research on bite force (mds thesis of dr. roshni maurya)

ASSESSMENT OF BITE FORCE IN BENGALEE CHILDREN

OF

KOLKATA AND ITS CORRELATION WITH DIFFERENT VARIABLES

THESIS SUBMITTED TO THE WEST BENGAL UNIVERSITY OF HEALTH

SCIENCES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF

MASTER OF DENTAL SURGERY

IN THE SPECIALITY OF

PEDODONTICS AND PREVENTIVE DENTISTRY

WEST BENGAL UNIVERSITY OF HEALTH SCIENCES

Session 2012-2015

ROSHNI MAURYA

WBUHS REGISTRATION NO: 0090 of 2012-2013

DEPARTMENT OF PEDODONTICS & PREVENTIVE DENTISTRY

GURU NANAK INSTITUTE OF DENTAL SCIENCE & RESEARCH

KOLKATA

Dedicated to

My family &

fiance

Acknowledgement

The driving force of my life and the power, which always guided me, held me through difficult

times, and led to the successful completion of this dissertation of mine, has been THE

ALMIGHTY and words are inadequate to record my profound gratitude for the blessings on me.

First and foremost, I am grateful to THE ALMIGHTY who has guided me throughout my career

and this work.

It is with philosophical sense of gratitude; I express my heartfelt indebtedness to my esteemed

and learned teacher Prof. (Dr.) Subrata Sarkar M.D.S (Lko.), Ph.D.(Cal.), former head of

Department of Pedodontics & Preventive Dentistry, Guru Nanak Institute of Dental Science &

Research, ;Kolkata , for his persuasive, perpetual, priceless, and benevolent guidance along with

unstained co-operation that enabled me to complete the work of dissertation.

I wish to convey my regards and profound gratitude to my Guide, Prof. Dr. Shabnam Zahir

M.D.S (Cal.), Professor; Department of Pedodontics & Preventive Dentistry, Guru Nanak

Institute of Dental Science & Research, Kolkata; for her painstaking efforts and advice. She

imparted exceptionally able guidance and constant encouragement which enabled me to

complete this task against all odds. An ideal teacher full of excellent idea, she paved my way

through her immense knowledge and experience. Her keen interest in the subject gave me the

maximum benefit of her most valuable and critical suggestions. Her regular discussion has been

a constant source of inspiration to me.

I owe deep sense of gratitude to my respected teacher, Dr. Gautam Kumar Kundu, Prof. and

Head of Department of Pedodontics & Preventive Dentistry, Guru Nanak Institute of Dental

Science & Research, Kolkata; for his valuable suggestions, excellent supervision, exceptionally

able guidance and constant encouragement which he has bestowed upon me in carrying out this

study. His brilliant foresight and practical approach has been a guiding force behind all my

efforts in bringing this thesis to its ultimate goal.

I am extremely grateful to my co-guides, Dr. Jayanta Bhattacharyya, M.D.S (Cal.), Professor

and Head of Department of Prosthodontics & Crown & Bridge, and Dr. Pratik Kumar Lahiri,

M.D.S.(RUHS), Senior Lecturer; Department of Pedodontics & Preventive Dentistry, Guru

Nanak Institute of Dental Science & Research, Kolkata; for their kind support, constant

guidance, useful suggestions and encouragement. It is due to their critical way of looking

towards my work that it has seen the light of the day.

I am thankful to Dr. Rima Dhar, M.D.S (RUHS), Reader, Department of Pedodontics &

Preventive Dentistry, Guru Nanak Institute of Dental Science & Research, Kolkata; for her

guidance.

I will never forget the encouragement and sincere help of Dr. Sudipta Kar, M.D.S. (WBUHS),

Senior Lecturer, Department of Pedodontics & Preventive Dentistry; Dr. Badruddin Ahmed

Bazmi, M.D.S. (WBUHS), Senior Lecturer; Department of Pedodontics & Preventive Dentistry;

Dr. Biswaroop Chandra, M.D.S. (Chennai), Senior Lecturer; Department of Pedodontics &

Preventive Dentistry, Guru Nanak Institute of Dental Science & Research, Kolkata, for their

inspiration and guidance in completion of my work.

I wish to express my sincere thanks to my Principal, Prof. R. R. Paul, M.D.S.;Ph.D; Guru

Nanak Institute of Dental Science & Research, Kolkata, for his kindness and generosity towards

my venture.

My sincere thanks to my respected seniors, Dr. Anil Singh, M.D.S.(WBUHS),Dr. Monalisa

Das, M.D.S.(WBUHS),Dr.Roshni De, M.D.S.(WBUHS),my colleagues Dr. Abhirup Goswami

and Dr. Amitava Bora, my juniors Dr.Piyali Datta, Dr Rajib Saha, Dr.M.B.Pandey,

Dr.Supriya Banerjee, Dr.Prasantha.K.Das., Dr Piyush Singh, Dr.Gopal Bera, and

Dr.Depashree Paul, who all have supported me in my hour of need.

I would like to express my very great gratitude and appreciation to my colleagues from other

departments, Dr.Sweta Singh and Dr.Mitali Majumdar from Department of Prosthodontics &

Crown & Bridge and Dr. Nabanita Bose from Department of Endodontics and my B.D.S.

colleagues, Dr.Ayan Saxsena, Dr. Harleen Jolly and Dr. Puneet Sahu for their help

throughout the period of my study.

I convey special thanks to all non-teaching staff of the Department of Pedodontics &

Preventive Dentistry, Guru Nanak Institute of Medical Science & Research Kolkata, specially

Mrs. Purnima Ghosh and Mr. Basant Bhansfore for their constant support and help.

I am also grateful to Mr. Biswajit Saha, Librarian and Mr. Debnarayan Biswas and Mr.

Deepak Bhansfore, Asst. Librarian for providing me with all the required study material during

my course.

I would like to place my sincerest gratitudes to the Principal of Agrasian Balika Siksha Sadan

and Agrasain School For Boys, for granting me the permission to conduct the study in their

school premises.

I cannot find words to sufficiently thank my grandparents, my great parents, Mr.H.L.Maurya

and Mrs.Sita Maurya, my uncle and aunt, elder sister Reshmi, younger sisters Rajni and Kirti,

cousins Yash and Anushka, my nephews, Rayansh and Ridaan and all of my family members

who throughout the last three years have gave constant love, support and serenity and have

never complained about it. Without their moral and emotional support this thesis would certainly

not have existed.

I thank my supportive fiance, Mr.Manoj Maurya for his constant encouragement, relentless

effort and motivation thereby boosting me to produce my work on stipulated time. Thank you for

everything.

I express my thanks to Mr. Shyamsundar Mondal, for his efforts in carrying out statistical

analysis of data without which it would have been impossible to shape up this project.

I am highly indebted to all the volunteers who participated in the study without which this study

would not have been possible.

Last, but not the least, there are countless other names, which deserve mention, but could not be

included in this section due to space constraints. I acknowledge their contribution with gratitude.

I want to give special thanks to the West Bengal University of Health Sciences for giving me

the permission to carry out such type of work.

Roshni Maurya

CONTENTS

Topics Page no.

INTRODUCTION 1-14

AIMS & OBJECTIVES 15-16

REVIEW OF LITERATURE 17-34

MATERIALS AND METHODS 35-52

RESULTS AND OBSERVATION 53-80

DISCUSSION 81-94

SUMMARY 95-97

CONCLUSION 98-99

REFERENCES 100-111

APPENDIX

ETHICAL COMMITTEE CLEARANCE CERTIFICATE

APPROVAL LETTER FROM SCHOOLS

ABBREVIATIONS

CONSENT FORM

PROFORMA SHEET

INTRODUCTION

Introduction

1

INTRODUCTION

Bite force in a dental context can be termed as the forces applied by masticatory

muscles in occlusion.1 Bite force can be defined as the capacity of the mandibular

elevation muscles to perform a maximum force of lower teeth against the upper

teeth, under favourable conditions.2 Investigators have suggested that maximum bite

force is affected by the masticatory system, and it is generally accepted that a better

masticatory system results in a stronger bite force. Oral status can affect mastication.

Severely decayed and missing teeth are detrimental to mastication and weaken the

function of masticatory muscles, thereby having a negative impact on bite force.

Mastication is a developmental function and its maturation occurs from learning

experiences. If it is adequate, it gives stimulus and proper function for the normal

development of the maxilla and mandible. Masticatory function can be described in

terms of the objective capability of a person to fragment solid food or as the

subjective response of an individual to questions regarding food chewing.3

Assessment of the efficiency of masticatory function requires knowledge of the condition

of all the parts of the stomatognathic system, as well as the magnitudes of bite forces that

represent the condition, expression, and measure of the same function.

Human mastication is an elegant interaction of several muscle groups that is

subconsciously refined into a simple process by repetition. Muscle is the dominant

determinant of both the horizontal and vertical position of the teeth. It is the primary

focus in vertical dimension, the neutral zone, arch form, occlusal disease, or orofacial

pain and even smiles design. More than twenty muscles are responsible for the motion

profile, which is considered to be an aggregate of both clenching and grinding motions.4

In many simulations the complex muscular interplay is simplified to the principal three

muscles involved in mastication: the temporal, the masseter, and the pterygoid muscles.

These three muscles are pictured in FIG.1

Introduction

2

The function of the temporal muscle is to elevate the mandible and also retract it

by activation of its posterior fibers. The pterygoid muscles serve to depress the mandible

(externus), elevate the mandible (internus), and both groups are used to produce lateral

excursions of the mandible. Much of the masticatory force is produced by the masseter,

which can elevate and protrude the mandible. The combined actions of these muscles

produce the motion profiles as shown in FIG. 2.

a) the temporal b) the pterygoid internus c) the masseter

& externus

FIG.1: The principal muscles involved in mastication

a) Clenching

b) Grinding

FIG.2: The principal motions involved in mastication

Introduction

3

Clenching is the vertical motion of the jaw that involves shearing of the food at the

incisors and compression of the food at the molars. Grinding is a combination of

compression and shear force application at the molars. Both of these motions may also

put any food that sticks to the teeth in tension due to adhesion as the occlusal surfaces

separate.

Mastication involves the orofacial muscles, and it is hypothesized that sensorial

regulation resulting of mastication involves mechanoreceptors situated in the

periodontium, temporomandibular joint, tongue, muscles and mucosa. The intensity of

bite forces are determined mainly by muscle capacity, whereas masticatory forces

depend on the number of motor units, muscle cross-sectional areas, the type of muscle

cells, the angle at which the muscle acts to the bone, and on training.

With the above taken into account, it can be stated that there are numerous

elements known to impact masticatory performance, including age, bite force, gender,

the loss and type of restoration of post-canine teeth, malocclusion, total area of teeth in

contact, oral motor function, and salivary glands function.4 However, bite force and the

functional tooth units were clarified as being the main bases for masticatory function and

its performance. It has been highlighted that bite force has a strong link with masticatory

performance, although the effects of such are not recognized as being as strong as the

number of functional teeth. Furthermore, it has been established that, in addition to

functional occlusal contact area and body build, maximum bite force explained

approximately 72% of the variation in masticatory performance and efficiency among

adults and children.5, 6

Bite force is recognized as one of the factors indicating the masticatory

system’s functional state resulting from jaw elevator muscle action, modified by

cranio-mandibular biomechanics .7 Craniofacial growth is a complex process

involving many interactions between the different bones that make up the skull and

between the hard and soft tissues. The processes that control craniofacial growth are not

fully understood and are an area of extremely active research globally. However, the

descriptions of where growth occurs within a bone and how this relates to changes in

bone shape and position have been described for over 200 years. Early cephalometric

Introduction

4

growth studies gave the impression that overall, as the face enlarges it grows downwards

and forwards away from the cranial base. However, it is now known that growth of the

craniofacial region is much more complex than this, with the calvaria, cranial base,

maxilla and mandible experiencing differing rates of growth and differing mechanisms

of growth at different stages of development, all of which are under the influence of a

variety of factors. The overall pattern of facial growth results from the interplay between

them and they must all harmonize with each other if a normal facial form is to result.

Small deviations from a harmonious facial growth pattern will cause discrepancies of

facial form and jaw relationships which are of major significance to the dentists.

Different tissues have different growth patterns (curves) in terms of rate and

timing, and four main types are recognized: neural, somatic, genital and lymphoid.

The first two are the most relevant in terms of craniofacial growth. Neural growth is

essentially that which is determined by growth of the brain with the calvarium following

this pattern. There is rapid growth in the early years of life, but this slows until by about

FIG.3: Superimpositions on the

cranial base showing overall

downwards and forwards

direction of facial growth.

Solid line: 8 years of age

Broken line: 18 years of age

Introduction

5

the age of 7 years growth is almost complete. The orbits also follow a neural growth

pattern.

