Effect of a full-arch maxillary occlusal splint on

parafunctional activity during sleep in patients with

nocturnal bruxism and signs and symptoms of
craniomandibular disorders
K. Holmgren, DDS,” A. Sheikholeslam, PhD,b and C. Riise, PhD’:
Karolinska Institutet, Stockholm, Sweden

This study was designed to investigate the effects of the occlusal splint on
parafunctional oral motor behavior (grinding and clenching) during sleep in
patients with bruxism and craniomandibular disorders. The results revealed that
the splint does not stop nocturnal bruxism. In 61% of the patients, wear facets on
the splint were observed at every visit (a-week intervals) and in 39%, from time to
time. The wear facets reappeared in the same location with the same pattern and
were caused mainly by grinding. The extension of the facets showed that, during
eccentric bruxism, the mandible moved laterally far beyond the edge-to-edge
contact relationship of the canines. (J PROSTHET DENT 1993;09:293-7.)

T he occlusal splint is the most widely accepted

form of therapy for nocturnal bruxism and ensuing signs
and symptoms of craniomandibular disorders (CMD). It
has been reported that in patients with nocturnal bruxism,
the level of cumulative nightly electromyographic (EMG)
activity of the masseter muscle is reduced after insertion of
a full-arch maxillary occlusal splint’ or a bite plate.2 When
patients discontinued use of the occlusal splint, the level of
EMG activity increased to the pretreatment 1evel.l How-
ever, because of methodological limitations and technical
difficulties in recording parafunctional activity of noctur-
nal bruxism over long periods, the long-term effects of the
occlusal splint in patients with nocturnal bruxism have not
been studied.
There have also been attempts to evaluate parafunc-
tional activity during sleep by means of sound transduction Fig. 1. Pattern of wear facets on occlusal splint of a pa-
and electromyography. Unfortunately, because of meth- tient with bilateral mandibular movements.
odological limitations of recorded data, such as single-
muscle EMG recording, these studies have not provided
adequate information concerning the kinesiology of brux- MATERIAL AND METHODS
ism. Thirty-one patients (26 women and five men, 18 to 38
The purpose of this investigation was to study the long- years of age, median age of 27 years) with nocturnal brux-
term effects of a full-arch maxillary plane occlusal splint on ism and signs and symptoms of CMD were included in this
the mechanical activity, or kinesiology, of parafunctional study. The patients were selected according to t,he follow-
oral motor behavior (grinding and clenching) during sleep ing criteria: (1) awareness of grinding and clenching during
in patients with nocturnal bruxism and signs and symp- sleep, (2) pain and a tired feeling in the masticatory mus-
toms of CMD. cles and/or headache on waking in the morning, (Z)
tenderness of the masticatory muscles on palpation, and (4)
complete natural dentitions except for third molars.”
A full-arch maxillary occlusal splint in heat-cured acrylic
aDepartmentof Clinical Oral Physiology. resin was made for each patient4 to wear during sleep. The
“Department of Clinical Oral Physiology. splint was adjusted with the patient in supine position to
CRepartmentof Clinical Oral Physiology.
provide a stable occlusion in the retruded contact position
Copyright 0 1993by The Editorial Council of THE JOURNALOF
PROSTHETIC DENTISTRY. and in habitual closure. To avoid restricting the mandible
0022-3913/93/$1.00 +.lO. 10/l/43328 during parafunction, the canine ramps were removed, so

MARCH 1993 393

THE JOURNAL OF PROSTHETIC DENTISTRY HOLMGREN, SHEIKHOLESLAM, RIISE

Fig. 3. Pattern of facets on occlusal splint of a patient

Fig. 2. Pattern of facets on occlusal splint of a patient with isometric contraction of the elevator muscles with
with unilateral mandibular movements. small lateral movements.

