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Year : 2021  |  Volume : 24  |  Issue : 11  |  Page : 1742-1748

Evaluation of the effect of bruxism on mandibular cortical bone using radiomorphometric indices on panoramic radiographs

1 Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Sivas Cumhuriyet University, Sivas, Turkey
2 Department of Biostatistics, Medical Faculty, Sivas Cumhuriyet University, Sivas, Turkey

Date of Submission09-Feb-2021
Date of Acceptance16-Apr-2021
Date of Web Publication15-Nov-2021

Correspondence Address:
Dr. I Eninanc
Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Sivas Cumhuriyet University, Sivas
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_71_21

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Background: This prospective study was designed to evaluate the effects of bruxism on mandibular cortical bone using radiomorphometric indices on digital panoramic radiographs. Materials and Methods: The mandibular cortical index (MCI), mental index (MI), and panoramic mandibular index (PMI) were measured on digital panoramic radiographs and evaluated for 128 bruxers (66 female, 60 male) and 128 control subjects. The data were analyzed statistically using intraclass correlation coefficients (ICC), Kappa statistics, Chi-square test, Kolmogorov–Smirnov test, independent t-test, and Pearson's correlation analysis. Results: There was no difference between the groups in terms of MCI type (P > 0.05). While mean MI values were significantly higher in bruxers than the control group (P = 0.007), the difference between groups in mean PMI values was nonsignificant (P > 0.05). In both groups, the C1 type was more prevalent in females than in males (P = 0.001). Females showed significantly lower mean MI values than males in both groups (P ≤ 0.040). However, the difference between genders in mean PMI values was not significant (P > 0.05). Conclusions: MI measurements may be useful when radiomorphometric indices are to be used for the diagnosis or follow-up of bruxism in the mandible. Among radiomorphometric indices, MI and MCI values are affected by gender differences.

Keywords: Bruxism, mandibular cortical index, mental index, panoramic mandibular index

How to cite this article:
Eninanc I, Yeler D Y, Cinar Z. Evaluation of the effect of bruxism on mandibular cortical bone using radiomorphometric indices on panoramic radiographs. Niger J Clin Pract 2021;24:1742-8

How to cite this URL:
Eninanc I, Yeler D Y, Cinar Z. Evaluation of the effect of bruxism on mandibular cortical bone using radiomorphometric indices on panoramic radiographs. Niger J Clin Pract [serial online] 2021 [cited 2022 Nov 26];24:1742-8. Available from:

   Introduction Top

Bruxism is defined as grinding and clenching of the teeth caused by the activity of the chewing muscles at night and/or throughout the day.[1] Three different definitions of bruxism have been made clinically based on a diagnostic grading system including possible, probable, and definite bruxism. According to this system, “possible” bruxism is based on self-report through questionnaires and/or the anamnestic part of the clinical examination, “probable” bruxism is based on self-report plus the inspection part of a clinical examination and “definite” bruxism is diagnosed based on self-report, a clinical examination, and polysomnographic or electromyographic records.[2]

Failure to control the forces created by bruxism may induce osteoclastic activity in the bone. Widening of the periodontal ligament space may occur and the vertical bone height may be reduced in the interdental septum, resulting in dental mobility.[3]

Radiomorphometric indices, which were developed in 1960, are predominantly based on cortical bone measurements, as cortical bone can be visualized more readily than trabecular bone on radiographs.[4] By calculating the ratio of cortical bone thickness to total thickness, bone mass and regional effects of osteoporosis can be evaluated using index measurements.[5],[6],[7] Accordingly, panoramic radiomorphometric measurements have been developed for assessment of changes in the mandibular bone radiographically.[8],[9],[10]

Radiomorphometric indices such as mandibular cortical index (MCI), panoramic mandibular index (PMI), and mental index (MI) applied on digital panoramic radiographs have been demonstrated to be useful for estimating bone quality and quantity.[6],[7] These index measurements are also more advantageous than other advanced techniques in terms of cost and radiation exposure.[11]

The present study is aimed to evaluate radiographic changes occurring in the mandibles of bruxers as a result of exposure to prolonged, strong bite forces. Patients with sleep bruxism may not be aware that they are grinding or clenching their teeth. Therefore, radiomorphometric indices can help diagnose sleep bruxism in combination with specific clinical findings. The effect of bruxism on mandibular cortical bone was investigated by comparing radiomorphometric index values such as MCI, MI, and PMI on digital panoramic radiographs of bruxers and control subjects.