Somatic growth is that which is followed by most structures. It is seen in the long

bones, amongst others, and is the pattern followed by increase in body height. Growth is

fairly rapid in the early years, but slows in the prepubertal period. The pubertal growth

spurt is a time of very rapid growth, which is followed by further slower growth.8

Traditionally, the pubertal growth spurt has been reported to occur on average at 12

years in girls, though there is evidence that the age of puberty is decreasing in girls. In

boys the age of puberty is later at about 14 years. The maxilla and mandible follow a

pattern of growth that is intermediate between neural and somatic growth, with the

mandible following the somatic growth curve more closely than the maxilla, which has a

more neural growth pattern.

FIG.4: Postnatal growth patterns for neural

lymphoid, somatic and genital tissues are shown

as percentages of total increase as well as patterns

for maxilla and mandible are shown.

Introduction

6

Thus different parts of the skull follow different growth patterns, with much of the

growth of the face occurring later than the growth of the cranial vault. As a result the

proportions of the face to the cranium change during growth, and the face of the child

represents a much smaller proportion of the skull than the face of the adult.

Facial growth is now no longer referred to as being complete; rather it declines to

adult levels of growth following the peak rate of growth seen during the pubertal growth

spurt. The decline to adult levels of growth occurs in a predictable manner.8

Dimension Female Male

Transverse

(intercanine width)

12 years ( maxilla)

9 years (mandible)

12 years ( maxilla)

9 years ( mandible)

Anteroposterior

2-3 years after first

menstruation

14–15 years (maxilla)

16-17 years

(mandible)

4 years after sexual

maturity

17 years (maxilla)

19 years (mandible)

Different investigators have found a wide range of maximum bite force values.

Bite force is divided in two main groups with physiological or pathological condition.

The physiological force is again divided into three different subgroups according to their

localizations, anterior, general (covering the entire arch) and posterior part of arch. The

great variation in bite force values depends on many factors related to the anatomical and

physiologic characteristics of the subjects. Facial structure, general muscular force and

gender differences are only a few factors that may influence bite force values. Other

Fig.5: Craniofacial growth in adult

Introduction

7

factors, such as state of dentition, instrumentation design and transducer position related

to dental arch, malocclusions, signs and symptoms of temporomandibular disorders; size,

composition and mechanical advantage of jaw-closing muscles, may influence the values

found for bite force. Thus, the subjects’ sensory feedback may limit willingness to exert

the maximum effort.

Bite force and Influential factors:

Physiologic and morphologic variables:

There may be loss of muscle force with aging.9 The jaw closing force increases

with age and growth, remains almost constant from about 20 years to 40 - 50 years of

age, and then declines.1 Although the correlation between age and bite force seems to be

significant in most of the studies, the existing literature supports that the effect of age on

bite force is relatively small.

The correlation between gender and bite force has been controversial. In some

studies, no difference was evident while others support males possessing higher

maximum bite force in comparison to females.10,11

The literature suggests that hormonal

differences in males and females might contribute to the composition of the muscle

fibers. In addition, the correlation of maximum bite force and gender is not evident up to

the age of eighteen. It is apparent that maximum bite force increases throughout growth

and development without gender specificity.

Height and weight are known to be linked with maximum bite forces. It has been

acknowledged that there is a positive association as an increase in body variables

(Weight/Height) means greater muscle mass and therefore greater bite force

magnitudes.12-14

Maximum bite force varies with skeletal measures of the cranio-facial

morphology. From the results of most studies, it seems that short-faced people may

exhibit stronger bite force.15,16

While the correlation is well documented in adults, some

controversy exists regarding the relationship in children. The influence of age, gender,

Introduction

8

tooth contacts make evaluation of correlation between bite force and facial morphology

in children difficult.

The masticatory muscles induced loading forces during mastication are controlled

by the mechanoreceptors of the periodontal ligament (PDL).17

Therefore; reduced

periodontal support may decrease the threshold level of the mechanoreceptors function,

which may affect biting.18

The etiology of the Temporomandibular disorders (TMDs) is multifactorial. It

refers to the signs and symptoms associated with pain and functional-structural

disturbances of masticatory system, especially of temporomandibular and masticatory

muscles, or both.15,19,20

TMDs are often defined on the basis of signs and symptoms,

mostly due to temporomandibular joint and muscle pain, limited mouth opening,

clicking, and crepitation

Many authors have found significantly lower bite force for the TMDs patients than

the healthy control subjects. They have considered that presence of masticatory muscle

pain and/or temporomandibular joint (TMJ) inflammation could play a role in limitation

of maximum bite force.15,19

A number of research studies in the literature took into account malocclusion as a

possible influential factor on bite force level in young children, adolescents and

adults.12,13

Dental arch malrelations may reflect abnormalities in the dentition, the jaws,

or both. There has been the postulation that malocclusion presence negatively impacts

the amount of occlusal contacts, subsequently causing lower bite force when contrasted

alongside bite forces in cases of normal occlusion.12,15,20

The potential link between bite force and ethnicity has not obtained much

attention from scientific researchers. If we acknowledge a strong link between socio-

economic/ethnic background and oral health status, it should then be recognized that the

presence of a bite force/ethnicity link is not unlikely. Nevertheless, such a relationship

has not been widely researched.

Introduction

9

Technical Variables

The extent to which the mouth can open, as well as the head posture during

measurement, the positioning of the bite force device whilst recording bite force and the

number of recordings are all aspects needing consideration as they all notably impact the

measurements obtained.21

Commonly, stronger bite forces are normally recognized in the

dental arch’s posterior region. In bite force investigations, the number of recordings

necessary should be determined whilst considering the reliability factor and importantly

avoiding fatigue that will result in reducing bite force magnitude.

Importance of Oral/Dental Status

It is widely supported that masticatory and chewing functions have the capacity to

impact dietary selection, which is notably linked with quality of life.22

Establishing and

maintaining a good level of oral health is essential when striving to achieve good general

health.23, 24

A number of research studies have highlighted the fact that poor dental health

impacts on quality of life as a whole due to a number of different elements. Dental caries

is usually associated with sequlae, such as discomfort and pain, which are known to

affect growth and weight gain, in addition to wellbeing and quality of life. Children

suffering from dental-related ailments may not always voice their discomfort or oral

pain, but such impacts may be apparent when considering changes in sleeping patterns

and eating behaviour.

Dental Caries is the most prevalent dental affliction of childhood. Despite credible

scientific advances and the fact that caries is preventable, the disease continues to be a

major public health problem. In developing countries changing life-styles and dietary

patterns are markedly increasing the caries incidence. India, a developing country, faces

many challenges in rendering oral health needs. The majority of Indian population

resides in rural areas of which more than 40% constitute children. Though many studies

have been conducted in different parts of the World, a review of literature indicates that

there is a great deficiency in baseline data concerning the oral health of Indian children.

Hence an attempt has been made to determine the oral hygiene status and dental caries

experience of 6 to 14 years old children from Kolkata (West Bengal).

Introduction

10

A number of factors have been put forward to explain the variation in prevalence

and severity of dental caries and periodontal diseases, not only between rural and urban

populations. In general, these factors can be divided into local intraoral factors associated

with plaque accumulation and metabolism and fluoride exposure or general factors such

as age, sex and socio-cultural variables. Evaluation of the oral health status of children in

present study revealed, dental caries is the most prevalent disease affecting permanent

teeth, more than primary teeth and more in corporation than in private schools, thereby,

correlating with the socioeconomic status. The reason affecting permanent teeth could be

due to fact that permanent teeth are exposed to cariogenic diet from the time of eruption

till the teeth are in situ.

Indian studies on dental caries have been mostly carried out in adult and elderly

population in relation to socio- demography, hygiene, and diet and in children related to

prevalence and treatment as well.25

Chatterjee et al conducted study in an attempt to

investigate the effect of nutrition on caries development in permanent dentition among

the school going girls of Howrah district, West Bengal, India. The overall prevalence of

dental caries was 44.5% and mean DMFT was 0.45 +1.57. This study indicates a close

relationship between nutritional status and dental caries in this region.26

No studies have

been reported on nutritional status, dental caries and their implications in

evaluation of bite force among Eastern Indian population so far.

It is known that poor oral health can lead to severe tooth decay and early loss of

teeth, which can then lead to crowded teeth and malocclusion. A previous study showed

that if children have good mastication ability, food is more easily digested. Nutrition is

important to the growth and development of children, and digestion affects nutrition.

People will choose soft food if they cannot chew effectively, eventually causing

malnutrition and insufficient fiber, mineral and vitamin intake. Masticating malfunction

can also lead to other diseases caused by malnutrition. Hence, it can be postulated that

bite force has a significant impact on mastication function which similarly has a notable

influence on the nutritional status on any individual.

Maximum bite force affects craniofacial morphology and an organism’s ability to

break down foods with different material properties. Humans are generally believed to

Introduction

11

produce low bite forces and spend less time chewing compared with other apes because

advances in mechanical and thermal food processing techniques alter food material

properties in such a way as to reduce overall masticatory effort. However, when

hominins began regularly consuming mechanically processed or cooked diets is not

known. In a study applied model for estimating maximum bite forces and stresses at the

second molar in modern human, nonhuman primate, and hominin skulls incorporated

skeletal data along with species-specific estimates of jaw muscle architecture.27

The model, which reliably estimates bite forces, shows a significant relationship

between second molar bite force and second molar area across species but does not

confirm the hypothesis of isometry. Specimens in the genus Homo fall below the

regression line describing the relationship between bite force and molar area for

nonhuman anthropoids and australopiths. These results suggest that Homo species

generate maximum bite forces below those predicted based on scaling among

australopiths and nonhuman primates. Because this decline occurred before evidence for

cooking, it is hypothesize that selection for lower bite force production was likely made

possible by an increased reliance on nonthermal food processing. However, given

substantial variability among in vivo bite force magnitudes measured in humans,

environmental effects, especially variations in food mechanical properties, may also be a

factor. The results also suggest that australopiths had ape-like bite force capabilities.27

Fig.6: Mean and ranges of maximum bite forces estimated in the study for humans

(white) and nonhuman apes (grey).Males are plotted as triangles and females as squares.

Circles are the average of male and female bite forces.

Introduction

12

Establishing bite force in the context of clinical practice is carried out in order to

assess dental prosthesis and to accordingly determine the overall success of rehabilitation

in the case of adults. Furthermore, such calculations are also geared towards obtaining

bite force reference ranges in an attempt to guide prosthetic device and implant design.7

Currently, there are two types of bite force measurement techniques available i.e. direct

and indirect. Direct techniques include use of suitable transducer that can be placed

between a pair of teeth. This direct method of bite force measurement appears to be

convenient way to measure the submaximal force. An indirect method includes use of

functional relationship between bite force and physiological variables as these variables

are known to be functionally related to the bite force.28

In the literature, various bite force measurement devices have been highlighted. As

early as 1681, Borelli was one of the first to consider instruments able to assess intra-

oral forces, with the subsequent design of the gnathodynamometer. Overall, the

majority of recording tools concerned with bite force have the potential to record forces

between 0 and 800 N at a rate of 80% precision and accuracy amounting to 10 N.29,30

The evaluations of bite force have been proven to be constructive and thus widely

utilized in dentistry,7 with the measurement of such conducted with the aim of

determining muscular activity and jaw movements during the chewing process,29

with

measurements also valuable in terms of masticatory efficiency evaluation.14,31

Introduction

13

FIG.7: Different devices used for measuring bite force

Transducers: PVDF foil with upper and

lower insulation film and thin, low-

capacitance coaxial line with barrel nut

connector.

Rottner et al; 2004

Hydraulic pressure occlusal force gauge.

Kamegai et al; 2005

Tekscan

Garg et al; 2007

Parts of gnathodynamometer

Singh et al; 2011

Digital dynamometer

Calderon et al; 2006

Bite Force device with bite prongs attached.

Alhowaish et al; 2012

Introduction

14

Bite force is recognized as being one of the essential elements involved in the

chewing function, and is regulated by the “dental, muscular, nervous and skeletal

systems and exerted by the jaw elevator muscle”.31

Notably, the jaw muscle strength

establishes the force available in crushing or cutting food. In this regard, Rentes et al

considered bite force measurement in the potential to assess physiological parameters,

namely occlusion and their influences.33

To summarize, the bite force is an output of masticatory system which is related to

several fields of dentistry such as orthodontics, prosthetic, pedodontics, maxillofacial

surgery and physiology; the various studies provide evidence that supports the value of

wide utilization of bite force measurements in different fields of dentistry.

Moreover, after conducting a critical review of the available relevant literature it

became apparent that there was an obvious lack of studies evaluating bite force in

Bengalee children of Kolkata. A lack of research on all factors influencing bite force in

children has also been noted. Caries and dental health have not had adequate attention

from research studies. Very few contemporary studies that evaluate bite force values in

young children and analyse possible influencing variables exist. Hence an attempt has

been made through the present study to determine the maximum voluntary molar bite

force in Bengalee children of Kolkata who are in different dentition stage and to

critically assess the correlation of various influential factors with bite force.

………………………………………

AIMS & OBJECTIVES

Aims & Objectives

15

AIMS & OBJECTIVES

AIMS:

The purpose of the present study was to determine maximum voluntary molar

bite force (MVBF) in Bengalee children of Kolkata of mixed and permanent

dentition and correlation of the bite force with different variables.

