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Original article

Effect of occlusal splint therapy on maximum bite force in individuals with

moderate to severe attrition of teeth

Veena Jain MDSa,*, Vijay Prakash Mathur MDSb, Kumar Abhishek BDSa, Mohit Kothari BDS, PhDc

a Department of Prosthodontics, Centre for Dental Education & Research, All India Institute of Medical Sciences, New Delhi, Indiab Department of Pedodontics, Centre for Dental Education & Research, All India Institute of Medical Sciences, New Delhi, India

c Department of Clinical Oral Physiology, School of Dentistry, Faculty of Health Sciences, Arhus University Vennelyst Boulevard 9, DK-8000 Arhus C, Denmark

Received 22 November 2011; received in revised form 28 March 2012; accepted 11 May 2012

Abstract

Objective: The purpose of the pilot study was to determine the effect of restoring lost occlusal vertical dimension (OVD) due to attrition on

maximum bite force in humans.

Methodology: A total of 124 subjects in age range of 25–40 years, with moderate to severe attrition, having full complement of teeth were screened

according to inclusion and exclusion criteria. After consent, occlusal vertical dimension was assessed by employing mechanical and physiological

methods in the experimental group and a maxillary canine guided hard splint was fabricated for each subjects fulfilling inclusion criteria and with

positive consent (78). Bite force in experimental group was measured before, immediately after delivery of splint and subsequently at an interval of

four, eight, and twelve weeks. Due loss during follow up, only 50 subjects could be available for bite force recording till 12 weeks. Bite force of age,

gender, height and weight matched controls with no signs of attrition was also measured for comparison.

Results: Bite force of the experimental group was found to be significantly less than the matched controls (P = 0.000) initially. After delivery of

splint, bite force values increased progressively till twelve weeks. However comparison of bite force values of experimental group with control

group showed no significant difference at end of eight (P = 0.008) and twelve weeks (P = 0.162).

Conclusion: It was concluded that maximum bite force increases with restoration of lost vertical using splint therapy. A time period of 8–12 weeks

is required to restore the maximum bite force value approximately similar to matched controls.

# 2012 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.

Keywords: Attrition; Occlusal vertical dimension; Tooth wear; Soft splint therapy

www.elsevier.com/locate/jpor

Available online at www.sciencedirect.com

Journal of Prosthodontic Research xxx (2012) xxx–xxx

1. Introduction

Tooth wear is a normal physiological process that occurs

throughout life [1]. However, if the rate of wear challenges the

viability of teeth then it is considered to be pathological [1,2].

Occlusal wear leads to a reduction in tooth length and

significant dimensional changes in facial morphology are

inevitable unless mechanism exist to compensate for attrition

[3]. The loss of vertical dimension due to attrition causes

excessive closure which drives the mandible forcefully upward

to maintain contact with maxillary teeth. This leads to gradual

closure of space between the head of the condyle and articular

disc causing degenerative changes, accompanied with pain and

discomfort during mandibular movements. If the bite is not

* Corresponding author.

E-mail address: jainveena1@gmail.com (V. Jain).

Please cite this article in press as: Jain V, et al. Effect of occlusal splint th

attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.j

1883-1958/$ – see front matter # 2012 Japan Prosthodontic Society. Published b

http://dx.doi.org/10.1016/j.jpor.2012.05.002

raised and restored, then the condition may worsen [4]. The

effective management of patients with tooth wear is an ongoing

challenge for dental professionals as the condition can affect

both ends of the age spectrum and thus a large proportion of

people. Also the prevalence of tooth wear is likely to escalate as

life expectancy continues to increase and as people expect to

retain their teeth throughout life [1]. During the process of

restoration of lost occlusal vertical dimension, adequate

duration should be given for allowing biological adaptive

changes to occur in lengthened muscle fibers. The dentist must

hence be cognizant of biologic, aesthetic and psychological

aspects of prescribed dental care [2].

