Art-2-Slavicek
OCCLUSION AND TMJ www.stomaeduj.com
ON THE TRACK OF BRUXISM: QUANTITATIVE,
Original Articles
QUALITATIVE AND INTRAINDIVIDUAL ANALYSES
OF THE BRUXCHECKER® IN DAILY CLINICAL ROUTINE
1,2,a* 1,3 1,4,b 1,2,c
Gregor Slavicek , David Grimmer , Anastasia Novitskaya , Florian Slavicek
¹Steinbeis Transfer Institute Biomedical Interdisciplinary Dentistry, Steinbeis University Berlin, DE-12489 Berlin, Germany
²Orehab Minds GmbH, DE-70567 Stuttgart, Germany
³Zahntechnik Baltz GbR, DE-73728 Esslingen am Neckar, Germany
⁴Dental Clinic Smiletime, RU-14106 Podolsk, Podolsky District, Russia
a
MD, DDS, MSc, Director and Head, CEO and Head; e-mail: g.slavicek@orehab-minds.com; ORCIDiD: https://orcid.org/0000-0003-2454-4048
b
DDS; e-mail: anastasia.novitskaya@gmail.com; ORCIDiD: https://orcid.org/0000-0003-3446-3866
c
BSc ; e-mail: f.slavicek@orehab-minds.com; ORCIDiD: https://orcid.org/0000-0003-4245-7829
ABSTRACT https://doi.org/10.25241/stomaeduj.2020.8(3).art.2
Introduction Bruxism is a relevant topic in daily dental routine. Bruxism has to be confirmed by instrumental
procedures. The BruxChecker® (BC) is an inexpensive instrument that does not affect the stomatognathic
system while used and is suitable for routine use in diagnostics and follow-ups. A novel digital approach for
analyzing BC is described, based on first standard values.
Material and Method Within this pilot study, 30 participants (15 males, 15 females) used an upper BC for
one night and a lower BC during another night. A standardized digitalization process and a unique software
application measured all Tooth Contact Areas (TCAs) on the BC: number and size of each TCAs for each
occlusal segment.
Results The mean number of TCAs on upper BC is 28.17 (sd +/-7.84), for lower BC 27.70 (sd +/-7.41). The
mean size (mm2) of TCAs on upper BC is 71.81 (sd +/-51.27), for lower BC 68.11 (sd +/-42.64). There are only
minor, not significant, gender differences regarding the number and size of TCAs. The transversal right-left
TCAs distribution is almost symmetrical; a slightly increased difference can be observed for the size of TCAs
right and left. The sagittal distribution of the TCAs shows the dominance of the posterior contacts, while the
intermediate segments are least involved.
Conclusion Within the limits of this pilot study and based on the digital analyses of TCAs on BC, the paper
presents first standard values and a two-step systematic individual BC analysis.
KEYWORDS
Bruxism; Occlusal Functions; Oral Rehabilitation; Parafunction; Tooth Contact Areas.
1. INTRODUCTION But the majority of clinicians focus primarily on
the possible negative consequences of bruxism:
BC visualizes the contacts between teeth that occur chipping, occlusal trauma, tooth migration, temporo-
during unconscious teeth grinding or clenching mandibular disorder [2]. The issue of the significance
during awake and sleep bruxism. The BC is fabricated of teeth grinding in humans is controversially
for the individual patient using the pressure molding discussed in medicine. Is it an abnormal function,
technique. Comparing the actual bruxing scheme on a movement disorder [3]? Or, in contrast, can SB
the BC with a so-called optimal centric and eccentric be assessed as a relevant physiological occlusal
occlusal situation is one suggested possibility to function [4]? If one takes this view, then parafunction
analyze the BC. However, understanding the optimal represents a secondary function beside primary
occlusion does not make it easier to work with the occlusal functions. The increasing acceptance of
suggested classification scheme. In any case, the considering SB as a physiologic function modifies
BC analyses must consider the laterotrusive and the the fundamental methodical approach. Today
mediotrusive side contacts during bruxing [1]. SB is graduated in possible (based on patient's
A paradigm shift in the assessment of sleep bruxism self-reports), probable (determined by clinical
(SB) took place in recent years. SB is no longer inspection), and definite (verified by an instrumental
understood solely as a harmful movement disorder. analysis) [5].
OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
Peer-Reviewed Article
Citation: Slavicek G, Grimmer D, Novitskaya A, Slavicek F. On the track of bruxism: quantitative, qualitative and intraindividual analyses of the
BruxChecker® in daily clinical routine. Stoma Edu J. 2021;8(3):163-171.
Received: August 11, 2021; Revised: August 23, 2021; Accepted: August 31, 2021; Published: September 03, 2021
*Corresponding author: Dr. Gregor Slavicek; Zettachring 2, DE-70567 Stuttgart, Germany;
Tel./Fax: +49-7307-24922-11;
e-mail: g.slavicek@orehab-minds.com
Copyright: © 2021 the Editorial Council for the Stomatology Edu Journal.
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Dentists are interested in the best possible care for clinics. If, however, the use of instruments in bruxing
Original Articles
their (bruxing) patients. All diagnostics have impacts subjects primarily refers to polysomnography [4],
on the therapeutic decisions. Expert opinions the immediate practical implementation is limited
regarding the best therapeutic concepts of SB differ by apparent obstacles. Mobile devices that measure
substantially. Instead of the term "therapy" the phrase the muscle activity of selected masticatory muscles
"management" is often utilized [6]; however, both or record the forces on sensors in occlusal devices
terms exclusively refer to the negative consequences are available but elude clinical applicability due
of teeth grinding. Based on today's knowledge, there to missing cut-off values [15]. Devices measuring
is no indication to treat a most probably physiological tooth contacts in centric and eccentric mandibular
oral function. Management recommendations inclu- positions are available and successfully used in
de, among others, behavioral advice, medication, restorative dentistry. But such approaches are
physiotherapy, or physical intervention [7]. The suitable only to a minimal extent for verifying
therapeutic goal of "stop bruxing" can never be awake or sleep bruxism, as the measurement takes
achieved [8]. Such therapeutic concepts must be place in a completely different setting: awake
regarded as meaningless [9]. Dentists find themselves patients, sitting upright in a dental chair, with an
constricted between these points of view: is a invasive measuring instrument placed intraorally,
management strategy necessary? Or are occlusal performing artificial mandibular movements trying
measures to influence/stop bruxism? Are occlusal to simulate unconscious bruxing. The execution of
therapeutic changes indicated or contraindicated in so-called bruxing movements is very different from
bruxing patients? It must be understood that awake those performed in various sleeping postures with
and sleep bruxism will still be executed after occlusal changing head positions. The BC is a device for such
therapy, but maybe with less muscular strength minimally invasive investigation of unconscious
and minor eccentric mandibular movements. The tooth contacts during sleep. A classifying evaluation
ability and the necessity to influence bruxism by of the BC enables an initial assessment [16]. But
occlusal parameters is still a matter of controversy. occlusion and occlusal structures are core elements
Occlusal factors such as the inclination of occlusal
in dentistry, and this can be rated as unique
guiding structures in the anterior and posterior
proposition of dental clinics. Occlusal Rehabilitation
occlusal segments seem to play an important role
aims to maintain and re-establish oral function such
in muscle recruitment during bruxism [10]. In silico
as chewing and bruxing [17].
simulation demonstrated that both the direction
The BC visualizes functional TCAs. But the
and the size of the bruxing force vectors adapt and
interpretation of the BC remains challenging, and
change due to the position and the inclination of
many dentists left the use of BC again after their
occlusal guiding structures [10]. Grinding areas and
initial enthusiasm. For this reason, the authors of this
occlusal parameters such as anterior occlusal plane
article suggest a different, systematic approach for
and overbite are closely related [11]. The need of an
the BC analysis based on numerical data. This pilot
oral Rehabilitation of bruxing patients is a common
situation in daily dentistry. Patients present with study aims to determine quantitative and qualitative
impaired chewing surface morphology, the risk of data of occlusal contacts areas on BruxCheckers for
increased mechanical and technical complications sleep bruxism.