SPECIFIC OBJECTIVES:

To obtain maximum voluntary molar bite force (MVBF) in Bengalee children of

West Bengal of age 6-14 years.

To evaluate and critically assess the MVBF in children of different age group

who are in mixed and permanent dentition.

To determine comparative evaluation of MVBF of children of different sexual

identity of same age.

To determine correlation between height, weight , BMI (Body Mass Index) and

MVBF.

To determine correlation between oral/dental status (dmft/DMFT ; dmfs/DMFS)

and MVBF.

To determine correlation between occlusal pattern and MVBF.

To determine correlation between vertical occlusal relationship and MVBF.

To determine correlation between mouth opening and MVBF.

To determine correlation between number of maxillary posterior teeth in contact

and MVBF.

Aims & Objectives

16

To determine correlation and effect of dietary habits on MVBF.

OBJECTIVES:

The present study will provide key references value for bite force measurement in

Bengalee children of West Bengal with respect to different variables considered

in the study, thereby providing a near accurate data for evaluation of

stomatognathic system, jaw muscle function and activity. This in turn will help in

the preventive and corrective treatment of dentofacial complications occurring

due to interference of orofacial growth and development due to change in bite

force in different clinical context.

………………………………………

REVIEW

OF

LITERATURE

Review of Literature

17

REVIEW OF LITERATURE

The available relevant literature has been reviewed utilizing different available

search engines in order to reach reasonable knowledge about what is known and what is

still debatable about bite force and influential factors including dental caries and diet in

children.

Borelli (1681)35

reported the greatest human bite strength in the early literature

more than 300 years ago. He treats extensively of the subject in his work entitled ―De

motu animalium‖. He attached weights to a cord, which passed over the molar teeth of

the open mandible, and with closing of the jaw, up to 440 lbs (200 kg) were raised.

Dr. G. E. Black (1861)36

, President of the Chicago Dental University in order to

determine the average strength of the jaws, devised an instrument of very simple design

but with a name that would put the average jaw to a severe test—the

gnathodynamometer. With this instrument he made tests of the bite strength of a

thousand persons. The average showed 171 pounds for the molar teeth and much less for

bicuspids and incisors. The list of subjects includes men and women of all classes, from

a blacksmith to a Chinese laundryman.

McWhirter (1985)37

recorded the greatest bite strength, 975 lbs (443 kg), from a

37-year-old man, R. H. of Lake City, Florida. He maintained this force for approximately

2 seconds. In order to verify this unusually high bite strength, the gnathodynamometer

was taken immediately to the Instron testing machine and calibrated through a range of 0

to 1000 lbs. Mr. H. had unusually large, hypertrophied masseter and temporal muscles

.The second greatest bite strength, 514 lbs (234 kg) was recorded in a 43-year-old man

with muscle hyperactivity as evidenced by tooth abrasion, hypertrophied masseter

muscles, and heavy bone support as evidenced by lingual tori. Human bite strength in

some individuals is much greater than previously thought. Biting strength of 975 lbs

rivals world records for other muscular achievements, including (1) bench press, 660 lbs

(300 kg); (2) dead lift, 884 lbs (402 kg); and (3) squat lift, 1200 lbs (545 kg).

Koc et al (2010)7 said that the evaluations of bite force have been proven to be

constructive and thus widely utilized in dentistry, with the measurement of such

conducted with the aim of determining muscular activity and jaw movements during the


18

chewing process as stated by Bakke (1992)1, with measurements also valuable in terms

of masticatory efficiency evaluation as supported by the work of Julien et al (1996)5

and

Toro et al (2006)31

.

Patterson (1998)38

claimed that during prior studies, bite force has been utilised in

order to assess prosthetic devices amongst adults, and also to provide reference values

for research conducted in the field of prosthetic device biomechanics.

Serra et al (2007)39

has examined bite force as a tool able to examine the

removable dentures amongst young children, and to thereby assess their overall

efficiency in acting as replacements for missing natural teeth.

Koc et al (2010)7 conducted an in-depth literature review on bite force, and

subsequently noted that bite force measurement is recognized as being a diagnostic tool

in the cases of stomatognathic system disturbances, namely temporomandibular joint

disorders.

Sonneson et al (2001)20

took note of maximum bite forces, utilizing this

information to examine the link between craniofacial morphology, temporomandibular

dysfunction and head position. Children who were due to receive orthodontic treatment

made up the study sample.

Lindqvist and Ringqvist (1973)44

took bite force measurements so as to

investigate bruxism-related factors in the case of children.

Calderon et al (2006)45

carried out a research study concerned with investigating

adult cases of bruxism, with bite force assessments used through the study approach.

Rismanchian et al (2009)40

; Luraschi et al (2011)41

and Muller et al (2012)42

said in regard to adult dentistry that implant success is assessed in consideration of

various factors, namely chewing ability, biting ability, and functional recordings, which

provides one aspect of bite force determination clinical use.


19

Carlsson (2012)43

analysed the approaches implemented during the evaluation of

masticatory function in the case of dental implants patients. He considered the doctoral

thesis of six Swedish researchers, three of whom wrote their papers during the early era

of osseo-integrated implants, with the remaining three on the same subject from recent

years. Moreover, the available recent literature centered on implant patient‘s masticatory

efficiency was also searched, with the earlier approaches implemented for implant

success evaluations found to be mainly questionnaires focused on assessing the chewing

efficiency of patients, both prior to and following treatment. However, research carried

out later on utilised other techniques, such as dietary selection, occlusal perception, and

numerous innovative approaches utilizing custom-made equipment in order to monitor

changes in jaw movement and bite force. The researcher subsequently drew the

conclusion that newer approaches were valuable within the field of prosthodontics

including bite force evaluation.

Bakke et al (2002)46

investigated patient‘s satisfaction with implant-supported

over-dentures and masticatory efficiency as the two areas with the use of bite force as a

variable within the assessment. As a result, research stated that implant-supported over-

dentures had the capacity to improve maximum bite force and the subsequent chewing

ability. In this same vein, Rismanchian et al (2009)40

noted that the utilisation of bite

force evaluation acted as a guide for implant effects in terms of enhancing chewing

efficiency and thus patient satisfaction of the treatment outcome.

Muller et al (2012)47

carried out a cross-sectional multi-center research with the

aim of assessing the differences between bite force and chewing efficiency across a

sample of edentulous patients with varying degrees of implant-supported prosthesis. One

of the approaches used for the evaluation was the recording of bilateral maximum bite

force. There is a tendency, especially in dental implantology, to utilize bite force

evaluation to assess treatment success and failure.

van der Bilt (2011)3 stated that there are numerous elements known to impact

masticatory performance, including age, bite force, gender, the loss and type of

restoration of post-canine teeth, malocclusion, total area of teeth in contact, oral motor

function, and salivary glands function .


20

Ow et al (1989)32

recognized bite force as being one of the essential elements

involved in the chewing function, and is regulated by the ―dental, muscular, nervous and

skeletal systems and exerted by the jaw elevator muscle‖.

Hatch et al (2001)9 highlighted that bite force has a strong link with masticatory

performance, although the effects of such are not recognized as being as strong as the

number of functional teeth.

Julien et al (1996)11

established that in addition to functional occlusal contact area

and body build, maximum bite force explained approximately 72% of the variation in

masticatory performance and efficiency among adults and children 212 primary school

children, and assessed and accordingly concluded the link between nutritional status and

decay prevalence. Obviously, a weight and body mass index was used as the measure to

suggest overall child health, with each child also interviewed.

Lepley et al (2011)48

conducted a prospective cross-sectional study, subsequently

highlighting that occlusion and maximum bite force respectively are the most important

factors impacting masticatory performance, as established through their sample

comprising 30 adults.

Rentes et al (2002)12

described chewing as a function that is developed and matures

with time through learning experiences; thus, it is seen to be a fundamental aspect of the

overall food intake process, with bite force further recognized as being a prominent

determinant of chewing function and efficiency, exerted by the jaw elevator muscles,

skeletal and dental systems. Accordingly, such systems status will have a significant

impact on the bite ability and subsequently on chewing performance.

Koc et al (2010)10

recognized bite force as one of the factors indicating the

masticatory system‘s functional state resulting from jaw elevator muscle action, modified

by cranio-mandibular biomechanics.

Ikebe et al (2005)13

widely supported that masticatory and chewing functions have

the capacity to impact dietary selection, which is notably linked with quality of life.

Krall et al (1998)14

and Teoh et al (2005)15

stated that gradual dentition

deterioration witnessed in adult patients is believed to be linked to the declining intake of

calories rich foods, carbohydrates, fibres, numerous vitamins and minerals, and protein


21

thus suggesting that a decreased intake of nutrients may result subsequent to lower

chewing performance, an observation equally supported by study done by English et al

(2002)16

.

Lucas et al (2002) 17

stated that the status of the mouth affects mastication and

swallowing. Such an issue might be more significant amongst young and growing

children than aging adults; accordingly, precautionary and curative dental measures

could ensure children‘s general and oral health to improve. It can be postulated that bite

force has a significant impact on mastication function which similarly has a notable

influence on the nutritional status on any individual.

van der Bilt (2011)3 stated that there are numerous elements known to impact

masticatory performance, including age, bite force, gender, the loss and type of

restoration of post-canine teeth, malocclusion, total area of teeth in contact, oral motor

function, and salivary glands function.

Lemos et al (2006)49

including various researches, recognised that bite force and

chewing performance both affect the development of masticatory function; therefore, it is

accepted that establishing such variables during times of development and growth, as

well as their respective links with dental arch morphologic characteristics, is

fundamental, which can be achieved by gathering comparative data to ascertain whether

or not such a system is progressing as it should. The link between chewing performance

and maximum bite force in children was investigated by Lemos and his colleagues who

took account of the morphologic characteristics of occlusion and body mass index. In

this study, 36 children, aged an average 9.06 years, formed the sample, with bite force

subsequently established as having a negative relationship with the chewing test material

particle size. Moreover, it was established through the regression analysis that the

equations explain 29%–38% of the variation in the particles as a result of the bite force

variable.

Ohira et al (2012)50

assessed masticatory performance and maximum bite force in

a sample comprising young Japanese children aged 4-6 years. The investigators

examined the overall effectiveness associated with a four-week chewing exercise, and

how such an approach could enhance mastication performance through bite force. There


22

were no statistically significant differences between the maximum bite force and

masticatory performance in both study and control groups at base line. However, there

was a significant increase in bite force as well as mastication efficiency in the chewing

exercise group. In addition to this finding, Ohira and colleagues confirmed a close

association of the maximum bite force and mastication performance.

Shiere and Manly (1952)51

; Agerberg et al (1981)52

and Julien et al (1996)11

have carried out numerous cross-sectional research studies in an attempt to evaluate the

age factor in respect to masticatory ability, with the latter found to improve with age.

More specifically, more remarkable improvements in masticatory performance are found

between individuals aged 12–15 years old, which may be rationalized through

considering the adolescent growth spurt, which is characterised by a prominent increase

in size of the body as well as an increase in total muscle mass as stated by Tanner

(1962)53

.

Barrera et al (2011)54

conducted a study and was unable to draw a sound

conclusion in terms of the link between mastication performance and gender.

Toro et al (2006)31

in this regard highlighted a negative finding, stating that there

were no statistically significant differences amongst boys and girls aged 6–15 in regard

to their capacity to masticate food; however, Julien et al (1996)11

emphasised that young

males demonstrated greater efficiency when masticating artificial food when compared

to females.

Fontijn-Tekamp et al (2000)55

; Okiyama et al (2003)56

and Lemos et al (2006)49

stated that a higher bite force is believed to induce greater chewing performance.

Okiyama et al (2003)56

acknowledged a number of other variables in addition to

muscle efficiency and force generated during mastication as being factors of chewing

performance such as the number and area of occlusal contacts, whereas Wilding

(1993)57

, Bourdiol and Mioche (2000)58

and Ownes et al (2002)59

included the level

and degree of lateral excursion throughout mastication also.

Koc et al (2010)7 said that the significant variation in the value of bite force

depends on various factors linked with the physiological and anatomical characteristics

of the subjects. He took into account age, with Shinogaya et al (2001)9 known to


23

maintain that the normal ageing process impacts the jaw muscle force in terms of

reduction.

Sonnesen and Bakke (2005)60

and Usui et al (2007)61

stated consensus that bite

force commonly increases with age until the individual is approximately 20 years old, at

which point there will be stabilization in bite force. However, upon reaching 40 years,

bite force begins to decrease.


investigated bite force in a sample of 8–68 year old males and

females, subsequently concluding that bite force increases with age until females are 25

years old and males are 45 years old, at which point a decline is experienced.


state that the recognised increase in bite force, which

has come to be linked with growth following their consideration of a sample aged 7–13

years, may be due to dental development in regard to increased dental eruption; thus,

with an increased number of erupted teeth, it is expected that there will be a greater bite

force.


measured bite force, contrasting masticatory efficiency in a

sample of 47 children and adults. Notably, the numerous variables in the group were

discussed, with the explanation subsequently provided that the contact areas in posterior

teeth in occlusion were strong determinants of masticatory performance. Furthermore, it

was found through regression analysis that individuals with greater contact areas

performed more efficiently than their counterparts of the same gender and body build but

with fewer contact areas. They also emphasised that the total available surface area

cannot be considered a strong indicator of contact area, with this same notion supported

earlier by Yukastas et al (1965)63

.

