Wear Evaluation of Different Occlusal SplintsSection A -Research paper

and Fixed Prosthodontics Restorations

Wear Evaluation of Different Occlusal Splints and Fixed

Prosthodontics Restorations

Angham I. El-Gendy, BDS, MDS1, Mahmoud Shakal, BDS, MDS, PHD2,

Fatma A. Hasaneen, BDS, MDS, PHD3

ArticleHistory:Received:12.02.2022 Revised:29.03.2023 Accepted:15.04.2023

Abstract

Purpose: The purpose of this in vitro study was to evaluate the wear of different occlusal splints and opposing fixed
restorations.
Methods: Three different occlusal splints with two different antagonists were used (n=10). A full dentate typodont
was used with an occlusal splinton the upper arch opposing crowns on lower posterior molars either porcelain fused
to metal (PFM) or veneered polyetheretherketone (PEEK). Group I: 3D printed occlusal splint Group II: Heat-cured
occlusal splint Group III:vacuum-formed occlusal splint. All specimens were tested by chewing simulator including
the application of (50N) load for 75,000 cycles to simulate 6 months. Surface roughness and volume loss of all
specimens were measured using an optical profilometry before and after the chewing simulation.Descriptive
statistics, Student t-test and one-way ANOVA were done.Pearson’s correlation was done between volume loss and
roughness change.
Results: 3D printed group recorded the lowest surface roughness change and volume loss (p≤0.0001,
p=0.0013<0.05). Total volume loss against PFM was statistically significantly higher than the volume loss against
PEEK (p=0.014< 0.05). Pearson linear showed that there was a weak positive relation between surface roughness
and volume loss.
Conclusion: 3D printed occlusal splints are more wear-resistant after wear simulation for 6 months. The effect of
the antagonist on the wear of the splint could be considered as PFM causing more wear on the splint than the PEEK.
Clinical significance:Using 3D-printing technology in production of occlusal splints can improve wear resistance of
the occlusal splints made for bruxers especially those with PFM restorations.
Keywords:Bruxism, Occlusal Splints, fixed prosthodontics.
1. Assistant Lecturer, Department of fixed prosthodontics, College of Dentistry, University of Tanta, Tanta, Egypt.
2. Professor, Department of fixed prosthodontics, College of Dentistry, University of Tanta, Tanta, Egypt.
3. Lecturer, Department of fixed prosthodontics, College of Dentistry, University of Tanta, Tanta, Egypt.
Corresponding author:Angham I. El-Gendy E-mail: [email protected]

DOI: 10.31838/ecb/2023.12.4.087

INTRODUCTION Physiotherapy, occlusal splints, medication injections,

Bruxism is the grinding or clenching of teeth for arthroscopy, and surgery are the most common
reasons other than swallowing or eating, and it can be treatments.(3) The entire occlusal splint
divided into two types: sleep bruxism and awake manufacturing process was done manually. Recently,
bruxism.(1) It is commonly linked with tooth (Computer-Aided-Design / Computer-Aided-
abrasions and mobility, dental restoration fractures, Manufacture) CAD/CAM was utilized to produce the
masseter muscle hypertrophy, and myalgia or occlusal device by subtractive or additive
arthralgia, all of which are symptoms of techniques.(4) When compared to the traditional gold
temporomandibular disorders (TMD). The cause of standard, this would have various advantages such as
bruxism is unknown, but etiological variables like as superior fit, biocompatibility, and dimensional
stress, neurological illnesses, certain medicines, and stability.(5)
occlusal interferences have been reported.(2) Restorative materials should ideally wear at the same
ratio as posterior tooth enamel, which is between 20-

