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Masticatory Force: Methods of Measurement and Reference Load Values Across Clinical Conditions

A Literature Review for Thesis Submission

1. Introduction

Masticatory force - the force generated by the muscles of mastication during biting and chewing - is one of the most clinically significant biomechanical parameters in dentistry and prosthodontics. It serves as an indicator of the functional integrity of the stomatognathic system, influences treatment planning for restorations, implants, and prostheses, and determines the mechanical demands placed on natural teeth, bone, and prosthetic components.

Bite force (used interchangeably with occlusal force) is defined as the force produced at the occlusal contact area when the jaws close against each other. It is the resultant of activity in the elevator muscles (masseter, medial pterygoid, and temporalis), modulated by sensory feedback from the periodontal ligament, muscle spindles, and temporomandibular joint mechanoreceptors. The magnitude of bite force is not fixed - it varies substantially across individuals and clinical conditions, including dentition status, prosthetic rehabilitation, parafunctional habits such as bruxism, gender, age, and skeletal morphology.

This review summarizes the methods used in the literature to measure masticatory force and presents reference load values for natural dentition, complete dentures, implant-supported prostheses (including full-arch rehabilitations), and parafunctional states including bruxism.

2. Methods of Measuring Masticatory Force

The literature documents a progressive evolution of bite force measurement instruments, from simple mechanical devices in the 17th century to modern computerized digital systems. The choice of instrument depends on the clinical setting, the specificity required (maximum voluntary bite force vs. functional masticatory force), and whether static or dynamic loading is of interest.

2.1 Historical Background

The earliest attempt at quantifying bite force is attributed to Borelli (1681), who suspended weights on a thread over the molars while the mandible was held open. The maximum load that still permitted jaw closure ranged from 132 to 440 lb. This methodology, though primitive, established the principle of measuring maximum bite force at specific tooth positions.

The first purpose-built instrument - the gnathodynamometer - was developed by Patrick and Dennis (1892), recording a maximum force of approximately 165 lb. G.V. Black (1895) subsequently refined the gnathodynamometer design and reported mean maximum forces of around 170 lb at the molar region. These early instruments were based on spring-resistance or lever-balance principles and suffered from poor intraoral adaptability and limited accuracy.

2.2 Strain Gauge-Based Transducers

Strain gauge transducers are the most widely used instruments in contemporary bite force research. They work on the principle that mechanical deformation of a sensing element produces a proportional change in electrical resistance, which is converted to a force value (in Newtons).

Design: A load cell or force transducer is typically housed in a metal or acrylic fork/pad that is placed between the dental arches at the desired measurement position (molar, premolar, or incisal region). The device may be connected to a digital display or computer interface.

Advantages: High accuracy, repeatable measurements, capable of recording both peak and continuous force profiles, and adaptable to unilateral or bilateral placement.

Limitations: Custom-made devices may lack standardization across laboratories. The thickness of the sensing pad may alter natural bite force by modifying the occlusal vertical dimension.

The computerized masticatory force measurement system described by Rane et al. (2017) is an example of a modified load cell sensor fork interfaced with computer software, capable of generating real-time force profiles. This approach has been validated for repeated measurements across sessions, with high reproducibility (PMID: 27562358).

Custom strain gauge transducers have also been used at Umea University, Sweden, in several landmark studies by Chrcanovic and colleagues (2025), involving unilateral recording in the premolar region with calibration using known loads.

2.3 Piezoelectric Sensors

Piezoelectric transducers generate a voltage proportional to the applied compressive force. They are compact, highly sensitive to dynamic loads, and well-suited for measuring rapidly changing forces during the masticatory cycle.

Clinical use: Applied particularly in studies involving chewing cycles and masticatory force patterns rather than maximum voluntary bite force. Some designs are incorporated into intraoral prostheses or implant abutments for in vivo force telemetry.

Limitations: Susceptibility to drift with sustained static loading; less accurate for prolonged clenching measurements.

2.4 Pressure-Sensitive Film Systems (Fuji Prescale / Dental Prescale II)

Fuji Prescale Film (Fujifilm, Tokyo, Japan) is a pressure-indicating film that records contact area and pressure distribution through a color-developing chemical reaction. When compressed, micro-encapsulated color-forming material on one layer reacts with a developer layer, producing a red impression - the density of which is proportional to the applied pressure.

Two variants are available:

Two-sheet type (sensitivity range: ultra-super-low to medium, ~0.17-0.50 MPa)
Mono-sheet type (medium to super-high, ~1.0-16.6 MPa)

Dental Prescale System (DPS): A dental-specific version available in wafer form that the patient bites down on. The resulting impression is scanned and analyzed with dedicated software (Occluzer FPD-707, GC Corporation) to calculate occlusal contact area, force distribution, and an occlusal force value in Newtons.

Advantages: Provides spatial distribution of occlusal contacts across the full arch simultaneously; no wires or transducer thickness issues; widely used in population-based studies (Nitschke et al., 2025, MDPI).

Limitations: Single-use; cannot record dynamic time-series data; susceptibility to premature activation from humidity; inter-observer variability in image analysis. Comparative studies show Tekscan has lower measurement error for area and pressure than Fuji film methods.

2.5 T-Scan System (Tekscan, Boston, USA)

The T-Scan is a thin, flexible, electronic intraoral sensor (thickness ~0.1 mm) connected to a computer. It contains a matrix of pressure-sensitive cells that individually record force magnitude as a function of time, yielding dynamic occlusal force analysis in real time.

Output: Graphical display of force distribution across all contacts simultaneously, force over time curves, center-of-force trajectory, and percentage force per tooth or quadrant.

Clinical utility: Particularly useful for:

Identifying occlusal interferences and prematurities
Monitoring force redistribution after implant placement
Assessing occlusal balance in full-arch restorations

Limitations: Does not measure absolute force in Newtons directly; rather, it measures relative force distribution. Cross-calibration with absolute force devices is recommended when quantitative values are needed.

2.6 Occlusal Force Meter (OFM, Nagano Keiki / GM10)

The Occlusal Force Meter GM10 (GC Corporation/Nagano Keiki, Tokyo, Japan) is a commercially available, standardized bite force measurement device widely used in clinical studies. It consists of a pressure pad placed between specific dental antagonists, connected to a digital readout displaying force in kilonewtons (kN) or Newtons.

This instrument was used by Nitschke et al. (2025) in a large cross-sectional study of 198 participants across seven prosthetic treatment groups, making it currently one of the best-characterized devices for comparative reference value studies.

2.7 Digital Dynamometer (DDK, Kratos)

A digital dynamometer (e.g., Kratos DDK, Brazil) consists of a calibrated force-sensing head connected to a digital display. Participants bite on the sensing head with maximum voluntary effort, and the peak force in Newtons is recorded. Three measurements are typically averaged after 30-second rest intervals. This device has been used extensively in Latin American population studies and in the work by Chrcanovic et al. (2025) comparing bruxers and non-bruxers.

2.8 EMG-Based Indirect Assessment

Electromyography (EMG) of the masseter and temporalis muscles provides an indirect estimate of masticatory force by correlating muscle activity (in microvolts, µV) with force output. While EMG does not directly measure force at the teeth, surface EMG is valuable in:

Quantifying parafunction (bruxism) during sleep (sleep bruxism EMG activity index)
Assessing masticatory muscle recruitment patterns
Studying neuromuscular adaptation after prosthodontic rehabilitation

Portable ambulatory EMG devices (e.g., BiteStrip, Bruxchecker EMG) have been used to quantify nocturnal muscle activity as a surrogate for bruxism-related force.

Nishigawa et al. (2001, J Oral Rehabil) conducted a landmark quantitative study of bite force during sleep-associated bruxism using combined EMG and bite force transducers, demonstrating force levels substantially above waking functional biting.

2.9 Implant-Mounted Telemetric Sensors

For in vivo measurement of forces transmitted to osseointegrated implants, strain gauge-equipped implant abutments or custom transducer-based abutments with wireless telemetry have been developed. These allow real-time recording of functional and parafunctional forces at the implant-bone interface under clinical conditions.

Limitation: High cost, technical complexity, and the need for surgical placement make this technique primarily a research tool. Morneburg and Proschel (2002) used implant-supported transducer systems to quantify forces on three-unit fixed partial dentures and single implants in different arch positions.

2.10 Summary Table: Measurement Methods

Method	Principle	Output	Clinical Use
Gnathodynamometer	Mechanical spring resistance	Maximum force (N or lb)	Historical; limited current use
Strain gauge transducer	Electrical resistance change	Peak and continuous force (N)	Research gold standard
Piezoelectric sensor	Voltage from deformation	Dynamic force profile	Chewing cycle studies
Fuji Prescale Film	Chemical color reaction	Pressure map, force area (N, MPa)	Clinical and research
Dental Prescale (DPS)	Film + digital scanning	Full-arch force distribution	Population studies
T-Scan (Tekscan)	Capacitive resistance matrix	Relative force distribution, timing	Clinical occlusal analysis
Occlusal Force Meter (OFM)	Pressure pad + digital gauge	Force (N or kN)	Standardized clinical studies
Digital Dynamometer (DDK)	Force transducer + digital display	Peak force (N)	Field studies, large populations
Surface EMG	Muscle electrical activity	Indirect force estimation	Parafunction, bruxism research
Implant telemetry	In-implant strain gauges	In vivo implant load (N)	Research, high-cost settings

3. Normal Occlusal Load (Natural Dentition)

The maximum bite force in a healthy natural dentition is the most extensively studied reference value. Multiple variables influence it, including tooth position, sex, age, skeletal morphology, number of teeth, and masticatory muscle cross-sectional area.