   Materials and Methods Top

Patient selection

This study was conducted with individuals who were presented to Sivas Cumhuriyet University, Faculty of Dentistry, Oral, and Maxillofacial Radiology clinic for routine dental care between 2019 and 2020 and volunteered to participate in the research. The study protocol complied with the principles laid in the Declaration of Helsinki. Approval for the conduct of the study was obtained from the Ethics Committee for Noninterventional Clinical Research of Sivas Cumhuriyet University on 20.03.2019 (Decision No. 2019-03/25). All individuals signed a written informed consent form.

The inclusion criteria were age between 18 and 45 years, absence of a systemic disease (in particular those affecting the bone metabolism such as Paget's disease, hyperparathyroidism, hypoparathyroidism, osteomalacia, renal osteodystrophy, diabetes, rheumatoid arthritis, ankylosing spondylitis, osteogenesis imperfecta, and osteodystrophic diseases such as osteoporosis), missing not more than one tooth in the upper or lower jaw except for the third molar teeth, Angle's class 1 occlusion, and for those with bruxism a history of jaw clenching/teeth grinding for at least 6 months.

The study exclusion criteria were as follows: current or past use of bisphosphonates, use of other bone-related agents such as vitamin D and denosumab, presence of any pathology such as a cyst/tumor in the maxillofacial region, previous or current orthodontic treatment, early menopause status, neurological and psychiatric diseases, alcoholism and drug addiction, individuals with prosthetic restoration in any tooth and individuals with dental restorations with premature contacts in occlusion, and severe malocclusion (overjet and overbite of more than 6 mm, unilateral and anterior crossbite, position difference between centric relation and maximum intercuspation of greater than 5 mm).

Clinical examination

In this study, the questionnaire proposed by Pintado et al.[12] and the clinical selection criteria described by Rompre et al.[13] were used for the diagnosis of “probable bruxism.” Responses to the questionnaire, clinical findings, and the diagnosis of bruxism were reviewed by a single dentomaxillofacial radiologist with a total of 9 years of clinical experience including 3 years of experience in maxillofacial radiology.

When identifying bruxers according to Pintado et al.'s[12] criteria, participants were required to answer positively to at least two of the following questions:

  1. Has anyone told you before that you grind your teeth at night?
  2. Is your jaw ever fatigued when you wake up in the morning?
  3. Are your teeth and gums ever sore on awakening in the morning?
  4. Do you ever have a headache on awakening in the morning?
  5. Have you ever noticed that you grind your teeth during the day?
  6. Have you ever noticed that you have clenched your teeth during the day?

In addition, bruxers were identified based on the presence of all the clinical diagnostic criteria for bruxism proposed by Rompre et al.[13]:

  1. Clenching and grinding sound for at least 6 months and more than 3 nights a week.
  2. Tooth wear consistent with the movements of the jaw in a normal or eccentric position
  3. Hypertrophy of the masseter muscle during voluntary contraction
  4. Feelings of discomfort, tiredness, or stiffness in the chewing muscles on awakening in the morning.

Radiographic examination

This study involved panoramic radiographs taken from the patients for routine clinical examination. All panoramic radiographs were obtained by the same technician using a digital panoramic X-ray device (Instrumentarium OP200 D, Instrumentarium Dental, Finland) at the “P1 mode” with which standard panoramic images were taken in automatic dose control (ADC) application. In the ADC application, the device adjusts the dose to be administered to the patient 0.1 s before the full exposure depending on the individual bone tissue density of each patient. Thus, patients are saved from unnecessary radiation and an optimum image is obtained with minimal dose requirement.[14]

A number of radiomorphometric measurements and assessments were performed to investigate changes in the mandibular cortical bone in relation to bruxism. The following indices were used for the study:

Mandibular Cortical Index (MCI): This index, defined by Klemetti et al.[8] in 1994, is classified into three groups:

C1: The endosteal margin of the cortex is smooth on both sides.

C2: There are resorption cavities and stratification (1–3 layers) at the endosteal border unilaterally or bilaterally.

C3: The endosteal margin is clearly porous.

