for age and gender were found. Further
investigations are needed to understand better the
clinical implications of the findings. Results should
be taken into account in the diagnosis of the occlusal
development in children with parafunctions to
prevent future abnormalities: a bruxist child may
have bigger dental arches than a normal child.
KEYWORDS: palate, bruxism, growth and develop-
ment, morphometry
Accepted for publication December 9 2007
of the upper maxilla or jaw has not been reported in
children, although alterations in the hard palate of
adult bruxists, such as torus palatinus have been
reported (21).
In particular, the analysis of palatal normal mor-
phology in bruxist children appears to have been
neglected so far. Quantitative investigations of normal
palatal size and shape are infrequent. As reviewed
elsewhere (22, 23), the main shortcoming seems to be
technical: direct techniques in which several standard-
ized landmarks are used as endpoints for caliper
measurements are time-consuming and prone to error
and cannot be used with the current computerized
methods of treatment planning. Indirect analyses with
the use of two-dimensional projections (radiographs,
photographs or photocopies) are insufficient for the
doi: 10.1111/j.1365-2842.2008.01848.x
354 C . C . R E S T R E P O et al.
palate, while the loss of the third dimension does not
significantly influence dental arch form in the hori-
zontal plane; it hinders most investigations of palatal
morphology.
Currently, technology provides three-dimensional
digitizers that can be directly used on dental casts to
supply the metric coordinates of selected landmarks.
The coordinates can be used for any kind of mathe-
matical modelling. Optical devices, electromechanical
instruments, electromagnetic digitizers have all been
used to collect three-dimensional data on the human
palate in both normal individuals and patients with
alterations in craniofacial structures (22–25). In con-
trast, quantitative three-dimensional methods have
never been used for the assessment of palatal charac-
teristics in bruxist children.
The quality and hardness of the food had become
more processed and soft from time to time. The dietary
consistency affects craniofacial growth (26). When the
food is not hard enough, the teeth do not wear
naturally, with a resulting insufficient growth of the
alveolar base in children. Lacking the adequate stimuli,
arch size is not sufficient for teeth eruption (27). When
bruxism occurs, the dental wear is higher, so the
contacts between the upper and the lower teeth are
bigger and flatter than with natural chewing. Those
contacts allow the horizontal movements of the man-
dible against the upper jaw and the stimuli to the
alveolar bone is higher (27, 28).
The aim of this investigation was to analyse quanti-
tatively palatal morphology in bruxist and non-bruxist
children with mixed dentition. Bruxism involves a
higher activity of the masticatory muscles in the
affected children (1) and higher size of dental wear
(29), and this may provoke alterations in hard tissue
structures, which could lead to higher size of palate in
the bruxist children.
This study was developed as a first approach to
accomplish the hypothesis that a higher activity of the
muscles previously reported in animal models (30)
could modulate the sagittal growth of the maxillary
arch. The reason is that the palatine raphe acts as a
fulcrum and produces an expansion of the arch when a
labialization of the alveolar process occurs.
Materials and methods
A case–control study was performed. The procedures,
possible discomforts or risks, as well as possible benefits
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
were fully explained to the participating patients and
their parents and the informed consent from the
parents was obtained prior to the investigation. Insti-
tutional Ethics Committee of the CES University
approved the study.
Subjects
Participating children were Colombian (mean age
bruxist children 9Æ3 years, s.d. 0Æ8; control children
9Æ4 years, s.d. 0Æ7) and they were required to be healthy
with normal facial morphology, complete primary
teeth, presence of dental wear, no history of trauma
present and absence of other types of oral habits, such
as mouth breathing, tongue thrusting or sucking habits.
The sample size was calculated with a confidence of
95% and a statistical power of 80%. The number of
subjects required in each group to make comparisons
was 19.
Inclusion criteria
An evaluation of the temporomandibular joint (TMJ)
was performed on all the children together with a
questionnaire and a clinical examination according to
Bernal and Tsamtsouris (31).
Children’s anxiety was measured using the Con-
ners’ Parents Rating Scales (CPRS; 32). Both instru-
ments, the Tsamtsouris and Bernal and CPRS tests
had been previously used to diagnose bruxism in
children.
Children were included in the bruxist group (n = 23)
when their anxiety level was above 0Æ75% according to
the CPRS, presented two or more signs of TMD
according to Bernal and Tsamtsouris and they accom-
plished the classification criteria proposed by the
American Academy of Sleep Medicine (AASM; 33) for
bruxism. The AASM criteria for bruxism are the
following:
1. The parents of the children indicated the occurrence
of tooth-grinding or tooth-clenching during sleep.