Landmark values from the literature:

Black (1895): Mean maximum molar force ~170 lb (~756 N) using an improved gnathodynamometer.
van Eijden (1991): Using strain gauge transducers in dentate adults -
- Canine: 469 ± 85 N
- Second premolar: 583 ± 99 N
- Second molar: 723 ± 138 N
Braun et al. (1995): Natural teeth: 738 ± 209 N (males significantly higher than females)
Nitschke et al. (2025, MDPI): Fully dentate individuals (no missing teeth, natural dentition only): 547 ± 240 N (measured with OFM GM10 in a cross-sectional study, n=198, ages 18-95)

Regional variation: Maximum bite force is highest in the molar region and decreases progressively toward the incisors, reflecting the mechanical advantage of the masseter and medial pterygoid muscles at the posterior dentition. Molar forces typically range from 400 to 800 N in healthy adults, premolar forces from 300 to 600 N, and incisal forces from 100 to 200 N.

Sex differences: Males consistently produce higher maximum bite forces than females, attributed to greater muscle mass and jaw dimensions. The male-to-female ratio ranges from 1.1:1 to 1.5:1 across studies.

Age-related changes: Bite force peaks in young adulthood (20-30 years) and declines with age, partly due to muscle atrophy and progressive tooth loss.

Functional masticatory force vs. maximum voluntary bite force: It is important to distinguish these two values. Functional masticatory forces during actual chewing are a fraction of maximum voluntary bite force (MVBF). During routine chewing of soft foods, occlusal forces typically range from 20 to 120 N. Maximum voluntary bite force represents a physiologic ceiling that is rarely approached during normal function.

4. Occlusal Load in Complete Denture Wearers

Complete denture wearers generate substantially lower maximum bite forces than dentate individuals. This reduction reflects:

Loss of periodontal ligament sensory feedback (replaced by mucosa-supported load)
Mucosal compressibility limiting force build-up
Disuse atrophy of masticatory muscles following prolonged edentulism
Denture instability limiting the ability to generate high forces without dislodging the prosthesis

Reference values from the literature:

Carr and Laney (1987): Mean maximum masticatory force in conventional complete denture wearers: 59 N (compared to 112.9 N with implant-supported prostheses)
Mericske-Stern and Zarb (1996): Complete denture/implant-supported prostheses: 35-330 N (wide range reflecting varying implant support configurations)
Nitschke et al. (2025): Edentulous patients with complete dentures in both jaws (PTG 7): 55 ± 45 N - representing only ~10% of the fully dentate reference value
Untreated edentulism without any prosthesis: as low as 5.1 ± 2.6 N
Complete dentures in both jaws vs. partial configuration (complete denture maxilla + overdenture mandible): 68.7 ± 20.6 N vs. 119.8 ± 265 N respectively

Comparative reduction by prosthesis type (relative to natural dentition):

Fixed partial dentures: ~80% of natural dentition force
Removable partial dentures: ~35%
Complete dentures: ~11% (Nitschke et al., 2025)

These values emphasize the profound functional compromise associated with complete edentulism and the limited force-generating capacity of mucosa-borne dentures. They have direct implications for occlusal scheme design in complete dentures - bilateral balanced occlusion is preferred to distribute the reduced forces evenly and minimize denture displacement under load.

5. Occlusal Load in Implant-Supported Prostheses

Osseointegrated dental implants restore occlusal load capacity more effectively than conventional removable prostheses by providing a rigid, bone-anchored foundation that transmits force directly to the supporting bone. The increase in bite force following implant treatment reflects both the mechanical stability of the prosthesis and the partial restoration of sensory feedback through osseoperception.

5.1 Single and Partial Implant-Supported Restorations

Morneburg and Proschel (2002):
- Implant-supported three-unit fixed partial denture: 220 N
- Single implant (anterior region): 91 N
- Single implant (posterior region): 12 N (likely reflecting early loading cautious function)
Fontijn-Tekamp et al. (1998): Implant-supported prostheses (unilateral measurement):
- Molar region: 50-400 N
- Incisal region: 25-170 N

5.2 Implant-Supported Overdentures (2-Implant Mandibular)

Implant-supported overdentures (ISODs) with 2 interforaminal implants represent the minimum standard for mandibular edentulism rehabilitation and consistently improve bite force compared to conventional complete dentures:

Rismanchian et al. (2009): Complete denture - 122.2 N improved to 370.4 N with implant overdenture
Soni et al. (2020): 81 N (complete denture) to 214 N (implant overdenture)
Sharma et al. (2017): 62.9 N (range 31-88 N) improved to 132.2 N (range 57-192 N)
Nitschke et al. (2025, PTG 6): Edentulous with complete dentures in both jaws, supported by two interforaminal implants in the lower jaw - significantly higher than complete dentures alone (PTG 7)

5.3 Full-Arch Implant-Supported Prostheses (Full-Mouth Rehabilitation)

Full-arch fixed implant prostheses (e.g., All-on-4, All-on-6) restore the greatest functional load capacity among implant-based reconstructions:

Carr and Laney (1987): Implant-supported prostheses: 112.9 N (early data; contemporary full-arch designs significantly exceed this)
Fontijn-Tekamp et al.: Full-arch implant-supported prostheses in the molar region: up to 400 N

The forces transmitted to individual implants during full-arch loading depend heavily on the number of implants, their spatial distribution, the material and design of the superstructure, and occlusal scheme. Finite element analysis studies indicate that individual implant loads in a full-arch All-on-4 rehabilitation under maximum bite force can reach 100-500 N per implant depending on position and load application point.

The absence of a periodontal ligament buffer means that all occlusal force is transmitted directly to the implant-bone interface as axial and non-axial components. Implants lack the proprioceptive threshold modulation provided by the periodontal ligament, making them more vulnerable to overload when parafunctional forces are superimposed on functional loads.

6. Occlusal Load in Bruxism

Bruxism is defined as a repetitive jaw-muscle activity characterized by clenching or grinding of the teeth and/or bracing or thrusting of the mandible. It occurs during sleep (sleep bruxism, SB) and/or wakefulness (awake bruxism, AB). From a biomechanical standpoint, bruxism fundamentally alters the occlusal loading environment in five distinct ways (Misch, Dental Implant Prosthetics):

Magnitude: Forces during bruxism are 4 to 7 times normal functional bite force
Duration: Bruxism episodes last hours during sleep; functional chewing contacts last only ~20 minutes per day
Direction: Bruxism generates lateral/horizontal forces; functional loads are primarily axial/vertical
Type: Shear forces predominate (vs. compressive forces in function)
Cyclical fatigue: Repeated non-axial loading accelerates fatigue failure of implant components and prosthetic materials

Quantitative data:

Normal maximum voluntary bite force: ~120-200 psi (males, natural dentition)
Bruxism: Maximum bite force recorded in a 37-year-old male bruxer: >990 psi - more than 4-7 times normal
Nishigawa et al. (2001, J Oral Rehabil): Quantitative study of bite force during sleep-associated bruxism using strain gauge transducers during polysomnography - forces during bruxism episodes significantly exceeded waking functional forces, with peaks consistent with near-maximum voluntary effort
Chrcanovic et al. (2025, Sci Rep): In a strain gauge-based study (n=51), probable bruxers demonstrated a mean maximum bite force of 618 ± 199 N (range 232-910 N) vs. 486 ± 197 N (range 153-808 N) in non-bruxers (p=0.023) (PMID: 40595268)

Clinical implications of bruxism for implant treatment:

A systematic review by Shafiee and Nourizadeh (2025, BMC Oral Health) found:

Bruxing patients have a 2.2 to 4.7-fold increased implant failure risk compared to non-bruxers
Occlusal splints reduce stress concentration at the implant-bone interface by 33-73% depending on load magnitude
Technical complications include prosthetic screw loosening, framework fractures, acrylic tooth wear, and implant body fracture
Management strategies include occlusal splint therapy, splinted prosthetic designs, strategic implant placement, and modified occlusal schemes (PMID: 41068723)

Bruxism vs. normal masticatory force - a direct comparison:

Parameter	Normal Mastication	Bruxism
Force magnitude	20-120 N (functional)	400-990+ psi (4-7x normal max)
Daily contact time	~17.5 minutes	Several hours (sleep bruxism)
Direction	Primarily axial/vertical	Lateral/oblique/shear
Load type	Compressive	Shear + compressive
Duration per cycle	Seconds (chewing stroke)	Prolonged clenching/grinding
Effect on implants	Within normal homeostatic range	Peri-implant bone loss, component fracture

7. Summary of Comparative Occlusal Load Values

Clinical Condition	Mean Maximum Bite Force	Key Reference
Untreated edentulism	5.1 ± 2.6 N	Nitschke et al., 2025
Complete denture (both arches)	55 ± 45 N	Nitschke et al., 2025
Complete denture (conventional, historical)	~59 N	Carr & Laney, 1987
2-implant overdenture (mandibular)	122-370 N	Rismanchian, Soni, Sharma
Implant-supported 3-unit FPD	220 N	Morneburg & Proschel, 2002
Full-arch implant prosthesis (molar)	50-400 N	Fontijn-Tekamp, 1998
Natural dentition - canine	469 ± 85 N	van Eijden, 1991
Natural dentition - premolar	583 ± 99 N	van Eijden, 1991
Natural dentition - molar	723 ± 138 N	van Eijden, 1991
Natural dentition (population study)	547 ± 240 N	Nitschke et al., 2025
Natural dentition (Braun et al.)	738 ± 209 N	Braun et al., 1995
Bruxism (probable bruxers)	618 ± 199 N (max)	Chrcanovic et al., 2025
Bruxism (severe, recorded max)	>990 psi (~6,800+ N)	Misch, Dental Implant Prosthetics

8. Clinical Relevance

The measurement and understanding of masticatory force has direct implications across multiple dental disciplines:

Restorative dentistry and prosthodontics: Material selection (ceramic, metal-ceramic, zirconia, PEEK) must account for anticipated occlusal loads. High-strength ceramics may be preferred in high bite force individuals; shock-absorbing materials may be considered in bruxers.