in prosthodontic Rehabilitation rises. Prosthetic
intervention in a patient with (heavy) bruxism 2. MATERIAL AND METHOD
without taking into consideration heavy occlusal
loading on materials and constructions will end 60 already used BC from 30 subjects served as the
in a breakdown. "Failure to do so may indicate data source in this exploratory study. Females
earlier failure than is the norm." [12]. Successful oral and males participated in the study. The exclusion
Rehabilitation in patients with severely worn teeth criteria comprise persons younger than 16 years and
seems to be independent of the materials of choice. older than 35 years, participants with two or more
Direct or indirect materials may be feasible options missing teeth, removable (partial and total) and/or
to restore severely worn teeth [13]. extensive fixed prosthodontic Rehabilitation. This
From a clinician's point of view, more clinical studies manuscript did not require ethical approval. Each
are required, with a clear focus on the clinical impact subject signed an informed consent after being
on oral structures of bruxism. The decision-making informed about the study in detail. The use of the
process for successful interventions in bruxing BC followed the guidelines and recommendations of
patients requires more detailed and focused studies the manufacturer (Scheu Dental, Iserlohn, Germany).
[14]. As soon as patients recognize symptoms, The data analysis uses the BC used by the participants
they demand clarification. A link to awake or sleep for one night; clinical intervention did not take place.
bruxism is often not reported by the patient in this Each participant used two BC for one night, but
stage. The clarification of bruxism using instruments not simultaneously. Only sleep bruxism TCAs were
is required to confirm the subjective report of the analyzed in this pilot study. Before evaluation, white
patient [4]. The various uses of instrumental analysis silicon reinforced the contrast of the TCAs against
are known in dentistry and are routine in many dental the red color of the BC.
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A validated procedure was applied to digitize the BC. comparison (e.g., between lateral or sagittal
Original Articles
Reproducibility tests demonstrated the soundness of distribution) could recognize an effect size of 0.2
the digitizing process a priori - a series of 7 recordings with the same group size (paired t-test) [18].
of 16 BCs (8 upper and 8 lower BC) were included for After the study, all participants received a detailed
that test. A password-protected zip folder guarded report on their BC findings.
the data. Finally, the data set listed the automatically
measured key figures number and area of TCAs for 3. RESULTS
each BC. The calculation of the maximal differences
and the standard deviations for the differences The mean age of all participants was 27 years (sd
followed. The formula [means +/-(sd*1.96)] sets +/- 4.98 years). The female participants had an
an upper and lower tolerance limit. Bland-Altman average age of 26 years with a sd of 5.3 years, the
Diagrams visualized the results. If all means of record male study participants had an average age of 28
years (sd +/- 4.4 years). All participants had a natural
1 to record 7 for all BC were within the upper and
occlusion with only minor restorations. 27 (80%) had
lower tolerance limits, adequate reproducibility can
full dental arches, not considering wisdom teeth.
be derived (Fig. 1a,1b). For anonymization, a 7-digit
In comparison, 14 (47%) presented one or more of
unique identifier tags each BC. A short anonymous the following findings: lingual retainer of front teeth
questionnaire collected information on gender, [4 (13%) upper and 8 (26%) lower]; missing teeth [3
age, and subjective symptoms, possibly related to (10%) participant, one missing tooth 14, one missing
grinding and clenching. Table 1 presents the personal tooth 37 and one missing tooth 47].
functional status of the study participants. In an Table 1 presents the subjective functional status of
automatic evaluation process, using a calibrated the study participants (personal self-assessment
software (Orehab Minds GmbH, Germany), the via VAS). The symptom pain for different locations
number and size of each TCAs were determined appears with a minimum of 1 and a maximum of 4
and assigned to a specific segment of the occlusion on the VAS. The different localizations of the pain
(right-anterior, left-anterior, right-intermediate, showed no noticeable deviations. However, the
left-intermediate, right-posterior, left-posterior). intensity of the pain, including its impact on activities
For the statistical analysis, IBM SPSS Statistics 25 was of daily life (AoDL), individual stress levels, and the
used. The outcome measures are continuous data; reported quality of sleep, are widely spread. Although
this pilot study aimed not to identify associations
a pretest served to estimate the expected standard
between TCAs and symptoms, the collected data
deviation. The sample size for this pilot study (n=30
will serve as a basis for further studies to determine
participants, n=60 BC) was set on 20% of the sample
whether TCAs' number, size, or distribution are
size calculation for a planned clinical trial with equally related to patients' symptoms.