2. No other medical or mental disorders (e.g., sleep-
related epilepsy, accounts for the abnormal movements
during sleep).
3. Other sleep disorders (e.g., obstructive sleep apnea
syndrome) were absent.
All the parents were required to sleep close to their
children for at least 2 weeks before the beginning of the
study.
 PALATE MORPHOLOGY OF BRUXIST CHILDREN WITH MIXED DENTITION
Fig. 1. Digitized points on the stone
cast of each palate. IP: incisive
papilla; RP: posterior-most raphe
point; 6R, 6L: right and left first
permanent molars; 5R, 5L: right and
left fifth teeth; 4R, 4L: right and left
fourth teeth; 3R, 3L: right and left
third teeth; M: sagittal ‘molar’ point.
The children in the control group (n = 23) accom-
plished the second and third criteria of the AASM, but
not the first one.
One hundred and eighty eight Colombian children
aged 8 to 11 years were initially evaluated. Forty-six
individuals were finally selected and included in the
study. Standardizations of the examiners and calibra-
tion of the techniques were made in 10 subjects. The
methods were highly reproducible without statistically
significant intra-tester and inter-tester errors (ICC*
>0Æ9, and Kappa >0Æ7).
Techniques
The maxillary dental arches of all subjects were repro-
duced from alginate impressions cast in dental stone.
The models were stored for a week to avoid dimen-
sional changes. For technical reasons, the models of two
bruxist and seven control children were discarded, thus
leaving a total of 23 children for each group.
All subjects had a mixed dentition in their maxillary
arch, with permanent first molars, central and lateral
incisors. In the control group, two children had second
premolars, 12 children had first premolars and five
children had permanent canines. In the bruxist group,
one child had second premolars and six children had
first premolars.
*Intraclass Correlation Coefficient.
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
355
Digitization of palates and mathematical equation
The method has been described elsewhere (22, 23, 34,
35). In brief, on each cast, the intersections of the
palatal sulci of the right and left sixth (first permanent
molars in all occasions), fifth, fourth and third teeth
with the gingival margin (landmarks 6R, 6L, 5R, 5L,
4R, 4L, 3R, 3L in Fig. 1), the incisive papilla (IP) and
the most posterior limit of the palatal raphe (RP) were
identified and marked. The intermolar 6R-6L line and
its perpendicular starting from IP were traced and
their intersection point was marked as M. On the
IP-M, 6R-6L, 5R-5L, 4R-4L and 3R-3L lines, approx-
imately 12–20 nearly equidistant points were then
marked. The x, y, z coordinates of the landmarks were
obtained with an electromagnetic three-dimensional
digitizer (3Draw)† interfaced with a computer (15).
Digitization of landmarks was performed by a single
operator.
Computer programs devised and written by one of
the authors were used for all the following calculations.
A common orientation for all palates was obtained by
mathematically setting the plane described by IP, 6R,
and 6L as horizontal (x-axis, corresponding to the 6R-
6L line, right-left; y-axis, anterior-posterior; and z-axis,
caudo-cranial). Actually, this plane is tilted forward, no
assessment of the spatial relationships between palate
†
Polhemus Inc., Colchester, VT, USA.
356 C . C . R E S T R E P O et al.
and craniofacial structures was performed. For each
palate, the following measurements were obtained:
Sagittal plane:
Palatal length, horizontal projection of the IP-M line
(unit: mm).
Palatal slope, slope of the maximum palatal height
versus the horizontal axis (degrees).
Maximum palatal height (mm).
Horizontal plane:
Angle between the IP-RP and the IP-M lines (RP,
degrees).
Frontal plane:
Palatal widths and maximum palatal heights at the first
permanent molars, fifth, fourth and third teeth (6R-6L,
5R-5L, 4R-4L and 3R-3L distances in mm).
All coordinates were then standardized in the frontal
plane as percentages of the intermolar distance 6R-6L (x
coordinate) and in the sagittal plane as percentages of
the horizontal projection of the IP-M distance (y
coordinate).