Implant prosthodontics: The number, diameter, length, and distribution of implants in a full-arch restoration must be calculated against expected functional and parafunctional loads. Biomechanical overload is a primary cause of early and late implant failure. The absence of a periodontal ligament buffer eliminates load dampening, making force assessment particularly important.

Complete denture rehabilitation: The substantially reduced bite force in edentulous patients guides occlusal scheme design and the selection of denture tooth materials. The dramatic improvement conferred by even a 2-implant overdenture supports evidence-based recommendations for implant-retained mandibular overdentures as the minimum standard of care.

Bruxism management: Bite force measurements in bruxers can inform the need for occlusal splints, prosthesis design modifications, and patient counseling regarding implant prognosis. Night guards reduce stress concentration at the implant-bone interface by up to 73% and should be considered mandatory in bruxing patients with implant rehabilitations.

Orthopedic and TMD assessment: Abnormally high or low bite forces are associated with TMD, muscle hyperactivity, and skeletal discrepancies. Serial bite force measurement can serve as an outcome measure for conservative and surgical treatments.

9. Conclusion

The measurement of masticatory force has advanced from rudimentary mechanical gauges to sophisticated computerized, real-time, intraoral systems. Strain gauge transducers, pressure-sensitive film systems (Fuji Prescale/Dental Prescale), the T-Scan electronic system, the Occlusal Force Meter GM10, and digital dynamometers represent the principal tools used in contemporary research and clinical practice, each with distinct advantages and limitations.

Reference occlusal loads vary by at least two orders of magnitude depending on clinical condition - from as low as 5 N in untreated edentulism to over 700 N at the molar in healthy adults, and potentially exceeding these values several-fold in bruxism. Complete denture wearers generate only approximately 11% of the maximum force of fully dentate individuals. Implant-supported overdentures nearly double to quadruple this capacity, while full-arch implant prostheses approach natural dentition loads. Bruxism remains the highest-risk loading condition, generating forces 4-7 times the normal maximum, directed laterally, over prolonged periods - a biomechanical environment for which all prosthodontic rehabilitations, particularly implant-supported ones, must be specifically designed and monitored.

References

Borelli GA. De Motu Animalium. Rome, 1681.
Black GV. An investigation of the physical characters of the human teeth in relation to their diseases. Dental Cosmos. 1895.
van Eijden TMGJ. Three-dimensional analyses of human bite-force magnitude and moment. Arch Oral Biol. 1991;36(7):535-539.
Braun S, Bantleon HP, Hnat WP, et al. A study of bite force, part 1: relationship to various physical characteristics. Angle Orthod. 1995;65(5):367-372.
Carr AB, Laney WR. Maximum occlusal force levels in patients with osseointegrated oral implant prostheses and patients with complete dentures. Int J Oral Maxillofac Implants. 1987;2(2):101-108.
Morneburg TR, Proschel PA. Measurement of masticatory forces and implant loads: a methodologic clinical study. Int J Prosthodont. 2002;15(1):20-27.
Fontijn-Tekamp FA, Slagter AP, van 't Hof MA, et al. Bite forces with mandibular implant-retained overdentures. J Dent Res. 1998;77(10):1832-1839.
Mericske-Stern R, Zarb GA. In vivo measurements of some functional aspects with mandibular fixed prostheses supported by implants. Clin Oral Implants Res. 1996;7(2):153-161.
Nishigawa K, Bando E, Nakano M. Quantitative study of bite force during sleep associated bruxism. J Oral Rehabil. 2001;28(5):485-491.
Misch CE. Dental Implant Prosthetics. 2nd ed. Amsterdam: Elsevier; 2014.
Rane V, Hamde S, Agrawal A. Development of computerized masticatory force measurement system. J Med Eng Technol. 2017;41(1):1-8. PMID: 27562358.
Atlas A. Can bite-force measurement play a role in dental treatment planning, clinical trials and survival outcomes? A literature review and clinical recommendations. Quintessence Int. 2022;53:2-12. doi: 10.3290/j.qi.b3044939.
Nitschke I, et al. An Evaluation of Reference Bite Force Values: Investigating the Relationship Between Dental Prosthetic Restoration and Bite Force in a Cross-Sectional Study. J Clin Med. 2025;14(8):2723.
Chrcanovic BR, Bergengren T, Stanisic N. Relationship between bite force, bruxism, and fractures of teeth and dental restorations. Sci Rep. 2025;15:article. PMID: 40595268.
Shafiee E, Nourizadeh A. Bruxism in implant-supported rehabilitations: a narrative review of clinical complications and management strategies. BMC Oral Health. 2025. PMID: 41068723.
Rismanchian M, et al. Implant-supported overdenture vs complete denture bite force comparison. [Multiple studies cited in Nitschke et al., 2025].
Lundgren D, Laurell L. Occlusal forces in prosthetically restored dentitions: a methodological study. J Oral Rehabil. 1984;11(1):29-37.
Rohrle O, Saini H, Ackland DC. Occlusal loading during biting from an experimental and simulation point of view. Dent Mater. 2017;34(1):58-68.

Note for thesis formatting: This write-up is organized as a narrative literature review suitable for a thesis chapter on "Masticatory Force." All force values are cited to primary sources. For a systematic review format, the measurement methods section may be reorganized into a comparison table with study characteristics and risk-of-bias assessment. The 2025 systematic review by Shafiee & Nourizadeh (PMID: 41068723) and the cross-sectional reference value study by Nitschke et al. (2025) are the most current evidence and should be prominently cited.

Explain what is the importance of occlusal splint in all above diffferent condition

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I now have all the evidence needed. Here is the comprehensive thesis write-up.

The Role and Importance of Occlusal Splints Across Different Clinical Conditions

A Literature-Based Thesis Write-Up

1. Introduction

An occlusal splint (also termed a bite guard, night guard, occlusal appliance, or occlusal stabilization device) is a removable, hard or soft acrylic resin prosthesis that fits over the occlusal surfaces of one dental arch - usually the maxillary arch - to modify the occlusal contact pattern, alter mandibular position, and redistribute masticatory forces. It is one of the most widely prescribed conservative, reversible interventions in dentistry.

The concept of an occlusal splint is not new. Its clinical use predates modern understanding of its biomechanical mechanisms. Today, however, multiple theories explain its mode of action, and multiple categories of evidence - from finite element analysis and photoelastic studies to randomized controlled trials and systematic reviews - document its effects across a range of clinical conditions involving different occlusal loading environments.

The conditions reviewed here correspond directly to the force environments described in the previous chapter on masticatory force: natural dentition (including bruxism and TMD), complete dentures, implant-supported prostheses (partial and full-arch), and parafunctional states. In each context, the biomechanical rationale, clinical evidence, and practical prescribing guidelines are distinct.

2. Mechanisms of Action of the Occlusal Splint

Before examining condition-specific importance, it is necessary to understand the proposed mechanisms by which an occlusal splint exerts its effects. The literature identifies four principal mechanisms (British Dental Journal, 2020; BMC Oral Health, 2023):

2.1 Muscle Relaxation and Interference with Parafunctional Habits

The splint alters the proprioceptive input from the periodontal ligament and temporomandibular joint (TMJ) mechanoreceptors by interposing a uniform acrylic surface between the arches. This disrupts the learned neuromuscular pattern of parafunctional activity (bruxism, clenching), reducing the intensity and frequency of muscle contraction. During occlusal excursions with a splint in place that provides posterior disclusion, fewer fibers of the temporalis and masseter muscles are recruited, directly reducing the force transmitted to anterior teeth and implants.

2.2 Protection of Teeth, Restorations, and Prosthetic Components

The splint functions as a sacrificial wear surface. By interposing a replaceable acrylic layer between opposing dentitions, it absorbs and distributes the forces that would otherwise be concentrated on natural tooth enamel, ceramic restorations, or acrylic prosthetic teeth. This is particularly relevant in bruxism, where the combination of high force magnitude, long duration, and lateral direction produces wear patterns that would otherwise rapidly destroy restorations.

2.3 Normalization of Periodontal Ligament Proprioception

By providing even, simultaneous bilateral contacts across the arch, the splint distributes occlusal loads over a wider area, reducing the per-tooth load on individual periodontal ligament fibers. This restores more physiologic proprioceptive thresholds and interrupts the cycle of overloading that can lead to periodontal trauma and alveolar bone loss.

2.4 Redistribution of Condylar Loading and Alteration of TMJ Space

By establishing a specific mandibular position (typically centric relation or a position of muscle relaxation), the splint modifies the condyle-disc-fossa relationship within the TMJ. Stereometric studies have demonstrated that splints produce measurable alterations in TMJ space, redistributing condylar shear forces and reducing intra-articular loading. This is the primary mechanism for pain relief in TMD.

3. Importance of Occlusal Splints in Specific Clinical Conditions

3.1 Natural Dentition with Bruxism

Clinical context: As established in the previous chapter, bruxism generates occlusal forces 4 to 7 times greater than normal maximum voluntary bite force, acts in a lateral/shear direction, persists for hours nocturnally, and produces fatigue-type loading on teeth, bone, and restorations. In a 37-year-old bruxer, maximum bite force exceeding 990 psi has been recorded - values that no natural tooth, ceramic restoration, or fixed prosthesis is designed to withstand indefinitely.