that it was possible for the patient to make smooth lateral ied from patient to patient. In 61% of the patients, active
and protrusive movements. The stability of the splint was shiny wear facets were found at every visit (2-week inter-
also controlled and adjusted if necessary with the patient vals), whereas in the remaining 39 % , they were observed
seated upright. The patients were instructed strongly and from time to time.
repeatedly not to clench or grind on the splint before fall- The active wear facets on the splint reappeared in the
ing asleep. same location with a similar pattern and direction. In 71%
The patients were reexamined at 2-week intervals dur- of the patients, these facets were created by bilateral man-
ing the course of this study. In each visit, the location of dibular clenching excursions (Fig. 1) and in 13 % , by uni-
wear facets caused by bruxing and the retruded contact lateral excursions (Fig. 2). In one patient (3%) the facets
position on the occlusal splint were recorded and photo- were created by protrusive movements. In the remaining
graphed. The splint was then very gently polished with fine 13 % the facets were created by isometric clenching of the
sandpaper only to remove the shiny area of the active fac- jaw elevators with very small lateral movements (Fig. 3).
ets. The stability of the splint was also reexamined, and in The extension of the facets on the occlusal splint showed
case of alteration, it was readjusted. There were no alter- that during eccentric bruxism the mandible moved later-
ations to the occlusion, such as fillings and crowns, made ally far beyond the position of the canines’ edge-to-edge
during the course of this study. contact relationship.
The patients were instructed to take no medication such
as tranquilizers, muscle relaxants, or sleeping tablets dur- Signs and symptoms
ing the course of treatment. Treatment with the occlusal In general, the intensity and score of signs and symptoms
splint continued until total elimination of signs and symp- of CMD in these patients fluctuated day to day and from
toms or up to 6 months. period to period, and successively improved or were elim-
The signs and symptoms of CMD were recorded from 2 inated with use of the occlusal splint (Figs. 4 and 5).5
to 4 weeks before until 3 to 6 months after insertion of the When the patients whose signs and symptoms were im-
splint, and when the patients stopped using it.5 Nonpara- proved by the treatment (78%) were asked to stop using
metrical statistical analysis (chi-square test) was used to the splints, fluctuating signs and symptoms of CMD
compare before- and after-treatment observations of signs recurred in 89% of them within 4 weeks.5 Eighty-four per-
and symptoms of CMD. cent of the patients also reported continuation of nightly
bruxism.
RESULTS
Insertion of the occlusal splint DISCUSSION
Insertion of the splint resulted into a mean increase of The results of this study revealed that, in general, the
the vertical dimension by an average of 3.7 mm (range 3 to occlusal splint does not stop the habit of nocturnal brux-
4.5 mm) in the incisal area. ism. This is in line with the findings of Gentz,6 and Kydd
Active shiny facets caused by nocturnal bruxism ap- and Daly7 who reported that a plane occlusal splint did not
peared on the occlusal surface of the splints of all patients. stop nocturnal bruxism. The results also revealed that, in
However, the reappearance frequency of these facets var- spite of continuation of bruxism, the signs and symptoms

294 VOLUME 69 NUMBER 3

HOLMGREN, SHEIKHOLESLAM, RIISE THE JOURNAL OF PROS’! HRTIC DENTISTRY

Percentage of patients

90807060604030 2010 0

Pain in temporal region

’ Pain in cheek region

Pain in joint region

‘Pain in neck region

’ Headache

Reduced mobility

Joint sounds

m Before treatment
•j After treatment
Fig. 4. Symptoms of craniomandibular disorders in 31 patients with nocturnal bruxism
before and after occlusal splint therapy. Levels of significance as follows: ns, not signifi-
cant, p > 0.05; *O.Ol < p < 0.05; **O.OOl < p < 0.01; *** p < 0.001.