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Wear Evaluation of Different Occlusal SplintsSection A -Research paper
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40 µm per year(6). The surface roughness is a Group III:vacuum-formed occlusal splint (CRYSTAL
concern as it could affect plaqueaccumulation, PLATE 2,0 mm- PET-G, Bio art, 2BBrazil).
staining, and wear of opposing natural teeth and The design of the splint was standardized as: the
materials.(7) The wear of the restorative material's occlusal thickness was 2 mm posteriorly, 1 mm
occlusal surface can affect the thickness of the labially and the splint was extended to cover the
occlusal part of therestoration and the opposing incisal third labially and palatally to the cervical
structure, which can result in occlusion changes, area.(16)
unstable occlusal contacts due to wear facets creation For the vacuum-formed splints, upper arch
leading to a decrease in the appliance's longevity.(8) impressions were made with irreversible hydrocolloid
Porcelain fused to metal (PFM) was the most (Cavex cream alginate, Cavex Holland BV) then
common restoration as it offers a stronger restoration pouring was done with hard die stone ( Hard Rock,
while also being aesthetically pleasing. Also, highly Stone; Whip Mix, Corp, Louisville, USA). Two
resistant to wear, however, roughness of the porcelain thermoplastic sheets with 2mm thickness were used
cause wear of opposing natural teeth or restorations. with cold cure acrylic monomer applied in between
(9)Modified Polyetheretherketone (PEEK) had found them using a brush for bonding ( Dr. Amr Elkmaah
to have outstanding biocompatibility and elastic design). Then splints were adjusted on the cast to the
behavior comparable to that of bone. It might be desired extension. (16)For the heat-cured splint, a
manufactured using either CAD/CAM or wax pattern with the desired thickness and extension
compression molding techniques. Because modified was done on the maxillary cast to be replaced by the
PEEK has a pearl-white opaque color, it requires heat-cured acryl. Polymerization was done by the
veneering. (10) pressing technique. Then deflasking, finishing ,and
Because clinical wear evaluation is more expensive, polishing were done.(17)
required more time, and is methodologically For the 3D-printed occlusal splint Scanning was done
challenging, masticatory simulators have been by using a digital scanner (Ceramill 400 digital
developed to simulate the oral environment and create scanner, Amman Girrbach, Germany). The designing
wear in test specimens.(11) The chewing simulator was done by Exo Cad software ( Exo Cad 2019,
has been utilized in in-vitro research to measure the Gmbh, Germany) and then saved as an STL file.The
two-body wear resistance of various materials.(12) slicing software (Form Ware B.V., Amsterdam, The
Few studies had tested the wear of different occlusal Netherland) of the 3D printer (RASDENT 3D Printer
splints with the natural tooth,(13) composite resin(14) Model S RASPART) was used to convert the CAD
or steel ball(15) antagonist. So, the purpose of this STL file of the resin into a G-code. The sliced file
study was to evaluate the wear of different occlusal was sent to the 3D printer via the internet then 3D
splints opposing fixed prosthodontics restorations. printing was done by Stereolithography. All types of
The null hypothesis was that there would be no splints were cleaned with isopropyl alcohol and then
difference in wear resistance of occlusal splints finished and polished by using a disc on a rotary
fabricated by different methods. machine under wet condition. Finally, steam cleaning
MATERIALS AND METHODS was done and washing in ultrasonic at room
This study was carried out as controlled experimental temperature for 10 minutes.
study. The experimental study was carried out at Teeth no 36, 37, 38, 46, 47, and 48 (according to FDI)
Fixed Prosthodontics Department, Faculty of were used as abutments.A silicone putty index
Dentistry, Tanta University. The total sample size in (Express STD firmer set, 3M ESPE, St.Paul, MN
this study was 60 𝑠𝑎𝑚𝑝𝑙𝑒𝑠, 10 sample in each group. USA) of the tooth was done before tooth preparation
Each group had an occlusal splint (PolyMethylMetha to check the amount of tooth reduction and help in
Acrylate (PMMA)) on the upper arch opposing standardization of the thickness of the veneering
porcelain fused to metal (PFM) and PolyEther Ether material. The occlusal reduction was 1.5 mm on the
Keton (PEEK) crowns on the lower posterior molars nonfunctional cusp and 2mm on the functional cusp.
on a typodonte (Ramses, Egypt)( n=10): A deep chamfer finish line with axial reduction of 1.2
Group I:3D printed occlusal splint (Dental yellow mm. for PFM crowns, while 1 mm wide shoulder
clear, Harz lab, Moscow, Russia). finish line for PEEK crowns.
Group II:Heat-cured occlusal splint (Rapid simplified Each abutment was scanned then the coping was
heat cured clear acrylic resin, Vertex-Dental bv, The designed with 0.5 mm thickness. The coping design
Netherland). was 3d printed by using Castable resin ( EPAX
Castable Resin, EPAX, North Carolina, United