Bite force has been taken as one of the important indicators

of masticatory efficiency [5] and is often measured as

maximum biting force (MBF) [6]. Bite force is exerted by

the elevator muscles and is regulated by the nervous, muscular,

skeletal and dental systems [7]. Hence the condition of these

systems determines the maximum bite force. The average bite

erapy on maximum bite force in individuals with moderate to severe

por.2012.05.002

y Elsevier Ireland. All rights reserved.

Fig. 1. Bite force measuring instrument: Its components and intra-oral placement.

V. Jain et al. / Journal of Prosthodontic Research xxx (2012) xxx–xxx2

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force of a healthy individual is 500–700 N in the first molar

region [8,9] a wide range of maximum bite force values have

been reported in different conditions [10–12]. This may be

attributed to several factors which may be either specific to the

patient’s condition or the technique employed to measure bite

force [13]. These factors include malocclusion, occlusal contact

area, body size, interocclusal separations, location of the

measuring device on the dentition, posture of the subjects head

at the time of measurement, age, height, weight and sexual

dimorphism [10,14,15]. It has been reported in the literature

that bite force is affected by change in vertical dimension

[9,16]. Accurate bite force measurement has been a challenge

for the clinicians for several decades. As a part of this study, a

reliable tool for bite force measurement was also developed and

used for studying the effect of restoration of lost OVD.

The present study was undertaken as a pilot study to evaluate

the effect of restoration of lost OVD using splint therapy on

maximum bite force in patients with moderate to severe

attrition [17] of teeth, and compare it with asymptomatic

matched controls (without attrition) to know the difference in

bite force and time period required to restore the bite force

approximately similar to matched control.

2. Materials and method

Ethical clearance for the study was obtained from the

institutional ethics committee, prior to the study. A total of 124

subjects in age range of 25–55 years (mean age 35 � 8), with

moderate to severe attrition, having full complement of teeth

were screened following inclusion and exclusion criteria. The

severity of attrition was scored as described by Pergamalian

et al., i.e. Score 0, for no wear, Score 1(mild), for minimum

wear on the tip of the cusp, occluding planes or on the incisal,

Score: 2 (moderate): flattening of cusp or grooves, and Score 3

(severe) for total loss of contour or dentin exposure when

identifiable [17]. Patients with history of neuromuscular

disorder, arthritis, communication disorder, immunosuppres-

sant and muscle relaxant, periodontal disease, malocclusion,

any temporomandibular joint (TMJ) anomalies or surgery and

Please cite this article in press as: Jain V, et al. Effect of occlusal splint th

attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.

treated previously for occlusal rehabilitation by grinding of

teeth, splint or muscle relaxant were not included in the study.

Finally a total of 78 patients with moderate to severe attrition

were enrolled for restoration of lost vertical height using splint.

Another group with equal number of subjects as in the

experimental group and matching to the experimental group in

terms of age, gender, height, weight but showing no signs of

attrition served as the control group.

All participants were informed about the objectives and

methodology of the study and written informed consent was

obtained. The demographic data, relevant medical and dental

history were recorded on a predesigned performa. Experi-

mental subjects were thoroughly examined and the reduction in

vertical dimension was assessed by facial features, like

deepening of mento-labial fold, aged appearance, prominent

nasolabial folds and drooping of corners of mouth. Freeway

space was assessed during speech and vertical dimension was

measured at physiologic rest position and maximum inter-

cuspation of teeth. No alterations in occlusion morphology

were made during the study period.

A maxillary centric stabilizing splint with canine guided

occlusion was fabricated for each subject in experimental

group. For this purpose, maxillary and mandibular casts were

mounted at desired vertical dimensions on semi-adjustable

articulator with the help of facebow, and centric relation record.

Protrusive relation record at 6 mm of protrusion was used to

adjust the condylar guidance. Wax up was done on maxillary

cast and adjusted in eccentric movements to provide canine

guided occlusion. It was further processed in heat cure resin,

and delivered to patients after finishing and polishing.