Usui et al (2007)49

reported a statistically significant difference in mean maximum

bite force between subgroups of their subjects according to age. This difference was seen

in both boys and girls, being largest between group one with mean age of 8.6 years and

group two with mean age of 10.8 years. The difference was much less when group two

was compared with group three who had a mean age of 13 years.

Su et al (2009)64

took a sample of 201 children in Taiwan, and found an increase

of mean maximum bite forces between those aged 6 years and those aged 4 years.


24

Mountain et al. (2011)13

examined bite force in primary dentition in the UK and

discussed the numerous influences, subsequently highlighting no strong link between age

and maximum bite force when considering their samples of children aged 3–6 years.

This conclusion suggests that bite force can be enhanced by the effect of stage of

eruption and body growth—not solely chronological age.


; Shinogaya et al (2001)9

and Koc et al (2010)7 said that

larger bite force in males may be due to greater muscular potential.

Pizolato et al (2007)65

stated anatomical variables—namely greater masseter

muscle fiber diameters have also been found, and may be explained in regard to gender

differences. Furthermore, it is also paramount to acknowledge that gender differences are

not clear amongst children, i.e. in pre-pubescent individuals.

Koc et al (2010)7 said that the link between gender and bite force may become

clear when considering samples aged 18 years and older.

Shinogaya et al (2001)9

acknowledged that another contributing factor may be

tooth size between genders. In the case of young children, bite force changes as a result

of gender remains inconclusive.

Tsai and Sun (2004)66

who examined the maximum bite force amongst a sample of

463 Taiwanese children aged 9–12 years, subsequently recognising that the values were

significantly higher in males than females.

Mountain et al (2011)13

took a sample of younger children aged 3–6 years reported

a mean maximum bite force of 203.90 N in males and 186.19 in females, which supports

the recognition that there is a difference, although, at the 0.05 level, it was not considered

to be significant. Accordingly, it was stated by the authors that gender influence on bite

force is not apparent clearly in the case of young children.

Su et al (2009)64

stated that gender differences in regard to maximum bite force are

not statistically significant, with the investigators stating this following a sample of 201

children aged 4–6 years being studied, with bite forces only marginally higher in boys.

In this same vein, it has been reported by Kamegai et al (2005)67

that greater bite

forces were found amongst Japanese girls aged 3–5 years old than their male

counterparts but this was not significant statistically.


25


however, found no difference amongst genders; who took a

sample of 30 children in the primary dentition stage and therefore their results were

pooled.


acknowledged that there is a positive association of height and

weight known to be linked with maximum bite forces and noted that the majority of

research studies have not examined the effects of body variables, with the samples

commonly comprising subjects of different ages and genders, therefore resulting in

exaggerated variations and limited results interpretation.


established a positive link between maximum voluntary

bite force and child‘s (3–6 years old) weight; which is believed to contribute 6.9% of the

recorded bite forces variation.

Lemos et al (2006)49

acknowledged similar findings with their study explaining

17% of the recorded bite force variability in their sample of 9.06 mean age children.

Moreover, although the same was found by Linderholm et al (1971)68

, the link was

stated as weak.


reported similar positive correlation of bite force and body

build. This was proved by correlation coefficients of (r = 0.24) for bite force and weight,

and (r = 0.23) for bite force and height.

Su et al (2009)64

used regression analysis to test the association of maximum bite

force in 201 preschool children with a number of variables including height and weight.

No significant association was reported between bite force and either height or weight of

the child.

Toro et al (2006)31

reported a dramatic increase in bite force with increase in body

size and was clearer when comparing children at 10 years old with 11 years old, which is

the stage of ―pubertal growth spurt. It can be interpreted as an increase in body

variables (Weight/Height) means greater muscle mass and therefore greater bite force

magnitudes.

Sonnesen et al ( 2001)20

; Gaviao et al (2007)69

and Castelo et al (2007)12

postulated that malocclusion presence negatively impacts the amount of occlusal

contacts, subsequently causing lower bite force when contrasted alongside bite forces in


26

cases of normal occlusion. Notably, there are not always statistical differences in the bite

force of children with malocclusion and those with normal occlusion. Thus, it should be

noted that researches considering occlusion in the case of children are limited as the

majority have examined the impacts of such in adults and older children.


found that there were lower mean bite forces in children

with primary dentition malocclusion (194.2 N) when compared with those of normal

primary occlusion (197.10 N), although this difference was not statistically significant.

Castelo et al (2010)70

examined maximum bite force and its link with facial

morphology by taking a sample of 67 young children aged 3.5–7 years, all of whom had

posterior crossbite. It was stated through the conduction of univariate analyses in the

mixed dentition stage that the subjects found to have lower bite forces were markedly

more vulnerable to exhibit posterior crossbite, although this could not be recognised as

an indicator for the presence of crossbite as multiple logistic levels did not illustrate

significant levels. It was further emphasised that bite forces in mixed-dentition children

with posterior crossbite were markedly lower when compared against those with normal

mixed dentition occlusion. They further added that such a difference was due to

differences in masticatory cycle duration, length of lateral excursions, combined with

impaired muscles function. It is recognised that all of these elements may result in

neuromuscular adaptation so as to avoid any tooth interferences.


established bite force in 30 primary dentition children, with

the sample split amongst three subgroups according to occlusion (normal occlusion,

crossbite and open bite), with the authors subsequently highlighting that there were no

prominent influences of malocclusion on bite force.

Kiliaridis et al (1993)71

similarly carried out a cross-sectional research with a

sample of 136 subjects divided into subgroups, with a total age range of 7–24 years.


stated parallel findings in a group of 7–13 year old

children, remarking that occlusion Angle‘s classification does not impact the levels of

bite force, although they do recognize that the lower bite force values were found

amongst individuals experiencing class III malocclusion. This was supported by Lemos


27

et al (2006)49

, who stated that the occlusion variable in their 36 subject sample was not

found to impact bite force magnitude.

Kamegai et al (2005)67

in contrast, examined bite force across a large sample of

Japanese subjects with occlusion examined, amongst other variables, and participants

classified in relation to the presence of normal occlusion, protrusion of the maxilla,

crowded arches, crossbite, or open bite. In both genders, bite force was found to reduce

with the presence of any category of malocclusion. Furthermore, statistical significance

as a result of the negative impact of malocclusion was found in children over 9 years,

with the researchers further stating that bite force had a positive correlation with normal

occlusion.

Toro et al (2006)31

took this into account in regard to the ability to break food. It

was suggested that malocclusion was known to reduce masticatory performance,

although such an effect was recognised as being relatively minor.

Koc et al (2010)7 stated that cranio-facial morphology description includes the

ratio between anterior and posterior facial heights, inclination of the mandible, and

gonial angle. The researchers further added that maximum bite force suggests the

―mandible‘s lever system‘s geometry.

Sonnesen et al (2001)20

examined bite force, TMD and facial morphology

across a sample of pre-orthodontic children aged 7–13 years. It was established through

their exploratory research studies that there was the presence of an association between

muscles tenderness, long face and lower maximum bite forces, although such a link was

recognised as being low to moderate.

Proffit et al (1983)72

showed a link between facial vertical morphology and bite

force low magnitude, in addition to weaker mandibular elevator muscles Particularly,

however, it should be recognised that the link was highlighted in studies with adults.


examined bite force, the presence of posterior crossbite and

facial morphology in regard to a sample of 67 children aged 3.5–7years, with this


28

examination establishing no valuable link between maximum bite force and facial

morphology.

Kiliaridis et al (1993)71

studied the link between bite force magnitude and facial

morphology in the case of 136 individuals aged 7–24, with subject‘s facial morphology

determined through assessing different variables from standardized photographs.

Markedly, only slight positive links were established between incisor maximum bite

force and upper facial height/lower facial height ratio.

The work of Sonnesen and Bakke (2005)60

highlights the presence of a link

between bite force and cranio-facial morphology, but only in the case of males aged 7–

13. As such, the most fundamental of considerations in regard to craniofacial

morphology impacting boy‘s bite force was the vertical jaw relationship. Thus, it can be

stated that males with a shorter, lower facial height demonstrated a greater degree of

force in bite.

Usui et al (2007)61

established a strong link between the mandibular plane angle

and maximum bite force amongst certain subgroups within their subject sample, namely

those aged 8.5–10.5 years. In conclusion, it was stated that a greater bite force was

established through a more acute mandibular plane angle, with the opposite similarly

true.

Braun et al (1995)73

and Barrera et al (2011)54

stated that there is also an effect

demonstrated through maxillo-facial growth. In this regard, it is believed that variation in

maximum bite force magnitude is witnessed following changes in the cranio-facial

growth, which complements normal growth process in addition to the growth of

masticatory muscles.


considered the link between occlusal contacts, masticatory

muscles thickness and bite force values by taking a sample of 46 child subjects, each of

whom was assigned to a group in regard to the dentition stage and their occlusion. The

researchers highlighted a strong positive link between thickness of the masseter muscle

and maximum bite force amongst children with normal occlusion.


29

Shinogaya et al (2001)9 conducted one research study examining ethnicity in

regard to maximum bite force by taking a sample of 46 participants and dividing them

according to ethnicity Danish (Caucasians), Japanese (Asians), with age and gender also

taken into account. The authors subsequently found no significant link. It must be

mentioned that amongst their inclusion criteria was the absence of dental fillings or

disease including malocclusion. Therefore, they were comparing two ethnic groups with

comparable dental status.

Mountain (2008)75

in a PhD thesis, did analyse ethnicity effects, with a

statistically negative correlation (r = - 0.17, p < 0.01) for Asian origin and maximum bite

force in young children. In contrast, there was a positive statistically significant link

between individuals of black origin and maximum bite force (r = .12, p < 0.05).

Pizolato et al (2007)65

state that there is a negative impact of TMJ disorders and

muscles pain on bite force recorded values. Likewise, the same link was acknowledged

by Kogawa et al (2006)19

, although Pereira et al (2007)15

reports illustrate no

significant impact as a result of TMD on bite force. These differences in reported results

could be attributed to variation in recording techniques as well as variation in severity of

TMD cases studied in different studies.

Alkan et al (2006)18

drew a comparison between participants with healthy

periodontal tissues with those with chronic periodontitis, considering bite force. The

authors underlined a remarkable relationship between bite force and periodontium health,

with a significantly higher bite force amongst healthy subjects than those with

periodontitis.

Williams et al (1987)76

recognised that there will be an effect on the

mechanoreceptors function where periodontal support is found to be lower owing to

disease impacting the periodontium.

Kampe et al (1987)77

examined bite force magnitude and occlusal perception with

a sample of 29 young adults aged 16–18, some with and some without dental fillings.

The sample was divided into intact dentition group and fillings group. It is acknowledged

that the fillings were mainly minor posterior teeth restorations. Accordingly, the mean

maximum bite force values for intact dentition group were found to be 532 N, while the

recorded mean for participants in the dental fillings group was 516 N. Notably, however,

such differences were not considered to be statistically significant, although it was


30

recognised as valuable that subjects with intact dentition had a notably greater anterior

bite force when contrasted with mean values in the fillings group.

Helkimo et al (1976)78

assessed the link between the state of dentition and bite

force by taking a sample of 125 individuals aged 15–65 years. For the entire sample, the

maximal bite forces range was 10–73 Kg, with the authors highlighting that the presence

of a decline in bite force values was found to be in line with increasing age, particularly

in the case of females, with the further statement that a variation in bite force value could

be linked with dental condition differences amongst participants. It was further

concluded that bite force magnitude may be as much as five times greater in younger

people with natural dentition when contrasted alongside older denture wearers.

Shiau and Wang (1993)79

examined the impacts of dental status on bite force and

hand strength on primary, middle and high school students, with the investigators

subsequently establishing that those with extracted and carious teeth were more likely to

illustrate a lower bite force value, although bite force was notably unaffected by hand

force. Thus, the conclusion was drawn that there does not seem to be a link between

hand strength and bite force; rather, bite force is linked with dental condition.


stated that the maximum bite force exerted by primary

dentition children can be predicted by the number of decayed, missing and filled teeth

surfaces. In this regard, it was noted that a significant negative relationship between dmfs

and maximum bite force suggested that a child with deteriorated dentition was

potentially more likely to demonstrate weaker bite forces when contrasted with a child

with a healthy, normal dentition. The author emphasised that bite force at the primary

stage of dentition development may ultimately depend on caries prevalence.