The morphology of the mandibular cortical bone distal to the mental foramen was evaluated on both sides [Figure 1].
Figure 1: Examples of the mandibular cortex type. a) mandibular cortical index C1, b) mandibular cortical index

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Mental Index (MI): The mental foramen region was assessed according to the technique described by Ledgerton et al.[9] The MI is a distance that is measured from the line, which was perpendicular to the lowest border of the mandible at the center of the mental foramen.

Panoramic Mandibular Index (PMI): This is the ratio of mandibular cortical thickness at the mental foramen to the distance between the mental foramen and the lower edge of the mandible.[10] For this index, the mental foramen region, which is not related to the attachment points of the major masticatory muscles, was used as the standard reference examination region.[10] It has been demonstrated that although the alveolar bone above the mental foramen is resorbed, the distance from the mental foramen to the lower edge of the mandible remains relatively constant throughout adult life. Measurements can be made in two ways; PMI superior and PMI inferior based on the upper or lower border of the mental foramen.[10] It was defended that the use of the lower border is more effective because the upper border of the mental foramen cannot always be determined readily.[10],[15] Therefore, inferior PMI measurement was evaluated in this study.

MCI, PMI, and MI measurements were performed by the same dentomaxillofacial radiologist. The mean MI and PMI values obtained from the right and left were calculated on the panoramic radiographs of the participants [Figure 2] and compared between the study groups.
Figure 2: Mental index (A) and panoramic mandibular index measurement (A/B ratio)

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In addition, radiographs were not included in the study if there were artifacts or positioning errors in the panoramic images, the image quality did not allow meaningful examination, the mental foramen could not be visualized completely, or in the presence of bifid mental foramen. Therefore, nine radiographs were excluded due to various technical errors or other problems.

For this study, the sample size was determined as 126 individuals in each group at α = 0.05, β = 0.10, 1-β = 0.90 and the power of the test was estimated at P = 0.91.

A total of 126 bruxers (66 females, 60 males) meeting the prespecified criteria, and 126 control subjects were included in the study.

Display features

For evaluation of the radiomorphometric index values, all digital radiographs were examined by the same researcher in a semidark room at a resolution of 1366 × 768 pixels, using a 15.6-inch LED (light-emitting diode) illumination and a 64-bit LCD (liquid-crystal display) screen (Lenovo, Beijing, China).

Statistical analysis

The data obtained from this study were uploaded to the SPSS (22.0) software. Intraclass correlation coefficients (ICC) and Kappa statistics were used to assess intraobserver agreement. The Chi-square test was used to analyze categorical variables. Whether the continuous numerical variables followed a normal distribution was analyzed by the Kolmogorov–Smirnov test. The independent t-test was used to compare the means of measured values between the bruxers and control subjects. Age was treated as continuous quantitative values and Pearson's correlation analysis was used to examine the correlations in the MCI, MI, and PMI by age. Data were summarized as mean, standard deviation, and median in tabulated form and the error level was set at 0.05. A P value less than 0.05 was considered statistically significant.

To calculate intraobserver consistency, measurements were reevaluated on randomly selected 63 (25%) radiographs 2 weeks later by the same observer.

   Results Top

In this study, 504 (252 × 2) right and left MI and PMI and 252 MCI measurements were obtained from digital panoramic radiographs of 252 bruxers and control subjects, and the groups were compared in terms of bruxism.

The mean age of the study population was 26.34 ± 6.92 years (range: 18–45). Bruxers had a mean age of 26.89 ± 7.28 years and control subjects had a mean age of 25.80 ± 6.52 years. There was no significant age difference between the groups (P > 0.05).

Intraobserver agreement was calculated for repeated measurements on randomly selected 63 (25%) radiographs, and statistically, the level of agreement varied between high and excellent [Table 1].[16]
Table 1: Results of statistical analysis showing intraobserver agreement for 63 randomly selected individuals

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MCI types were examined for all participants. C1 type was found in 163 (64.6%) of 252 individuals, whereas C2 type was observed in 89 (35.3%). There was no C3 type in either group. Comparing bruxers and control subjects in terms of the MCI type, the difference was nonsignificant (P > 0.05) [Table 2].
Table 2: Comparison of MCI types in bruxers and controls