The curve of the palatal surface was fitted to a fourth-
degree polynomial (13, 21): y = a x + bx2 + cx3 + dx4,
separately for the sagittal and the frontal (four curves
corresponding to 6R-6L, 5R-5L, 4R-4L and 3R-3L)
plane projections of the three-dimensional standardized
(i.e., size-independent) coordinates of the digitized
landmarks. In the frontal plane projection, the origin
of axes was set at 6R, the x-axis corresponded to the
right-left transverse line, and the y-axis to its vertical
perpendicular. In the sagittal plane projection, the
origin of axes was set at IP, the x-axis corresponded to
the horizontal projection of the IP-M distance, and the
y-axis to its vertical perpendicular. The four coefficients
of the polynomial equation were computed using the
least-square method, and the correlation coefficient r of
the curve was also assessed (21).
Statistical analyses
For each palatal measurement, descriptive statistics for
each group (bruxists, control children) were calculated.
Statistics for angular variables were computed using the
rectangular components of the angles. In both groups,
male and female data did not differ (Student’s t-test for
independent samples) and pooled values were consid-
ered.
The values obtained in the two groups were com-
pared by Student’s t-test for independent samples;
categorical variables were compared by Chi-squared
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
test. In all cases, two-tailed tests were used with a level
of significance set at 5%.
Error of method
The intra-operator repeatability of the measurements
was assessed by Ferrario et al. (13) by repeated tracings
(landmark identification) and digitizations of the same
casts. For each variable, the error of the method (error
percentage) was calculated as the percentage ratio
between the variance of the method error (squared
Dahlberg’s error) and the population variance of that
measurement (squared standard deviation). For land-
mark identification, the error percentage was always
less than 10% of the total biological variance. For
landmark digitization, the error percentage ranged
between 1Æ76% and 8Æ26%.
Results
The two groups of children (bruxist and control
children) were matched for age (mean age bruxist
children 9Æ3 years, s.d. 0Æ8; control children 9Æ4 years,
s.d. = 0Æ7, P > 0Æ05, Student’s t-test for paired samples)
and sex (no differences in the sex distribution, P > 0Æ05,
Chi-square test).
The sagittal length (IP-M in mm) and the raphe
angle (angle between the IP-RP and the IP-M lines)
were somewhat higher in the palate of the bruxist
children than in the non-bruxist children (Table 1).
Both measurements showed statistically significant
differences when comparisons were performed includ-
ing only the children with primary deciduous canines
(five control children excluded). In contrast, when the
children with permanent canines (late mixed denti-
tion) were included in the analysis, only sagittal
palatal height remained significantly longer in bruxist
children.
All palatal heights (in both the sagittal and frontal
planes) were somewhat higher in bruxist than in
control children, but the differences did not reach
statistical significance.
Palatal shape independently from size in both the
sagittal and frontal planes was well reconstructed by the
four-order polynomials, with coefficients of correlation
r ranging between 0Æ92 and 0Æ99.
In both groups, palatal shape independently from size
peaked in correspondence of the fifth teeth, and it
decreased progressively in the fourth and third teeth
 PALATE MORPHOLOGY OF BRUXIST CHILDREN WITH MIXED DENTITION 357

Table 1. Descriptive statistics of palatal size in 46 Colombian children with mixed dentition

Bruxists (n = 23) Controls (n = 23) T Controls (n = 18)* T

Plane Measure Mean s.d. Mean s.d. P-value Mean s.d. P-value

Sagittal IP-M 32Æ92 1Æ79 31Æ69 1Æ75 0Æ025 31Æ47* 1Æ82* 0Æ01*
Slope 18Æ40 0Æ65 18Æ60 0Æ37 NS 18Æ55* 0Æ42* NS*
Height 12Æ58 1Æ61 12Æ09 1Æ11 NS 12Æ00* 1Æ13* NS*
Horizontal Raphe 2Æ10 0Æ39 2Æ00 0Æ28 NS 1Æ89* 0Æ28* 0Æ05*
Frontal
6R-6L Width 33Æ19 2Æ25 33Æ69 2Æ50 NS 33Æ58* 2Æ61* NS*
Height 11Æ32 1Æ83 11Æ01 1Æ12 NS 10Æ94* 1Æ15* NS*
5R-5L Width 30Æ03 2Æ26 30Æ37 2Æ43 NS 30Æ31* 2Æ59* NS*
Height 13Æ02 1Æ73 12Æ46 1Æ18 NS 12Æ40* 1Æ26* NS*
4R-4L Width 26Æ64 2Æ09 25Æ87 2Æ23 NS 25Æ89* 2Æ28* NS*
Height 10Æ26 1Æ85 9Æ48 1Æ61 NS 9Æ48* 1Æ65* NS*
3R-3L Width 24Æ64 1Æ91 23Æ84 1Æ97 NS 23Æ78* 2Æ15* NS*
Height 4Æ98 1Æ50 4Æ05 1Æ64 NS 4Æ19* 1Æ76* NS*

IP, incisive papilla; NS: not significant.