relevant subgroups (e.g., dental status, gender, age, All 60 BC (30 upper and 30 lower) from 30 individuals
comorbidity, occlusal characteristics). One hundred are analyzed. The mean value of the number of TCAs
fifty participants would still be sufficient to assign for the upper occlusion is n = 28.2 (sd +/- 7.8) with a
minor standardized differences in occlusal contact minimum number of 11 and a maximum number of
areas with a power of 80% for two-sided errors of 39 TCAs (Fig. 2a). The mean value of the number of
type 1 (alpha) (two-sample t-test). Intra-individual TCAs for the lower occlusion is 27.7 (sd +/- 7.4), with
Figure 1a. Bland-Altman-Diagram to demonstrate the reproducibility Figure 1b. Bland-Altman-Diagram to demonstrate the reproducibility
of the analytic process for BC. Here, the measurement parameter is the of the analytic process for BC. Here, the measurement parameter is size of
number of TCAs on upper BC. 8 BC were included; digitizing was repeated TCAs on upper BC. 8 BC were included; digitizing was repeated 7 times per
7 times per BC (56 records in total). The mean difference (1,5) and the BC (56 records in total). The mean difference (0,6) and the tolerance limits
tolerance limits (upper: 4,46 and lower: -1,46) were calculated. The mean (upper: 1,03 and lower: 0,168) were calculated. The mean differences per
differences per BC are indicated (•); all are located between the upper and BC are indicated (•); all are located between the upper and lower limit. No
lower limit. No outliers are detectable; the limits are not exceeded. A slight outliers are detectable; the limits are not exceeded. A slight dependence
dependence on the number of TCAs may exist. on the number of TCAs may exist.
BC BruxChecker; TCAs Tooth Contact Areas. BC BruxChecker; TCAs Tooth Contact Areas.
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Original Articles Parameter
VAS 0-10
Mean sd min max
tooth_ache* 3.77 0.68 1 4
headache* 3.67 0.55 2 4
backpain* 3.30 0.70 1 4
facialpain* 3.93 0.37 2 4
temporal_pain* 3.90 0.40 2 4
ear_tmj_pain* 3.77 0.57 2 4
pain_mouth_open* 3.83 0.46 2 4
pain_mastication* 3.87 0.43 2 4
Figure 2c. Histogram to show the distribution of the size of TCAs for all
AoDL_influenced* 3.10 1.73 1 8 upper BC, females and males. The mean number of TCAs is 71.81 with a sd
overal_pain_intensity* 3.00 1.64 1 8 of 51.273 and a range of 211 (minimum 13, maximum 224). Based on this
sample, a normal distribution cannot be assumed (KS Test, p=0,021).
sleep_quality* 7.00 1.80 4 10 Measurements in mm2.
stress_level* 1 5.80 1.77 2 9 BC BruxChecker; TCAs Tooth Contact Areas; KS test Kolmogorov-Smirnov Test.
Table 1. Overview: reported symptoms of the participants. These data
were not collected to analyze correlations of TCAs (number and/or size)
with subjective complaints but to check the sample for consistency and to
support future sample size calculations.
TCAs Tooth Contact Areas; sd standard deviation, min minimum; max maximum, AoDL Activities of
Daily Living , VAS Visual Analog Scale..
Figure 2d. Histogram to show the distribution of the size of TCAs for all
lower BC, females and males. The mean number of TCAs is 68.11 with a sd
of 42.643 and a range of 183.5 (minimum 11, maximum 194.5). Based on
this sample, a normal distribution cannot be assumed (KS Test, p=0.047).
Measurements in mm2.
BC BruxChecker; TCAs Tooth Contact Areas; KS test Kolmogorov-Smirnov Test.
194.5mm2 for the inferior occlusion (Fig. 2c, 2d),
Figure 2a. Histogram to show the distribution of the number of TCAs for respectively. Table 2a and 2b summarizes these
all upper BC, females and males. The mean number of TCAs is 28.17 with a results. Kolmogorov-Smirnov Tests (KS test) tested
sd of 7.844 and a range of 28 (minimum 11, maximum 39). Based on this
the null hypotheses "Within this sample, number and
sample, a normal distribution cannot be assumed (KS Test, p=0.019).
BC BruxChecker; TCAs Tooth Contact Areas; KS test Kolmogorov-Smirnov Test
size of TCAs are normal-distributed." For the upper
BC, a normal distribution for both number (KS test,
p=0.019) and size (KS test, p=0.021) of TCAs cannot
be assumed; for the lower BC, a normal distribution
cannot be assumed for size (KS test, p=0.047), but for
the number of TCAs (KS test, p=0.2).