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States) then soaking the copings in isopropanol for 20 Neumuenster, Germany) according to the
minutes, and excess resin was removed.post- manufacturer’s recommendations.
polymerization was done for the copings for 60 Two-body wear test was performed using a chewing
minutes after cleaning. Metal coping was fabricated simulator ( ROBOTA chewing simulator Model
by using the lost wax technique: spruing, investment, ACH-09075DC-T, AD-TECH TECHNOLOGY CO.,
burn out, casting ,and finishing to receive the LTD., Germany). 50 Newton force was exerted for
porcelain. Preparation of metal copings was done then 75000 cycles to simulate 6 months(18) with vertical
porcelain application and glazing.Dry milling was movement of 1mm, horizontal movement of 3mm
done by five-axis milling machine (DWX-52D 5-Axis ,and 1.6Hz frequency.
Dental Milling Machine, Roland, DGSHAPE, North Surface roughness and volume loss were measured
America). PEEK ( Bre CAM BioHPP, Bredent, before and after wear simulation through optical
GmbH & Co. KG, Germany)specimens milled profilometry. Specimens were photographed using a
copings were veneered using vacuum formed index USB Digital microscope (Scope Capture Digital
with Visio.Lign system ( Bredent, GmbH & Co. KG, Microscope, Guangdong, China). Analyzing was
Germany). done with WSxM software (Ver 5 develop 4.1,
Sandblasting was done with aluminum oxide powder Nanotec, Electronica, SL, Madrid, Spain )as shown in
(Al2O3) on all the crowns. Cementation was done Figures.1 to calculate the average of heights (Ra)
with the aid of a custom-made cementing device with expressed in μm and volume loss expressed in
a 5 kg load application using glass ionomer cement mm3.(19),(20)
(Medicem, Promedica Dental Material GmbH,

a b

Figure 1.Surface topography of the splint surface showing surface roughness before (a) and (b) after chewing simulator.

than the change mean value against PEEK as

STATISTICAL ANALYSIS confirmed by unpaired t-test (p=0.4435> 0.05) as
This was done by (InStat 3; Graph Pad Inc) as shown in Table 1.
follows: descriptive statistics for each group results, Total roughness change of PFM against different
Student t-test was done between mean groups before splint materials was statistically non-significant
and after wear simulation results and One-way higher than the change mean value of PEEK as
ANOVA followed by Tukey’s post-hoc (if showed confirmed by unpaired t-test (p=0.064> 0.05).
significance) was performed between wear changes. The difference in volume loss recorded between splint
Pearson’s correlation was done between volume loss groups against PEEK was statisticallynon-
and roughness change. significant(p=0.6984 > 0.05)and against PFM was
statisticallysignificantas indicated by ANOVA test
RESULTS (p=0.0013< 0.05)with the 3D-printedgroup recorded
The difference in roughness changes recorded the lowestvolume loss mean value(-0.002 mm3),(-
between groups against PEEK andPFM were 0.00154 mm3)respectively.
statistically significant as indicated by ANOVA test Total volume loss against PFM was statistically
(p≤0.0001< 0.05) with heat-cured recorded the significantly higher than mean value against PEEK as
highest change mean value(0.0102µm),(0.0166µm) confirmed by unpaired t-test (p=0.014< 0.05) as
respectively. shown in Table2.
Total roughness change regardless of splint type Total volume change in PEEK crowns was
against PFM was statistically non-significant higher statistically non-significant higher than the change

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 Wear Evaluation of Different Occlusal SplintsSection A -Research paper
and Fixed Prosthodontics Restorations

mean value in PFM crowns against splint material as (µm) as indicated by Pearson linear correlation
confirmed by unpaired t-test (p=0.0853> 0.05). (Correlation coefficient (r) = 0.1234, r 2= 0.0152 and p
It was found that there wasa weak positive correlation > 0.05) as shown in Table 3.
between volume loss (mm3) and roughness change

