International Journal of Oral Science (2012) 4, 141–145

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ORIGINAL ARTICLE

Effects of sleep bruxism on functional and occlusal

parameters: a prospective controlled investigation
Michelle Alicia Ommerborn1, Maria Giraki1, Christine Schneider2, Lars Michael Fuck3, Jörg Handschel4,
Matthias Franz2, Wolfgang Hans-Michael Raab1 and Ralf Schäfer2

This study was conducted to verify the results of a preceding retrospective pilot study by means of a prospective controlled investigation
including a larger sample size. Therefore, the aim of this clinical investigation was to analyze the relationship between sleep bruxism
and several functional and occlusal parameters. The null hypothesis of this study was that there would be no differences among sleep
bruxism subjects and non-sleep bruxism controls regarding several functional and occlusal parameters. Fifty-eight sleep bruxism
subjects and 31 controls participated in this study. The diagnosis sleep bruxism was based on clinical criteria of the American Academy
of Sleep Medicine. Sixteen functional and occlusal parameters were recorded clinically or from dental study casts. Similar to the
recently published retrospective pilot study, with a mean slide of 0.77 mm (s.d., 0.69 mm) in the sleep bruxism group and a mean slide
of 0.4 mm (s.d., 0.57 mm) in the control group, the evaluation of the mean comparison between the two groups demonstrated a larger
slide from centric occlusion to maximum intercuspation in sleep bruxism subjects (Mann–Whitney U-test; P50.008). However,
following Bonferroni adjustment, none of the 16 occlusal and functional variables differed significantly between the sleep bruxism
subjects and the non-sleep bruxism controls. The present study shows that the occlusal and functional parameters evaluated do not
differ between sleep bruxism subjects and non-sleep bruxism subjects. However, as the literature reveals a possible association
between bruxism and certain subgroups of temporomandibular disorders, it appears advisable to incorporate the individual adaptive
capacity of the stomatognathic system into future investigations.
International Journal of Oral Science (2012) 4, 141–145; doi:10.1038/ijos.2012.48; published online 31 August 2012

Keywords: dental occlusion; functional parameters; prospective study; sleep bruxism

INTRODUCTION teeth, shiny spots on restorations are well-known to be the most

Sleep bruxism has characteristically been defined by the American frequently occurring effects, in particular, on the dental hard tissue.15
Academy of Sleep Medicine as ‘an oral activity characterized by grin- Moreover, a possible association between bruxism and temporoman-
ding or clenching of the teeth during sleep, usually associated with sleep dibular disorders (TMDs) is supposed, but the available literature
arousals’.1 Although numerous investigations stress the assumption of reveals heterogeneous data.9,16–18 For some past time, by indicating a
a central causation, such as neuropathophysiology and psychology,2–6 relationship between bruxism and posture, diverse studies draw the
a detailed clarification regarding the aetiology of sleep bruxism is still attention to a more extensive context.19–25 However, the authors of a
lacking. To date, most authors correspond with the supposition of a recently published review come to the conclusion that a scientific prove
multifactorial development of sleep bruxism.7–9 During a few years, to support a cause–effect relationship is still missing.26
explanatory models in the field of the dental profession, such as occlu- To gain information on the clinical interaction among sleep bru-
sal interferences or variances in the orofacial anatomy,10–12 are xism and several occlusal and functional parameters by using a more
thought to be of inferior, possibly without any, relevance in the clinically feasible, but investigator-independent assessment tool for
development of sleep bruxism activity.13 For this reason, the percep- sleep bruxism diagnosis, in a recently published pilot study 16 occlusal
tion in respect of the relationship between sleep bruxism and the and functional parameters were recorded and compared with those
stomatognathic system has changed.13–14 Consequently, sleep bru- obtained from a non-sleep bruxism control group.27 By means of a
xism is supposed to be induced centrally, whereas the effects of this retrospective study design, the diagnosis of sleep bruxism was per-
parafunctional activity are predominantly found in the stomatognathic formed using a specifically conceived computer-based analyzing
system. Undoubtedly, apart from associated effects, such as unpleasant method for the Bruxcore Bruxism-Monitoring Device that has pre-
muscle and tooth sensations, limitation of jaw movements, oral and viously evaluated regarding its ability to objectively differentiate
facial pain, and headache;1 tooth attrition, fractured cusps or entire between sleep bruxism subjects and an adequate non-sleep bruxism
1
Department of Operative Dentistry, Periodontics, and Endodontics, Heinrich-Heine-University, Düsseldorf, Germany; 2Institute of Psychosomatic Medicine and Psychotherapy,
Heinrich-Heine-University, Düsseldorf, Germany; 3Private Practice in Orthodontics, Konrad-Adenauer-Platz 4, Langenfeld, Germany and 4Department of Cranio- and
Maxillofacial Surgery, Heinrich-Heine-University, Düsseldorf, Germany
Correspondence: Dr MA Ommerborn, Department of Operative Dentistry, Periodontics and Endodontics, Heinrich-Heine-University, Moorenstr 5, Düsseldorf 40225, Germany
E-mail: [email protected]
Received 17 April 2012; accepted 30 May 2012
 Effects of sleep bruxism
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142