The comparison between females and males
shows only minor, not significant differences for
number of TCAs: for the males, an average of 29.13
(sd +/- 8.55) TCAs for the upper occlusion; for the
females, 27.2 (sd +/- 7.25); for the lower occlusion,
an average of 27.13 (sd +/- 6.01) TCAs for males,
for the females 28.26 (sd +/- 8.77), respectively.
The following data can be described for the size
Figure 2b. Histogram to show the distribution of the number of TCAs
for all lower BC, females and males. The mean number of TCAs is 27.7 with of TCAs: males, upper occlusion: 87.27mm2 (sd +/-
a sd of 7.405 and a range of 30 (minimum 13, maximum 43). Based on this 57.88mm2), females, upper occlusion: 56.35mm2 (sd
sample, a normal distribution can be assumed (KS Test, p=0.2). +/- 39.79mm2); males, lower occlusion: 80.38mm2 (sd
BC BruxChecker; TCAs Tooth Contact Areas; KS test Kolmogorov-Smirnov Test. +/- 46.11mm2), females, lower occlusion: 55.83mm2
a minimum number of 13 and a maximum number (sd +/- 36.29mm2) (Tab. 3). The minimal differences
of 43 (Fig. 2b). The mean size of TCAs is 71.8mm2 (sd between women and men related to TCAs also
appear in the direct comparison (Fig. 3a, 3b) [Mann-
+/- 51.3mm2) for the upper occlusion and 68.1mm2 Whitney U test for size of TCAs: upper BC p=0.09;
(sd +/- 42.6mm2) for the lower occlusion. The range lower BC p=0.08; Mann-Whitney U test for number
of TCAs size for upper occlusion encompasses a of upper BC: p=0.37; independent samples t-test for
span from 13mm2 to 224mm2 or from 11mm2 to number of lower BC: p=0.6].
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Original Articles
Upper Number of Tooth Size of Tooth Females Number of Tooth Size of Tooth
BruxChecker ® Contact Areas (n) Contact Areas Contact Areas Contact Areas
(mm2)
Upper Mean 27.2000 56.3533
N 30 30 BruxChecker ®
15 BC analysed sd 7.24273 39.79228
Mean 28.1667 71.81
Lower Mean 28.2667 55.8333
sd 7.84366 51.27321 BruxChecker®
15 BC analysed sd 8.76247 36.29183
Minimum 11.00 13.00
Maximum 39.00 224.20 Table 3a. Key figures for number and size of TCAs of upper and lower BC,
female participants.
Table 2a. Key figures for number and size of TCAs of upper BC, male and TCAs Tooth Contact Areas; BC BruxChecker; sd standard deviation.
female participants.
TCAs Tooth Contact Areas; BC BruxChecker; sd standard deviation. Males Number of Tooth Size of Tooth
Contact Areas Contact Areas
Lower Number of Tooth Size of Tooth
BruxChecker® Contact Areas (n) Contact Areas Upper Mean 29.1333 87.2667
(mm2) BruxChecker ®
15 BC analysed sd 8.54289 57.88172
N 30 30 Lower Mean 27.1333 80.3800
Mean 27.7000 68.1067 BruxChecker®
15 BC analysed sd 6.01031 46.11729
sd 7.40526 42.64273
Minimum 13.00 11.00 Table 3a. Key figures for number and size of TCAs of upper and lower BC,
male participants.
Maximum 43.00 194.50 TCAs Tooth Contact Areas; BC BruxChecker; sd standard deviation.
Table 2b. Key figures for number and size of TCAs of lower BC, male and Further attention during the analyses of BC has to
female participants. be paid to the distribution of TCAs right and left, the
TCAs Tooth Contact Areas; BC BruxChecker; sd standard deviation.
transversal (lateral) distribution. The number of TCAs
is almost identical on the right and left sides (Fig.