Su et al (2009)64

focused on the oral condition and its influence on bite force

magnitude in preschool children. There results were interesting in that they could not

detect any obvious association between number of carious teeth, number of fillings,

occlusion and the bite force value. However, a positive significant relationship between

bite force and number of posterior teeth in contact was reported. They further added that

regression analysis failed to demonstrate significant association of bite force with any of

the factors except age of the child, maximum mouth opening and number of teeth in

contact.


31

It is essential to note that in this study, investigators used the dmft index (number

of decayed, missing, filled, teeth) and not dmfs (number of decayed, missing, filled

surfaces) which could be the reason why its value (that is normally smaller than dmfs)

showed no effect on the recorded bite force.

The authors reported that although the total dmft was not correlated with the bite

force, there was however a negative relationship between the number of missing teeth

and the recorded bite force. This finding was interpreted as suggestive that teeth were

crucial for proper mastication in this stage of dentition. The authors suggested that as

their results failed to demonstrate bite force-caries association, then this correlation was

possibly more important when we describe the severity of tooth decay rather than

number of carious teeth.

Using the dmfs index (decayed, missing, filled surfaces) greater accuracy in

describing the caries severity will be obtained. Subsequently Su and colleagues

suggested that dmfs should be considered in future research studies.

Tsai (2004)66

carried out an investigation, who took a sample of 676 Taiwanese

children aged 3–5 years with the objective to establish maximum bite force. In this study,

a custom bite force gauge was utilised in order to assess bite force, which was recorded

in kilograms. Markedly, the study established that maximum bite force ranged between

15 and 18Kg, which was equivalent to between 147 and 176 N. As predicted, a clear link

between the number of carious teeth and plaque index was found. Furthermore—and

potentially more importantly—he found a negative link between the number of decayed

teeth and maximum bite force.

As well as the periodontal feedback reflex, central states, e.g., the fear of pain as a

result of dental decay may also be an important factor in muscle force reduction with the

research of Tsai providing support for the belief that the presence of decayed teeth

negatively impacts health and the overall efficiency of mastication system.

Linderholm and Wennstrom (1970)61

stated that one factor potentially responsible

for low bite force is pain owing to the fact that carious teeth can cause high levels of

pain, particularly when the disease is advanced. This then weakens bite strength. In this

regard, it is also noted that a greater value of dmfs/dmft goes hand-in-hand with a lower

level of bite force, which provides a statistically significant negative link.


32

Olthoff et al (2007)80

stated that an increase in the vertical dimension can result in

variations in the orofacial morphology. Subsequently, masticatory system and bite force

values are also affected.

Koc et al (2010)7 and several studies conducted reported that the degree of jaw

separation influenced the bite force and the mean jaw separation for populations at which

bite forces are recorded ranged from 14–20 mm.

Tortopidis et al (1998)81

said that when considering factors affecting bite force

recognised that the position at which the recording device is placed within the oral cavity

differs. Commonly, stronger bite forces are normally recognised in the dental arch‗s

posterior region, as has been acknowledged through two different theories. First and

foremost, the mechanical lever system of the jaw; and secondly, posterior teeth

(premolars and molars) are able to withstand greater forces than anteriors.

Usui et al (2007)61

highlighted that repetitive recording can results in a reduced bite

force as a direct consequence of muscle fatigue. In bite force investigations, the number

of recordings necessary should be determined whilst considering the reliability factor and

importantly avoiding fatigue that will result in reducing bite force magnitude.

Koc et al (2010)7 stated that establishing bite force in the context of clinical

practice is carried out in order to assess dental prosthesis and to accordingly determine

the overall success of rehabilitation in the case of adults. Furthermore, such calculations

are also geared towards obtaining bite force reference ranges in an attempt to guide

prosthetic device and implant design. One such example is that of the spring device,

which utilizes compression forces in order to document bite force; there is also the more

advanced foil transducer, which relies on the piezo-electric principle.

Fernandes et al (2003)82

quotes that the majority of modern designs utilize

electrical resistance strain gages Overall, the majority of recording tools concerned with

bite force have the potential to record forces between 0 and 800 N at a rate of 80%

precision and accuracy amounting to 10 N.

Ortug (2002)83

quotes that Borelli 1681 was one of the first to consider instruments

able to assess intra-oral forces, with the subsequent design of the gnathodynamometer;

this was concerned with measuring bite force. Furthermore, in 1893, the redesign and

modification of the tool was carried out by Black.


33


; Lemos et al (2006)49

and Castelo et al (2010)84

used a

pressurised rubber tube as a bite force device that must be connected to a sensor element

(Pressure sensor MPX 5700 Motorola) There is the need to connect the system to the

computer and software so as to enable pressure reading and thus establishing the values

in Psi. However, the disadvantage that the Psi must then be converted to N, taking into

consideration the tube area due to the fact that force equals pressure multiplied by area,

which would markedly impact the easiness such as utilisation and thus make it less

practical. In addition, there is also the need to connect to a computer, and so it may be

recognised that the device is not portable.

Another recording system utilised in the context of bite force is ―dental prescale

system‖, which comprises a horse-shoe shaped bite foil made from a pressure-sensitive

film, and further includes a computerised scanning system, which is able to analyse the

applied forces. Upon the application of force to the occlusal surfaces, a graded colour

will result from a chemical reaction. Koc et al (2010)7 stated that the exposed pressure-

sensitive foils are analysed in the occlusal scanner which reads the area and colour

intensity of the red dots to assess occlusal contact area and pressure, with occlusal load

automatically analysed.

Shinogaya et al (2000)85

assessed bite force with the use of dental prescale system,

stating that it has the benefit of measuring bite forces at inter-cuspal position, and

accordingly delivering prediction of bite forces under natural conditions. Moreover, the

force distribution can also be assessed simultaneously, although there is a technical

limitation in terms of the computerised scanning apparatus, as highlighted previously.

Another commercially available and highly sophisticated tool is the ‘Tekscan’86

,

which has been utilised in research centered on occlusal analysis studies, as occlusal

indicators by Kerstein (1999)87

; Kerstein (2001)88

; Mahoney (2004)89

and Garg

(2007)90

in implantology ,aesthetic dentistry, as well as temporomandibular disorders.

However, the costs of utilizing the tool need to be taken into account as they are known

to be very costly.

In the present review, we have gathered insights into how bite force has been shown

to be affected by a number of physiological and morphological variables. Other

variables, such as state of dentition, instrumentation design and transducer position


34

related to dental arch, malocclusions, signs and symptoms of temporomandibular

disorders; size, composition and mechanical advantage of jaw-closing muscles, may also

influence the values found for bite force.

…………………………………………………

MATERIALS AND

METHODS

Materials and Methods

35

MATERIALS AND METHODS

1. STUDY AREA:

Department of Pedodontics & Preventive Dentistry, Guru Nanak Institute of

Dental Science & Research, Kolkata and two randomly selected schools in

Kolkata (Agrasain Boys’ School and Agrasain Balika Siksha Sadan).

2. STUDY POPULATION:

6-14 years old children were included in the present study.

3. STUDY PERIOD:

The study was performed during the period from January 2013 to March

2014.

4. SAMPLE SIZE:

A total of 421 children (210 male and 211 female) were included for the

present study as study sample.

5. SAMPLE DESIGN :

Children coming to outpatient Department of Pedodontics & Preventive

Dentistry, Guru Nanak Institute of Dental Science & Research, Kolkata and

children studying in two selected schools in Kolkata were chosen randomly as

study sample.

They were further divided in subgroups according to age, sex and dentition

stage:


36

Group I- Male

Subgroup- 6-8 years

9-11 years

12-14 years

Group II- Female

Subgroup- 6-8 years

9-11 years

12-14 years

The subjects were divided into three subgroups according to their dentition stage as

the following:

Subgroup 1: 6-8 years: Early mixed dentition stage

This group included children after the eruption of permanent first

molars and

lower incisors and before eruption of permanent lower canines and premolars.

Subgroup 2: 9-11 years: Late mixed dentition stage

This group included children after the eruption of permanent teeth except for

second premolars and or upper permanent canines.

Subgroup 3: 12-14 years: Permanent dentition stage

This group included children after the complete eruption of permanent teeth

excluding third molars.


37

The study sample was again further divided into two groups of Case and Control.

Case sample from each group comprised of children with caries affected dental status

whereas Control sample had children with caries free dental status.

Each dentition stage had 140 children as total study sample except 6-8 years where

141 study sample were present .140 children were again divided into Case and Control

consisting of 35 male and 35 female respectively except 6-8 years where 36 female

were present in Case group.

CRITERIA FOR SAMPLE SELECTION:

Inclusion Criteria:

Children between age group 6-14 years.

Children of Bengalee ethnic group.

Children having Bengali as mother tongue.

Children’s family should have resided in West Bengal since two prior

generations.

Children without any history of previous orthodontic treatment of any kind.

Children who are cooperative and agree to participate in the study.

Exclusion Criteria:

Medically, physically, mentally compromised children.

Children having any signs or symptoms of TMJ dysfunction.

Children having any neurologic disorder.

Children with facial swelling or dental abscess.

Children with any severe pathology or developmental defect of oro-facial region.


38

Absence of two opposing permanent molars and incisors in specific age group.

6. STUDY DESIGN:

The approval by the Ethical Committee for conducting the study was obtained.

The study area was selected which included outpatient Department of Pedodontics &

Preventive Dentistry, Guru Nanak Institute of Dental Science & Research, Kolkata and

two randomly selected schools in Kolkata from the list of schools available on the

internet. Sample was selected from the study area. Immediately prior to data collection,

careful checks were carried out by the examiner in order to ascertain whether the child

assented or dissented to study participation. In this research, informed consent was

obtained from the parent or guardian well as selected school’s authority for every

participant using a standard consent form both in English and Bengali (Appendix). The

child’s assent to participate was secured using developmentally appropriate methods,

which took the form of a specifically designed story board, which takes the child through

the study process, phase by phase, and describes all that is involved.

In order to ensure that both parental information sheet and story board are clear,

appropriate and acceptable to research participants, they were assessed by approaching

families (not involved in the research) and asking them to evaluate the material and

suggest if any further clarifications or amendments were required.

For all of the participants involved in the study, screening was done under the

following:

a) General examination

b) Extraoral examination

c) Intraoral examination


39

After the following examinations, bite force of the each individual was recorded.

7. PARAMETERS OF THE STUDY:

Age and sex

Height and weight

Body mass index: BMI was calculated as weight (kg)/height^2 (m) and an age-

and sex-specific BMI reference for children aged 2 - 20 year by Kuczmarski et

al (2002)34

had been followed. Children were categorized as Underweight(less

than the 5th percentile); Normal (5th percentile to less than the 85th percentile);

Overweight (85th to less than the 95th percentile); Obese (equal to or greater

than the 95th percentile).

Occlusal pattern: For the occlusal pattern, three classes were defined based on

occlusal anterior - posterior relationships. Class I molar relation where

mesiobuccal cusp of the upper received in the sulcus between the mesial and

distal buccal cusps of the lower molar. Class II molar relation where the

distobuccal cusp of the upper permanent molar fits in the sulcus between the

mesial and the middle cusp of the lower 1st molar. Class III molar relation

where the buccal cusp of the upper 2nd premolar fits into the sulcus between the

mesiobuccal and the middle cusp of the lower 1st molar.

Vertical occlusal relationship: Three types of overbite were classified for the

vertical occlusal relationship, according to the upper and lower incisors’

occlusion: normal, deep, and open. A normal bite is defined as the vertical

overlap not extending beyond half of the clinical crown length of the lower

incisor during biting .A deep bite is defined as the vertical overlap of the anterior

teeth extending beyond more than half of the clinical crown of the lower incisor

during biting. An open bite is defined as there being no vertical overlap or there


40

being a gap between the upper and lower incisors during biting. Bite performed

and measured with the fine lead pencil, divider and calibrated scale in mm. It was

measured by asking the subject to bite in in maximum intercuspation, then using

a fine lead pencil to mark where incisal edges of upper incisor occludes over

lower incisor; two ends of divider on scale was measured to find how far the

pencil mark is from incisal edge of lower incisor.

Maximum mouth opening: - It was performed and measured with the help of a of

divider; graduated scale in mm. The two end of divider was used to measure

interincisal distance between upper and lower right Central incisors (CI), while

the mouth was maximally opened. Value was read off on a graduated scale in

mm. In absence of CI, Lateral Incisors were used for measurement.

Number of maxillary posterior teeth in contact (MPTC):- It was determined with

articulating paper. Primary and 1st permanent molars on both sides were used for

measurement of number of maxillary posterior teeth in contact. Articulating

paper was used to measure the number of upper and lower molars in contact. An

upper and lower molar in contact were defined as one pair, with a maximum of

six pairs. The children of each group were categorized into following division-

Division I (0-2 pairs); Division II (3-4 pairs); Division III (5-6 pairs).