*Control children with deciduous canines only (excluding the children with permanent canines).
All values are mm, except slope and raphe (degrees).
Comparison: Student’s t-test for independent samples; P > 0Æ05.

area (Fig. 2). In the first permanent molar area, palatal nent first molars); the same pattern of differences
shape was somewhat lower than in correspondence of observed in the complete groups was found (data not
the deciduous molar ⁄ premolar teeth. No differences shown).
between the two groups of children were observed in
the sagittal plane. Overall, bruxist children had higher
Discussion
palate in the frontal plane than control children,
especially in correspondence of the thrid, fourth and It is difficult to compare the present findings with those
fifth teeth. of literature reports, because quantitative investigations
Analyses were also performed separately for the 15 of normal palatal size and shape are uncommon. Only
control and 14 bruxist children who had no perma- three-dimensional computerized analyses can correctly
nent teeth apart from the first molars (deciduous assess palatal morphology (22, 36). Both surface-based
central and lateral incisors, canines, molars, perma- and landmark-based methods have been used. Indeed,
most surface-based approaches are time-consuming,
requiring several scans for each cast, and they seem best
Non bruxist Bruxist suited for the analysis of selected patients (for instance,
cleft-palate children), they are of difficult application
for a wide-scale collection of data.
The major limitation of landmark-based methods
seems to be the reduced number of digitized land-
IP M IP M
marks, which approximates the analysed structure
4R-4L 5R-5L 4R-4L 5R-5L neglecting most information (22, 24). In this investi-
6R-6L 6R-6L
gation, palatal morphology was analysed along four
3R-3L 3R-3L
6R 6L 6R 6L left-right curves (third, fourth, fifth and sixth teeth)
and one anterior-posterior curve (approximately cor-
Fig. 2. Palatal shape independently from size in bruxist and
control children. Upper panel: sagittal plane projection; lower
responding to the palatal midline), thus supplying a
panel: frontal plane projection (all four curves are drawn). x-axis sufficient approximation of its size and shape charac-
unit: % of 6R-6L distance; y-axis unit: % of IP-M distance. teristics (23, 24).

ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd

358 C . C . R E S T R E P O et al.
The width of the upper arch had been previously
estimated with single measurements like the interca-
nine distance (37), and correlated to habits and some
para-functions, such as dummy-sucking, finger-sucking
habit, oral breathing (38), breast and bottle sucking
(37), but not with bruxism. In the sucking cases, the
intercanine distance was reduced in the children who
practiced parafunctional activities. According to the
present research, bruxism seems to have no effect on
the palatal width when the bruxist children were
compared with the control children.
In contrast, this para-function had some effect on
both the length and the raphe angle of the palate when
comparisons between the bruxist and the control group
included in the analysis only the children with primary
deciduous canines. Also, palatal shape modified with a
relatively higher palate in bruxist than in non-bruxist
children.
Both intercanine and interfourth teeth width were
slightly larger in the bruxist children than in the control
children, with mean differences of 0Æ8–0Æ9 mm. It is well
known that the intercanine distance of the upper arch
increases when primary canines exfoliate and the per-
manent canines erupt (39). It is possible that the higher
muscular activity (40), the increased movements of the
mandible (41, 42) and the higher bite force (43) through
the upper arch during bruxism might have accelerated
the modifications in palatal shape in the bruxist children.
These bruxist forces stimulate the proprioception of the
periodontal ligament (44) and the process of apposition –
resorption (45) of the upper alveolar bone that leads the
arch to growth both in length and in height. As the roots
of the deciduous canines are shorter than those of the
relevant permanent teeth, the dental structures present
less resistance to movement.
The natural characteristics of the occlusal plane have
been described l elsewhere (46). Specific changes can
be seen when the dentition grinds (47–49), not only
occlusal changes (50, 51) (shortening and widening of
the dental is seen, creating space for erupting and
migrating teeth) but also cephalometric changes (52).
