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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 5  |  Issue : 1  |  Page : 11-16

Evaluation of occlusal forces in different stages of children - An exploratory study


1 Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bengaluru, India
2 Department of Dentistry, Hassan Institute of Medical Sciences, Hassan, Karnataka, India

Date of Web Publication12-Mar-2018

Correspondence Address:
Priya Subramaniam
Department of Pedodontics and Preventive Dentistry, The Oxford Dental College, Hospital and Research Centre, Bommanahalli, Hosur Road, Bengaluru - 560 068, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjos.SJOralSci_52_17

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  Abstract 


Introduction: Bite force is one of the indicators of the functional state of mastication and loading of teeth. Bite force measurement is a reliable method of assessing the biomechanical properties of the masticatory system.
Aim: To evaluate the occlusal bite force of children in different stages of dentition and to relate the occlusal bite force to body mass index (BMI).
Methodology: One hundred and twenty children (60 boys and 60 girls) aged 3–13 years were selected and divided into three groups of forty children each matched for age and gender. The children were divided according to the teeth present into primary, mixed, and permanent dentition. BMI was calculated using the formula, weight/height2. The height was measured using a portable height measuring unit. Body weight of each child was measured using a portable glass electronic personal scale. Occlusal bite force was measured using a portable occlusal bite force gauge. The bite force was measured in triplicate, alternately on the right and left sides of the mouth. Data obtained were subjected to statistical analysis.
Results: Mean occlusal bite force was highest in children with permanent dentition (269.7 N). Males showed a higher bite force than females in all three groups. The highest occlusal bite force recorded was in males with permanent dentition (326.6 N), which was statistically significant (P ≤ 0.05). The mean BMI of males was significantly higher than that of females in children with primary dentition. In children with primary and mixed dentition, bite force showed an inverse relationship with BMI. A positive but weak association was found between occlusal bite force and BMI in children with permanent dentition.
Conclusions: There was a difference in the occlusal bite force at different dentition stages. It was significantly higher in males and in the permanent dentition stage. Height and weight can be considered as predictors of occlusal bite force in older children with permanent dentition.

Keywords: Bite force, body mass index, mixed, permanent, primary


How to cite this article:
Subramaniam P, Girish Babu K L, Ifzah. Evaluation of occlusal forces in different stages of children - An exploratory study. Saudi J Oral Sci 2018;5:11-6

How to cite this URL:
Subramaniam P, Girish Babu K L, Ifzah. Evaluation of occlusal forces in different stages of children - An exploratory study. Saudi J Oral Sci [serial online] 2018 [cited 2018 May 26];5:11-6. Available from: http://www.saudijos.org/text.asp?2018/5/1/11/227134




  Introduction Top


Occlusal bite force is reported to be a key predictor for masticatory performance. Bite force can be defined as the forces applied by masticatory muscles in dental occlusion. It is believed that stronger the bite force, the better is the system.[1],[2] Maximum bite force is one of the indicators of the functional state of masticatory system and loading of teeth. It is exerted by the jaw elevator muscles and regulated by the nervous, muscular, skeletal, and dental systems.[3]

Normal development of the primary dentition is indispensible for establishing a healthy chewing movement in the permanent dentition.[4] Since the primary occlusion undergoes continuous change and it is adapt to growth and development, its functional determinants must be established to explain and assure appropriate growth and development of the stomatognathic system. It would also allow a better understanding of the functional aspects of masticatory system development.[5] Considering the fact that bite force is one of the components of mastication, it is important to understand the nature of occlusal force during growth.