The bite force was recorded using a customized piezo-

electric bite force measuring instrument (Fig. 1). This

instrument has three components, quartz miniature force

sensor (2.5 kN) mounted in a stabilizing device integrated

cable and charge meter with LC display (M/s Kistler Inc.,

Switzerland). The intraoral part of the sensor was modified for

use in oral cavity. Two stainless steel (SS) plates (1.5 mm thick)

were used. An indentation was made for placement of force

sensor in one plate and a guiding pin (to prevent flexure within

erapy on maximum bite force in individuals with moderate to severe

jpor.2012.05.002

Table 1

Showing means values of age, height and weight of subjects.

Experimental (Group I) Control (Group II) P value

Age 35.60 � 8.19 35.76 � 8.68 0.925

Height 164.38 � 7.20 165.84 � 6.15 0.279

Weight 61.66 � 9.49 63.16 � 7.73 0.388

V. Jain et al. / Journal of Prosthodontic Research xxx (2012) xxx–xxx 3

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the apparatus during biting) was incorporated in the other.

Thus, the total thickness of the transducer was 9 mm

(6 mm + 1.5 mm + 1.5 mm). The cable passed through the gap

between the plates connecting the force sensor to the charge meter.

The patients were seated comfortably on a dental chair in

upright position and the method of bite force measurement was

explained to the subjects. The intra oral part of appliance was

covered with a disposable plastic sleeve for preventing infection

and placed at the first molar area and an acrylic block of same

dimensions was placed on the contra lateral side to counter

balance the force. The patients were asked to bite on the sensor as

hard as possible. The peak bite force reading on the charged

meter was recorded. Similarly bite force was measured on the

contra lateral side. Measurement was accomplished three times

on each side, keeping a 3 min interval between each measure-

ment to avoid muscular fatigue. Bite force of matched controls

was measured only once. Bite force of experimental subjects was

measured before and immediately after the delivery of splint to

the subjects. The subjects were instructed to wear the appliance

8–10 h/day, according to their convenience. Patients were

recalled after 48 h for evaluation of TMJ and surrounding soft

and hard tissues.

Bite force was measured at 5 time points i.e. at baseline, just

after delivery of the splint and at follow up of 4, 8 and 12 weeks.

At subsequent visits during the follow-up the bite force was

measured without the splint. Out of total 78 subjects treated;

only 50 subjects (36 males, 14 females) could be available at all

5 time points for bite force measurement. Hence, the data of

only those 50 subjects and their age, gender, height and weight

matched controls will be presented in this paper (Table 1).

Patient compliance about regular wearing of the splint was

monitored by a regular telephonic check to ensure that they

were using the appliance regularly besides their scheduled

follow-up appointment.

2.1. Statistical analysis

Statistical package SPSS Version 11.5 was used for

statistical analysis and comparison. Independent Sample ‘t’

test was used to assess the difference in bite force values

between the right and left side and for inter and intra group

comparison.

3. Results

The maximum bite force was measured on the first molar

region on both, the right and the left side and the difference was

not significant statistically (P = 0.902). Hence, the mean of the

two sides was taken as maximum bite force for the subject.

Please cite this article in press as: Jain V, et al. Effect of occlusal splint th

attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.j

It was observed that the baseline mean maximum bite force

of subjects in the experimental group (464.85 � 148.89 N) was

less than that of the control group (665.43 � 125.35 N). There

was an increasing trend in the bite force measurement between

baseline to immediate post insertion and upto 12 weeks (Table

2, Graph 1). However, the results reveal a significant increase in

bite force in subsequent follow-up of four (546.83 � 199.39),

eight (583.57 � 175.29 N) and twelve (622.33 � 176.41 N)

weeks as compared to baseline values. The eight and twelve

week values were also significantly higher than immediate post

operative values. Twelve week value was also significantly

higher than four week value (Table 3).