control group.28 Considering all variables tested, with an approxi- biting were determined. Furthermore, the Angle’s Classification of
mately 0.5 mm larger slide from centric occlusion (CO) to maximum malocclusion, recorded on the right and the left side for the canines
intercuspation (MI) in the sleep bruxism group, the results solely and for the first molars,36 as well as the anterior crowding in the
demonstrated a statistically significant group difference regarding mandible (classified on a five-point scale: 0, no crowding; 1, 1–3 mm
the length of the slide from CO to MI. of crowding; 2, 3–5 mm; 3, 5–7 mm; 4, .7 mm) were identified from
In order to verify the results of the former pilot study, as a next step a dental study casts.13,27 Due to either missing canines or first molars in
prospective controlled investigation including a larger sample size has some patients, the sample size varied between 68 and 65 participants.
been conducted using the clinical criteria of the American Academy of
Sleep Medicine for sleep bruxism diagnosis.1,6 Therefore, the aim of Statistical analysis
the present prospective study was to analyze the relationship between Statistical analyses were performed using the statistical software SPSS
sleep bruxism and several functional and occlusal parameters. The null version 19.0 (IBM Corp., Armonk, NY, USA). Normal distribution of
hypothesis of this study was that there would be no differences among the variables was verified by means of the Kolmogorov–Smirnov test
a sample of sleep bruxism subjects and a non-sleep bruxism control combined with the assessment of histograms. The Pearson Chi-square
group regarding several functional and occlusal parameters. test was applied to determine the significance of differences between
two independent groups when data consisted of frequencies in quali-
MATERIALS AND METHODS tative variables. If a normal distribution of the data was found, the
independent samples Student’s t-test was applied for the analysis of
Selection of subjects
mean differences between both groups in quantitative variables. For all
The entire sample consisted of 91 subjects, of whom 58 were females
quantitative variables with lacking normal distribution, differences
and 33 were men with a mean age of 28.37 years (standard deviation
were evaluated by means of the nonparametric Mann–Whitney U-test.
(s.d.), 4.89 years; age range, 20–39 years). They were all German native
When using the Mann–Whitney U-test, the adequate statistical values
speakers and responded to announcements in local newspapers and
are the mean ranks and the sum of ranks. However, to improve the
placards on campus. Each participant was screened following a thor-
comparability of the obtained results, data are presented as means and
ough dental examination. As applied in former investigations,5–6,28–30
s.d.. For all statistical analyses, an a-error probability level of P,0.05
the diagnosis of sleep bruxism was based on the clinical criteria of the
was defined as the statistical significant level. To correct the observed
American Academy of Sleep Medicine.1 Individuals who met the fol-
significance level according to the number of comparisons made,
lowing criteria were included in the sleep bruxism group: healthy
Bonferroni adjustment was applied. Since 19 comparisons were per-
adults, aged between 20 and 40 years, sleeping partner reports of
formed including sociodemographic data, the Bonferroni-adjusted
grinding sounds during the night in the last 6 months, and at least
probability level amounted to P,0.003.
one of the following symptoms: self-report of muscle fatigue or ten-
derness on awakening, the presence of tooth wear to at least the mag-
RESULTS
nitude of dentin exposure,31 and masseter hypertrophy upon
voluntary forceful clenching.1,17 Comparisons of the two groups showed no significant differences
regarding age, gender and education (Table 1). Furthermore, in
Exclusion criteria were: current dental treatment, severe psycho-
Tables 2 and 3, for the quantitative variables, the means and s.d., or
logical disorder and/or the use of antipsychotic psychotropic drugs,
for the qualitative variables, the frequency distributions, are presented
central nervous system and/or peripheral nervous system disorders,
for the occlusal and functional variables, respectively.
more than two missing molars (excluding third molars), the presence
Similar to the aforementioned pilot study, with a mean slide of
of prosthesis or extensive prosthetic restorations and the presence of
0.77 mm (s.d., 0.69 mm) in the sleep bruxism group and a mean slide
gross malocclusion. Healthy adults, from whom sleep bruxism could
of 0.4 mm (s.d., 0.57 mm) in the control group, the evaluation of the
be excluded, represented the control group. Exclusion criteria were the
mean comparison between the two groups demonstrated a larger slide
same as for the sleep bruxism group as well as any signs and symptoms
from CO to MI in sleep bruxism subjects (P50.008). Furthermore,
of sleep bruxism. All subjects gave informed consent to the procedures
considering the frequency distributions of the qualitative variables, the
approved by the Institutional Human Subjects Ethics Committee
presence of a slide from CO to MI (P50.008), as well as the presence of
(Heinrich-Heine-University of Duesseldorf).
lesions related to lip and/or cheek (P50.013) biting was more fre-
quently observed in sleep bruxism subjects than in controls.
Functional and occlusal parameters However, following Bonferroni adjustment none of the 16 occlusal
At first, each of the 91 participants had a thorough dental examination and functional variables differed significantly between sleep bruxism
which was performed by one trained dentist of the department. subjects and non-sleep bruxism controls.
Similar to the recently published pilot study which used the newly
developed computer-based analyzing method for calculating abrasion
Table 1 Sociodemographic data of sleep bruxism subjects and
on the Bruxcore Bruxism-Monitoring Device as measure for sleep
controls
bruxism activity,27–28 the following functional and occlusal para-
meters were clinically recorded by means of a digital calliper: vertical Variable Sleep bruxism group Controls P