Bite force evaluation is well recognized in the literature as a clinical indicator of masticatory performance.[6],[7],[8] Apart from age, gender, size, and facial morphology, the thickness and activity of the masticatory muscles along with temporomandibular joint (TMJ) influence occlusal bite force. The number of teeth present, their alignment, condition of dentition, dental occlusion, and pain are other individual variations that influence the magnitude of bite force.[9],[10]

Studies have been done to compare the masticatory function of children and adults using electromyography of masticatory muscles, recording of mandibular movements, and bite force measurement.[4],[11],[12] However, there still remains a need to fully understand the magnitude of occlusal bite forces in different dentition stages in children and the relation of occlusal bite force to body mass index (BMI). Hence, the present study was undertaken to evaluate the bite force in children with primary, mixed, and permanent dentition and to correlate it with their BMI.


  Methodology Top


The study protocol was approved by the Ethical Committee of the Institutional Review Board. School children aged between 3 and 13 years from different schools in Bengaluru city were selected for the study. Prior informed written permission was obtained from the respective school authorities to examine the children. Two hundred children aged between 3 and 13 years were initially examined using sterile mouth mirrors and blunt dental probes. Inclusion criteria[13] included (1) cooperative children; (2) children with sound healthy dentition; (3) children with no missing teeth in the region of recording; (4) children with no history of orthodontic treatment; (5) children with no parafunctional habits, no pathological wear facets, or any other soft tissue abnormality; (6) children with no anomalies of form, structure, and number or alterations that could compromise their dimensions; (7) children with a healthy periodontal status, free from any pathology; (8) normal overjet and overbite; (9) no or minor crowding or spacing; and (10) normal oral tissue. Exclusion criteria included (1) children with TMJ disturbances or with history of surgery of TMJ; (2) medically compromised children; (3) children with apparent facial asymmetry that could affect the recordings; (4) children with occlusal discrepancies; and (5) children with anterior or posterior crossbites or openbite. Written consent was obtained from parents of children who fulfilled the inclusion criteria. A pro forma was used to record children's age, gender, height, weight, and occlusal bite force. Based on the previous study,[13] it was calculated that at least forty subjects in each group were required to detect a medium effect size (0.25 standard deviation [SD]) between the three groups at a significance level of 0.05 with a power of 0.99.

The study group consisted of 120 children (60 boys and 60 girls) aged 3–13 years. They were divided into three groups of forty children each, matched for age and gender: Group 1 – Children aged 3–4 years having all primary teeth; Group 2 – Children aged 7–9 years with eruption of all permanent first molars, incisors, and primary canines and molars; and Group 3 – Children aged 12–15 years with complete eruption of all permanent teeth excluding third molars.

Training and calibration for oral examination were carried out in our department. Examination of the children was done by only one examiner to avoid inter-examiner variability. Ten percent of children were examined twice for intra-examiner reliability. The kappa value for intra-examiner agreement of the tooth status was 0.88.

Body mass index

Height of each child was measured to the nearest 0.5 cm, using a portable height measuring unit (BICON™, size 200 cm, imported by Bharat Enterprises, Delhi). Each child stood without shoes and with his/her back straight against the measuring rod with the feet closely aligned and with the foot positioner and child's head in a straight line. The caliper gauge was then adjusted on the head so that the measuring tongue rested without sagging.[14] Body weight of each child without shoes was measured using a portable glass electronic personal scale (Model - Perfect™, PET 0030) capable of measuring up to the nearest 0.1 kg. BMI was calculated using the formula, i.e., weight in kilograms divided by height in meter square (weight/height2).

Occlusal bite force

Measurements of occlusal bite force were undertaken during a single session for each child, using a portable digital occlusal force gauge (GM 10 Nagano Keiki, Tokyo, Japan) [Figure 1]. The instrument consisted of a hydraulic pressure gauge and a biting element (17 mm in width and 5.4 mm in height) made of a vinyl material encased in a disposable plastic tube. Each tube was used for one recording after which the device was cleaned with a cloth moistened with disinfectant. The measuring range of this instrument is from 0 to 1000 N, with an accuracy of ± 1 N. To record occlusal bite force, each child was seated on a chair with their head and body in a natural upright position with their head fixed keeping the Frankfort horizontal plane approximately parallel to the floor. Before the recording, children were asked to practice their highest occlusal bite force by biting on the occlusal force gauge. Occlusal bite force was measured alternately on the right and left sides of the mouth. The measurements were taken in the primary and permanent first molar area unilaterally on both the right and left sides of the jaw, during a few seconds of maximal clenching. This was repeated in triplicate, with a 15 s interval between each recording. The highest value of the three occlusal bite force measurements per side was recorded as the maximum occlusal bite force for that side. The mean of the values obtained for both sides was considered as the child's occlusal bite force.[13],[15]
Figure 1: Occlusal bite force meter