The comparison of experimental group and control group

revealed that the mean maximum bite force values at baseline,

immediate post insertion, four, eight and twelve weeks were

less than control group and the difference was statistically

significant for all the periods but not for the 12 week period

(Table 3).

Eleven self motivated subjects were followed for a longer

duration and their maximum bite force (609.66 � 165.61 N)

was recorded at 6 months of follow up. It was found that the

maximum bite force remained almost constant after 12 weeks

(P = 0.941) in these eleven subjects.

4. Discussion

A number of methods and devices have been reported to

measure the bite force [18–21] but in the present study, a quartz

sensor based on piezo electric principle was used. The

Piezoelectric transducers have high modulus of elasticity.

Even though piezoelectric sensors are electro mechanical

system, they react on compression. Piezoelectric sensor are

rugged, have an extremely high natural frequency and an

excellent linearity over a wide amplitude range. Further,

insensitivity to electromagnetic fields and radiation, highly

stable over temperature (1000 8C) etc. are inherent advantage

of piezoelectric material. Piezoelectric transducers are accurate

and reproducible unlike other strain gauge based oral force

monitoring devices which have limited sensitivity, large size

and also require frequent standardization due to permanent

strains in their gauges [22].

To measure the bite force, a sensor was placed in the first

molar region as maximum bite force is exerted in molar region.

The literature suggests that the bite force in the incisor region is

only one third to one quarter of the molar region [14–16]. Bite

force increase progressively in a non-linear but monotonic

manner as the bite point moves more posterior. This may partly

because of the lever effect of the mandible and partly because

there is a larger area of periodontal ligament around posterior

teeth [14,19].

Most of the studies have shown that bite force during

bilateral clenching is larger than unilateral clenching [23].

According to Van Der Bilt et al. the lower bite force during

unilateral clenching as compared to bilateral clenching may be

a result of inhibition by receptors in periodontal ligament and

joint [23]. Van Eijden, stated that during unilateral clenching

which is highly asymmetric activity, the force at balancing side

erapy on maximum bite force in individuals with moderate to severe

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Table 2

Average maximum bite force of experimental and control group.

N Mean bite force � standard

deviation (Newton)

Min Max

Base line 50 464.86 � 148.89 190.67 863.50

Immediate post operative 50 512.47 � 174.17 201.33 1032.16

4 weeks 50 546.83 � 199.39 231.83 1000.83

8 weeks 50 583.57 � 175.28 242.83 1058.33

12 weeks 50 622.33 � 176.40 278.66 1011.16

Control group 50 665.43 � 125.35 N 371.50 978.50

Table 3

Intra and inter group comparison of bite force.

Groups Duration in weeks Mean difference P value

Experimental Baseline Immediate post operative �47.61 0.145

Four �81.98 0.022*

Eight �118.71 0.000*

Twelve �157.47 0.000*

Immediate post operative Four �37.36 0.365

Eight �71.09 0.045*

Twelve �109.86 0.002*

Four week Eight �36.73 0.330

Twelve �75.49 0.048*

Eight week Twelve �38.76 0.273

Control Baseline �200.57 0.000*

Immediate post operative �152.96 0.000*

Four �118.60 0.001*

Eight �81.86 0.008*

Twelve �43.10 0.162

* Significant P < 0.05.

V. Jain et al. / Journal of Prosthodontic Research xxx (2012) xxx–xxx4

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joint would be larger than the force at the working side [24].

Therefore acrylic blocks of the same dimensions were placed on

the contra lateral side to balance the mandibular force [23,25],

although Fields et al. observed in his study that contra lateral

support is not necessary when recording vertical occlusal force in

first molar region [16]. The supported condition which might be

expected to distribute the force more evenly did not reduce the

vertical occlusal force but slightly increased it during chewing.

Analysis of results show that subjects in both the groups had

approximately equal bite force on left and right side, which is in

agreement with previous studies [26–31]. Our study further

demonstrated that individuals with attrition of teeth had

significantly less bite force as compared to matched controls.