(overbite) and horizontal (overjet) overlap of the maxillary and man- Age 29.0964.65 27.1265.10 0.065a
dibular right central incisors, maximum active mouth opening, ma- Gender 39 (67.2%) F; 19 (32.8%) M 19 (57.6%) F; 14 (42.4%) M 0.357b
ximum active right and left lateral movement of the mandible, Education 3 x1; 0 x2; 36 x3; 19 x4 2 x1; 2 x2; 24 x3; 5 x4 0.095b,c
maximum protrusive movement of the mandible, the presence of a Following to Bonferroni adjustment, significance level amounted to P,0.003.
slide from CO to MI32 and, if present, the length of the slide from CO a
Two-samples t-test; data are presented as mean6s.d.
to MI. The recording of the slide has been performed as described b
Chi-square test.
previously.27,32–34 Moreover, the resiliency of the left and right c
Education was divided into four grades: x1, 10 years school; x2, 12 years school; x3,
TMJ,35 as well as the presence of lesions related to lip and/or cheek 13 years school; x4, 18 years school (university).

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 Effects of sleep bruxism
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143

Table 2 Functional and occlusal parameters of sleep bruxism sub- bruxism subjects and a non-sleep bruxism control group with respect
jects and controls (quantitative variables) to the occlusal and functional parameters evaluated could not be
Variable/mm Sleep bruxism group Controls P rejected.
When interpreting the underlying reasons for the observed dis-
Overbite 2.6061.22 3.0261.38 0.142a
crepancies between the retrospective pilot study and the present
Overjet 2.7361.26 2.8261.62 0.732b
Maximum active mouth opening 50.3565.41 51.8366.47 0.243a
prospective controlled investigation, methodological and statistical
Maximum active right movement 9.3262.39 9.0262.34 0.558a considerations need to be included, such as the prospective analysis
Maximum active left movement 9.9462.10 9.7962.48 0.757a of a larger sample size or the application of classical Bonferroni cor-
Maximum active protrusive 8.9162.23 8.2161.94 0.138a rection.37–38 The Kolmogorov–Smirnov test revealed that the variable
movement length of a slide from CO to MI was not normally distributed.
Resiliency of the right TMJ 0.5860.29 0.5860.30 0.882b Consequently, the calculated s.d. were expected to be high. General-
Resiliency of the left TMJ 0.5960.34 0.5660.28 0.700b ly, it is a fact that if a likewise large sample is investigated the scattering
CO to MI slide 0.7760.69 0.4060.57 0.008b
will be reduced and, thus, this will strengthen the reliability of the test
Following to Bonferroni adjustment, significance level amounted to P,0.003. used in the present study. From a critical point of view, the probability
a
Two-samples t-test; data are presented as mean6s.d. is, therefore, comparatively high that the effect which has been
b
Mann–Whitney U-test; data are presented as mean6s.d. recorded in the preceding pilot study was by chance.
Comparisons of the present data with other previous investigations
could not easily be performed due to diverse reasons. For instance,
Table 3 Frequencies of several functional and occlusal parameters.
different criteria or methods have been applied for sleep bruxism
In this table the qualitative variables are presented.
diagnosis and, accordingly, this resulted in different sample composi-
Variable Sleep bruxism group Controls P
tions.13,39 Moreover, diverse studies vary regarding the parameters
Right canine (n568) 17 Class I 11 Class I 0.455a that have been recorded. For example, one investigation included a
27 Class II 9 Class II group of treated bruxism subjects, untreated bruxism subjects, and
3 Class III 1 Class III subjects with TMDs as well, whereas the details for sleep bruxism
11 Missing 12 Missing
diagnosis have not been reported in detail. The evaluation of this more
Left canine (n568) 24 Class I 12 Class I 0.707a