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In Group 1, occlusal bite force was recorded bilaterally by placing the occlusal bite gauge in the second primary molar region. In Groups 2 and 3, occlusal bite force was recorded by placing the occlusal bite force gauge in the first permanent molar region. The data obtained were statistically analyzed.

Data were expressed as the mean ± SD. Student's t-test (two tailed, independent) was used to find significance of study parameters on continuous scale between the groups. ANOVA and Pearson's correlation coefficient were used to find the significance of study parameters and correlation of study parameters on categorical scale between two or more groups, respectively.Statistical Package of the Social Sciences (SPSS) software 19.0 (Armonk, NY: IBM Corp)using Windows was used to analyze the data. The P ≤ 0.05 was considered as significant, and P < 0.001 was taken as highly significant.


  Results Top


The mean occlusal bite force was highest in children with permanent dentition (269.7 N), which was significantly higher than that of the other two groups (P ≤ 0.05) [Table 1]. In all three groups, no significant differences were observed in occlusal bite forces measured between right and left sides [Table 2]. Among males, occlusal bite force was highest in the group with permanent dentition (326.6 N) and it was significantly different from that of the other two groups (P< 0.001) [Table 3]. BMI of males was significantly higher (15.53 N) than that of females (14.62 N) only in children with primary dentition (P ≤ 0.05) [Table 4]. A positive but weak association was seen between BMI and occlusal bite force in both males and females with permanent dentition [Table 5].
Table 1: Comparison of occlusal bite force between males and females

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Table 2: Comparison of occlusal bite force between right and left sides in each group

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Table 3: Gender-wise comparison of occlusal bite force between the groups

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Table 4: Comparison of body mass index between males and females in each group

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Table 5: Correlation between occlusal bite force and body mass index in each group

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  Discussion Top


Bite force is one of the indicators of the functional state of mastication and loading of teeth. Bite force results from the action of jaw elevator muscles, which is determined by the central nervous system and feedback from muscle spindles, mechanoceptors, and nociceptors modified by craniomandibular biomechanics.[3] It is generally accepted that a better masticatory system results in a stronger bite force.[1],[2]

There are a limited number of studies primarily based on subjects with normal occlusion to define the range of normal maximal masticatory forces in subjects without disturbed morphological and functional occlusion. Routine recording of bite force for clinical purposes can provide normal values and knowledge of factors responsible for their variability. Few contemporary studies have been done to evaluate occlusal bite force at different dentition stages in children.[16],[17]

In this study, children with a wide age range from 3 to 13 years were selected because the rate of growth is maximum from birth to 5 years of age, which then decreases between 6 and 10 years, and later reaches a maximum at puberty (11–15 years). Age 6–10 years is particularly important for dental and orthodontic treatment planning because minimal growth occurs during this period. Occlusal bite force of both boys and girls was evaluated to compensate for gender differences in the bite forces such as developmental milestones, BMI, and hormonal changes.

