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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, India
b
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

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).
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

1883-1958/$ – see front matter # 2012 Japan Prosthodontic Society. Published by Elsevier Ireland. All rights reserved.
http://dx.doi.org/10.1016/j.jpor.2012.05.002

Please cite this article in press as: Jain V, et al. Effect of occlusal splint therapy on maximum bite force in individuals with moderate to severe
attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.jpor.2012.05.002
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Fig. 1. Bite force measuring instrument: Its components and intra-oral placement.
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 therapy on maximum bite force in individuals with moderate to severe
attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.jpor.2012.05.002
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
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V. Jain et al. / Journal of Prosthodontic Research xxx (2012) xxx–xxx
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
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 therapy on maximum bite force in individuals with moderate to severe
attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.jpor.2012.05.002
3
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
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Table 2
Average maximum bite force of experimental and control group.
N Mean bite force  standard Min Max
deviation (Newton)
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.

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
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

Please cite this article in press as: Jain V, et al. Effect of occlusal splint therapy on maximum bite force in individuals with moderate to severe
attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.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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attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.jpor.2012.05.002
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Please cite this article in press as: Jain V, et al. Effect of occlusal splint therapy on maximum bite force in individuals with moderate to severe
attrition of teeth. J Prosthodont Res (2012), http://dx.doi.org/10.1016/j.jpor.2012.05.002