of CMD were reduced successively with use of the occlusal clusal splint on parafunctional activity of bruxers without
splint. Therefore, it seems most likely that the therapeutic CMD remain to be studied for further comparison.
mechanism of the splint must be related to factors that In 39% of the patients, the wear facets on the occlusal
modify and reduce parafunctional activity and/or redis- splint reappeared from time to time. The results indirectly
tribute its overloading in the masticatory system instead of are in line with t.he findings of Kardashi et a1.l’ and Rugh
eliminating bruxism.5 and Ohrbach,12 who reported that the level of cumulative
The etiology and neurologic mechanism that generates EMG activity of nocturnal bruxism fluctuates from night
the episode of nocturnal bruxism are not well understood. to night and from month to month. The cause of this fluc-
However, a growing body of evidence suggests that noctur- tuation is not understood. It has been reported that the
nal bruxism appears to be induced within the central ner- number of episodes of nocturnal bruxing increases in indi-
vous system and, in part, is associated with the phenome- viduals anticipating stressful situationsI and is closely re-
non of arousal reactions during sleep.8-10The findings of lated to the stress level of the previous day.‘, l* It seems
this study showed that changes in input feedbacks of pe- likely that changes in daily emotional stress can not be
ripheral oral receptors (alteration in the occlusal contact solely responsible for eliciting nocturnal bruxism, because
relationship and increased vertical dimension), do not stop 19 % of the patients in this study have been grinding their
the bruxism. Further studies however are needed to deter- teeth since childhood, and they continued to do so during
mine the effects of the occlusal splint on intensity and du- the study and after discontinuing use of the splint.
ration of the episode of parafunctional activity. The results showed that the location and pattern of wear
It should be noted that because of the criteria used for facets on the occlusal splint did not change during the
the selection of patients, the findings of this study are lim- course of the study. This finding indirectly can explain the
ited to bruxers with CMD. Therefore, the effects of the oc- cause of the selective tooth attrition in patients with noc-

MARCH 1993
THE JOURNAL OF PROSTHETIC DENTISTRY HOLMGREN, SHEIKHOLESLAM, RIISE

Percentage of patients
100 90 80 70 60 50 40 30 20 10 0

Tenderness in anterior temporal m.

Tenderness in posterior temporal m.

Tenderness in temporal tendon

Tenderness in masseter m.

Tenderness in TMJ

Tenderness in postcervical m.

Tenderness in sternocleidomastoid m

Maximal opening<40 mm.

Reciprocal clickings
n Before treatment
Crepitation sounds
q After treatment
Fig. 5. Signs of craniomandibular disorders in 31 patients with nocturnal bruxism before
and after occlusal splint therapy. Levels of significance as follows: ns, not significant,
p > 0.05; *0.01 < p < 0.05; **0.001 < p < 0.01; *** p < 0.001.

turnal bruxism. In an electron microscopic study of the (grinding and clenching) during sleep were studied in
structural morphology of wear facets, Xhonga” reported bruxers with craniomandibular disorders. The results re-
that the scratches on enamel had the same direction as vealed that the occlusal splint does not stop the habit of
those in the dentine into which the wear had progressed. nocturnal bruxism. In 61% of the patients, active wear
In more than 80 % of the patients, the wear facets on the facets on the splint were observed at every visit (2-week
occlusal splints were created by lateral mandibular move- intervals) and in 39 % , from time to time. The wear facets
ments (grinding). The result is in line with findings of Rugh reappeared in the same location with the same pattern and
and Ohrbach,i2 who reported that the action in nocturnal were caused mainly by grinding. The extension of the fac-
bruxism is primarily grinding instead of clenching. The ets also showed that during eccentric bruxism the mandi-
high frequency of grinding behavior in the patients in our ble moves laterally far beyond the edge-to-edge contact re-
study can also be the result of the selection criteria that lationship of the canines.
were used.
The results revealed that during eccentric bruxism, the REFERENCES
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296 VOLUME 69 NUMBER 3

HOLMGREN, SHEIKHOLESLAM, RIISE THE JOURNAL OF PROS’I’BNTIC DENTISTRY

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