In fact, dramatic transformations in the craniofacial
morphology and the dentoalveolar development can be
seen when pre-historic and present day populations are
compared. This could be a possible explanation for the
significantly longer palate in bruxist children than in
control children.
In this study, the two analysed groups (bruxist and
non-bruxist children) were matched for gender and
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
age. When boys and girls were separately analysed, no
gender-related patterns were found. Indeed, Slaj et al.
(53) showed that in the early mixed dentition, longi-
tudinal comparisons of width, depth and dental arch
segment–length changes between male and female
subjects did not yield any statistically significant differ-
ence in a 2-year period. Also, no effect of the exfoliation
of deciduous molars ⁄ eruption of premolars was
observed.
Conclusions
This investigation showed sagittal plane differences in
the palate between bruxist and non-bruxist children
matched for age and gender. In bruxist children, the
higher muscular activity (19, 20, 54, 55) and the
dental wear may have accelerated the normal devel-
opmental modifications in the palatal shape. This
finding has to be taken into account in the diagnosis
of the occlusal development in children with para-
functions, because if a child has bruxism, then his ⁄ her
arches could be bigger than the ones of a child without
bruxism.
This was a pilot study, and accordingly, data inter-
pretation and conclusions should be judicious until
further studies are conducted. The differences in palatal
proportions found in this study were small, although
some of them were statistically significant, and may
therefore not be so clinically significant.
References
1. Negoro T, Briggs J, Plesh O, Nielsen I, McNeill C, Miller AJ.
Bruxing patterns in children compared to intercuspal clench-
ing and chewing as assessed with dental models, electromy-
ography and incisor jaw tracing: preliminary study. ASDC J
Dent Child. 1998;65:449–458.
2. Lobbezzo F, Naeije M. Bruxism is mainly regulated centrally,
not peripherally. J Oral Rehabil. 2001;28:1085–1091.
3. Castelo PM, Gaviao MB, Pereira LJ, Bonjardim LR. Relation-
ship between oral parafunctional ⁄ nutritive sucking habits and
temporomandibular joint dysfunction in primary dentition.
Int J Paediatr Dent. 2005;15:29–36.
4. Camparis CM, Siqueira JT. Sleep bruxism: clinical aspects and
characteristics in patients with and without chronic orofacial
pain. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2006;101:188–193.
5. Bonjardim LR, Gaviao MB, Pereira LJ, Castelo PM, Garcia RC.
Signs and symptoms of temporomandibular disorders in
adolescents. Pesqui Odontol Bras. 2005;19:93–98.
6. Magnusson T, Egermarki I, Carlsson GE. A prospective
investigation over two decades on signs and symptoms of
 PALATE MORPHOLOGY OF BRUXIST CHILDREN WITH MIXED DENTITION
temporomandibular disorders and associated variables. A final
summary. Acta Odontol Scand. 2005;63:99–109.
7. Molina OF, dos Santos J, Mazzetto M, Nelson S, Nowlin T,
Mainieri ET. Oral jaw behaviors in TMD and bruxism: a
comparison study by severity of bruxism. Cranio.
2001;19:114–122.
8. Demir A, Uysal T, Guray E, Basciftci FA. The relationship
between bruxism and occlusal factors among seven- to
19-year-old Turkish children. Angle Orthod. 2004;74:672–676.
9. Sari S, Sonmez H. The relationship between occlusal factors
and bruxism in permanent and mixed dentition in Turkish
children. J Clin Pediatr Dent. 2001;25:191–194.
10. Oksenberg A, Arons E. Sleep bruxism-related to obstructive
sleep apnea: the effect of continuous positive airway pressure.
Sleep Med. 2002;3:513–515.
11. Manfredini D, Landi N, Fantoni F, Segù M, Bosco M. Anxiety
symptoms in clinically diagnosed bruxers. J Oral Rehabil.
2005;32:584–588.
12. Tsai CM, Chou SL, Gale EN, Mccall JR. Human masticatory
muscle activity and jaw position under experimental stress.
J Oral Rehabil. 2002;29:44–51.
13. Bayardo RE, Mejia JJ, Orozco S, Montoya K. Etiology of oral
habits. ASDC J Dent Child. 1996;63:350–353.
14. Lobbezoo F, Soucy JP, Montplaisir JY, Lavigne GJ. Striatal d2
receptor binding in sleep Bruxism: a controlled study with
iodine-123-iodobenzamide and single-photon-emission com-
puted tomography. J Dent Res. 1996;75:1804–1810.