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Although the mean MI values calculated from panoramic radiographs were significantly greater in bruxers than in controls (P = 0.007), there was no difference between the groups in terms of mean PMI values [Table 3]. These findings can be explained by the fact that the distance between the lower border of the mental foramen and the lower edge of the mandible was longer in bruxers than in the control group. This value was 15.12 in bruxers, and 14.28 in the control subjects.
Table 3: Comparison of mean MI and PMI values in bruxers and controls

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When the MI and PMI values from the right and left sides of the bruxers were compared, MI and PMI values of the right side were significantly greater compared with the left side (P ≤ 0.008). In control subjects, right MI values were found to be significantly higher than left (P = 0.017), but no difference was found between right and left PMI values [Table 4].
Table 4: Comparison of right and left MI/PMI values in bruxers and controls

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The relationship between gender and MCI type was examined and C1 type was significantly more common in females than in males in both groups (P = 0.001) [Table 5]. Analyzing the relationship between the MI means and gender, females were found to have significantly lower mean MI values than males in both groups (P ≤ 0.040). On the other hand, the difference between genders in mean PMI values was nonsignificant (P > 0.05) [Table 6].
Table 5: Distribution of MCI types in bruxers and controls by gender

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Table 6: Mean MI and PMI values of bruxers and controls by gender

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The coefficients of correlation between age and MCI, age and MI and age and PMI values in bruxers and controls were the same direction, very small, and statistically nonsignificant (P > 0.05). (MCI: r = 0.096, r = 0.031, respectively) (MI: r = 0.052, r = 0.012, respectively) (PMI: r = 0.015, r = 0.012, respectively).

   Discussion Top

It has been reported that there is not a generally accepted method for the diagnosis of bruxism due to its controversial, nonspecific, and subjective nature.[17] Although there are many methods used for the diagnosis of bruxism such as questionnaires, clinical examination, EMG, and polysomnography, each method has its drawbacks.[17]

In a 2007 study by Rompre et al.,[13] they investigated the accuracy of diagnoses with PSG in individuals diagnosed with clinical diagnostic criteria such as a history of grinding sounds and jaw clenching during sleep at least 5 nights per week for 6 months, tooth wear, fatigued and sore chewing muscles in the morning, and masseter muscle hypertrophy. They reported that these diagnostic criteria provided a high level of discrimination between bruxers and control subjects. In light of the aforementioned study and because of the high cost and relative difficulty of access to polysomnographic and electromyographic recording for the diagnosis of definitive bruxism,[2] the easy-to-use questionnaire method described by Pintado et al.[12] and Rompre et al.'s[13] selection criteria, which were approved by polysomnographic studies, were preferred in the current study. Thus, a more reliable study group was established.

One study found that 40% of tooth wear in the participants was caused by factors other than bruxism and underscored that tooth wear observed in bruxism should be distinguished from changes associated with oral habits such as acidic diet, pencil biting, and pipe smoking, and age-related dental attrition.[18] Since the etiology of existing dental hard tissue damage was not investigated in the current study, parafunctional tooth wear was taken into consideration. To avoid this present a limitation, the diagnosis of bruxism was made when all clinical diagnostic criteria described by Rompre et al.[13] were fulfilled.

Patient positioning affects the sensitivity of the measurements made on panoramic radiographs. [19,20] It has been reported that when the mandible is tilted up or down, very small changes occur in vertical measurements. [21,22] In this study, to avoid positioning errors as much as possible, the image acquisition and calibration were carried out by a single technician, and efforts were made to obtain quality images by fully complying with the reference points established by the manufacturer on the device.

To our knowledge, there is only one study in the literature evaluating panoramic radiomorphometric indices on digital panoramic radiographs in bruxers.[23] In a 2020 study involving 60 bruxers and 60 control subjects (mean age of the study sample: 35.1 years, range: 24–52 years), Isman[23] found a significant association between MCI and bruxism (P < 0.05) and the C3 type was more common among bruxers. However, in their study, matching for gender and age was not performed between the groups and the sample size was small. In the present study consisting of a young population (excluding the effects of menopause in females), no difference was found between bruxers and controls in terms of the MCI type. Studies have reported that the MCI types correlate with age and the prevalence of C3 increases with age in both genders.[24],[25] In Isman's study,[23] the control group may have consisted of younger individuals and the C3 type may be more common in older female bruxers due to the risk of osteoporosis. In the present study with a narrow age range (18–45 years), there was no correlation between age and MCI values.

