Journal of Oral Rehabilitation 2007 34; 663–670

Head posture and dental wear evaluation of bruxist children

with primary teeth
A . L . V É L E Z * , C . C . R E S T R E P O * , †, A . P E L Á E Z - V A R G A S * , †, ‡, G . J . G A L L E G O * , †,
E . A L V A R E Z * , V . T A M A Y O †, § & M . T A M A Y O * , † *CES University, Medellı́n, Colombia, †CES-LPH Research
Group, Medellı́n, Colombia, ‡Universidad Nacional de Colombia – Sede Medellı́n, Colombia, §FUMC, Medellı́n, Colombia

SUMMARY The aim of the present study was to group (n = 20). The variables of the two groups
compare the head position and dental wear of were compared, using the Student t-test and
bruxist and non-bruxist children with primary Mann–Whitney U-test.
dentition. Results: A more anterior and downward head tilt
Methods: All the subjects had complete primary was found in the bruxist group, with statistically
dentition, dental and skeletal class I occlusion and significant differences compared with the controls.
were classified as bruxist or non-bruxist according More significant dental wear was observed in the
to their anxiety level, bruxism described by their bruxist children.
parents and signs of temporomandibular disorders. Conclusions: Bruxism seems to be related to altered
The dental wear was drawn in dental casts and natural head posture and more intense dental wear.
processed in digital format. Physiotherapeutic Further studies are necessary to explore bruxism
evaluation and a cephalometric radiograph with mechanisms.
natural head position were also performed for KEYWORDS: bruxism, head, posture, dental wear
each child to evaluate the cranio-cervical position
for the bruxist group (n = 33) and the control Accepted for publication 4 February 2007

Bruxism not only affects the masticatory muscles, but

Introduction
also all the muscles of the cranio-facial complex,
The aetiology of bruxism has been defined as multifac- shoulders and neck (18). These structures share inner-
torial (1). It is mainly regulated centrally, not periph- vations through the trigemino-cervical complex, which
erally (2). This fact means that oral habits (3), is conformed by the upper cervical and trigeminal
temporomandibular disorders (TMD) (4–7), malocclu- nerves (18). Also, anatomically, the axes for the excen-
sions (8, 9), hypopnoea (10), high-anxiety levels (11) tric movements of the mandible and cervical column
and stress (12), among others (13) could influence the concur in the occiput (19). These connections cause the
peripheral occurrence of bruxism. These factors act as a jaw position to influence the activity of the cervical
molar stimulus to the central nervous system, which muscles (20) and the neck inclination to influence the
reacts with an alteration in the neurotransmission of bilateral sternocleidomastoid activity (21).
dopamine (14, 15) and the result is the clenching or If the masticatory system, neck and shoulders are
grinding of the teeth. anatomically and physiologically connected and brux-
During early infancy, children react to the habits of ism affects all the above described structures, it might
their parents, such as smoking, alcohol and the use of be possible that the head position and the home-
psychoactive drugs among others (16). These habits are ostasis of the cranio-cervical system could be affected
risk factors involved in acquiring bruxism (17), thus when a parafunction occurs, so the head posture
they have to be evaluated to make a reliable diagnosis could be different between bruxist and non-bruxist
of the parafunction. subjects.

ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd doi: 10.1111/j.1365-2842.2007.01742.x
664 A . L . V É L E Z et al.