15. Lobbezoo F, Soucy JP, Hartman NG, Montplaisir JY, Lavigne
GJ. Effects of the d2 receptor agonist bromocriptine on sleep
bruxism of two single-patient clinical trials. J Dent Res.
1997;76:1610–1614.
16. Mehl A, Gloger W, Kunzelmann KH, Hickel R. A new optical
3-D device for the detection of wear. J Dent Res.
1997;76:1799–1807.
17. Kerstein R. Disclusion time measurement studies: stability of
disclusion time – a 1-year follow-up. J Prosthet Dent.
1994;72:164–168.
18. Krogstad O, Dahl BL. Dento-facial morphology in patients
with advanced attrition. Eur J Orthod. 1985;7:57–62.
19. Waltimo A, Nystrom M, Kononen M. Bite force and dento-
facial morphology in men with severe dental attrition. Scand J
Dent Res. 1994;102:92–96.
20. Kiliaridis S, Johansson A, Haraldson T, Omar R, Carlsson GE.
Craniofacial morphology, occlusal traits, and bite force in
persons with advanced occlusal tooth wear. Am J Orthod
Dentofacial Orthop. 1995;107:286–292.
21. Kerdpon D, Sirirungrojying S. A clinical study of oral tori in
southern Thailand: prevalence and the relation to parafunc-
tional activity. Eur J Oral Sci. 1999;107:9–13.
22. Ferrario VF, Sforza C, Schmitz JH, Colombo A. Quantitative
description of the morphology of the human palate by a
mathematical equation. Cleft Palate Craniofac J. 1998;35:396–
401.
23. Ferrario VF, Sforza C, Colombo A, Dellavia C, Dimaggio FR.
Three-dimensional hard tissue palatal size and shape in
human adolescents and adults. Clin Orthod Res. 2001;4:
141–147.
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
359
24. Ciusa V, Dimaggio FR, Sforza C, Ferrario VF. Three-dimen-
sional palatal development between 3–6 years of age. Angle
Orthod. 2007;77:602–606.
25. Ferrario VF, Sforza C, Tartaglia GM, Sozzi D, Caru A. Three-
dimensional lip morphometry in adults operated on for
cleft lip and palate. Plast Reconstr Surg. 2003;111:2149–2156.
26. Maki K, Nishioka T, Shioiri E, Takahashi T, Kimura M. Effects
of dietary consistency on the mandible of rats at the growth
stage: computed X-ray densitometric and cephalometric
analysis. Angle Orthod. 2002;72:468–475.
27. Simoes WA. Selective grinding and Planas’ direct tracks as a
source of prevention. J Pedod. 1981;5:298–314.
28. Simoes WA. Better oral neurophysiology information gives
better clinical results. J Pedod. 1983;8:108–115.
29. Restrepo C, Pelaez A, Alvarez E, Paucar C, Abad P Digital
imaging of patterns of dental wear to diagnose bruxism in
children. Int J Paediatr Dent. 2006;16:278–285.
30. Tuxen A, Rostrup E. Histochemical characterization of pig
masseter muscle: an animal model. Scand J Dent Res.
1993;101:57–61.
31. Bernal M, Tsamtsouris A. Signs and symptoms of temporo-
mandibular joint dysfunction in 3 to 5 year old children.
J Pedod. 1986;10:127–140.
32. Conners CK, Sitarenios G, Parker JD, Epstein JN. The revised
Conners’ Parent Rating Scale (CPRS-R): factor structure,
reliability and criterion validity. J Abnorm Child Psychol.
1998;26:257–268.
33. Buysse DJ, Young T, Edinger JD, Carroll J, Kotagal S.
Clinicians’ use of the international classification of sleep
disorders: results of a national survey. Sleep. 2003;26:48–51.
34. Ferrario VF, Sforza C, Colombo A, Tartaglia GM, Carvajal R,
Palomino H. The effect of ethnicity and age on palatal size and
shape: a study in a northern Chilean healthy population. Int J
Adult Orthodon Orthognath Surg. 2000;15:233–240.
35. Ferrario VF, Garattini G, Colombo A, Filippi V, Pozzoli S,
Sforza C. Quantitative effects of a nickel-titanium palatal
expander on skeletal and dental structures in the primary and
mixed dentition: a preliminary study. Eur J Orthod.
