My AOX Bruxism Protocol

Ahhh bruxism… 

The irony. Patients who frequently require a procedure like AOX, yet a group who we are often hesitant or unwilling to treat. 

Should we or should we not treat bruxers? And how should we do it? 

Today I’m going to share with you a brief outline regarding how I approach these cases. 

I do frequently treat bruxism patients. While I absolutely have had some complications with these patients, overall I have had consistent full-arch success. 

Here’s my two cents. Take it for what it’s worth. 

My AOX Bruxism Protocol

1. Medical Assessment

As always, a full medical work-up is completed for the surgical patient on hand. 

Where this is a bit unique, is that I tend to be slightly more conservative with implant related medical comorbidities in patients who are ALSO bruxers.

For instance, let’s consider an immunocompromised patient on a potential medication/medications known to adversely affect implant healing – AND the patient is ALSO a severe bruxer. In this case I would tread very cautiously and/or consider other non-immediately loaded options. 

2. CT Scan Review

Typically bruxers will have more bone than most. This is because they are still dentate and also typically have a thicker, wider facial structure.

Upon review of the scan, I am assessing the available bone and likelihood of a 4-6 implant configuration that will eliminate the cantilever. 

3. Adequate Reduction

One of the downsides to the mechanical action of bruxing is that it can create prosthetic fractures. This is especially true if there are weak or thin points in the prosthetic. 

There is often some hesitation during bone reduction on bruxism patients as the tendency is to want to save bone “in case something fails”.

However, inadequate reduction will greatly increase the risk of prosthetic failure. And even worse, inadequate reduction can lead to implant failure secondary to multiple prosthetic fractures. 

Therefore, one of the ways in which we can minimize this risk from a surgical standpoint is to meet the ideal space requirements for the prosthetic we are providing. I am always cognizant to provide adequate reduction for the prosthetic on hand. I also ensure this reduction is carried out posteriorly through the entire extent of the prosthesis.  

4. Eliminate Cantilever

Cantilever elimination is critical in bruxism patients. I understand that not every single patient can have a completely eliminated cantilever. But – most bruxism patients can. This is because as we have mentioned prior – they typically are dentate with ample bone. 

I do not necessarily think “more” implants are better in bruxism patients. In my experience, 4 or 5 or 6 implants is not the magical answer. The answer is the elimination of the cantilever. 

If I can eliminate the cantilever with 4 implants – this is usually all that I will place. 

If it takes 6 implants to eliminate the cantilever (i.e. pterygoids, palatal root implants, short implants posterior to the foramen etc.) – then 6 implants it is. 

I almost never place 5 implants – but that’s another discussion. 

If I am not confident I can eliminate, or greatly minimize the cantilever surgically, then it is done prosthetically by shortening the arch. One way or another – I attempt to shorten the cantilever in these patients. 

5. Ti-Bar Prosthetic

I have worked with most all current materials available for full-arch surgery. Having done so – I am firm believer that a ti-bar prosthetic is the best option for bruxism patients from a surgeon’s point of view. 

In my clinical experience, the presence of the ti-bar simply handles the forces of bruxism better with less failures than an all zirconia prosthetic. 

For this reason, I prefer to exclusively treat bruxism patients with a ti-bar prosthetic. 

6. (+/-) Botox Therapy

Botox therapy is a great way to limit bruxism forces, especially during the integration period. 

That being said, I do not recommend botox therapy to most bruxers. I reserve this for truly, truly severe bruxism patients. 

I will add that I recommended it much more frequently when using an all zirconia prosthetic and/or when using an acrylic temporary for the 4-month integration period. Out of my past 1100 arches with a ti-bar prosthetic – I have only recommended this therapy to one bruxism patient.

7. Night Guard

This may be obvious, but I will put it on the list nonetheless. All of my patients do go home with a night guard. This is no different, and even more important for bruxers. 

8. (+/-) Delayed Load

While not an option I love, I do want to be clear that this is always an option.

Taking the immediate loading out of bruxism patients really takes the stress out of the surgery and comes as close as possible to ensuring integration. 

As stated, however, most of these patients are dentate and also often younger. Therefore, talking these patients into a planned delayed load is really where the difficulty lies. 

I will note that “integrated” implants for obvious reasons can handle the forces of bruxism much better than “integrating” implants. However, integrated implants can and do still fail as a result of severe bruxism. So your surgical plan should still account for the increased forces of bruxism – even if you are planning a delayed load. 

And… That’s it. 

Nothing magical. 

Just a little extra planning and some “over-engineering”. 

My hope is that this information can help make performing these surgeries – well… not such a grind. 

Matthew Krieger DMD

P.S.  Please note, as reference, that I have always performed an immediate load to date on bruxers (unless it is a “re-do” case and there has been a history of multi-implant or total arch failure). 

P.P.S. These are anecdotal findings based on 1,921 arches to date. These are not controlled, research based findings. This is anecdotally what has worked well for me, in my hands with this group of patients over a significant volume of arches.