The head posture could be affected by the skeletal required to be healthy, with normal facial morphology,
(22) and dental occlusion (23, 24). During the mixed complete primary teeth, absence of other types of oral
dentition, the dental occlusion changes (25), so the habits, presence of dental wear and with no history of
head posture could be affected (26). In the primary trauma.
teeth period, the arch dimensions seem to be stable (27, The sample size was calculated with a confidence of
28), so if there are changes in the head and cervical 95% and a statistical power of 80%. The number of
column posture, these might be due to other factors subjects required in each group to make the compar-
besides changes in occlusion, for example, the occur- isons was 20.
rence of oral parafunctions.
The available evidence-based dentistry is still not
Inclusion and exclusion criteria
enough to support the multifactorial diagnosis of brux-
ism, especially in children. Historically, the background The exclusion criteria were skeletal malocclusions
of bruxism has been confined to the visual examination confirmed with cephalometric X-rays (37, 38) and
of dental wear (1, 4) and the reports of grinding by dental malocclusions confirmed with dental casts. The
parents. reports of respiratory diseases, presence of mouth
The difference between normal and pathological breathing and functional alterations in the body pos-
dental wear has been previously described in the mixed ture were also reasons to exclude patients from the
dentition with digital analysis (29). Dental wear pro- study. Asymmetry in children’s legs or any other
duced by bruxism is characterized by a plane surface mobility alteration that could generate changes in head
with a central zone that sometimes reaches the dentine, posture due to anatomically detectable reasons were
surrounded by enamel zones (30). Waltimo et al. (31) also exclusion criteria.
found that the most common dental facets in adults are An evaluation of the temporomandibular joint (TMJ)
those with a horizontal shape that indicates the occur- was performed on all the children together with a
rence of a grinding pattern rather than a clenching questionnaire and a clinical examination, according to
pattern of bruxism. Bernal and Tsamtsouris (39).
There are sophisticated methods to measure the Children’s anxiety was measured using the Conners’
dental wear related to bruxism (29, 32–36), but other Parents Rating Scales (40) (CPRS). Both instruments,
factors contributing to parafunction, such as body Tsamtsouris and Bernal and CPRS had been previously
posture, have not been measured together with the used to diagnose bruxism in children (16).
dental wear, to gain a better understanding of the Children were included in the bruxist group (n = 33)
peripheral multifactorial aetiology of bruxism. when their anxiety level was above 0Æ75% according to
The aim of the present study was to compare the the CPRS, presented two or more signs of TMD
head posture and dental wear of bruxist and non- according to Bernal and Tsamtsouris and fulfilled the
bruxist children with primary dentition. American Academy of Sleep Medicine (AASM) (41)
criteria for sleep bruxism:
1 The children’s parents indicated the occurrence of
Materials and methods
tooth-grinding or tooth-clenching during sleep.
A case–control study was performed. The procedures, 2 No other medical or mental disorders which could
possible discomforts or risks, as well as possible benefits account for abnormal movement during sleep were
were fully explained to the participant patients and present (e.g., sleep-related epilepsy).
their parents, and written informed consent from their 3 Other sleep disorders (e.g., obstructive sleep apnoea
parents was obtained prior to the investigation. syndrome) were absent.
All children not fulfilling the above criteria were
included in the control group. If children fulfilled the
Subjects
2nd and 3rd criteria of the AASM, they were excluded
Participating children were selected from Susalud from the control group.
(a clinic of the Colombian Private Health Service) and Seventy-two children were initially evaluated and 53
CES Sabaneta (Clinic of the CES University Dental were finally included in the study, 33 in the bruxist
School). All the subjects (bruxist and non-bruxist) were group and 20 in the control group. Eleven subjects were