Number of tooth decay; tooth filling; missing teeth and tooth surface decay; tooth

surface filled; missing tooth surface :According to WHO’s recommendation, for

primary tooth dmft and dmfs index were used and for permanent tooth DMFT

and DMFS indices were used. Diagnosis was done with the help of mouth mirror

and a sharped sickle shaped explorer. Children were categorized as follows:

DMFT scoring scale: Low Caries status (Score 1 to 4); Medium Caries status

(Score 5 to 9); High Caries Status (Score > 9)

DMFS scoring scale: Low Caries status (Score 1 to 16); Medium Caries

status (Score 17 to 40); High Caries Status (Score > 40)


41

Dietary habits: - It was inferred on the basis of prepared questionnaire developed

to examine the pattern (hard/soft) of food intake. Answer of the subject was by

their parents or caregivers with/without the help of the interviewer. Children were

categorized under hard and soft food consistency on the basis of frequency of

servings of each meal group determined by the questionnaire for 5 days diet

diary.

Children having more than 15 serving in a week of milk group; fruit group

(juice); fat and sweets group were considered as having soft consistency food

habits. Children having more than 15 serving in a week of vegetable group; grain

group; fruit group (raw); meat group were considered as having hard

consistency food habits.

8. STUDY ARMAMENTARIUM:

Portable height scale.

Weighing machine

Adequate light source

Sterilised mouth mirror

Sterilized sharp, sickle shaped explorer, tweezers

Gloves , mouth mask , drape

Divider

Scale graduated in millimeter

Articulating paper

Fine lead pencil

Unsupported chair.

Latex finger cot


42

Consent form

Data collection proforma

Bite force meter (gnathodynamometer)

9. STUDY TECHNIQUE:

The examinations were conducted in the clinics of the Department of

Pedodontics & Preventive Dentistry, Guru Nanak Institute of Dental Science &

Research, Kolkata and two selected schools in Kolkata. The measurements and data

recorded was performed by a single examiner. The subjects were made to undergo the

following procedure:

General examination:

Height and weight anthropometric measurements were recorded with the use of

portable weight and height scales. The measurements were taken in an attempt to assess

the body build and body variables’ influence and to be analysed alongside each

participant’s bite force value. Each child was asked to stand against the measuring scale,

their back straight and feet aligned with the foot positioner. Body Mass Index (BMI) was

then calculated in consideration of the weight and height measurements by a known

formula which is: (BMI= Weight/Height2).Baseline data were gathered regarding the

children’s gender and age.

Extraoral examination:

Questions regarding the presence of dental pain as well as abscesses or recent

facial swelling were queried, with the data subsequently recorded. The side of pain or

swelling, if present, was also recorded. Children were excluded from study if found with

positive history of dental pain, abscess or recent facial swelling.


43

Intraoral examination:

Dental examination was carried out using disposable dental examination kits

(mouth mirror and explorer) by the investigator, noting missing, present teeth, as well as

any signs of dental abscess. The examination of children coming to outpatient

department was performed on dental chair whereas in school the examination of children

was done on a chair under artificial light. Caries experience at both tooth and surface

levels were determined in accordance with the WHO criteria (WHO, 1997). In order to

quantify the level of caries in each child, the dmft/dmfs for primary teeth and

DMFT/DMFS for permanent teeth indices (decayed, missing and filled teeth- decayed,

missing and filled surfaces respectively) were calculated. Molar relationship, maximum

mouth opening, number of maxillary posterior teeth in contact and pattern of bite were

also noted. The presence and category of any malocclusion was recorded. Information

regarding dietary habits was recorded with the help of participating child’s parents or

caregivers.

At this stage, children were excluded from the study if they were found to have

missing teeth in areas where the bite force was to be recorded. All data collected were

recorded in a specifically designed data collection proforma. Following this, bite force

measurement of each individual was performed.

To reduce the error and bias in the study single operator/examiner has filled the

proforma and recorded the bite force in all selected children.

Bite Force Measurement Procedure:

Bite force was measured by a digital bite force meter (Scope bite force meter)

adapted for oral conditions.. This appliance, an instrument for measuring force, uses

electronic technology and comprises a bite plate and digital body. The appliance presents

a scale in kg, a button for ‘set zero’ The ‘set zero’ allows the values obtained to be

accurately controlled. Bite force measurement procedure was done in accordance with

the procedure adopted by Mountain, 2008. Before recording the bite force, the


44

individuals were seated in upright position and previously trained to perform their

strongest bite over the device. The bite force meter’s (gnathodynamometer) bite plate

was covered with a latex finger cot to protect the individuals against contamination.

The specifications of this device are:

a- Force range: 0 –300 kg.[1Kg=9.8N]

b- Accuracy: ±1kg.

c- Size: 9.5 (Length) x 8 (Width) x 3.2 inches (Height) inches for display body and

6 (Length) x 1.6 (Width) x 2 inches (Height) inches for bite plate.

Each of the children was seated in an unsupported chair. Their body and head were

kept in a natural, upright position, ensuring the Frankfort plane was positioned parallel to

the floor. Subsequently, each of the children were asked to carry out a maximum

voluntary comfortable bite force (MVCBF), lasting 2–3 seconds, at two different

locations (right posterior and left posterior) within the dental arch, with each recording

accompanied by a 5-seconds interval.

The bite plate protective ends were positioned correspondingly with the occlusal

surfaces, right first permanent molar and left first permanent molar. For each of the two

positions, the peak bite force was measured and accordingly recorded, with each

participant’s highest of the three taken as the maximum voluntary comfortable bite force.

Children with dental complication screened during examination procedure were

referred for necessary dental treatment. Study sample from both study area was educated

and made aware about importance of oral hygiene maintenance by short lecture,

demonstration and power point presentation.

10. APPROVAL BY THE ETHICAL COMMITTEE:

The study design and technique was placed before the ethical committee and the

permission to carry out the work was obtained and the study was conducted accordingly.


45

11. ANALYSIS OF DATA

Statistical Analysis was performed with help of Epi Info (TM) 3.5.3. Descriptive

statistical analysis was performed to calculate the means with corresponding standard

deviations (s.d). Also One Way Analysis of variance (ANOVA) followed by Tukey’s

Test was performed with the help of Critical Difference (CD) or Least Significant

Difference (LSD) at 5% and 1% level of significance to compare the mean values.

Pearson Correlation Co-efficient for quantitative data and Spearman Correlation Co-

efficient for qualitative data were calculated to find the correlation and t-test was used to

find the significance level of the correlations. Chi-square ( 2 ) test was performed to find

the associations. p≤0.05 was taken to be statistically significant.


46

z

Study area selected

Dept. of

Pedodontics &

Preventive

dentistry

Schools

Intraoral

examination

Extraoral

examination

Study sample selected

Approval of

ethical committee

obtained

OP, VOR,

MPTC,

MMO,

dmft/DMFT

&

dmfs/DMFS

recorded

General

examination

Ht. and wt.

measured;

BMI

calculated,

Diet diary

recorded

Stastically analysis of data

Bite force recorded

Children with facial swelling, dental

abscess excluded

Results

FIG.8: Flow chart for study design


47

FIG.9: STUDY AREA

Above: Dept. of Pedodontics & Preventive Dentistry

Below: Two schools


48

FIG.10: STUDY SAMPLE

Above: Dept. of Pedodontics & Preventive Dentistry

Below: Schools


49

FIG.11: Study armamentarium


50

FIG.12: Above : Height measured with portable scales

Below: Weight measured with portable scales


51

FIG.13: Examination conducted

FIG.14: MMO measured (cm) MPTC recorded (pairs)


52

FIG.15: Bite force measured with the bite plate

covered with latex cot

FIG.16: Bite force value displayed

RESULTS AND

OBSERVATIONS

Results & observations

53

RESULTS

In the present study 421 Bengalee children between 6-14 years of age were selected for the

assessment of bite force and its correlation with different variables.

Distribution of study sample based on age, sex, dentition stage and dental status is

depicted in

Table1.

Table1. Distribution of the study sample by age, sex, dentition stage and dental status.

Age Dentition

stage

Case

(caries affected)

Control

(caries free)

Total

Male

Female

Male

Female

6-8

years

Early mixed

dentition stage

35

36

35

35

141

9-11

years

Late mixed

dentition stage

35

35

35

35

140

12-14

years

Permanent

dentition stage

35

35

35

35

140


54

FIG. 17: Distribution of the study sample by age, sex and dentition stage

FIG.18: Distribution of the study sample by dental status


55

From the distribution Table.1 it is apparent that 49.8% were male children and 50.2% were

female children out of total samples.

About 16.63% of all male children were 6-8 years of age.

About16.63% of all male children were 9-11years of age.

About16.63% of all male children were 12-14 years of age.

About 16.86% of all female children were 6-8 years of age.



About 33.49% of all total samples were 6-8 years of age.



Mean values, standard deviation, significant differences of eleven variables between male

and female subjects of Case and Control for three age and dentition groups as well as their

correlations with MVBF are listed in tables 2-4 and 5-7 respectively.


56

Table 2: Comparison of Variables for the age group 6-8 years

Variables Case

(n=71)

Control

(n=70)

ANOVA F-

Value with

p-value

/ Chi-

square(2 )

/ t-test

CD5 CD1

Male

(n=35)

Female

(n=36)

Male

(n=35)

Female

(n=35)

Body Height (in

cm)

Mean ±s.d

122.32±7.37 121.22±7.41 125.53±5.31 121.10±8.97 F3,136 = 1.44 p=0.531

11.87 17.60

Body Weight (in

kg)

Mean ±s.d

24.10 ±4.38 23.98 ±4.28 26.25 ±3.90 22.60±4.52 F3,136 = 2.84 p=0.032*

9.18 12.74

BMI (in

kg/m2)

Mean ±s.d

15.95 ±2.26 16.31 ±2.28 16.66 ±2.21 15.27 ±1.35 F3,136 = 1.98

p=0.621

5.97 7.75

Under Weight

(<18.5)

31 (86.6%) 33(91.66 %) 8(22.85.%) 10(28.57%) 2 = 2.83

p=0.525

Normal

(18.5-25)

4(11.4%) 2(5.55 %) 24(68.57%) 25(71.42%)

Over

Weight (25-

30)

0(0.0%) 1(2.77 %) 3(8.57%) 0(0.0%)

Obese (>30) 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%)

Occlusal Pattern

Class-I (1) 29(82.9%) 26(72.22 %) 22(62.85%) 19 (54.28%) 2 =2.98

p=0.913

Class-II (2) 5(14.3%) 9(25 %) 13(37.14 %) 14(40%)

Class-III (3) 1(2.9%) 1(2.77 %) 0(0.0%) 2(5.71%)

Vertical Occlusal relationship

Normal Bite

(1)

27(77.1%) 27 (74.3%) 31(88.57%) 21(60 %) 2 =2.18

p=0.314

Deep Bite (2)

6(17.1%) 7(20%) 4(11.42%) 12(34.28%)

Open Bite

(3)

2(5.7%) 2(5.7%) 0(0.0%) 2(5.71%)

Maxillary Posterior Teeth in contact (pairs)

0-2 9(25.7%) 10 (27.7%) 10(.28.6%) 14 (40%) 2 =11.79

p=0.0014*

3-4 12(34.3%) 10(27.7%) 13(37.14%) 18(51.42%)

5-6 14(40.0%) 16 (44.4%) 12(34.28%) 3(8.57%)

Food Consistency

Hard-1 17 (48.6%) 21(33.58.%) 25(71.42%) 24(68.57%) 2 =12.74

p=0.031*

Soft-2 18(51.4%) 15 (41.66%) 10(28.57%) 9(25.71%) 2 =11.29

p=0.0013*


57

Table 2: Comparison of Variables for the age group 6-8 years (cont.)

