UPOTREBA BRUKSOANALIZATORA KOD PACIJENATA SA RAZLIČITIM OBLICIMA BRUKSIZMA USE OF BRUXCHECKER IN PATIENTS WITH DIFFERENT TYPES OF BRUXISM

Uvod: U rečniku protetičkih termina bruksizam je definisan kako nesvesna, oralna navika ritmičkog nefunkcionalnog pritiskanja na zube pri izvođenju nemastikatornih kretnji. Horizontalni oblik bruksizma dijagnostikuje se ozbilјnim trošenjem incizalnih ivica na prednjim i kvržica na bočnim zubima i temporomandibularne disfunkcije, a vertikalni bruksizam, kao nesvesna centralna rotacija donje vilice, dijagnostikuje se gublјenjem zubne supstance u predelu okluzalnih fisura izazvano kontaktom sa funkcionalnim kvržicama i mišićno-skeletnim bolom. Cilј: Cilј ovog ispitivanja bio je da se prikaže svrha upotrebe bruksoanalizatora kod pacijenata sa različitim oblicima bruksizama, kao i koristi ranog otkrivanja ove pojave. Materijal i metode: Klinički metod dijagnostikovanja bruksizma izvodi se bruksoanalizatorom (Bruxchecker), individualno izrađenim za svakog pacijenta. Izrada aparata se vrši termičkim presovanjem polivinilske folije. Bruksoanalizator se nosi svake noći za vreme spavanja. Rezultati: Pri analizi bruksoanalizatorom (Bruxchecker) 140 pacijenata, došlo se do saznanja da 60% njih ima horizontalan bruksizam (20% pri centralnim kretnjama, a 80% pri lateralnim kretnjama) i 40% vertikalni oblik bruksizma. Pored oblika i šeme kretnji pri bruksizmu, preduzeta je odgovarajuća terapija. Ona se izvodi repozicijskim šinama kod horizontalnog i stabilizacijskim okluzalnim šinama kod vertikalnog bruksizma. Zaključak: Horizontalni tip bruksizma je češći i izraženiji od vertikalnog bruksizma. Pacijenti sa horizontalnim bruksizmom imaju izraženije morfološke defekte zubnog niza i potrebe za protetičkom restauracijom, a kod vertikalnog bruksizma nema izraženih morfoloških defekata, ali su bolnije reakcije kod pacijenata češće i izraženije.


Introduction: In a dictionary of prosthetic terms, bruxism is defined as an unconscious, rhythmic, dysfunctional oral habit of clenching the teeth during nonmasticatory movements. The horizontal bruxism is recognized by the extreme wear of the incisal edges of the front teeth, tubers of the lateral teeth and by temporomandibular disorder (TMD). Vertical bruxism is an unconscious centric rotation of the lower jaw, diagnosed by occlusal wear in the fissures caused by contact with the functional tubers and musculoskeletal pain.
Material and method:The of this paper was to show the use of bruxchecker in patients with different type of bruxism as a useful device for early diagnosis.Bruxchecker is used to clinically diagnose bruxism, and it is individually made for each patient.After taking an impression from the mouth the device is constructed by pressure molding from a prefabricated layer of polyvinyl.The patients wear the bruxchecker each night during sleep.Results: The bruxchecker investigations on 140 patients showed that 60% suffered from horizontal type of bruxism (20% mediotrusive, 80% laterotrusive movements) and 40% had vertical bruxism.Depending on the pattern of bruxing movements, we prescribed repositioning splints for horizontal bruxism with TMD, and stabilization splints for vertical bruxism with musculofascial pain.

Conclusion:
The horizontal type of bruxism is growing in the population and it has more severe repercussions compared to the vertical bruxism.Patients with horizontal bruxism have more pronounced dental morphological defects and thus require prosthetic reconstructions, whereas vertical bruxism is characterized by significant morphological defects, but stronger and more frequent musculoskeletal pain.

Introduction
Diagnosis is the process of determining a medical condition.Early diagnosis of bruxism is very important for the doctor and patient.In a dictionary of prosthetic terms, bruxism is defined as an unconscious, oral rhythmic, dysfunctional habit of clenching the teeth during non-masticatory movements¹.The horizontal bruxism is recognized by the serious wear of the incisal edges of the front teet, tubers of the lateral teeth and presence of TMD.Vertical bruxism is an unconscious centric rotation of the lower jaw, diagnosed by occlusal wear in the fissures caused by contact with the functional tubers and presence of musculoskeletal pain².These parafunctions always lead to aesthetic and functional defects.The situation should be identified by the doctor at the first examination of the patient.This will further enable specific treatment appropriate to the activities of the patient (clenching or grinding), the degree of bruxism (light, medium, severe) and the time when this occurs (during sleep, awakening and in both situations)³.Early discovery of patients from this profile will allow the physician to prevent unwanted situations.This applies to subsequent prostodontic reconstructions or complex orthodontic occlusal rehabilitation and treatment.Determining the time of onset and the type of bruxism that develops in a patient is useful for prevention of unnecessary treatments 4 .Accurately diagnosed bruxism is important for all investigators who want to identify and measure this condition.In order to achieve this, it is necessary to use technology that is usually not available to the practitioners.The tools for detecting and evaluating bruxism include: clinical diagnosis which includes taking into account clinical symptoms (questionnaires and anamnesis), clinical signs (examination of the mouth, photographic model and test for quantification of tooth wear (BiteStrip), sleep polysomnography and likewise 5 .Additional methods that are clinically used are: intraoral devices for measuring tooth wear (Bruxcorе, Boston, MA, USA), detectors of bite force, electromyography (EMG) of masticatory muscles 6 .