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 HEAD POSTURE AND TOOTH WEAR OF BRUXIST CHILDREN 665

excluded because they presented exfoliating move- reported (29). The size and shape of the dental wear
ments of the primary teeth or appearance of eruption of were calculated for each dental cast.
permanent molars. Three presented skeletal malocclu- The size of the dental wear was quantified through its
sions in the cephalogram, three were excluded by area (mm2) and perimeter (mm) and the shape by the
difficulties in their behaviour during the required initial roundness and the form factor (D factor) (29), which
procedures, one presented functional scoliosis, one are non-dimensional. The last two measurements were
showed leg asymmetry and one presented cerebral used to calculate the format of objects without geo-
palsy. metrical shapes (29).
All the children were 3–6 years old. In the bruxist For D factor, the following ratio was used:
group, the mean age was 56Æ70  7Æ22 months, pffiffiffi
a
while for the non-bruxist children it was 55Æ20  D factor ¼
p
7Æ89 months. As can be observed, with regard to their
chronological age the groups were homogeneous.
where a is the area (mm2) and p the perimeter (mm).
Each X-ray was taken with an Orthophos Plus Ceph*
Techniques for lateral cephalograms. The machine was vertically
adjustable; it had a standardized focus – film distance of
The risk factors to acquire TMD were assessed by
190 cm and a distance from the film to the medial plane
questioning those in charge of the children, using the
of 10 cm. The subject stood up without fixation in
questionnaire of the Bernal and Tsamtsouris test. The
orthoposition after balancing forward and backward
clinical evaluation of TMD included the auscultation of
three times, with the teeth together and the lips in rest,
TMJ sounds, the palpation of discontinuous condylar
looking to a light in a mirror, located perpendicular to
movement, measurement of the maximum opening of
the eyes of the child. This position made sure that the
the mouth and deviation of the mandible during
head and the neck were in natural position. The
opening.
exposures were taken at 60–80 kv and 32 mAs. A
The physiotherapeutic evaluation (42) was per-
vertical 0Æ5 mm wide wire was put in front of the
formed to exclude any possible anatomical disturbance
cassette to register the perfect vertical line (VV).
of the cervical column that could affect the head
The technique used to take the lateral cephalogram
posture or the craniofacial growth of the studied
was the natural head posture, described previously by
children. The test included a questionnaire to ask the
different authors (43). It is a reproducible technique
parents about family history that could indicate poss-
(44–46) and allows the clinician to evaluate the natural
ible alterations in the body posture of the subjects.
position of the cervical vertebras and the inclination of
Then, the real and apparent measurements of the legs
the cervical column and head posture.
were taken with the subjects in supine position with a
Afterwards, the lateral cephalograms were scanned
standardized technique. The examination also included
and traced digitally according to Solow and Tallgren (43),
impression of the plantar foot with the child in
in a dark room, using a MATLAB 5Æ3† program. Based on
bipedestation over a non-sliding surface. With this
the vertical reference, a horizontal line (HOR) was traced
procedure, the feet track of the subject was copied.
perpendicular to the vertical one. These two lines were
Additionally, photographs of the front, back and both
the references to calculate the angles between head and
sides’ views of each child were taken. The data
neck in the cephalogram. All the measurements to
obtained in the physiotherapeutic examination were
evaluate the head and cervical column posture can be
analysed separately by two different physiotherapists at
seen in Fig. 1.
different moments to detect abnormalities or asymme-
The following angles were measured to analyse the
tries.
head and cervical column posture:
The upper and lower dental arches of all subjects
- Angle between tangent (CVT) to the cervical vertebra
were reproduced from alginate impressions cast in
(cv4ip) and VV: the wider the angle, the more relevant
dental stone with a standardized technique.
the kyphosis of the cervical column.
The dental wear of all the casts was drawn, acquired
in digital format and processed automatically. The *Sirona Co, Alemania, Long Island City, NY, USA.
†
technique to analyse dental wear was previously MathWorks, Inc., Natick, MA, USA.

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666 A . L . V É L E Z et al.

investigators. To determine the intra-tester and inter-

tester reliability, the intra-class correlation coefficient
was applied (ICC >0Æ6).
The dental wear was traced only by one investigator
whose intra-class error was not statistically significant
(ICC >0Æ7).

Statistical analysis
Univariant and bivariant analysis were performed for
each variable, using frequencies and mean values. The
bivariant analysis was carried out using Student’s
t-test, or Mann–Whitney U-tests, depending on the
normality of the variables distribution. Distributions
were tested using the Shapiro–Wilk test.