Although Isman[23] found higher mean MI values in bruxers compared with nonbruxers, mean PMI values were not different between the groups. Similarly, in the current study, significantly greater right, left, and mean MI values were found in bruxers compared with controls (P ≤ 0.017). This can be explained by a reactive response that occurs in the mandibular cortex as a result of the pressure exerted on the mandible corpus by the masticatory forces due to bruxism. Also, while greater MI values were observed in bruxers, the difference in PMI values between the groups was nonsignificant. (P > 0.05) This nonsignificant relationship can be attributed to the higher the distance measured between the lower border of the mental foramen and the lower border of the mandible in bruxers.

Significantly greater MI values were measured on the right side compared with the left side in both groups. In addition, the right PMI value was greater than the left PMI value in bruxers (P = 0.001). This may have resulted from significantly greater right MI values of bruxers compared with controls. It was not questioned whether the study population had a unilateral chewing habit. This may be attributed to the unilateral chewing habits of the individuals as a limitation of this study.

There are studies in the literature that reported disparate findings for the gender and MCI relationship. In a study conducted by Koç and Çağırankaya,[26] it was reported that the prevalence of MCI type varies according to gender, C1 and C3 types are more common in women than men, and C2 type is more frequently seen in men. Bozdağ and Şener[25] reported that although the C3 type is generally more common in females, the prevalence of C1 is higher in the younger female group compared with men. Gulsahi et al.[24] and Isman[23] found no relationship between gender and MCI in the Turkish population. In the current study, a higher rate of C1 type was found in women compared with men both among bruxers and controls (P = 0.001), which is consistent with the results of Koç and Çağırankaya[26] and Bozdağ and Şener.[25] Based on these data, it can be suggested that young males tend to have more erosive cortex than females.

Hardanti et al.[27] explored the relationship between MI and gender by calculating the MI in 20 female and 20 male individuals between the age group of 40–60 years and reported that cortical bone was statistically thinner in women than in men. However, Isman[23] did not find any correlation between gender and MI or PMI. Similar to the findings of Hardanti et al., in the present study, MI values were significantly lower in women compared with men in both groups (P ≤ 0.040), and the difference between PMI values was nonsignificant (P ≥ 0.052). This can be associated with gender-related differences in muscle strength as well as hormonal and metabolic differences between males and females.

In one study, Bozdağ and Şener[25] divided the study group into age groups of 18–40, 41–55, 56–69, and 70 and above and reported that MI and PMI values increased with advancing age in women. However, they could not find a relationship between MI and PMI values with age in men. Gulsahi et al.[24] found that the prevalence of C3 increased with age, and in the logistic regression analysis, the likelihood of C3 in the 50–69 age group and the group over 70 years of age increased 9.17 and 79.14 times, respectively, compared with the 20–49 age group. In the current study, the coefficients of the correlations between age and MI, age and PMI, and age and MCI were found to be nonsignificant. In studies of Bozdağ and Şener[25] and Gulsahi et al.,[24] although the age range was kept wide, the number of teeth of the individuals varied. In addition, failure to evaluate systemic disease and osteoporosis in retrospective studies may affect the results of the studies. However, in the current study in which the mean age was 26 years, the absence of any type of C3, and lack of a correlation can be explained by the narrow age range of the study group and the fact that this group consisted mostly of younger individuals.

   Conclusion Top

Panoramic radiomorphometric indices used in the fields of medicine and dentistry for the diagnosis and treatment follow-up were employed in the present study to examine changes in the cortical bone tissue of the individuals caused by bruxism. The current study is the second in the literature to report on the relation between bruxism and radiomorphometric measurements. In conclusion, MI measurements can be considered for the diagnosis or follow-up of bruxism in the mandible. Among radiomorphometric indices, MI and MCI values are affected by gender differences. Possible unilateral chewing habits should be ruled out in further studies.

Compliance with ethical standards

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Declaration of Helsinki of 1975, as revised in 2008. Informed consent was obtained from all patients for being included in the study. The study protocol was approved by the Ethics Committee for Clinical Research of Cumhuriyet University (Sivas, Turkey) (2019-03/25).

The study was funded by the authors and it was produced from a thesis.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

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  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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