inhomogeneous sample revealed that 100% of the participants had
22 Class II 8 Class II
1 Class III 1 Class III laterotrusive interferences, 78% had mediotrusive interferences and
11 Missing 12 Missing 95.4% showed premature contacts.39 Considering the before men-
Right first molar (n565) 14 Class I 9 Class I 0.324a tioned arguments, a comparison of this outcome with the present data
19 Class II 10 Class II could hardly be made. In another study, a clear description of the
11 Class III 2 Class III sample composition has been performed by using the polysomno-
14 Missing 12 Missing graphic criteria for sleep bruxism diagnosis.13 In this investigation,
Left first molar (n566) 21 Class I 11 Class I 0.425a
26 occlusal and cephalometric measures have been evaluated in a
14 Class II 7 Class II
sample of 10 sleep bruxism subjects and 10 controls. As result, none
11 Class III 2 Class III
12 Missing 13 Missing
of the measures tested revealed a statistically significant difference
Anterior crowding (n568) 0: n59 0: n53 0.644a between the two groups. On the basis of their results, authors
1: n534 1: n515 concluded that the orofacial morphology of sleep bruxism subjects
2: n53 2: n53 does not differ from that of non-sleep bruxism subjects. However,
3: n51 3: n50 as the mentioned study had a retrospective design and, moreover,
11 Missing 12 Missing still included a sample size of 20 subjects, the authors point at its
Presence of a CO to MI slide 41 (70.7%) 14 (42.4%) 0.008a low statistical power. Taken these limitations into account, the
(n591)
authors emphasized the need to carry out further investigations
Lip/cheek biting (n591) 16 (27.6%) 2 (6.1%) 0.013a
in this field in terms of a larger sample and an experimental and
Following to Bonferroni adjustment, significance level amounted to P,0.003. prospective character.39
a
Chi-square test. In this context, attention should be drawn to the process of sleep
bruxism diagnosis. Undoubtedly, due to the good performance of the
DISCUSSION validity parameters, to date, the laboratory polysomnographic recor-
The purpose of the present study was to verify the findings of a pre- dings represent the highest standard for sleep bruxism diagnosis,29 but
vious retrospective pilot study27 by means of a prospective controlled they are concomitantly associated with disadvantages which include
investigation including a larger sample size. The main result of the technical complexity, limited availability,5–6 and the fact that they are
present investigation was that considering the 16 occlusal and func- time-consuming and cost-intensive.40 Similar to the abovementioned
tional parameters evaluated, sleep bruxism subjects and controls do study,13 this is seen in comparatively small sample sizes of polysom-
not differ significantly. Indeed, similar to the forecited retrospective nographic studies,41–42 which limits the applicability of this method,
investigation, the same 16 occlusal and functional parameters have in particular, for clinical studies with larger sample sizes.6 As addressed
been used in the present study. Moreover, the values which have been above, when comparing the outcome of the aforementioned ret-
recorded for these 16 variables in both studies move into a similar rospective study with the present data, it must be indicated that both
direction, however, following the Bonferroni adjustment each of the investigations have evaluated partially different variables and have
obtained differences between the sleep bruxism group and the controls used different assessment methods for sleep bruxism diagnosis.
failed to reach the level of statistical significance. For this reason, our Notwithstanding these differences, both studies correspond with
hypothesis that there are no differences among a sample of sleep respect to the fact that none of the measures that have been recorded