Results
The non-bruxist group was composed of nine girls and
11 boys, while in the bruxist group there were 14 girls
and 19 boys. In both groups there were more boys:
Fig. 1. Cephalometric analysis. 55% and 58% respectively for each group (Table 1).
The four outcome parameters of dental wear were
- Angle between CVT and HOR: the narrower the compared between the bruxist and non-bruxist groups
angle, the more significant the anterior tilt of the head. (Table 2). There was no statistically significant differ-
- Angle between the tangent (OPT) to odontoides ence for the shape (roundness and D factor) of the
(cv2ip) and VV: the wider the angle, the more relevant dental wear between the bruxist and the non-bruxist
the kyphosis of the cervical column. children (P > 0Æ05). The size of dental wear (area and
- Angle between OPT and HOR: the narrower the perimeter) showed higher values in the case of bruxist
angle, the more relevant the anterior tilt of the head. children (P < 0Æ05) for both the upper and lower
The examiners evaluating the condition of brux- arches. The only measurement that was not statisti-
ism ⁄ non-bruxism were not aware who performed the cally significant regarding the size of the dental wear
physiotherapeutic evaluation and who analysed the was the perimeter in the upper arch (p = 0Æ058)
dental wear and the X-ray images. (Table 2). The localization of dental wear in the bruxist
group was mainly in the anterior zone (incisive)
(82Æ4%), while for the control group it was in the
Error of method
molars (73Æ56%).
Standardizations of the examiners and calibration of all The head posture of the bruxist children was found to
the techniques to evaluate the children regarding the have a statistically more significant anterior and down-
clinical examination, TMD and anxiety level were ward tilting of the head, when compared with the
made on 12 subjects different from those included in control group. The OPT_HOR angle was wider in the
the investigation. The Intra-tester and intertester error
was not statistically significant (ICC >0Æ9 and Kappa Table 1. Gender distribution of both groups in this study
>0Æ7).
Sex Bruxist Non-bruxist
A calibration of the X-ray technique and a standard-
ization of the digital tracing of the cephalogram were Female 14 (42) 9 (45)
also performed. The tracing of the cephalogram was Male 19 (58) 11 (55)
Total 33 20
standardized between two investigators with 10 X-rays,
scanned and traced three times each by each of the two Values in parentheses are percentage.

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 HEAD POSTURE AND TOOTH WEAR OF BRUXIST CHILDREN 667

Table 2. Comparison between

Criteria Diagnosis n Mean  s.d. P-value
dental wear measurements in bruxist
and non-bruxist children Upper arch roundness of dental wear Bruxist 33 0Æ12  0Æ07 0Æ341
Non-bruxist 20 0Æ14  0Æ13
Lower arch roundness of dental wear Bruxist 33 0Æ17  0Æ26 0Æ788
Non-bruxist 20 0Æ15  0Æ09
Upper arch D factor of dental wear Bruxist 33 11Æ18  1Æ98 0Æ310
Non-bruxist 20 10Æ59  2Æ18
Lower arch D factor of dental wear Bruxist 33 10Æ52  2Æ60 0Æ086
Non-bruxist 20 9Æ15  3Æ00
Upper arch area of dental wear (mm2) Bruxist 33 33Æ24  20Æ52 0Æ004
Non-bruxist 20 20Æ26  10Æ45
Lower arch area of dental wear (mm2) Bruxist 33 20Æ23  13Æ92 0Æ003
Non-bruxist 20 11Æ22  6Æ82
Upper arch perimeter of dental wear (mm) Bruxist 33 59Æ35  30Æ54 0Æ058
Non-bruxist 20 44Æ47  19Æ86
Lower arch perimeter of dental wear (mm) Bruxist 33 45Æ42  27Æ01 0Æ008
Non-bruxist 20 29Æ42  15Æ23

Significance p < 0Æ05.

Bold figures indicate a significance of p < 0.01.