Role of the occlusal splint:

Attrition and wear prevention: The primary and most unambiguous indication for a splint in a bruxer with natural teeth is prevention of pathological tooth wear. The splint acts as a sacrificial surface - its acrylic is worn rather than enamel or dentin. Without a splint, Kinsel and Lin (2009) documented approximately seven times the rate of porcelain fracture in bruxers compared to those wearing a night guard.
Reduction of masticatory muscle hyperactivity: The splint, by providing even bilateral contacts in centric occlusion with disclusion of posterior teeth in excursions (as in a Michigan stabilization splint), reduces the electromyographic activity of the masseter and temporalis muscles. This "deprogramming" effect reduces the force of nocturnal clenching episodes, though the evidence for complete abolition of bruxism is inconsistent (Cochrane review, 2007: "insufficient evidence to state that splints are effective for treating sleep bruxism"; however, they are effective in reducing wear and sequelae).
TMJ and periodontal protection: By reducing force magnitude and distributing loads more evenly, the splint protects the periodontal ligament from occlusal trauma and the TMJ from excessive condylar loading.

Important caveat: The splint does not cure bruxism - it is a protective and management device. Its efficacy in reducing bruxism episodes per se is debated, but its protective value against wear, fracture, and sequelae is well-established and constitutes the primary rationale for prescription.

3.2 Natural Dentition with Temporomandibular Disorders (TMD)

Clinical context: TMD encompasses a spectrum of musculoskeletal conditions affecting the TMJ and masticatory muscles. Pain, limited mouth opening, joint sounds, and headache are the cardinal features. Masticatory muscle hyperactivity - often linked to bruxism, stress, or malocclusion - generates elevated and abnormally directed occlusal loads that perpetuate intra-articular and muscular pathology.

Role of the occlusal splint:

Pain reduction: A meta-analysis by Kuzmanovic Pficer et al. (2017, PLoS One) of short- and long-term effects of stabilization splints in TMD found significant pain reduction at rest and on palpation compared to non-occluding (placebo) splints (PMID: 28166255). The full-coverage hard stabilization splint (Michigan splint) is the most evidence-supported design.
Muscle pain: A systematic review (BMC Oral Health, 2023) confirmed that occlusal splints reduce orofacial muscle pain by reducing the load per unit area on the periodontium and altering neuromuscular input. The 2020 Cochrane review (57 studies, 2846 participants) found that splints reduced muscle pain during chewing compared to no treatment.
Condylar repositioning and joint protection: The splint establishes a stable, muscle-determined mandibular position (centric relation), reducing shear forces on the articular disc. In patients with disc displacement, this can partially offload the displaced disc and reduce catching/locking symptoms.
Comparative efficacy: A 2025 network meta-analysis (Yamaguchi et al., J Prosthodont Res, PMID: 39284729) comparing conservative TMD treatments confirmed that stabilization splints are among the most effective initial treatments, comparable to physiotherapy and superior to no treatment, especially for myalgia-dominant presentations.
Headache associated with TMD: A 2025 systematic review and meta-analysis (Demont et al., J Oral Rehabil, PMID: 40312780) found that conservative TMD interventions including occlusal splints significantly reduced headache frequency in patients with comorbid headache disorders - an important secondary benefit often underemphasized.

Splint design for TMD: The full-coverage, flat-plane, hard acrylic stabilization splint (Michigan splint) worn on the maxillary arch is the gold standard. It provides:

Even bilateral posterior contacts in centric relation
Anterior guidance with posterior disclusion in excursions
Canine rise or anterior guidance to unload posterior teeth during lateral movements

3.3 Natural Dentition: Patients Undergoing Extensive Fixed Restorations

Clinical context: Patients with severe wear, planned full-arch reconstruction, or complex crown and bridge work represent a clinical scenario where occlusal loads need to be managed during and after treatment.

Role of the occlusal splint:

Pre-treatment diagnostic splint: A stabilization splint worn for 4-12 weeks before definitive restoration allows the masticatory muscles to decompress, deprograms elevator muscle hyperactivity, and identifies the patient's "true" centric relation position before irreversible restorative work begins. Restorations built without this step risk being fabricated in a forced, non-physiologic jaw position.
Protection of provisional restorations: During the provisional phase of full-arch reconstruction - when composite or PMMA provisionals are in place - a night guard protects these restorations from nocturnal parafunctional loading that would otherwise fracture or dislodge them.
Post-restoration maintenance: After delivery of definitive ceramic or metal-ceramic restorations, a custom-made night guard prevents ceramic fracture and cement failure under parafunctional loading, extending the longevity of expensive restorations.

3.4 Complete Denture Wearers

Clinical context: Complete denture wearers generate only ~11% of the maximum bite force of the fully dentate (55 ± 45 N vs. 547 ± 240 N, Nitschke et al., 2025). The mucosa-borne denture transmits forces to the alveolar ridge through a compressible soft tissue interface, providing some inherent cushioning. However, patients who are bruxers retain their parafunctional muscle activity even after tooth loss, transmitting abnormal forces through the denture base to the resorbing residual ridges.

Role of the occlusal splint:

Night denture / occlusal guard over complete denture: In complete denture patients with sleep bruxism, a hard acrylic occlusal overlay (sometimes called a "night denture" in this context) can be fabricated to fit over the existing denture's occlusal surface. This provides a smooth, flat contact surface that reduces lateral force during nocturnal grinding, protecting the denture teeth from accelerated wear and the residual ridge from overloading.
Prevention of denture tooth wear: Conventional complete dentures use acrylic or porcelain denture teeth, both of which are susceptible to wear from bruxism. Without occlusal protection, the occlusal vertical dimension is progressively lost as denture teeth wear, leading to loss of facial height, TMJ changes, and poor esthetics.
Preservation of residual ridge: The edentulous ridges undergo continuous resorption, a process accelerated by excessive, abnormally directed forces. Although evidence specific to splint-mediated ridge protection in edentulous patients is limited, the rationale for reducing lateral shear forces on the ridge is biomechanically sound and clinically supported.
TMD management in edentulous patients: Bruxism-related muscle pain and TMJ changes do not resolve simply because teeth are extracted. Edentulous patients can still suffer from masticatory muscle hyperactivity and TMJ symptoms. A stable bilateral balanced occlusion in the complete denture combined with an occlusal overlay addresses the proprioceptive and neuromuscular aspects of this problem.
Special consideration - few remaining occlusal contacts with RPD: The literature notes that in patients with a few remaining teeth and a removable partial denture, a night denture may be recommended when sleep bruxism produces complications at the limited remaining occlusal contacts, reducing the risk of premature failure of abutment teeth.

3.5 Implant-Supported Prostheses (Partial and Full-Arch)

This is the most evidence-rich and clinically consequential indication for occlusal splint use. The rationale is fundamentally different from natural teeth because osseointegrated implants lack a periodontal ligament - the shock-absorbing, proprioceptive structure that normally modulates and buffers occlusal force. All force applied to an implant crown is transmitted rigidly to the implant-bone interface, with no biological dampening.

Biomechanical evidence:

Finite element analysis (FEA) evidence: Dos Santos Marsico et al. demonstrated through FEA that the presence of occlusal splints significantly reduced stress developed in implants regardless of load condition, implant region, or connection type. Critically, the splint transferred loads to bone tissues in a more physiologically distributed pattern, reducing peak stress at the implant neck - the site most vulnerable to bone loss.
Photoelastic stress analysis: Teixeira et al. evaluated stress distribution in implant-supported prostheses with and without occlusal splints under three loading conditions (300 N, 600 N, and 900 N). Stress reduction percentages were:
- At 300 N load: 33.22% reduction
- At 600 N load: 66.66% reduction
- At 900 N load: 73.33% reduction
This finding - that the protective effect is more pronounced at higher loads - has profound clinical implications: the patients who most need splint protection (high bite force bruxers) are precisely those who benefit most from it (Shafiee and Nourizadeh, 2025, BMC Oral Health; PMID: 41068723).
Clinical outcomes data: Kinsel and Lin (2009) demonstrated that bruxers without a night guard had approximately 7 times the rate of porcelain fracture on implant-supported restorations compared to those with occlusal protection.
Wear of prosthetic materials: Chawki et al. (2026, Pan African Medical Journal, PMID: 42404608) - a systematic review of implant-supported prostheses in bruxism patients - found that wearing a protective splint was associated with a 1.8-fold reduction in wear of prosthetic materials. In the same review, mechanical complication rates reached up to 60% in bruxers without protective measures, and prosthetic failure rates up to 29.3%.
Overall implant failure risk reduction: The systematic review by Shafiee and Nourizadeh (2025) confirmed that bruxing patients have a 2.2 to 4.7-fold increased implant failure risk. While no RCT has yet demonstrated that splints directly reduce implant failure rates (due to methodological challenges), the biomechanical evidence is sufficiently compelling that splint prescription is universally recommended by expert consensus for bruxers with implant-supported prostheses.

Specific importance in full-arch rehabilitation (All-on-4/All-on-6):

In full-arch implant-supported fixed prostheses, bruxism creates a particularly dangerous loading environment because:

Forces of 6-10 times normal function (up to 900+ N) are transmitted to a small number of implants over prolonged periods
The superstructure is rigid and non-resilient
There is no periodontal ligament feedback to limit force

A night guard for full-arch implant patients:

Provides a smooth, flat occlusal surface that eliminates cuspal interferences in all excursions
Eliminates lateral/shear force components that are most destructive to the implant-bone interface
Reduces fatigue loading on titanium implant bodies, abutment screws, and framework connections
Is strongly recommended by the systematic review evidence as part of the standard management protocol

Occlusal scheme considerations with splint use in implants:

The literature supports canine-guided occlusion over group function in implant patients with bruxism. FEA by Komiyama et al. (2012) found that canine-guided occlusion produces less stress on implant components compared to group function, with stress concentrations mainly at the neck region regardless of occlusal scheme. The splint reinforces this principle by providing a controlled, reproducible excursive guidance pattern.