Table 1.Comparison between mean values and standard deviations (SD) for roughness change results (µm) for all
splint materials against PEEK vs. PFM after 6 months wear simulation cycles.
Change Statistics
PEEK antagonist PFM antagonist P value
Mean 0.0033 0.0026
Gr_I 0.0555 ns
SD 0.0013 0.0006
Mean 0.0102 0.0166
Gr_II <0.0001*
SD 0.0039 0.0004
Mean 0.0066 0.0014
Gr_III <0.0001*
SD 0.0018 0.0005
*; significant (p≤0.05) ns; non-significant (p>0.05)

Table 2. Comparison between (mean values +SD) for volume loss results (mm3) for all splint materials against
PEEK vs. PFM after 6 months wear simulation cycles
Volume loss Statistics
PEEK antagonist PFM antagonist P value
Mean -0.002 -0.00154
Gr_I 0.7747 ns
SD 0.0024 0.00111
Mean -0.00223 -0.00283
Gr_II 0.3457 ns
SD 0.001931 0.000318
Mean -0.0025 -0.00354
Gr_III 0.092 ns
SD 0.001082 0.001511
Statistics P value 0.6984 ns 0.0013*
*; significant (p<0.05) ns; non-significant (p>0.05)

Table 3. Linear correlation between volume loss (mm3) and roughness change (µm).
Parameter Correlation coefficient (r) r2 P value
3
Volume loss (mm )
0.1234 0.0152 0.8158 ns
Roughness change (µm)

DISCUSSION teeth or restorations caused by contact with different

The null hypothesis was rejected as the 3D-printed splint materials and fabrication techniques.(21)
occlusal splint was found to have the least wear Wear limits the appliance's lifetime by preventing the
change among the other types of splint. Occlusal equilibration of occlusal contacts. This could result in
splints are considered the main element in the a negative effect on treatment outcomes and the
treatment of bruxism and TMJ disorders. Hard splints requirement for better-suited materials.(22)
could be an indication when there is a need to The uniqueness of the current study was using a
decrease tooth wear and protect the restorations. typodont, with artificial upper and lower arch full
However, little information is available on the wear of dentate. This geometry may allow similarity to the
aspect that exists in the mouth when dental materials
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wear out during function. As it was found that flat The total volume loss of splint material against PFM
samples were shown more wear than crown-shaped crowns was significantly higher than that against
samples.(23) PEEK crowns as feldspathic porcelains had low
In this study three upper different splints were used, toughness and had leucite crystals that were liable to
vacuum-formed splints were fabricated as they had fatigue so wear could initiate cracks. Repeated
the advantages of ease of fabrication and cheapness. loading will lead to cracks propagation and material
The second one was the most common manufacturing loss that could accelerate the wearing of the opposing
material, conventional heat-cured acrylics. Because of resulting in a rough and abrasive surfaces.(35)
its good biocompatibility, less expensive, easy The 3D-printed and vacuum-formed splints were
processed ,and has high strength.(24)With the found to have the lowest comparable surface
introduction of CAD/CAM in dentistry, additive roughness change. This difference may be due to the
manufacturing (AM);(25) 3D-printed occlusal splints fabrication process that could result in different
were fabricated. They had the advantages of being degrees of conversion and cross-linked densities of
less time-consuming, low shrinkage ,and a more the polymers. These findings were supported by a
homogenous products.(26) previous study(8) showed that vacuum-formed,
All splints were stored for two weeks in distilled additive ,and subtractive occlusal splints showed
water at 25 °C before testing to avoid water sorption comparable results. Another study(36) measured the
of heat cured that occurs during clinical use to surface roughness of different occlusal splint
produce water balance to compensate for material materials and showed that vacuum-formed had
shrinkage.(27)All Tested materials received a comparable surface roughness with other types of
polishing procedure to reach a similar degree of splint.
baseline surface roughness. This was suggested by According to the finding of this study, the 3D printed
Amer et al(28) who recommended standardization of occlusal splint had shown to have the least wear loss
the initial roughness (Ra). which might be due to less polymerization shrinkage,
In this study chewing simulator was used by setting less residual monomer content, less porosity ,and less
the occlusal bruxial force to 50 Newton for 75000 manual error. Reyes-Sevilla et al.(14) concluded that
cycles to simulate 6 months.(18) This was printed PMMA and polyamide-based splints
accompanied by continuous washing with exhibited less wear than the chemical-cured or milled
demineralized water at 30 C(13) to remove abraded PMMA splints which was matching with the result of
particles which could reduce the coefficient of friction this study.On the contrary, another study(30) that
and decrease the wear.(29) Many previous evaluated wear of 3D-printed, milled ,and heat-cured
studies(15),(30),(13),(22),(31) had used an average PMMA occlusal splints found that the lowest wear
force of 49 to 50 N which would be equal to a single resistance was the 3D-printed splint, this may be due
point contact. On average, it was recommended to to difference in the specimen geometry as they used a
wear occlusal devices from 1 to 12 months with crown-like coping occlusal device and cemented it on
continuous follow-ups.(12) tapered metal alloy abutment. Another difference was
The heat-cured splint was found to have the highest the printer as they used a DLP printer as it was found
surface roughness change which was significantly that the flexure strength was highest in SLA printed
higher than the other two types of splint occlusal devices with vertical printing direction.(37)
(p≤0.0001<0.05). This may be due to the release of Also they used the replica technique for wear
residual monomer, which could affect its dimensional measurement and the cycles were set to reach 120,000
stability and could result in porosity that increases cycles.
surface roughness. (32) These results were supported The results of wear and surface roughness for tested
by the findings of two studies(32),(33) with the splint materials in the current study showed that the
conventional heat-polymerized had higher surface increase in surface roughness could lead to more
roughness values. volume loss as found in a previous study.(22) The
However, a study(34) compared the surface coefficient of friction, which increased by surface
roughness of PMMA produced by heat-cured and roughness, had been reported to result in greater wear
CAD/CAM reported that higher roughness was for of the antagonist.(38)
the CAD/CAM splint. This may be due to milling out The limitations of this study were: first, it was done
from blanks, hand finished then cutting of the pre- as an in vitro study. Clinically, corrosive wear is
polymerized specimen which could result in important. Water, resin ,and alcohol could lead to the
additional surface roughness and internal tensions in leaching of filler, and some microorganisms could
the resin, which wouldn’t be in the conventional cause resin degradation.(39) Another limitation was
specimen. the lack of saliva in the chewing simulation, so it was