Table 3. Comparison of the cervical column posture between specific measurement methods or criteria to diagnose
bruxist and non-bruxist children bruxism (52), but as it has a multifactorial aetiology
(53), the study of its associated factors (54) could lead to
Variable Diagnosis n Mean (angles) s.d. P-value
an accurate diagnosis of the parafunction. The diagnosis
CVT_HOR Bruxist 33 82Æ99  4Æ98 0Æ000 of bruxism, as it was performed in this study, should be
Non-bruxist 20 87Æ17  2Æ04 multifactorial and include the associated peripherally
OPT_HOR Bruxist 33 82Æ20  6Æ15 0Æ001
factors, such as the analysis of the dental wear digitally,
Non-bruxist 20 86Æ34  2Æ36
CVT_VV Bruxist 33 7Æ01  4Æ98 0Æ000 evaluation of the TMD and alterations in anxiety levels.
Non-bruxist 20 2Æ83  2Æ04 In this study, dental wear present in bruxist and non-
OPT_VV Bruxist 33 7Æ80  6Æ15 0Æ001 bruxist children was used to compare the size and shape
Non-bruxist 20 3Æ66  2Æ36 differences of dental wear between the two groups. It
was found to be more significant in the bruxist group,
control group, while the CVT_HOR measurement pre- being located mainly in the incisive zone. These
sented lower values in the bruxist children. (Table 3). findings agree with other studies (29), which had
The cervical column also showed statistically more previously correlated wear of the incisives with bruxism
significant kyphotic position in the bruxist group with (55). There are reports (31) in adults of the horizontal
wider CVT_VV and OPT_VV angles (Table 3). form of dental wear when the teeth grind. In this
investigation, no differences were found regarding the
shape of the dental wear between bruxist and non-
Discussion
bruxist subjects. However, the studied teeth here were
Bruxism is considered to be a parafunctional behaviour deciduous, whose enamel hardness is higher than that
that has a multifactorial aetiology (47–50). In the in the permanent dentition [primary enamel has a
present work, dental wear was more significant in mean hardness of 4Æ88  0Æ35 GPa (56). In the perma-
the bruxist group. However, it must not be taken as nent dentition, the hardness of the normal enamel is
the only sign to diagnose this parafunctional activity. 3Æ66  0Æ75 GPa (57)], so the shape of wear could be
Some studies in the literature have left aside factors more uniform, as it is more difficult to wear it out (56).
related to the parafunction that give important infor- High anxiety levels have been previously reported as
mation regarding the aetiology of bruxism in the closely associated with bruxism (58). The anxiety state is
central and peripheral nervous system (1), such as a prominent factor in the development of bruxing
body and cervical column positions (51). There are no behaviour in children (58). Indeed, some authors have

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668 A . L . V É L E Z et al.

shown that when the anxiety is treated, either with masticatory muscles be more hypertonic (73). This
psychological techniques (16) or with drugs (59), the finding coincides with the muscular signs found by other
signs of bruxism decrease. Bruxist children studied in the authors (74), when the parafunction is exacerbated.
present research had high anxiety level and they were This study did not explore the relationship between
found to present anterior head posture when compared mandibular rotation and the head posture, because we
with the non-bruxist group. Although there are reports would have needed a bigger sample to match the children
of anxiety affecting the body posture (60), a specific head for malocclusions class I, II and III. However, observa-
tilt in an anxiety state has not been previously reported. tions of past studies (51, 74) indicate that anterior and
Oral parafunctions, especially bruxism, have a signi- downward head postures affect the mandibular position.
ficant association with TMD (54, 61), even in children The results of the present research showed that if
(54). The objective of the present investigation was not the parafunction has a multifactorial aetiology, then
to seek an association of TMD with head posture. the diagnosis and the treatment has to be multifacto-
However, controversy does exist regarding the rela- rial as well.
tionship between TMD and head posture. Some authors
support it (62, 63), but their methodology is not good
Conclusions
enough to establish the relationship between TMD and
anterior head posture in children. Some of them used a The head postures found in the bruxist group were
stethoscope to detect only TMJ sounds (62), leaving more anterior and downward than those found in the
aside other TMD that are not audible. Others used the control group.
Helkimo’s index (64), whose measurements of the It is always important to make a multifactorial
muscle tenderness and pain are not reliable in children diagnosis of the parafunction to establish the individual
(63). However, other authors have better evidence to causes of bruxism in each case and determine the best
conclude about the poor relationship between TMD therapeutic alternative for each subject.
and head posture (65, 66). Further work is required to understand whether head
Bruxism is mainly centrally regulated, not peripher- postures are causes or consequences of bruxism.
ally regulated (2, 4). Alterations in body position have
been identified and described in the literature, as one of
Acknowledgment
the peripherical factors that could initiate the para-
function (67, 68), while in the central nervous system, The authors acknowledge the financial support to this
the partial hypoxia (69) has been defined as one of the study from Susalud EPS and CES University.
factors that could generate the failure in the neuro-
transmission of dopamine (15).
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