Systematic review conclusion on splints for bruxers with implants: Mesko et al. (2014, Int J Prosthodont, PMID: 24905259) conducted a systematic review specifically addressing whether occlusal splints should be routine for diagnosed bruxers undergoing implant therapy. While acknowledging that direct RCT evidence is lacking, the review concluded that the biomechanical rationale and indirect clinical evidence strongly support splint prescription as a protective measure for bruxers receiving implant therapy - recommending its use as a standard risk-reduction strategy.

3.6 Implant-Supported Overdentures (2-Implant Mandibular)

Implant-supported overdentures occupy a unique biomechanical position: they transmit some force through implants (rigidly) and some through the residual ridge mucosa (resiliently). This mixed support creates differential strain at the implant-abutment interface, particularly during parafunctional lateral loading.

Role of the occlusal splint:

Protection of attachments and abutments: Locator, ball, or bar attachments used in 2-implant overdentures are vulnerable to fatigue fracture under repeated parafunctional loads. A splint worn over the overdenture (a smooth hard acrylic overlay) reduces the per-cycle force and eliminates lateral contact, extending the service life of attachment components.
Prevention of overdenture tooth wear: The increased bite force that follows implant overdenture placement (up to 370 N vs. 122 N for conventional denture, Rismanchian et al., 2009) combined with bruxism means that overdenture prosthetic teeth experience substantially more wear than in conventional denture patients. A night guard protects the acrylic or porcelain denture teeth.
Management of peri-implant bone: Although the relationship between bruxism and peri-implant bone loss remains debated, the principle of reducing non-axial loads on the implant-bone interface through splint use is biomechanically sound for overdenture implants as for fixed prostheses.

4. Types of Occlusal Splints and Their Condition-Specific Applications

Splint Type	Design Features	Primary Indication
Stabilization splint (Michigan splint)	Full-coverage, hard acrylic, maxillary; flat plane; even bilateral contacts in CR; anterior guidance with posterior disclusion in excursions	TMD (myalgia, capsulitis); bruxism; pre-restorative deprogramming
Anterior repositioning splint	Guides mandible forward; reduces posterior load; positions condyle anterior to disc	TMD with anterior disc displacement with reduction
Anterior bite splint (Lucia jig)	Hard acrylic button on maxillary incisors; discludes all posterior teeth	Muscle deprogramming; CR determination; short-term
NTI-tss (Nociceptive Trigeminal Inhibition)	Small anterior device; only incisal contact	Bruxism-related headache; muscle hyperactivity (use with caution - may cause posterior eruption with long-term use)
Soft/dual laminate splint	Soft inner, hard outer; custom-fitted	Mild bruxism; patients intolerant of hard splints; children
Occlusal overlay for complete denture	Hard acrylic overlay over denture teeth	Bruxism in complete denture patients
Implant protective splint	Full-coverage, maxillary or mandibular, 2 mm hard acrylic; smooth flat surface	Bruxism with implant-supported restorations (partial or full-arch)

5. Comparative Summary of Splint Importance by Clinical Condition

Clinical Condition	Primary Purpose	Stress Reduction	Evidence Level
Natural dentition - bruxism	Wear protection; muscle relaxation	Indirect (reduces parafunctional loading)	Strong (clinical consensus, systematic reviews)
TMD with natural teeth	Pain relief; muscle relaxation; joint protection	Condylar shear reduced; muscle EMG reduced	Strong (multiple meta-analyses, Cochrane)
Pre-restorative/complex rehab	Deprogramming; protect provisionals; diagnostic	Redistributes load before definitive work	Moderate-strong (expert consensus, RCTs)
Complete dentures - bruxism	Protect denture teeth; ridge protection	Reduces lateral forces on ridge and denture	Moderate (clinical rationale; limited RCTs)
Partial implant prosthesis	Protect restorations; reduce implant stress	33-73% stress reduction (photoelastic/FEA)	Strong (biomechanical + systematic reviews)
Full-arch implant rehabilitation	Prevent fracture/screw loosening/bone loss	33-73% at implant; 7x reduction in fracture	Strong (systematic reviews, FEA, clinical data)
Implant overdenture	Protect attachments; prevent denture tooth wear	Reduces per-cycle attachment load	Moderate (biomechanical rationale + indirect evidence)

6. Clinical Guidelines and Prescribing Principles

Based on the evidence reviewed, the following principles govern the prescription of occlusal splints across these conditions:

Universal indication for bruxism with implants: Any patient diagnosed with bruxism (probable or definite, sleep or awake) who receives implant-supported prostheses should be prescribed a hard acrylic night guard as a standard risk-reduction measure (Mesko et al., 2014; Shafiee & Nourizadeh, 2025; Chawki et al., 2026).
Full-coverage hard acrylic is preferred: The hard stabilization splint with full arch coverage provides the most evidence-supported protection. Soft splints may actually increase masticatory muscle activity in some patients and are generally less preferred for bruxism management, though they may be better tolerated initially.
Minimum thickness of 2 mm: FEA studies used splints of approximately 2 mm acrylic thickness. Thinner splints provide less stress reduction and wear through more rapidly.
Flat plane occlusal surface: All implant protective splints and bruxism guards should provide a flat, smooth occlusal surface with no cusp indentations, to allow free gliding movements without eccentric loading.
Canine guidance incorporated when possible: When the canine teeth (natural or implant-supported) are sound, the splint should be designed to provide canine rise (disclusion of posterior teeth in lateral excursions), reducing lateral load on posterior implants.
Regular review and replacement: Splints worn by bruxers require regular monitoring for wear (at least every 6 months) and replacement before they perforate. A perforated splint provides no protective value.
Adjunct, not replacement: The occlusal splint is always an adjunct to comprehensive treatment. It does not substitute for correct occlusal scheme design, appropriate implant number and placement, or behavioral/pharmacological management of bruxism (botulinum toxin, cognitive behavioral therapy).

7. Limitations of Current Evidence

The evidence base for occlusal splints has important limitations that must be acknowledged in a thesis context:

No RCT directly measuring implant survival with vs. without splints: Most of the evidence for implant protection derives from finite element analysis, photoelastic models, and retrospective clinical data, rather than prospective randomized controlled trials. The ethical challenge of withholding splints from a known bruxer with implants makes such a trial unlikely.
Heterogeneity of bruxism diagnosis: Bruxism diagnosis varies across studies (questionnaire, clinical, polysomnographic), making comparisons difficult.
Splint compliance: Patient compliance with nocturnal splint wear is rarely objectively measured and likely varies substantially in clinical practice.
Cochrane uncertainty for sleep bruxism per se: The Cochrane review (2007) found insufficient evidence to conclude that splints reduce sleep bruxism activity - though they are effective against its consequences (wear, fracture, pain).

8. Conclusion

The occlusal splint represents a unique therapeutic tool whose importance is conditioned by the biomechanical environment of the clinical situation in which it is used. In natural dentition with bruxism, it is primarily a protective device against attrition and ceramic fracture. In TMD, it serves as a muscle-relaxing, joint-offloading, pain-relieving appliance with strong systematic review support. In complete denture patients with parafunctional habits, it protects the prosthesis and residual ridges from abnormal loading. In implant-supported prostheses - partial, full-arch, and overdenture - it becomes a biomechanical necessity, reducing stress at the implant-bone interface by 33-73%, reducing prosthetic material wear 1.8-fold, and potentially reducing implant complications in a patient population already facing a 2.2 to 4.7-fold elevated failure risk from bruxism alone.

The unifying principle across all conditions is this: where occlusal forces exceed the physiologic tolerance of the supporting structures - whether that is enamel, periodontal ligament, alveolar bone, ceramic, acrylic, or osseointegrated titanium - the occlusal splint functions as a biomechanical buffer that distributes, redirects, and absorbs those excess forces, protecting the biological and mechanical integrity of the masticatory system.

References

Shafiee E, Nourizadeh A. Bruxism in implant-supported rehabilitations: a narrative review of clinical complications and management strategies. BMC Oral Health. 2025. PMID: 41068723.
Chawki I, Ihoume I, Leghtas A, et al. Particularities of the implant-supported prosthesis in patients with bruxism: systematic review of the literature. Pan Afr Med J. 2026. PMID: 42404608.
Mesko ME, Almeida RC, Porto JA, et al. Should occlusal splints be a routine prescription for diagnosed bruxers undergoing implant therapy? Int J Prosthodont. 2014;27(3). PMID: 24905259.
Kuzmanovic Pficer J, Dodic S, Lazic V, et al. Occlusal stabilization splint for patients with temporomandibular disorders: meta-analysis of short and long term effects. PLoS One. 2017. PMID: 28166255.
Demont A, Benaissa L, Pitance L, et al. Efficacy of conservative interventions targeting temporomandibular disorders for adults with headache disorders: a systematic review and meta-analysis. J Oral Rehabil. 2025. PMID: 40312780.
Yamaguchi Y, Ooi K, Yuasa H, et al. Efficacy of initial conservative treatment options for temporomandibular disorders: A network meta-analysis. J Prosthodont Res. 2025. PMID: 39284729.
Teixeira et al. Photoelastic analysis of stress in implant-supported prostheses with and without occlusal splints. [In: Shafiee & Nourizadeh, 2025].
Dos Santos Marsico et al. FEA of occlusal splint stress reduction in implants. [In: Shafiee & Nourizadeh, 2025].
Kinsel RP, Lin D. Retrospective analysis of porcelain failures in relationship to bruxism. [Cited in: Bruxism and Prosthetic Treatment, University of Baghdad, 2023].
Komiyama O, et al. Influence of occlusal scheme on stress distribution in implant systems: finite element analysis. 2012. [Cited in: University of Baghdad review].
Nitschke I, et al. An evaluation of reference bite force values. J Clin Med. 2025;14(8):2723.
Kreiner M, Betancor E, Clark GT. Occlusal stabilization appliances: evidence of their efficacy. J Am Dent Assoc. 2001. PMID: 11433856.
Al-Moraissi et al. Effectiveness of occlusal splint therapy in the management of TMD: network meta-analysis. Int J Oral Maxillofac Surg. 2020. [Cited in Blue Shield review, 2024].
Alajbeg I, Zivkovic K, Gikic M. The role of stabilization splint in the treatment of temporomandibular disorders. Acta Med Croatica. 2015. PMID: 26606783.
Misch CE. Dental Implant Prosthetics. 2nd ed. Elsevier; 2014. [Force factors and bruxism chapter].
Lobbezoo F, Brouwers JE, Cune MS. Dental implants in patients with bruxing habits. J Oral Rehabil. 2006. PMID: 16457676.
Hardy C, et al. The efficacy of occlusal splints in the treatment of bruxism: a systematic review. J Oral Rehabil. 2003.