4a). There are minor differences in the distribution of
the size of TCAs on the right and left (Fig. 4b). Tab. 4a
and 4b present these results. The transversal (lateral)
distribution seems to be regardless of the number
or the size of TCAs (Fig. 4c, 4d). The evaluation of the
sagittal distribution weighs three sections: anterior
(corresponds largely to anterior teeth including
the canine), intermediate (corresponds largely to
the premolar region), and posterior (corresponds
largely to the molar region). The sagittal distribution
Figure 3a. Comparison of number of TCAs for females and males, of TCAs in the upper jaw is 8.2 (sd +/- 3.3) anterior,
shown for upper and lower BC. Boxes indicate the IQR [Q3-Q1], the lines (-)
7.5 (sd +/- 2.5) intermediate, and 12.5 (sd +/- 4.8)
indicate the median (Q2). The whiskers are limited by minimum and
maximum. Outliers (о) are identified if the distance to Q1 or Q3 is bigger posterior. The sagittal distribution of TCAs in the
than IQR multiplied by 1.5. In such cases, the whiskers are limited by the lower jaw is 8.3 (sd +/- 3.1) anterior, 6.6 (sd +/- 2.1)
value that just does not represent an outlier. intermediate, and 12.8 (sd +/- 4.6) posterior. The
TCAs Tooth Contact Areas; IQR Interquartile Range; Q1 First Quartile, Q2 Second Quartile, Q3 Third
Quartile.
following values describe the mean size of TCAs:
for the upper occlusion 28.2mm2 (sd +/- 23.7mm2)
anterior, 13.9mm2 (sd +/- 10.8mm2) intermediate
Figure 3b. Comparison of size of TCAs for females and males, shown
for upper and lower BC. Boxes indicates the IQR [Q3-Q1], the lines (-)
indicate the median (Q2). The whiskers are limited by minimum and Figure 4a. Comparison of the transversal (lateral) distribution of number
maximum. Outliers (о) are identified as such if the distance to Q1 or Q3 is of TCAs for total vs. right vs. left. Total (□), right (◄), and left (►) TCAs are
bigger than IQR multiplied by 1.5. In such cases, the whiskers are limited by shown for upper and lower BC (males and females).
the value that just does not represent an outlier. TCAs Tooth Contact Areas, BC BruxChecker.
TCAs Tooth Contact Areas; IQR Interquartile Range; Q1 First Quartile, Q2 Second Quartile, Q3 Third
Quartile.
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Original Articles
Figure 4b. Comparison of the transversal (lateral) distribution of size of Figure 5a. Comparison of the sagittal distribution of the number of
TCAs for total vs. right vs. left. Total (□), right (◄), and left (►) TCAs are TCAs for anterior vs. intermediate vs. posterior. Anterior (▲), intermediate
shown for upper and lower BC (males and females). (●), and posterior (♦) number of TCAs are shown for upper and lower BC
TCAs Tooth Contact Areas, BC BruxChecker. (males and females). Posterior sections are dominantly involved, while the
intermediate sections have the lowest number of TCAs. Similar distri-
butions are shown for upper and lower BC.
TCAs Tooth Contact Areas; BC BruxChecker.
Figure 4c. Scatter plot for size of right vs. left TCAs for the upper BC Figure 5b. Comparison of the sagittal distribution of the size of TCAs for
(males and females). The R2 value of 0,873 shows a tendency towards a anterior vs. intermediate vs. posterior. Anterior (▲), intermediate (●), and
symmetrical lateral distribution of the number of TCAs. posterior (♦) size of TCAs are shown for upper and lower BC (males and
TCAs Tooth Contact Areas; BC BruxChecker; R2 coefficient of determination. females). The dominance of posterior sections can only be seen for lower
BC, while the anterior and posterior sections of the upper BC are almost
equally involved. The intermediate sections show the smallest sizes of
TCAs.
TCAs Tooth Contact Areas; BC BruxChecker.
Based on this pilot study, the authors recommend a
two-step procedure for the systematic BC analysis:
Step 1 - Quantitative analysis; Step 2 - Qualitative
Analysis. In the future, an option of a third step (intra-
individual analysis) for individual occlusal planning
exists.
Step 1 - Quantitative analysis
The quantitative analysis of a BC: based on the
measured critical numbers for number and size; the
Figure 4d. Scatter plot for size of right vs. left TCAs for the lower BC
extent to which the individual uses occlusion when
(males and females). The R2 Value of 0,704 shows a tendency towards a
symmetrical lateral distribution of the size of TCAs. bruxing during sleep, compared to average values
TCAs Tooth Contact Areas; BC BruxChecker; R2 coefficient of determination. (Fig. 6).