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recommended to artificial saliva incorporation in the opposed to zirconia ceramic. J Prosthet Dent
chewing simulator ,and exposure of the specimens to [Internet]. 2010;104(2):105–13. Available
an exogenous chemical substances during the from: http://dx.doi.org/10.1016/S0022-
chewing simulation to investigate the corrosive wear 3913(10)60102-3
aspect. Limited studies were available on 3D-printed 7. Naumova EA, Schneider S, Arnold WH,
occlusal device materials so further investigation was Piwowarczyk A. Wear behavior of ceramic
recommended, especially on printing build angles and CAD/CAM crowns and natural antagonists.
settings. Materials (Basel). 2017;10(3):1–13.
8. Huettig F, Kustermann A, Kuscu E, Geis-
CONCLUSION Gerstorfer J, Spintzyk S. Polishability and
According to the finding of this study and within its wear resistance of splint material for oral
limitation of this study, it was found that: appliances produced with conventional,
1. 3D-printed occlusal splints have the least subtractive, and additive manufacturing. J
wear change after wear simulation for 6 Mech Behav Biomed Mater [Internet].
months when compared with heat-cured and 2017;75(June):175–9. Available from:
vacuum-formed occlusal splints. https://doi.org/10.1016/j.jmbbm.2017.07.019
2. PFM crowns produce more wear on the 9. Weigl P, Saarepera K, Hinrikus K, Wu Y,
opposing splint surface. Trimpou G, Lorenz J. Screw-retained
monolithic zirconia vs. cemented porcelain-
fused-to-metal implant crowns: a prospective
Conflict of interest: randomized clinical trial in split-mouth
None of the authors have any conflict of interest. design. Clin Oral Investig. 2019;23(3):1067–
75.
10. Tekin S, Cangül S, Adıgüzel Ö, Değer Y.
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