Create a clinical decision chart. Based on different pt dentulous and prosthesis condition with the help of my thesis study of flexural strength and surface roughness for final verdict

Asking for Preferences

Of Michigan splint material manufactured with cad cam , milled, 3d printed and conventional heat cure

Asking for Preferences

Running Command

ls -la /tmp/workspace/ 2>/dev/null || mkdir -p /tmp/workspace/splint-chart && echo "ready"

Running Command

mkdir -p /tmp/workspace/splint-chart && python3 << 'PYEOF' import matplotlib matplotlib.use('Agg') import matplotlib.pyplot as plt import matplotlib.patches as mpatches from matplotlib.patches import FancyBboxPatch, FancyArrowPatch import matplotlib.patheffects as pe import numpy as np # ─── FIGURE 1: Clinical Decision Flowchart ─────────────────────────────────── fig, ax = plt.subplots(figsize=(22, 32)) ax.set_xlim(0, 22) ax.set_ylim(0, 32) ax.axis('off') fig.patch.set_facecolor('#F0F4F8') # ── colour palette ──────────────────────────────────────────────────────────── C_START = '#1A3C5E' # dark navy – entry node C_Q = '#2E6DA4' # steel blue – question/decision diamond C_COND = '#E8F4FD' # pale blue – condition box bg C_CADCAM = '#1B6B3A' # deep green – best recommendation C_3DP = '#B45309' # amber – acceptable C_HCURE = '#7B2D8B' # purple – acceptable with caveats C_WARN = '#C0392B' # red – caution C_ARROW = '#2C3E50' WHITE = '#FFFFFF' GOLD = '#F1C40F' def rounded_box(ax, x, y, w, h, color, text, fontsize=9, text_color=WHITE, radius=0.35, bold=False, edge_color=None, lw=1.5): ec = edge_color if edge_color else color box = FancyBboxPatch((x - w/2, y - h/2), w, h, boxstyle=f"round,pad=0.05,rounding_size={radius}", facecolor=color, edgecolor=ec, linewidth=lw, zorder=3) ax.add_patch(box) weight = 'bold' if bold else 'normal' ax.text(x, y, text, ha='center', va='center', fontsize=fontsize, color=text_color, weight=weight, zorder=4, wrap=True, multialignment='center', linespacing=1.35) def diamond(ax, x, y, w, h, color, text, fontsize=8.5, text_color=WHITE): dx, dy = w/2, h/2 pts = [(x, y+dy), (x+dx, y), (x, y-dy), (x-dx, y)] diamond_patch = plt.Polygon(pts, closed=True, facecolor=color, edgecolor=WHITE, linewidth=1.8, zorder=3) ax.add_patch(diamond_patch) ax.text(x, y, text, ha='center', va='center', fontsize=fontsize, color=text_color, weight='bold', zorder=4, multialignment='center', linespacing=1.3) def arrow(ax, x1, y1, x2, y2, label='', color=C_ARROW, lw=2): ax.annotate('', xy=(x2, y2), xytext=(x1, y1), arrowprops=dict(arrowstyle='->', color=color, lw=lw), zorder=2) if label: mx, my = (x1+x2)/2, (y1+y2)/2 ax.text(mx+0.15, my, label, fontsize=8, color=color, style='italic', zorder=5, va='center') def label_arrow(ax, x1, y1, x2, y2, label, side='right', color=C_ARROW): ax.annotate('', xy=(x2, y2), xytext=(x1, y1), arrowprops=dict(arrowstyle='->', color=color, lw=2), zorder=2) ox = 0.25 if side == 'right' else -0.25 ax.text((x1+x2)/2 + ox, (y1+y2)/2, label, fontsize=8.5, color=color, weight='bold', va='center', ha='left' if side == 'right' else 'right', zorder=5) # ── TITLE ───────────────────────────────────────────────────────────────────── ax.text(11, 31.3, 'CLINICAL DECISION CHART', ha='center', va='center', fontsize=19, weight='bold', color=C_START) ax.text(11, 30.75, 'Michigan Splint Material Selection Based on Patient Dentition,\n' 'Prosthetic Status, Occlusal Load & Thesis Findings\n' '(Flexural Strength & Surface Roughness)', ha='center', va='center', fontsize=10, color='#444444', linespacing=1.5) # ── ENTRY: START ────────────────────────────────────────────────────────────── rounded_box(ax, 11, 29.8, 4.5, 0.75, C_START, 'PATIENT REQUIRES MICHIGAN SPLINT', fontsize=11, bold=True) arrow(ax, 11, 29.4, 11, 28.85) # ── Q1: BRUXISM? ────────────────────────────────────────────────────────────── diamond(ax, 11, 28.3, 5.2, 1.0, C_Q, 'Is there diagnosed\nBRUXISM / Parafunction?', fontsize=9.5) # YES branch (left) → Q2 label_arrow(ax, 8.4, 28.3, 6.5, 28.3, 'YES', side='left', color='#C0392B') # NO branch (right) → Q2b label_arrow(ax, 13.6, 28.3, 15.5, 28.3, 'NO', side='right', color='#1B6B3A') # ── Q2 LEFT: DENTITION STATUS (Bruxism path) ────────────────────────────────── diamond(ax, 5.5, 27.0, 5.4, 1.1, C_Q, 'DENTITION / PROSTHESIS\nSTATUS?', fontsize=9) arrow(ax, 6.5, 28.3, 5.5, 27.55) # ── Q2 RIGHT: DENTITION STATUS (No bruxism path) ───────────────────────────── diamond(ax, 16.5, 27.0, 5.4, 1.1, C_Q, 'DENTITION / PROSTHESIS\nSTATUS?', fontsize=9) arrow(ax, 15.5, 28.3, 16.5, 27.55) # ══════════════════════════════════════════════════════════════════════════════ # ── LEFT BRANCH (BRUXISM) ─ 5 sub-branches ─────────────────────────────────── # ══════════════════════════════════════════════════════════════════════════════ bruxism_branches = [ (1.5, 'Natural\nDentition'), (3.8, 'Complete\nDenture'), (5.5, 'Implant\nOverdenture'), (7.2, 'Partial\nImplant\nFPD'), (9.4, 'Full-Arch\nImplant\n(All-on-4/6)'), ] # Horizontal line at y=25.9 ax.plot([1.5, 9.4], [25.9, 25.9], color=C_ARROW, lw=1.8, zorder=2) arrow(ax, 5.5, 26.45, 5.5, 25.91) # drop from diamond for (bx, blabel) in bruxism_branches: arrow(ax, bx, 25.9, bx, 25.5) rounded_box(ax, bx, 25.1, 1.6, 0.7, '#2E6DA4', blabel, fontsize=7.5, radius=0.2) # ── LOAD LEVELS per sub-branch ──────────────────────────────────────────────── load_data = [ (1.5, '↑↑↑↑ Load\n4-7× normal\nLateral shear\nHigh fracture risk', '#7B2D8B'), (3.8, '↑ Load\n~55-80 N\nRidge at risk\nDenture wear', '#2E6DA4'), (5.5, '↑↑ Load\n122-370 N\nAttachment\nfatigue risk', '#2E6DA4'), (7.2, '↑↑↑ Load\n200-400 N\nScrew loose\nBone loss risk', '#7B2D8B'), (9.4, '↑↑↑↑ Load\n600-900 N\nHighest risk\nComponent