and 29.7mm2 (sd +/- 24.9 mm2) posterior; for the Step 2 - Qualitative analysis
lower occlusion: 23.7mm2 (sd +/- 17.2mm2) anterior, Understand the distribution of TCAs on the BC is a
12.3mm2 (sd +/- 8.8mm2) intermediate and posterior crucial element in occlusal functional analysis. The
32.2mm2 (sd +/- 24.5mm2) posterior. The results following assumptions facilitate the qualitative
are summarized in Tables 5a and 5b and shown in analysis of a BC: involvement of all occlusal sections;
Figures 5a and 5b. A TCAs may exceed the midline symmetric transversal distribution; the sagittal
(right-left) or the boundaries between sections distribution shows the dominance of the posterior
(anterior-intermediate or intermediate-posterior). occlusal segments, both for the number and the
In such situations, TCAs are split up and allocated size of TCAs, followed by the anterior segments. The
proportionally to both sides of the adjacent sections. intermediate section shows the least participation
The areas are measured per TCAs and summed up (Fig. 7).
for each segment. Rounding errors can lead to Typically, the dental focus is on "large" and "eye-
minimal inaccuracies in the automatic summation in catching" grinding spots. However, such a focus
the decimal places. inhibits a deeper understanding of the involved
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occlusion. It is essential to pay attention to those This quantitative approach to BC enables the
Original Articles
occlusal sections not used in bruxing. In addition, it clinician not only to focus on adverse effects [1,6,8,
might be helpful to superimpose the visible TCAs on 12,13] but instead on therapeutic aspects – which
the BC and the functional structures of the occlusal occlusal parameters to be changed [10,11,17]. It
morphology (Fig. 8). seems possible to change the muscle recruitment
during bruxing activity by modifying occlusal
structures [10,11], based on an increased alertness
of dentists for TCA´s and their distribution by BC
visualization and numerical analyses. In addition,
it appears reasonable to alter bruxing patterns by
the design of occlusal parameters such as canine
guidance concerning the temporomandibular joint
movement pattern [17].
Figure 6. The quantitative analysis of an individual BC based on the The BC constitutes a clinically suitable instrument
measured key numbers for number and size of TCAs; value table and for long-time observation and a functional recall
graphical overview. after Rehabilitation. It is up to the supervising team
TCAs Tooth Contact Areas; BC BruxChecker.
whether other diagnostic methods should be used
[1,2,4,11].
Missing teeth may influence the quantitative
analysis of a BC. The number of the OCA´s on the
upper BC of participant with missing teeth are close
to the sample mean (missing first premolar: 36 TCAs;
Figure 7. The qualitative analysis of an individual BC based on the bar missing first lower molar: 29 TCAs; missing second
charts to point out the transversal and sagittal distribution of TCAs.
lower molar: 30 TCAs). The size of the OCA´s on the
TCAs Tooth Contact Areas; BC BruxChecker.
upper BC of these participant are close to the sample
mean (missing first premolar: 96.7mm2 TCAs; missing
first lower molar: 69.2mm2 TCAs; missing second
lower molar: 80.82mm2 TCAs). The number of the
OCA´s on the lower BC of these participant are close
to the sample mean (missing first premolar: 36 TCAs;
missing first lower molar: 22 TCAs; missing second
lower molar: 15 TCAs). The size of the OCA´s on the
upper BC of these participant are still high and close
Figure 8. An additional opportunity to use an individual BC is the
to the sample mean (missing first premolar: 92.4mm2
intraindividual occlusal analysis in comparing the distribution of actual and
expected TCAs within the dental arches. TCAs; missing first lower molar: 63.2mm2 TCAs;
TCAs Tooth Contact Areas; BC BruxChecker. missing second lower molar: 38.9mm2 TCAs). Missing
4. DISCUSSION teeth have to be considered in the BC analyses.
The effect of absent teeth on the key figures of BC
From the authors' point of view, the quantitative analysis has to be evaluated in future studies
approach is an advantage to understand the BC,
and thus for tooth grinding pattern of the individual 5. CONCLUSION
patient. The claim for instrumental confirmation by
the SB is fulfilled [4]. The key figures support the • The average size of TCAs in this study population
possibility to compare the individual situation with shows a high variance (72mm² +/-51 mm²).
standard values and expectations for optimized • The average number of TCAs in this study population
occlusion [3,16,17,19]. The distribution of TCAs for is 28 with a sd of +/-8.
the upper and lower occlusion is symmetric for the • There is only a not significant gender-specific
transversal (lateral) distribution and well-adjusted difference.