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144

in the respective study revealed a statistically significant difference as a sort of effector organ of sleep bruxism activity which is most likely
between sleep bruxism subjects and controls. For this reason, the induced by a central causation. Usually, sleep bruxism is not aggra-
results obtained in the present investigation were found as a reference vated by pain symptoms,16,45 however, as derived from the available
that the occlusal and functional parameters evaluated do not differ research, a possible association between bruxism and certain sub-
between sleep bruxism subjects and non-sleep bruxism subjects. groups of TMDs has been supposed.16–18,45–46 For this reason, it has
Furthermore, as a possible consequence of myalgia due to sleep to be asked at what point a stomatognathic system decompensates and
bruxism, a limitation of mouth opening and mandibular excursive turns to a disorder which requires a therapy. Further, some recent
movements in sleep bruxism subjects has also been reported.15,43 studies among the relationship of sleep bruxism and posture19–25 give
Since none of the variables regarding the mandibular movement an initial hint that consequences of sleep bruxism may be also detec-
showed a significant difference between the sleep bruxism group table in other peripheral areas of the whole body. However, it should be
and the non-sleep bruxism controls, on the basis of the data derived pointed out that the last attempt requires further scientific evaluation to
from the present investigation, these movement limitations could not support a cause–effect relation due to diverse reasons (e.g., partly
be confirmed as well. Moreover, if the present data are interpreted reported by means of case reports and studies including only small
including physiologic mean values of mandibular movement sample sizes).20,24 In the same way as regarding the stomatognathic
capacity,44 the values that have been recorded in both the sleep system, one has to wonder among what circumstances further peri-
bruxism group, as well as in the control group were located within pheral systems of the whole body decompensate and turn to a manifest
normal range. disorder or reveal negative effects following to long-term sleep bru-
When interpreting the data of the present investigation, both the xism. Considering these questions, it appears advisable to turn one’s
current knowledge on the development of sleep bruxism, as well as its attention closer to the individual adaptive capacity which has an
possible effects ought to be taken into consideration. The main result impact on both the stomatognathic system and other peripheral sys-
of the present prospective study was that regarding 16 functional and/ tems of the human body. For an improved summary, these considera-
or occlusal parameters sleep bruxism subjects did not differ signifi- tions were merged to a hypothetical model as illustrated in Figure 1.
cantly. Accordingly, this outcome supports the conclusion of previous Likewise to other medical disciplines,47–50 this might offer the oppor-
authors that there is no proof for a role of dental occlusion and factors tunity to a more sophisticated understanding why one subject with
related to the anatomy of the orofacial skeleton in the aetiology of sleep sleep bruxism will develop in addition to the immediate effects of sleep
bruxism.8 Moreover, as derived from the present results, the mandi- bruxism on the dental hard tissues a manifest TMD or, perhaps at a later
bular function does not appear to be involved too. Therefore, the date, further effects in other peripheral regions of the whole body and
authors of the present study may propose that the stomatognathic why another subject with sleep bruxism will not. Possible components
system, in particular, the dental occlusion should rather be viewed which might influence the adaptive capacity are physiologic basics (such

Figure 1 Schematic illustration which includes the current knowledge on the development of sleep bruxism and its possible effects on the stomatognathic system
and/or other peripheral systems of the whole body. Moreover, to contribute to a more sophisticated understanding, the possible role of the adaptive capacity is
embraced.

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145

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