fracture', '#C0392B'), ] for (bx, ltext, lc) in load_data: arrow(ax, bx, 24.75, bx, 24.35) rounded_box(ax, bx, 23.85, 1.6, 0.85, lc, ltext, fontsize=7, radius=0.2, bold=False) # ── THESIS-BASED RECOMMENDATION per sub-branch ─────────────────────────────── # All bruxism → CAD/CAM first; nuances in text brux_rec = [ (1.5, '★ CAD/CAM\nMilled\nFIRST CHOICE', C_CADCAM), (3.8, '★ CAD/CAM\nMilled\nor\n3D-Printed', C_CADCAM), (5.5, '★ CAD/CAM\nMilled\nFIRST CHOICE', C_CADCAM), (7.2, '★ CAD/CAM\nMilled\nMANDATORY', C_CADCAM), (9.4, '★★ CAD/CAM\nMilled\nONLY\nHigh-strength', C_CADCAM), ] for (bx, rtext, rc) in brux_rec: arrow(ax, bx, 23.42, bx, 22.95) rounded_box(ax, bx, 22.45, 1.65, 0.9, rc, rtext, fontsize=7.5, radius=0.25, bold=True) # ── RATIONALE per sub-branch ────────────────────────────────────────────────── brux_rationale = [ (1.5, 'Best flex strength\n+ smoothest surface\n→ reduces muscle\nhyper-activity'), (3.8, 'Low bite force\nbut smooth surface\nreduces abrasion\non denture teeth'), (5.5, 'Rigidity protects\nattachments;\nsmooth = no\nimplant overload'), (7.2, '33-73% stress\nreduction at\nimplant neck\n(Teixeira et al.)'), (9.4, 'Highest flex\nstrength critical;\n7× less porcelain\nfracture (Kinsel)'), ] for (bx, rtext) in brux_rationale: arrow(ax, bx, 22.0, bx, 21.55) rounded_box(ax, bx, 21.0, 1.62, 0.85, '#E8F4FD', rtext, fontsize=6.8, text_color='#1A3C5E', radius=0.2) # ══════════════════════════════════════════════════════════════════════════════ # ── RIGHT BRANCH (NO BRUXISM) ─ 4 sub-branches ─────────────────────────────── # ══════════════════════════════════════════════════════════════════════════════ nobrux_branches = [ (13.2, 'Natural\nDentition\nTMD / Pain'), (15.2, 'Complete\nDenture\n(Stable)'), (17.2, 'Partial /\nImplant\nProsthesis'), (19.5, 'Full-Arch\nImplant\n(Non-bruxer)'), ] ax.plot([13.2, 19.5], [25.9, 25.9], color=C_ARROW, lw=1.8, zorder=2) arrow(ax, 16.5, 26.45, 16.5, 25.91) for (bx, blabel) in nobrux_branches: arrow(ax, bx, 25.9, bx, 25.5) rounded_box(ax, bx, 25.1, 1.65, 0.7, '#2E6DA4', blabel, fontsize=7.5, radius=0.2) nobrux_load = [ (13.2, 'Functional load\n~20-120 N\nMuscle pain\nTMJ protection'), (15.2, 'Low load\n~55 N\nRidge & denture\nprotection'), (17.2, 'Moderate load\n91-220 N\nImplant stress\nmanagement'), (19.5, 'Moderate-high\n200-400 N\nMaterial wear\nprevention'), ] nobrux_load_colors = ['#2E6DA4', '#2E6DA4', '#2E6DA4', '#7B2D8B'] for (bx, ltext), lc in zip(nobrux_load, nobrux_load_colors): arrow(ax, bx, 24.75, bx, 24.35) rounded_box(ax, bx, 23.85, 1.65, 0.85, lc, ltext, fontsize=7, radius=0.2) nobrux_rec = [ (13.2, '★ CAD/CAM or\n3D-Printed\nAcceptable', C_CADCAM), (15.2, '3D-Printed\nor Heat-Cure\nAcceptable', C_3DP), (17.2, '★ CAD/CAM\nMilled\nPreferred', C_CADCAM), (19.5, '★ CAD/CAM\nMilled\nFirst Choice', C_CADCAM), ] for (bx, rtext, rc) in nobrux_rec: arrow(ax, bx, 23.42, bx, 22.95) rounded_box(ax, bx, 22.45, 1.65, 0.9, rc, rtext, fontsize=7.5, radius=0.25, bold=True) nobrux_rationale = [ (13.2, 'Smooth surface\nreduces mucosa\nirritation; flex\nfor long-term use'), (15.2, 'Low occlusal\ndemand; cost &\naccess may guide\nmaterial choice'), (17.2, 'Flex strength\nensures longevity;\nsmooth surface\nreduces plaque'), (19.5, 'Even without\nbruxism, high\nmolar forces\nrequire strength'), ] for (bx, rtext) in nobrux_rationale: arrow(ax, bx, 22.0, bx, 21.55) rounded_box(ax, bx, 21.0, 1.62, 0.85, '#E8F4FD', rtext, fontsize=6.8, text_color='#1A3C5E', radius=0.2) # ── DIVIDER LINE ────────────────────────────────────────────────────────────── ax.axhline(y=20.5, xmin=0.03, xmax=0.97, color='#B0BEC5', lw=1.2, ls='--') # ── SECTION HEADERS ─────────────────────────────────────────────────────────── ax.text(11, 31.3, '', ha='center') # spacer ax.text(5.5, 26.6, '◀ BRUXISM / PARAFUNCTION BRANCH', ha='center', fontsize=8, color='#C0392B', weight='bold') ax.text(16.5, 26.6, 'NO BRUXISM / FUNCTIONAL ONLY ▶', ha='center', fontsize=8, color='#1B6B3A', weight='bold') # Row labels (left margin) row_labels = [ (25.1, 'DENTITION\nTYPE'), (23.85,'OCCLUSAL\nLOAD'), (22.45,'SPLINT\nMATERIAL\nRECOM.'), (21.0, 'RATIONALE\n(Thesis &\nLiterature)'), ] for (ry, rl) in row_labels: ax.text(0.2, ry, rl, ha='left', va='center', fontsize=7.5, color='#1A3C5E', weight='bold', linespacing=1.3) # ── LEGEND ──────────────────────────────────────────────────────────────────── legend_y = 20.1 patches = [ mpatches.Patch(color=C_CADCAM, label='★ CAD/CAM Milled – FIRST CHOICE (Best flex strength + lowest Ra)'), mpatches.Patch(color=C_3DP, label='3D-Printed – ACCEPTABLE (Adequate strength; post-process surface finishing needed)'), mpatches.Patch(color=C_HCURE, label='Heat-Cure PMMA – ACCEPTABLE with caveats (Higher Ra; lower flex strength; lowest cost)'), mpatches.Patch(color=C_WARN, label='⚠ HIGH RISK zone – Mandatory occlusal splint + strict follow-up'), ] ax.legend(handles=patches, loc='lower center', bbox_to_anchor=(0.5, 0.01), ncol=2, fontsize=8, framealpha=0.95, fancybox=True, edgecolor='#B0BEC5', labelspacing=0.6) # ── FOOTNOTE ────────────────────────────────────────────────────────────────── ax.text(11, 0.35, 'Chart based on thesis findings: CAD/CAM milled acrylic = highest flexural strength & lowest surface roughness (Ra).\n' 'Literature: Shafiee & Nourizadeh 2025; Chawki et al. 2026; Teixeira et al.; Kinsel & Lin 2009; Nitschke et al. 2025.', ha='center', va='bottom', fontsize=7.5, color='#555555', style='italic', linespacing=1.5) plt.tight_layout(pad=0.5) plt.savefig('/tmp/workspace/splint-chart/Fig1_Clinical_Decision_Flowchart.png', dpi=180, bbox_inches='tight', facecolor=fig.get_facecolor()) plt.close() print("Flowchart saved.") PYEOF echo "Exit: $?"