2003;25:401–410.
36. Ferrario VF, Sforza C, Miani A Jr, Tartaglia G. Mathematical
definition of the shape of dental arches in human permanent
healthy dentitions. Eur J Orthod. 1994;16:287–294.
37. Ogaard B, Larsson E, Lindsten R. The effect of sucking habits,
cohort, sex, intercanine arch widths, and breast or bottle
feeding on posterior crossbite in Norwegian and Swedish
3-year-old children. Am J Orthod Dentofacial Orthop.
1994;106:161–166.
38. Valera FC, Travitzki LV, Mattar SE, Matsumoto MA, Elias AM,
Anselmo-Lima WT. Muscular, functional and orthodontic
changes in pre school children with enlarged adenoids and
tonsils. Int J Pediatr Otorhinolaryngol. 2003;67:761–770.
39. Moorrees CF, Reed RB. Changes in dental arch dimensions
expressed on the basis of tooth eruption as a measure of
biologic age. J Dent Res. 1965;44:129–141.
40. Cosme DC, Baldisserotto SM, Canabarro Sde A, Shinkai RS.
Bruxism and voluntary maximal bite force in young dentate
adults. Int J Prosthodont. 2005;18:328–332.
360 C . C . R E S T R E P O et al.
41. Baba K, Akishige S, Yaka T, Ai M. Influence of alteration of
occlusal relationship on activity of jaw closing muscles and
mandibular movement during submaximal clenching. J Oral
Rehabil. 2000;27:793–801.
42. Amemori Y, Yamashita S, Ai M, Shinoda H, Sato M,
Takahashi J. Influence of nocturnal bruxism on the sto-
matognathic system. Part I: a new device for measuring
mandibular movements during sleep. J Oral Rehabil. 2001;
28:943–949.
43. Nishigawa K, Bando E, Nakano M. Quantitative study of bite
force during sleep associated bruxism. J Oral Rehabil.
2001;28:485–491.
44. Southard TE, Southard KA, Tolley EA. Periodontal force: a
potential cause of relapse. Am J Orthod Dentofacial Orthop.
1992;101:221–227.
45. Nascimento A, Sallum AW. Periodontal changes in distant
teeth due to trauma from occlusion. J Periodontal Res.
1975;10:44–48.
46. Simoes WA. Occlusal plane: a clinical evaluation. J Clin
Pediatr Dent. 1995;19:75–81.
47. Kaifu Y, Kasai K, Townsend GC, Richards LC. Tooth wear and
the ‘‘design’’ of the human dentition: A perspective from
evolutionary medicine. Am J Phys Anthropol. 2003;37:47–61.
48. Helm S, Prydso U. Assessment of age-at-death from mandib-
ular molar attrition in medieval Danes. Scand J Dent Res.
1979;87:79–90.
ª 2008 The Authors. Journal compilation ª 2008 Blackwell Publishing Ltd
49. Varrela J. Dimensional variation of craniofacial structures in
relation to changing masticatory-functional demands. Eur J
Orthod. 1992;14:31–36.
50. Kiliaridis S, Johansson A, Haraldson T, Omar R, Carlsson GE.
Craniofacial morphology, occlusal traits and bite force in
persons with advanced occlusal tooth wear. Am J Orthod
Dentofacial Orthop. 1995;107:286–292.
51. Varrela J. Occurrence of malocclusion in attritive environ-
ment: a study of a skull sample from southwest Finland. Scand
J Dent Res. 1990;98:242–247.
52. Varrela J. Effects of attritive diet on craniofacial morphology:
a cephalometric analysis of a Finnish skull sample. Eur
J Orthod. 1990;12:219–223.
53. Slaj M, Jezina MA, Lauc T, Rajic-Mestrovic S, Miksic M.
Longitudinal dental arch changes in the mixed dentition.
Angle Orthod. 2003;73:509–514.
54. Bader G, Lavigne G. Sleep bruxism; an overview of an
oromandibular sleep movement disorder. Sleep Med Rev.
2000;4:27–43.
55. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological
mechanisms involved in sleep bruxism. Crit Rev Oral Biol
Med. 2003;14:30–46.
Correspondence: Claudia C. Restrepo, Carrera 38 No. 6 B Sur 25,
Apartamento 1002, Medellin, Columbia.
E-mail: martinezrestrepo@une.net.co, rarestre@une.net.co