in the sagittal distribution. The following concepts • The lateral distribution of TCAs is symmetrical for
may explain the quantitative differences between both number and size.
upper and lower BC: a) different nights: bruxing • The sagittal distribution shows a dominance of the
activity varies from night to night; b) The lower posterior occlusion.
dental arch is smaller than the upper dental arch. c) • Based on the quantitative analysis, the clinician has
grinding of teeth has different effects on the upper the option to assess occlusion with the number and
and lower teeth, especially on anterior teeth: while size of TCAs and thus perform a functional-occlusal
the lower front teeth will contact with a relatively analysis: all sections of occlusal seems to be involved
small area during the entire bruxing movement, the in bruxing.
upper front teeth will be "used" widely – from centric • In the future, dentists’ attention can be focused
occlusion contact points up to the incisal edge. In more on the number of TCAs in combination with
the premolar and molar regions, these differences the size of TCAs: few but large TCAs should be seen
are less significant. differently compared to many but small TCAs.
Stoma Edu J. 2021;8(3): 163-171 pISSN 2360-2406; eISSN 2502-0285 169
Slavicek G, et all.
www.stomaeduj.com
• Occlusal segments without any TCAs have to be analysis and critically revising the manuscript. AN: contributed
Original Articles seen as critical as those with huge TCAs to the gathering and analysis, their interpretation and critically
• Based on the knowledge of the distribution of revising the manuscript. FS: contributed to the data analysis, their
number and size of TCAs, a qualitative analysis of interpretation and critically revising the manuscript.
the BC serves as a valuable element in the functional
assessment of the individual occlusion. ACKNOWLEDGMENTS
None.
AUTHOR CONTRIBUTIONS
GS: contributed to the concept, protocol, data gathering and CONFLICT OF INTEREST
analysis, their interpretation and critically revising the manuscript. Gregor Slavicek and Florian Slavicek are CEO’s of Orehab Minds
DG: contributed to the concept, protocol, data gathering and GmbH, DE-70567 Stuttgart, Germany.
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Gregor SLAVICEK
MD, DDS, MSc
CEO, Head & Director
Steinbeis Transfer Institute Biomedical Interdisciplinary Dentistry
Steinbeis University Berlin
DE-12489 Berlin, Germany
CV
Dr. Slavicek is an MD, specialized in Dentistry. He is currently Director of the Steinbeis Transfer Institute Biomedical Interdisciplinary
Dentistry, Steinbeis University Berlin. Since 2019, he has been CEO of Orehab Minds GmbH in Stuttgart, Germany. He graduated
from the University Vienna (medicine and dentistry), also specializing in Clinical Research at the same university (Master of
Science). He attended additional postgraduate orthodontic training at University Aarhus (Denmark), Prof. B. Melsen, and
postgraduate gnathological training at University of Florida (USA), Prof. H. Lundeen and Prof. C. Gibbs. He is an honorary member
of the Italian Gnathological Society. He was awarded an honorary professorship by the Ukrainian Dental Society. He was visiting
professor at the first medical state University in Moscow Sechenov (2014-2018).
170 Stoma Edu J. 2021;8(3):163-171 pISSN 2360-2406; eISSN 2502-0285
A systematic approach to understand BruxChecker®
www.stomaeduj.com
Questions
Original Articles
1. How can bruxism be graduated according to the actual international consensus?
qa. Possible, confirmed, severe;
qb. Possible, probable, definite;
qc. Confirmed and not definite;
qd. Possible, harmless, sometimes.
2. Which number of tooth contact areas to expect on an upper BruxCheckers® (males and
females)?
qa. Number: 8 +/-2;
qb. Number: 71 +/-51;
qc. Number: 28 +/-8;
qd. Number: 101 +/-51.
3. Which size of tooth contact areas to expect on an upper BruxCheckers® (males and
females)?
qa. Size: 71mm2 +/-51mm2
qb. Size: 7,1mm2 +/-5,1mm2
qc. Size: 17mm2 +/-15mm2;
qd. Size: 171mm2 +/-151mm2.
4. Which answer is correct?
qa. The lateral distribution of tooth contact areas on BruxCheckers® is almost symmetrical;
qb. The posterior segments are dominant in the sagittal distribution of tooth contact areas on BruxCheckers®;
qc. There are only minor differences between females and males regarding tooth contact areas;
qd. Answers 1-3 are correct.
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