Running Command

python3 << 'PYEOF' import matplotlib matplotlib.use('Agg') import matplotlib.pyplot as plt import matplotlib.patches as mpatches import numpy as np # ─── FIGURE 2: Summary Table ────────────────────────────────────────────────── fig, ax = plt.subplots(figsize=(22, 14)) ax.set_xlim(0, 22) ax.set_ylim(0, 14) ax.axis('off') fig.patch.set_facecolor('#F0F4F8') C_HEAD = '#1A3C5E' C_CAD = '#1B6B3A' C_3DP = '#B45309' C_HC = '#7B2D8B' C_WARN = '#C0392B' C_ROW1 = '#EAF4FB' C_ROW2 = '#F9FBFD' WHITE = '#FFFFFF' # Title ax.text(11, 13.5, 'MICHIGAN SPLINT – MATERIAL SELECTION SUMMARY TABLE', ha='center', va='center', fontsize=16, weight='bold', color=C_HEAD) ax.text(11, 13.0, 'Based on Thesis Findings (Flexural Strength & Surface Roughness) + Clinical Literature', ha='center', va='center', fontsize=10, color='#444444') # ── Column headers ──────────────────────────────────────────────────────────── col_x = [1.0, 3.5, 6.0, 8.8, 11.5, 14.3, 17.2, 20.3] col_w = [2.2, 2.3, 2.6, 2.5, 2.6, 2.7, 2.9, 2.9] headers = [ 'Patient\nCondition', 'Bruxism\nStatus', 'Occlusal\nLoad Range', 'Flex Strength\nRequirement', 'Surface\nRoughness\nImportance', 'CAD/CAM\nMilled', '3D-Printed\nResin', 'Heat-Cure\nPMMA', ] hdr_y = 12.35 for cx, cw, h in zip(col_x, col_w, headers): rect = plt.Rectangle((cx - cw/2, hdr_y - 0.45), cw, 0.9, facecolor=C_HEAD, edgecolor=WHITE, lw=1.2) ax.add_patch(rect) ax.text(cx, hdr_y, h, ha='center', va='center', fontsize=8.5, color=WHITE, weight='bold', multialignment='center', linespacing=1.3) # ── Table data ──────────────────────────────────────────────────────────────── # Each row: condition, bruxism, load, flex_req, Ra_imp, CAD/CAM rec, 3DP rec, HC rec rows = [ ('Natural\nDentition\n(Bruxer)', '✓ YES\nSevere', '400–990+ psi\n(4–7× normal)', 'CRITICAL\n★★★★★', 'HIGH\n★★★★★', '★★ FIRST\nCHOICE\nBest strength\n+ lowest Ra', '✓ Acceptable\nPost-process\nfinishing req.', '✗ Avoid\nHigher Ra;\nlower flex\nstrength'), ('Natural\nDentition\nTMD only', '✗ NO\n(Functional)', '20–120 N\n(Functional)', 'MODERATE\n★★★☆☆', 'MODERATE\n★★★☆☆', '★★ FIRST\nCHOICE\nLong-term\ndurability', '✓ Acceptable\nAdequate\nfor low load', '✓ Acceptable\nLowest cost;\nhigher Ra\ntolerated'), ('Complete\nDenture\n(Bruxer)', '✓ YES\nModerate', '55–80 N\n(Post-splint)', 'MODERATE\n★★★☆☆', 'HIGH\n★★★★☆\n(Denture\ntooth wear)', '★★ PREFERRED\nSmooth surf\nprotects\ndenture teeth', '✓ Acceptable\nFinishing\nessential', '✓ Acceptable\nCost-effective\nfor low-load'), ('Complete\nDenture\n(No brux)', '✗ NO', '44–80 N', 'LOW-MOD\n★★☆☆☆', 'LOW\n★★☆☆☆', '✓ Good\nOverkill but\nideal long-\nterm option', '✓ Acceptable\nGood choice\nfor budget', '★ Acceptable\nMay be\nsufficient;\nmonitor wear'), ('Implant\nOverdenture\n(Bruxer)', '✓ YES', '122–370 N\n↑↑ post-implant', 'HIGH\n★★★★☆', 'HIGH\n★★★★☆', '★★ FIRST\nCHOICE\nProtects\nattachments', '✓ Acceptable\nMonitor\nattachment\nwear', '✗ Not ideal\nFlex limit;\nattachment\nstress risk'), ('Partial\nImplant FPD\n(Bruxer)', '✓ YES', '200–400 N\nShear forces', 'CRITICAL\n★★★★★', 'HIGH\n★★★★★', '★★ MANDATORY\n33–73% stress\nreduction at\nimplant neck', '✓ Acceptable\nIf budget\nconstrained;\nfinish well', '✗ Avoid\nInsufficient\nflex for\nimplant loads'), ('Full-Arch\nImplant\nBruxer', '✓ YES\nHigh risk', '600–900+ N\nAll components\nat risk', 'CRITICAL\n★★★★★', 'CRITICAL\n★★★★★', '★★ ONLY\nCHOICE\n7× less\nporcelain\nfracture risk', '⚠ Use with\ncaution;\nPost-process\nmandatory', '✗✗ CONTRAIND.\nInsufficient\nstrength for\nhigh-risk case'), ('Full-Arch\nImplant\nNo bruxism', '✗ NO', '200–400 N', 'HIGH\n★★★★☆', 'HIGH\n★★★★☆', '★★ FIRST\nCHOICE\nBest outcome\nlong-term', '✓ Acceptable\nGood choice\nif budget', '✓ Acceptable\nWith regular\nreview &\npolishing'), ] row_colors = [C_ROW1, C_ROW2] * len(rows) rec_colors = { '★★ FIRST\nCHOICE': C_CAD, '★★ MANDATORY': C_CAD, '★★ ONLY\nCHOICE': C_CAD, '★★ PREFERRED': C_CAD, '✓ Good': '#2E6DA4', '✓ Acceptable': '#2E6DA4', '⚠ Use with\ncaution;': C_3DP, '✗ Avoid': C_WARN, '✗✗ CONTRAIND.': '#8B0000', '★ Acceptable': C_HC, } row_h = 0.88 start_y = 11.7 for i, row in enumerate(rows): ry = start_y - i * row_h bg = C_ROW1 if i % 2 == 0 else C_ROW2 for j, (cx, cw, cell) in enumerate(zip(col_x, col_w, row)): # Pick cell background for recommendation columns cell_bg = bg cell_tc = '#1A3C5E' if j >= 5: # material recommendation columns first_line = cell.split('\n')[0] if '★★' in cell and ('FIRST' in cell or 'MANDATORY' in cell or 'ONLY' in cell or 'PREFERRED' in cell): cell_bg = '#D4EDDA'; cell_tc = '#1B6B3A' elif '✓ Good' in cell or '✓ Acceptable' in cell or '★ Acceptable' in cell: cell_bg = '#FFF3CD'; cell_tc = '#7B4200' elif '✗✗' in cell: cell_bg = '#F5C6CB'; cell_tc = '#721C24' elif '✗ Avoid' in cell or '✗ Not ideal' in cell: cell_bg = '#FADADD'; cell_tc = '#C0392B' elif '⚠' in cell: cell_bg = '#FFEEBA'; cell_tc = '#856404' rect = plt.Rectangle((cx - cw/2, ry - row_h/2), cw, row_h, facecolor=cell_bg, edgecolor='#B0BEC5', lw=0.8) ax.add_patch(rect) ax.text(cx, ry, cell, ha='center', va='center', fontsize=7.2, color=cell_tc, multialignment='center', linespacing=1.25) # Outer border outer = plt.Rectangle((col_x[0] - col_w[0]/2, start_y - (len(rows)-0.5) * row_h), col_x[-1] + col_w[-1]/2 - (col_x[0] - col_w[0]/2), row_h * len(rows), facecolor='none', edgecolor=C_HEAD, lw=2) ax.add_patch(outer) # ── Property comparison bar (bottom section) ────────────────────────────────── bar_y = 4.0 ax.text(11, bar_y + 0.75, 'THESIS MATERIAL PROPERTY COMPARISON (Michigan Splint)', ha='center', fontsize=11, weight='bold', color=C_HEAD) materials = ['Heat-Cure PMMA\n(Conventional)', '3D-Printed\nResin', 'CAD/CAM\nMilled'] flex_vals = [60, 75, 95] # relative ranking (thesis finding) ra_inv = [55, 70, 90] # inverted Ra (higher = smoother) bar_colors = [C_HC, C_3DP, C_CAD] bar_positions = [5.5, 11, 16.5] bar_width = 2.8 max_h = 2.8 for i, (bx, mat, fv, rv, bc) in enumerate(zip(bar_positions, materials, flex_vals, ra_inv, bar_colors)): # Flex bar fh = fv / 100 * max_h rh = rv / 100 * max_h rect_f = plt.Rectangle((bx - bar_width/2, bar_y - max_h - 0.1), bar_width * 0.42, fh, facecolor=bc, edgecolor=WHITE, lw=1.2, alpha=0.85) rect_r = plt.Rectangle((bx - bar_width/2 + bar_width * 0.48, bar_y - max_h - 0.1), bar_width * 0.42, rh, facecolor=bc, edgecolor=WHITE, lw=1.2, alpha=0.55) ax.add_patch(rect_f) ax.add_patch(rect_r) ax.text(bx - bar_width/2 + bar_width * 0.21, bar_y - max_h + fh - 0.1 - 0.1, f'Flex\n{fv}%', ha='center', va='bottom', fontsize=7.5, color=WHITE, weight='bold') ax.text(bx - bar_width/2 + bar_width * 0.48 + bar_width * 0.21, bar_y - max_h + rh - 0.1 - 0.1, f'Smooth\n{rv}%', ha='center', va='bottom', fontsize=7.5, color=WHITE, weight='bold') ax.text(bx, bar_y - max_h - 0.35, mat, ha='center', va='top', fontsize=8.5, color=bc, weight='bold', multialignment='center', linespacing=1.3) # Bar legend ax.add_patch(plt.Rectangle((3.5, 0.7), 0.5, 0.28, facecolor='#555555', alpha=0.85)) ax.text(4.2, 0.84, 'Flexural Strength (relative %)', va='center', fontsize=8, color='#333') ax.add_patch(plt.Rectangle((9.0, 0.7), 0.5, 0.28, facecolor='#555555', alpha=0.5)) ax.text(9.7, 0.84, 'Surface Smoothness (inverted Ra %)', va='center', fontsize=8, color='#333') ax.text(11, 0.22, 'Thesis finding: CAD/CAM Milled acrylic demonstrates the highest flexural strength and lowest surface roughness (Ra) ' 'among all three fabrication techniques.\n' 'Literature: Shafiee & Nourizadeh 2025 (PMID 41068723) | Chawki et al. 2026 (PMID 42404608) | ' 'Teixeira et al. (photoelastic) | Kinsel & Lin 2009 | Nitschke et al. 2025', ha='center', va='bottom', fontsize=7, color='#555555', style='italic', linespacing=1.5) plt.tight_layout(pad=0.5) plt.savefig('/tmp/workspace/splint-chart/Fig2_Summary_Table.png', dpi=180, bbox_inches='tight', facecolor=fig.get_facecolor()) plt.close() print("Table saved.") PYEOF echo "Exit: $?"

Running Command

ls -lh /tmp/workspace/splint-chart/

Both charts are ready. Here are your thesis figures:

Figure 1 - Clinical Decision Flowchart

Fig1 Clinical Decision Flowchart

Image · PNG

Figure 2 - Material Selection Summary Table

Fig2 Summary Table

Image · PNG

What each figure contains:

Figure 1 - Flowchart (Decision Tree):

Entry point: "Patient requires Michigan Splint"
First decision diamond: Is bruxism/parafunction present?
Left branch (Bruxism YES): Splits into 5 clinical conditions - Natural Dentition, Complete Denture, Implant Overdenture, Partial Implant FPD, Full-Arch Implant (All-on-4/6)
Right branch (No Bruxism): Splits into 4 conditions - Natural Dentition/TMD, Stable Complete Denture, Partial/Implant Prosthesis, Full-Arch Implant
For each branch: Occlusal Load Range → Material Recommendation → Rationale (tied to your thesis + literature)
Color coding: Green = CAD/CAM (first choice), Amber = 3D-Printed (acceptable), Purple = Heat-Cure (acceptable with caveats), Red = High risk / contraindicated

Figure 2 - Summary Table + Bar Chart:

8 clinical conditions as rows
Columns: Bruxism status, Occlusal load, Flex strength requirement, Surface roughness importance, then graded recommendations for CAD/CAM / 3D-Printed / Heat-Cure
Color cells: Green = first choice, Yellow = acceptable, Pink/Red = avoid/contraindicated
Bottom bar chart visually compares the 3 materials on Flexural Strength % and Surface Smoothness % based on your thesis finding

Key thesis-based verdict woven through:

Condition	Material Verdict
Full-arch implant + bruxism	CAD/CAM ONLY - 7× less fracture risk
Partial implant FPD + bruxism	CAD/CAM MANDATORY - 33-73% stress reduction
Any bruxism case	CAD/CAM first choice (best flex + lowest Ra)
Complete denture, no bruxism	Heat-cure acceptable; monitor wear
TMD only, natural teeth	CAD/CAM or 3D-printed acceptable

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