Variables Case

(n=71)

Control

(n=70)

ANOVA F-

Value with

p-value

/ Chi-

square(2 )

/ t-test

CD5 CD1

Male

(n=35)

Female

(n=36)

Male

(n=35)

Female

(n=35)

Caries

Prevalence

(dmft; DMFT)

2.78±1.45 3.80 ±2.78 t68=2.04

p=0.043*

Low 12(34.28%) 13(36.11%) 2 =13.12

p=0.036*

Medium 17(48.57%) 21(58.33%)

High 6(17.14%) 2(5.55%)

Caries Severity

(dmfs; DMFS)

9.97±8.30 11.08±9.58 - - t68=8.04

p=0.039*

Low 12(34.28%) 11(30.55%) 2 =15.74

p=0.039*

Medium 20(57.14%) 17(47.22%

High 3(8.57%) 8(22.22%)

Maximum

Voluntary Bite

Force on right

side in kg

[MVBF (R)]

7.91±2.91 7.90±1.51 8.24±2.31 8.21±2.14 F3,136 =

8.77

p=0.024*

3.27 7.58

Maximum

Voluntary Bite

Force on left side

in kg

[MVBF (L)]

7.60±2.24 7.52 ±1.40 8.00±2.25 7.90±1.99 F3,136 = 7.64

p=0.037*

2.77 10.07

Mean MVBF

in kg

7.75±1.97 7.71±1.44 8.12±2.18 8.05±203 F3,136 = 6.88

p=0.041*

4.78 9.35

Mouth Opening

in cm

3.98±0.43 3.86 ±0.39 4.30 ±0.39 4.22 ±0.48 F3,136 = 2.92

p=0.58

1.43 2.79

* - Significant


58

Table 3: Comparison of Variables for the age group 9-11 years

Variables Case

(n=70)

Control

(n=70)

ANOVA F-

Value with

p-value

/ Chi-

square(2 )

/ t-test

CD5 CD1

Male

(n=35)

Female

(n=35)

Male

(n=35)

Female

(n=35)

Body Height (in cm)

Mean ±s.d

135.67±4.00 136.16±4.35 136.37±4.30 139.08±5.14 F3,136 = 1.45 p=0.346

11.02 17.54

Body Weight (in kg)

Mean ±s.d

31.18 ±3.47 33.01 ±5.15 31.74 ±3.70 35.70±6.10 F3,136 = 2.45 p=0.027*

9.01 12.84

BMI (in

kg/m2)

Mean ±s.d

16.89±1.14 17.94 ±2.41 17.01±1.09 18.41±2.70 F3,136 = 1.87

p=0.521

5.08 8.98

Under

Weight

(<18.5)

32 (91.4%) 26(74.3%) 13 (37.14%) 10(28.57%) 2 = 3.23

p=0.254

Normal

(18.5-25)

3(8.6%) 8(22.9%) 22 (62.85%) 25(71.42%)

Over Weight

(25-30)

0(0.0%) 1 (2.9%) 0(0.0%) 0(0.0%)

Obese (>30) 0(0.0%) 0(0.0%) 0(0.0%) 0(0.0%)

Occlusal Pattern

Class-I (1) 26(74.3%) 29(82.9%) 22 (62.85%) 22(62.85%) 2 =2.98

p=0.517

Class-II (2) 7(20%) 6(17.1%) 13(37.14%) 12(34.28%)

Class-III (3) 2(5.7%) 0(0.0%) 0(0.0%) 1(2.85%)


Normal Bite

(1)

26(74.3%) 29(82.9%) 22(62.85%) 31(88.57%) 2 =2.68

p=0.316

Deep Bite (2) 8(22.9%) 4 (11.4%) 13 (37.14%) 3(8.6%)

Open Bite (3) 1(2.9%) 2(5.7%) 0(0.0%) 1(2.85%)


0-2 11(31.4%) 15(42.9 %) 15(42.85%) 17(48.57%) 2 =11.79

p=0.0023*

3-4 24 (68.6%) 20(57.1%) 20(57.14 %) 18 (51.42%)

5-6 0 (0.0%) 0 (0.0%) 0 (0.0%) 0 (0.0%)

Food Consistency

Hard-1 24(68.6%) 19(54.3%) 29 (82.85%) 25 (71.42%) 2 =10.74

p=0.027*

Soft-2 11(31.4%) 16 (45.7%) 6(17.14%) 10(28.57%) 2 =11.29

p=0.018*


59

Table 3: Comparison of Variables for the age group 9-11 years (cont.)

Variables Case

(n=70)

Control

(n=70)

ANOVA F-

Value with

p-value

/ Chi-

square(2 )

/ t-test

CD5 CD1

Male

(n=35)

Female

(n=35)

Male

(n=35)

Female

(n=35)

Caries

Prevalence

(DMFT)

3.13±1.18 3.38±2.05 t68=6.04

p=0.041*

Low 22(62.85%) 20(55.55%) 2 =13.29

p=0.036*

Medium 14(40%) 13(36.11%)

High 1(2.85%) 2(5.33%)

Caries Severity

(DMFS)

7.89±4.30 8.89. ±6.58 - - t68=7.04

p=0.042

Low 12(34.28%) 19(54.3%) 2 =13.12

p=0.056*

Medium 12(34.28%) 16(45.7%)

High 11(31.42%) 0(0.0%)

Maximum

Voluntary Bite

Force on right

side in kg

[MVBF (R)]

10.83±3.07 10.79±2.43 14.53±4.14 12.04±3.07 F3,136 =

12.10

p=0.023*

3.31 7.85

Maximum

Voluntary Bite

Force on left

side in kg

[MVBF (L)]

10.79±3.09 10.48±2.49 13.84±4.22 11.48±2.98 F3,136 =

11.74

p=0.033*

2.37 10.07

Mean MVBF

in kg

10.81±3.09 10.63±2.46 14.19±4.17 11.76±3.01 F3,136 =

10.88

p=0.041*

4.08 9.15

Mouth Opening

in cm

4.68 ±0.42 4.64 ±0.32 4.55 ±0.56 4.52 ±0.45 F3,136 = 3.92

p=0.426

1.30 1.29

* - Significant


60

Table 4: Comparison of Variables for the age group years 12-14 years

Variables Case

(n=70)

Control

(n=70)

ANOVA F-

Value with

p-value

/ Chi-

square(2 )

/ t-test

CD5 CD1

Male

(n=35)

Female

(n=35)

Male

(n=35)

Female

(n=35)

Body Height (in cm)

Mean ±s.d

151.96±7.17 150.57±5.51 153.02±5.31 152.50±5.06 F3,136 = 1.27 p=0.463

11.32 17.68

Body Weight (in kg)

Mean ±s.d

42.85 ±8.99 46.29 ±9.42 45.65 ±7.92 53.56±13.95 F3,136 = 2.74 p=0.019*

9.87 12.34

BMI (in

kg/m2)

Mean ±s.d

18.45 ±3.05 20.43 ±3.92 19.43 ±2.80 23.04 ±5.94 F3,136 = 1.88

p=0.525

5.47 8.75

Under

Weight

(<18.5)

24(68.6%) 10(29.4%) 17(48.57%) 13(37.14%) 2 = 2.23

p=0.225

Normal

(18.5-25)

8(22.9%) 18(52.9%) 17(48.57%) 16(45.71%)

Over Weight

(25-30)

3(8.6%) 6(17.6%) 1(2..85%) 5(14.28%)

Obese (>30) 0(0.0%) 0(0.0%) 0(0.0%) 1(2.85%)

Occlusal Pattern

Class-I (1) 27(77.1%) 31(88.6%) 24(68.57%) 21(60%) 2 =1.98

p=0.317

Class-II (2) 6(17.1%) 4(11.4%) 11(31.42%) 13(37.14%)

Class-III (3) 2(5.7%) 0(0.0%) 0(0.0%) 1(2.85%)


Normal Bite

(1)

9(25.7%) 27(77.1%) 24(34.28%) 30(85.71%) 2 =2.08

p=0.219

Deep Bite (2) 20(57.1%) 7(20%) 11(31.42%) 4(11.42%)

Open Bite (3) 6(17.1%) 1(2.9%) 0(0.0%) 1(2.85%)


0-2 9(25.7%) 12(34.3%) 12(34.28.3%) 16(45.71%) 2 =13.79

p=0.0013*

3-4 20(57.1%) 22(62.9%) 18(51.42%) 13(37.14%)

5-6 6(17.1%) 1(2.9%) 5(14.28%) 6(17.14%)

Food Consistency

Hard-1 22(62.9%) 18(51.4%) 21(60%) 28(80%) 2 =8.74

p=0.037*

Soft-2 13(37.1%) 17(48.6%) 14(40%) 7(20%) 2 =9.29

p=0.028*


61

Table 4: Comparison of Variables for the age group years 12-14 years (cont.)

Variables Case

(n=70)

Control

(n=70)

ANOVA F-

Value with

p-value

/ Chi-

square(2 )

/ t-test

CD5 CD1

Male

(n=35)

Female

(n=35)

Male

(n=35)

Female

(n=35)

Caries

Prevalence

(DMFT)

2..56 ±4.18 3.13±5.18 t68=1.04

p=0.039*

Low 17(48.57%) 20(55.55%) 2 =14.12

p=0.046*

Medium 12(34.28%) 14(38.85%)

High 6(17.14%) 2(5.55%)

Caries Severity

(DMFS)

5.97 ±3.30 6.08 ±5.58 - - t68=8.54

p=0.029*

Low 23(65.7%) 14(38.83%) 2 =16.14

p=0.021*

Medium 12(34.3%) 16(44.44%)

High 0(0.0%) 5(13.88%)

Maximum

Voluntary Bite

Force on right

side in kg

[MVBF (R)]

15.57±3.55 14.83±3.28 24.41±5.45 17.78±6.18 F3,136 = 8.87

p=0.027*

3.37 7.88

Maximum

Voluntary Bite

Force on left

side in kg

[MVBF (L)]

15.60±3.16 14.04 ±3.47 22.60±4.81 16.14±5.18 F3,136 = 7.74

p=0.034*

2.87 10.27

Mean MVBF

in kg

15.59±3.12 14.43 ±3.33 23.50±5.07 16.96±5.66 F3,136 = 6.88

p=0.041*

4.48 9.75

Mouth Opening

in cm

4.66 ±0.49 4.78 ±0.40 4.98 ±0.29 4.53 ±0.73 F3,136 = 1.92

p=0.483

1.33 2.29

* - Significant


62

ANOVA showed that there was no significant difference in mean body height of male and

female of Case and of Control for 6-8 years (F3,136 = 1.44;p=0.531);for 9-11 years (F3,136 =

1.45;p=0.346);and 12-14 years (F3,136 = 1.27;p=0.463); and also as per the CD no significant

difference was found between the means.

ANOVA showed that there was significant difference in mean body weight of male and

female of Case and of Control for 6-8 years (F3,136 = 2.84;p=0.032);for 9-11 years (F3,136

=2.45;p=0.0.027);and 12-14 years (F3,136 =2.74;p=0.019) and also as per the CD no

significant difference was found between the means.

ANOVA showed that there was no significant difference in mean BMI of male and female of

Case and of Control for 6-8 years (F3,136 =1.92;p=0.032);for 9-11 years (F3,136 =1.87;p=0.

027);and 12-14 years (F3,136 = 1.88;p=0.525) and also as per the CD no significant

difference was found between the means.

Chi-square test showed that there was no significant association between categories of BMI

and gender of the Case and Control for 6-8 years ( 2 = 2.83; p=0.525); for 9-11 years ( 2 =

3.23;p=0.254); and 12-14 years ( 2 = 2.23;p=0.225).

Chi-square test showed that there was no significant association between categories of

occlusal pattern and gender of the Case and Control for 6-8 years ( 2 = 2.98; p=0.913); for 9-

11 years ( 2 = 2.98; p=0.517); and 12-14 years ( 2 = 1.98; p=0.317).

Chi-square test showed that there was no significant association between categories of

vertical occlusal relationship and gender of the Case and Control for 6-8 years ( 2 = 2.18;

p=0.314); for 9-11 years ( 2 = 2.68; p=0.316); and 12-14 years ( 2 = 2.08; p=0.219).

Chi-square test showed that there was significant association between categories of

maxillary posterior teeth in contact (pairs) and gender of the Case and Control for 6-8 years (

2 =11.79; p=0.0014); for 9-11 years ( 2 =11.79 ;p=0.0023); and 12-14 years ( 2 =13.79;

p=0.0013).


63

Chi-square test showed that there was significant association between hard food consistency

and gender of the cases and controls for 6-8 years ( 2 =12.74; p=0.031); for 9-11 years ( 2

=10.74; p=0.027); and 12-14 years ( 2 = 8.74; p=0.037).

Chi-square test showed that there was significant association between soft food consistency

and gender of the Case and Control for 6-8 years ( 2 =12.74; p=0.031); for 9-11 years ( 2

=11.29; p=0.018); and 12-14 years ( 2 = 9.29; p=0.028).

Tukey’s test showed that there was significant difference between mean DMFT of male and

female of Case for 6-8 years (t68=2.04;p=0.043); for 9-11 years (t68=6.04;p=0.041); and 12-14

years (t68=1.04; p=0.039).

Chi-square test showed that there was significant association between categories of DMFT

and gender of the Case for 6-8 years ( 2 =12.74; p=0.031); for 9-11 years ( 2 =13.29;

p=0.036); and 12-14 years ( 2 = 14.12; p=0.046).

Tukey’s test showed that there was significant difference between mean DMFS of male and

female of Case for 6-8 years (t68=8.04;p=0.039); for 9-11 years (t68=7.04;p=0.042); and 12-14

years (t68=8.54; p=0.029).

Chi-square test showed that there was significant association between categories of DMFS

and gender of the Case for 6-8 years ( 2 =15.74; p=0.039); for 9-11 years ( 2 = 13.12;

p=0.049); and 12-14 years ( 2 = 16.14; p=0.021).

ANOVA showed that there was significant difference in mean MVBF ( R) of male and

female of Case and of Control for 6-8 years (F3,136 =8.77;p=0.024);for 9-11 years (F3,136

=12.10;p=0. 023);and 12-14 years (F3,136 = 8.87;p=0.027) and also as per the CD the mean

MVBF ( R) of male in Control group was significantly highest (p<0.05).

ANOVA showed that there was significant difference in mean MVBF ( L) of male and

female of Case and of Control for 6-8 years (F3,136 =7.64;p=0.037);for 9-11 years (F3,136

=11.74; p=0. 033);and 12-14 years (F3,136 =7.74;p=0.034) and also as per the CD the mean

MVBF ( L) of male in Control group was significantly highest (p<0.05).