Reduction in bite force may be due to a decrease in occlusal

vertical dimension (OVD) [32,33]. Mackenna and colleagues

have stated that with any increase or decrease in jaw separation

from the physiological optimum results in decreasing the strength

of maximum incising force [31]. Similarly Boucher et al. state

that reduction of vertical dimensions in edentulous patients leads

to less amount of force on their edentulous ridges [9].

Bite force increases just after the placement of splint (Graph

1). An increase in vertical dimension may lead to changes in

orofacial structure i.e. jaw elevator muscles, temporomandib-

ular joints and periodontium. It is stated that such changes in

vertical dimension alter the length of main jaw elevator muscles

and the position of mandibular head in the fossa temporalis.

Thus they may affect the masticatory function, resulting in the

Please cite this article in press as: Jain V, et al. Effect of occlusal splint th

attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.

higher bite force values [34,35]. Hence as the vertical

dimension increases from the occlusal contact on insertion

of an occlusal splint, muscle effort decreases resulting in the

relaxing of muscles and the TMJ [36]. Manns et al. noted an

inverse relationship between muscle activity and bite force.

They noted that for each subject there is an optimum muscle

elongation (i.e. between 13 and 21 mm of mouth opening, distal

to canine) where the masseter muscle develops the strongest

force with minimum EMG activity. That can be a reason for

increase in bite force after insertion of inter occlusal appliance

[11]. Various studies [11,30,37,38] indicate that, bite force

decreases with increase or decrease in jaw separation from

optimum. Lindauer et al. [38] recorded maximum bite force

values between 15–20 mm anterior vertical jaw opening when

masseter muscle activity was kept constant. Chandu et al. in

their study noted that after the insertion of inter occlusal

appliance, bite force increases even in healthy individuals [12]

A steady increase in bite force was noted till 12 weeks. This

increase in bite force with time might be due to increase in

number and extent of tooth contact and increase in vertical

dimension of jaw elevator muscles during clenching after the

insertion of splint [39]. Although splint was removed just

before the measurement of bite force as splint functions as a

single unit and therefore with splint we were not able to record

‘true’ bite force at the first molar region [37]. As the limitations

addition of height to the transducer was not possible. According

to Boero the increase in OVD with the splint allows the muscles

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jpor.2012.05.002

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to function more efficiently during contact and be less active

during postural position [40]. However while the splint

induced changes in rest posture, reduction in muscle activity

occur quickly over one week or less, adaptive changes may

occur with long term increase in OVD. Increase in muscle

length stimulates addition of sarcomeres to the myofibirils.

Long term increase in vertical may change a muscle anatomical

configuration [35,40]. They also noted that for each subject

there is an optimum muscle elongation, where the masseter

muscle develops the strongest force with minimum EMG

activity between 13 and 21 mm of mouth opening distal to

canine. Although we may think for change in muscle volume or

strength but Dawson says we do not have any acceptable

scientific data to support such claims [41]. Another possible

reason for the progressive increase in bite force could be the

increased confidence of the subject, enhancing the amount of

bite force to his/her original capacity prior to any teeth damage.

The subject’s periodontal receptors which monitor the pressure

applied to their teeth [42,43] and the pain receptors in and

around the teeth which detect the noxious stimulus give

positive feedback after the placement of an intra occlusal

appliance [44].

Overall, our study was in agreement with some of the past

findings in literature with respect to bite force measurement.

However, our results highlight that a minimum period of 12

weeks is required for the adaptation of tissues to a new vertical

dimension, because we observed the bite force to remain almost

constant after twelve weeks. Further studies in larger patient

cohorts are warranted to confirm the findings of our study.

Conflict of interest statement

All the authors had no conflict of interest.

Acknowledgement

The authors thank the Department of Biotechnology (DBT),

Govt. of India for funding this project under (RGYI) scheme.

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