Occlusal bite force values can be directly influenced by the accuracy of the measuring apparatus itself. In a number of devices measuring bite force, the bite element is constructed from rigid material, making it difficult to measure bite force accurately in younger children. To overcome these limitations, an occlusal bite force gauge was introduced. This instrument consists of a hydraulic pressure gauge and a biting element made of a vinyl material encased in a disposable plastic tube.[16] It is reported to be an accurate device[18],[19] wherein the bite force recorded is displayed digitally and it is also advantageous to use in children. In the present study, the use of an occlusal bite force gauge enabled safe and comfortable recording of bite force. With this instrument (gauge), recording of the bite force was simple and noninvasive and could be carried out as a convenient chairside procedure. Since recording of bite force measurement is associated with intra-individual variation, it was recorded in triplicate on each side for every child.[20],[21]

Apart from instrument design, position of the instrument in the dental arch is an important factor influencing the maximum bite force. Bite force varies within the regions of the oral cavity and is greatest in the first molar area.[3] The occlusal tooth contacts are more frequent in the posterior region. Due to the biomechanics of the jaw elevator muscles and the lever system of the mandible, the occlusal force is greater on the molars than on the incisors. The molar teeth resist more compression during clenching than anterior teeth because of their large periodontal areas. It has been stated that the most comfortable position of the transducer in younger patients is in the region of first premolar/deciduous molar.[12] Hence, in the present study, occlusal bite force was recorded bilaterally in the molar region in both primary and mixed dentition and in the region of first permanent molar in the permanent dentition.

Occlusal forces are age and gender related. They may begin to increase dramatically at the age of 9 years, when the root formation of the first molar is complete. Gender differences may also begin to become significant at this age.[22] A study done in children aged 3–5.5 years with normal occlusion showed the mean bite force to be 213.17 N,[23] which is higher than the mean occlusal bite force of 172.2 N observed in this study. As reported earlier, higher occlusal bite force was seen in boys as compared to that of girls.[14],[24] The mean occlusal bite force in boys was significantly higher in the permanent dentition. The mean occlusal bite force of children in the mixed dentition stage was found to be the lowest (169.3 N) and particularly observed in males. During this phase, physiologic root resorption of primary molars would have already begun. Moreover, the roots of the first permanent molars may not have completed formed resulting in lower bite forces.

The difference in growth intensity between the genders could be a reason for the difference in bite force in their permanent dentition.[25] The correlation of maximum bite force to gender is not evident up to the age of 18 years mainly because the excretion of ketosteroids in postpubertal young males is related to an increase of muscle mass. This increase in muscle mass occurs at a greater rate in males only beyond 16 years as compared to females.[12]

As individuals grow older, there is an increase in body size with concomitant increase in muscle mass and strength. This is also accompanied by changes in dentition and increased occlusal contacts resulting in their ability to apply larger bite forces. In our study, in children with primary dentition, the mean BMI of males was significantly higher than that of females indicating differences in growth and development at an early age.

BMI presented an inverse correlation with bite force in both primary and mixed dentition, whereas a positive but weak association was seen between BMI and bite force in the permanent dentition. The correlation between chewing function and body variables could become stronger when children are older, with an increase in muscle mass during growth and development influenced by androgenic steroids. The observations made in this study have its limitations due to the cross-sectional nature of the investigation. The other factors which cannot be controlled but can influence the results are children fatigue from the repetitive measurements of the biting force and time of the day the measurements were taken. Further studies taking these factors into considerations can be conducted and throw light on the changes in bite force of children followed through various stages of their dentition.


  Conclusions Top


From this exploratory study, the following observations were made:

  • Mean occlusal bite force was highest in children with permanent dentition
  • Males showed higher occlusal bite force than females in all three groups. This difference was significant only in the permanent dentition
  • Among males, mean occlusal bite force was significantly higher in the stage of permanent dentition
  • Occlusal bite force showed an inverse relation with BMI in children with primary and mixed dentition. A positive but weak correlation was seen between BMI and occlusal bite force in children with permanent dentition.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kamegai T, Tatsuki T, Nagano H, Mitsuhashi H, Kumeta J, Tatsuki Y, et al. Adetermination of bite force in Northern Japanese children. Eur J Orthod 2005;27:53-7.  Back to cited text no. 16
    
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24.
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    Figures

  [Figure 1]
 
 
    Tables

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



 

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