Materials and methods
Bruxchecker is used to clinically diagnose bruxism and it is individually made for each patient (Figure 1).The patients wear the bruxchecker each night during sleep.In our clinical practice we treated 140 patients with various manifestations of bruxism symptoms and assessed the pattern of parafunctional movements with bruxchecker.All patients suffering from bruxism leave distinctive demarcation of occlusal wear pattern on the surface of the splints 7 .The grinding pattern from bruxism always appears in the same region and with the same direction.These demarcations served as an idea to develop diagnostic methods for bruxism 8 .Bruxchecker is a simple and effective device that is used for determining the patterns of occlusal contacts performed at lateral grinding movements of the lower jaw performed by patients with bruxism and is used to diagnose this condition 9 .Using the bruxchecker, we can record the occlusal contact points and direction of grinding during nocturnal bruxism.Bruxchecker can also be used as an indicator of the correlation between the state of occlusion and the occurrence of periodontal disease and TMD 10 .The preparation of bruxchecker is done according to a model fabricated from anatomic impression of the patient's teeth.In the working model, we remove any bubbles that may remain after the casting.The model is placed in the chamber of the apparatus for thermal pressing and immersed until only the crowns of the teeth are uncovered.The model is then used to adapt the specially developed foil with the method of heat pressure and vacuum folding.This foil is a prefabricated polyvinyl layer with thickness of 0.1mm, colored on one side with edible colors.The foil is placed on the working model with its colored surface placed upward.The time for heat adjusted molding under pressure is 15 seconds, and the temperature equals 220°C.Different apparatuses for pressure molding may have varying durations, the New Biostar with halogen heating duration is 25s, for Ministar is 30s, and for Ministar-S it is 35s¹¹.Once the foil is adapted, its thickness is less than 0.1mm, so that doesn't cause a change in the strength of masticatory muscles under EMG testing¹².Izrađuju se dve ovakve folije koje će pacijent nositi u toku dva naredna dana, kako bi se sprečilo dobijanje netačnih rezultata.Bruksoanalizator će pacijent nositi u svojim ustima za vreme spavanja.Kada se bruksoanalizator izvadi iz usta pacijenta, na njemu se vide bele tačke na mestu gde se ostvaruju okluzalni kontakti i bele površine na mestima na kojima je bilo trenje pritiska zbog kretanja pri bruksizmu.Na površinama bruksoanalizatora beleže se dve vrste kretnji, jedna kretnja uz prisustvo centričnih kontaktnih tačaka u predelu površine trenje i jedan oblik kretnje bez prisustva centralnih kontaktnih tačaka.Kada se na bruksoanalizatoru utvrde horizontalne kontaktne brusne površine možemo da dijagnostikujemo prisustvo horizontalnog bruksizma (Slika 2).U protivnom, kada otkrijemo prisustvo tačkastih brusni, smatramo da je kod pacijenta prisutan vertikalni oblik bruksizma (Slika 3) 13 .
The adapted foil is removed then from the apparatus and cut at cervical margin of the teeth.The vestibular margin of the foil in the front teeth is longer than their cervical edge to prevent deformation of the foil during its placement of the dental arch.Two separate foils should be fabricated in order for the patient to be tested on two consecutive days to prevent getting incorrect results.The patient wears the bruxchecker during sleep.When the bruxchecker was removed from the patient's mouth we noticed white points created by occlusal contacts caused by teeth clenching or vertical bruxism (Figure 2) and white surfaces in the places where teeth grinding was preformed or horizontal bruxisam (Figure 3) 13 .
We also observed two types of bruxingmovements.A movement is characterized by centric contact points in the region of the abraded surface and a movement without the presence of centric contact points.In the treatment of patients with horizontal bruxism we used restrictive occlusal splints.Complete repositioning splints are solid occlusal treatment appliance with specific shape and method of construction which covers the entire dental arch and guides the mandible downward and forward, moves the mandibular condyle intherapeutic retruded position and thus unloadsthe joint pressure and reduces its inflammation 14 .The most important indications of using this splint is bruxism, TMJ disk displacement with clicking sounds, reduced mobility of the lower jaw, TMJ arthralgia, arthritis and TMD 15 .The treatment of patients with vertical bruxism was done with stabilization splints.The complete stabilization splints are solid occlusal treatment appliances with specific shapeand method of construction which provides temporary removable contact between the teeth and the splint, ideal for muscles and TMJ and thus achieve miofascial relaxation, cessation of inflammatory processes and pain in the jaw joint, ear, head and masticatory musculature 16 .Indications for the stabilization splints are: night or socalled nocturnal bruxism, daily teeth clenching, a.k.a.bruxomania, miofascial pain a.k.a.myalgia, arthralgia or osteoarthritis of the TMJ, tympanic reflected pain caused by TMD syndrome, headaches caused by muscle tension, toothache caused by bruxism (reversible pulpitis or periapical pain) 17 .

Results
The bruxchecker investigations on 140 patients showed that 60% suffered from horizontal type of bruxism (20% mediotrusive, 80 % laterotrusive movements) and 40 % had vertical bruxism.Depending on pattern of bruxing movements we prescribed repositioning splints for horizontal bruxism with TMD, and stabilization splints for vertical bruxism with musculofascial pain.

Conclusion
The horizontal type of bruxism is growing in the population and it has more severe repercussions compared to the vertical bruxism.Patients with horizontal bruxism have pronounced dental morphological defects and thus require prosthetic reconstruction, whereas vertical bruxism is characterized by significant morphological defects, but stronger and more frequent musculoskeletal pain.