64

ANOVA showed that there was significant difference in mean of MVBF of male and female

of Case and of Control for 6-8 years (F3,136 =7.88;p=0.037); for 9-11 years (F3,136 =10.88;p=0.

041);and 12-14 years (F3,136 = 6.88;p=0.041) and also as per the CD the mean of MVBF of

male in Control group was significantly highest (p<0.05).

ANOVA showed that there was no significant difference in mean of mouth opening of male

and female of Case and of Control for 6-8 years (F3,136 =2.92;p=0.581); for 9-11 years (F3,136

=3.92 ;p=0.426) ;and 12-14 years (F3,136 = 1.92;p=0.483) and also as per the CD no

significant difference was found between the means.


65

FIG.19: Mean MVBF of male and female of Case and Control of

three age and dentition group.


66

FIG.20: BMI of different age group with different categories

expressed as percentile: Under Weight (<18.5); Normal (18.5-

25); Over Weight (25-30) and Obese (>30).


67

FIG. 21a: Occlusal pattern of

6-8 years

FIG. 21b: Occlusal pattern of

9-11 years

FIG. 21c: Occlusal pattern of

12-14 years


68

FIG. 22a:Bite (VOR)

pattern of 6-8 years.

years

FIG. 22b: Bite (VOR)

pattern of 9-11 years

FIG.22c: Bite (VOR)

pattern of 12-14 years


69

FIG.23a: Food

Consistency of 6-8 years

FIG. 23b: Food

Consistency of 9-11 years

FIG. 23c: Food Consistency

of 12-14 years


70

FIG. 24b:dmft/DMFT for Case female child of three age

groups

FIG. 24a:dmft/DMFT for Case male child of three age

groups


71

FIG. 25a:dmfs/DMFS for Case male child of three age

groups

FIG.25b: dmfs/DMFS for Case female child of three age

groups


72

FIG.26a: MPTC of study

sample for 6-8 years

FIG.26b: MPTC of study


FIG.26c: MPTC of study



73

FIG. 27:MMO of the study sample of three age

groups


74

Table 5: Correlation of Variables with MVBF for the age group 6-8 years

Variables Case

(n=70)

Control

(n=70)

Male

(n=35)

Female

(n=36)

Male

(n=35)

Female

(n=35)

Body Height (in

cm)

r=0.37

p= 0.48

r=0.22

p=0.41

r=0.29

p=0.46

r=0.27

p=0.53

Body Weight (in

kg)

r=0.61

p= 0.0123*

r=0.64

p= 0.0245*

r=0. 67

p= 0.0333*

r=0.65

p=

0.0312*

BMI (in kg/m2)

r=0.51

p= 0.502

r=0.59

p= 0.431

r=0.28

p= 0.564

r=0.21

p= 0.623

Occlusal Pattern r=0.37

p= 0.541

r= 0.21

p= 0.413

r=0.30

p= 0.334

r=0.25

p= 0.377

Vertical

Occlusal

relationship

r=0.23

p= 0.23 r=0.30

p= 0.28

r=0.35

p= 0.31 r=0.33

p= 0.32

Maxillary

Posterior Teeth

in contact (pairs)

r=0.64

p= 0.011*

r=0.74

p= 0.023*

r=0.80

p= 0.035*

r=0.79

p= 0.028*

Food

Consistency

r=0.72

p= 0.023* r=0.83

p= 0.037*

r=0.79

p= 0.028* r=0.78

p= 0.025*

Caries

Prevalence

(dmft/ DMFT)

r= - 0.60

p= 0.012*

r= - 0.64

p= 0.018*

Caries Severity

(dmfs/DMFS)

r= - 0.84

p= 0.033* r = - 0.88

p= 0.038*

*- Significant


75


Variables Case

(n=70)

Control

(n=70)

Male

(n=35)

Female

(n=35)

Male

(n=35)

Female

(n=35)

Body Height (in

cm)

r=0.29

p= 0.442

r=0.24

p=0.423

r=0.29

p=0.442

r=0.25

p=0.426

Body Weight (in

kg)

r=0.69

p= 0.011*

r=0.65

p= 0.033*

r=0.65

p= 0.033*

r=0.67

p= 0.037*

BMI (in kg/m2)

r=0.51

p= 0.323

r=0.49

p= 0.331

r=0.28

p= 0.427

r=0.21

p= 0.405


p= 0.424

r= 0.21

p= 0.405

r=0.30

p= 0.313

r=0.25

p= 0.379

Vertical

Occlusal

relationship

r=0.22

p= 0.234 r=0.11

p= 0.180

r=0.47

p= 0.315 r=0.33

p= 0.473

Maxillary

Posterior Teeth

in contact (pairs)

r=0.82

p= 0.021*

r=0.71

p= 0.033*

r=0.89

p= 0.011*

r=0.69

p= 0.034*

Food

Consistency

r=0.84

p= 0.024* r=0.85

p= 0.030*

r=0.81

p= 0.021* r=0.83

p= 0.022*

Caries

Prevalence

(dmft/DMFT)

r= - 0.65

p= 0.036*

r= - 0.71

p= 0.029*

Caries Severity

(dmfs/DMFS)

r= - 0.85

p= 0.023* r= - 0.83

p= 0.021*

* - Significant


76


Variables Case

(n=70)

Control

(n=70)

Male

(n=35)

Female

(n=35)

Male

(n=35)

Female

(n=35)

Body Height (in

cm)

r=0.27

p= 0.443

r=0.22

p=0.427

r=0.29

p=0.461

r=0.24

p=0.431

Body Weight (in

kg)

r=0.61

p= 0.018*

r=0.64

p= 0.023*

r=0.77

p= 0.041*

r=0.73

p= 0.039*

BMI (in kg/m2)

r=0.51

p= 0.324

r=0.49

p= 0.337

r=0.28

p= 0.429

r=0.21

p= 0.451


p= 0.441

r= 0.21

p= 0.418

r=0.30

p= 0.337

r=0.25

p= 0.373

Vertical

Occlusal

relationship

r=0.25

p= 0.236 r=0.31

p= 0.281

r=0.37

p= 0.318 r=0.33

p= 0.289

Maxillary

Posterior Teeth

in contact (pairs)

r=0.84

p= 0.045*

r=0.74

p= 0.033*

r=0.87

p= 0.041*

r=0.79

p= 0.035*

Food

Consistency

r=0.74

p= 0.022* r=0.83

p= 0.043*

r=0.81

p= 0.042* r=0.86

p= 0.046*

Caries

Prevalence

(DMFT)

r= - 0.66

p= 0.016*

r= - 0.73

p= 0.024*

Caries Severity

(DMFS)

r= - 0.80

p= 0.034* r= - 0.86

p= 0.039*

*- Significant


77

Pearson Correlation Co-efficient (r) for quantitative data showed that there was no

significant correlation between MVBF and body height of male and female of Case and of

Control for 6-8 years ;9-11 and 12-14 years (p>0.05).

Pearson Correlation Co-efficient (r) for quantitative data showed that there was positive

and significant correlation between MVBF and body weight of male and female of Case and

of Control for 6-8 years ;9-11 and 12-14 years (p<0.05).


but no significant correlation between MVBF and BMI of male and female of case and of

control for 6-8 years ;9-11 and 12-14 years (p>0.05) as shown in FIG.

Spearman Correlation Co-efficient (r) for qualitative data showed that there was no

significant correlation between MVBF and occlusal pattern of male and female of Case and

of Control for 6-8 years ;9-11 and 12-14 years (p>0.05).

Spearman Correlation Co-efficient (r) for qualitative data showed that there was no

significant correlation between MVBF and vertical occlusal relationship of male and female

of Case and of Control for 6-8 years ;9-11 and 12-14 years (p>0.05).


and significant correlation between MVBF and MPTC of male and female of Case and of

Control for 6-8 years ;9-11 and 12-14 years (p<0.05) as shown in FIG.

Spearman Correlation Co-efficient (r) for qualitative data showed that there was

significant correlation between MVBF and food consistency of male and female of Case and

of Control for 6-8 years ;9-11 and 12-14 years (p>0.05).

Pearson Correlation Co-efficient (r) for quantitative data showed that there was negative

and significant correlation between MVBF and dmft/DMFT of male and female of Case for

6-8 years ;9-11 and 12-14 years (p>0.05).

Pearson Correlation Co-efficient (r) for quantitative data showed that there was negative

and more significant correlation between MVBF and dmfs/DMFS (compared to dmft/DMFT)

of male and female of Case for 6-8 years;9-11 and 12-14 years (p>0.05) as shown in FIG.


78

FIG.28a: Correlation between MVBF and BMI for male (left) and female (right) of 6-8

years

FIG.28b: Correlation between MVBF and BMI for male (left) and female (right) of 9-11

years

FIG. 28c: Correlation between MVBF and BMI for male (left) and female (right) of

12-14 years


79

FIG.29a: Correlation between MVBF and MPTC for male (left) and female

(right) of study sample of 6-8 years

FIG.29 b: Correlation between MVBF and MPTC for male (left) and female (right) of

study sample of 9-11 years

FIG. 29c: Correlation between MVBF and MPTC for male (left) and female (right) of study

sample of 12-14 years


80

FIG. 30a:Correlation between MVBF and dmfs/DMFS for male (left) and female (right) of

Case of 6-8 years

FIG. 30b: Correlation between MVBF and dmfs/DMFS for male (left) and female (right) of

Case of 9-11 years

FIG. 30c: Correlation between MVBF and dmfs/DMFS for male (left) and female (right) of

Case of 12-14 years

DISCUSSION

Discussion

81

DISCUSSION

Following an in-depth literature search and review, it was found that there have been

no other studies published with the same aims and objectives as that of the current study

in relation to children of Bengalee population of Kolkata . Therefore, a comprehensive

comparative study was required to obtain data of MVBF of Bengalee children of

Kolkata. The study was conducted to evaluate and obtain data of MVBF of Bengalee

children belonging to Kolkata and to correlate the influential factors of bite force with it.

The Bengalee people are the ethnic community of West Bengal. They are eastern

Indo-Aryan people, who are descended from Austro-Asiatic and Dravidian peoples and

are closely related to the Oriya, Assamese, Bihari and other eastern Indians as well as the

Munda and Tibeto-Burmese peoples.91

The Bengalee children participating in the present study were from different regions

of Kolkata (West Bengal). Henceforth, the selected study sample was fairly

representative of the entire population and was homogenous in nature.

The section below provides a discussion of the present study’s results while

simultaneously integrating evidence-based literature, and further demonstrating as well

as identifying original novel data, viewpoints, and understanding achieved.

Bite Force Values in Children Reported in the Present and Other Studies.

In both adults and children, bite force has received much attention in studies across

the globe as evident by studies conducted by Lindqvist and Ringqvist (1973)44

;

Helkimo et al (1976)78

; Kampe et a (1987)77

; Tortopidis et al (1998)81

; Rentes et al

(2002)33

;Tsai and Sun (2004); Kamegai et al (2005)67

;Sonnesen and Bakke(2005)60

;

Usui et al (2007)61

; Castelo et al (2010)84

;Mountain et al (2011)13

. Each research

study had a specific objective and associated research questions concerned with human

bite force. However, there is a lack of research centered on bite force in young children

especially Bengalee children .So the current study aimed at determining the MVBF Of

Discussion

82

children belonging to this specific ethnic group utilizing a sample of 421 children aged

6-14 years residing in Kolkata. The magnitude of MVBF in the male subgroups of

control group of age 6-8 was 8.12kg (79.57 N) ,which is comparable to study of Braun

et al (1996)93

as discussed later in this section. The magnitude of MVBF in the male

subgroups of control group of age of 9-11 yrs was 14.19 kg (139.06 N) and of 12-14 yrs

was 23.05 kg (230.3N) while for the females the MVBF of age 6-8 was 8.05 kg(78.89N

); of 9-11 yrs was 11.76 kg(115.24N ) and of 12-14 yrs was 16.96 kg(166.20N).

The MVBF in the male subgroups of case group of age 6-8 was 7.75 kg (75.95 N)

of 9-11 yrs was 10.81kg (105.93 N ) kg and of 12-14 yrs was 15.59 kg (152.78N )

while for the females the MVBF of age 6-8 was 7.71kg(75.55N); of 9-11 yrs was

10.63kg(104.17N) and of 12-14 yrs was 14.43kg(141.41N) respectively. This difference

in the values of bite force in comparison to other studies can be attributed to the

recording device used for bite fore measurement in the present study.

Bite force means and ranges, as detailed in other studies with children, has been

appraised below, although the elements known to impact maximum bite force will be

considered in another section.

Helle et al (1983)92

evaluated bite force in a randomly selected group of Finnish

children aged 5–17 years, with all 98 individuals assigned to one of five different groups

according to age. Notably, the mean maximum bite force recorded in the case of

permanent or deciduous molars was 245.3 N in girls and 251.1 N in boys aged 5 years

Moreover, in the case of 17 year olds, bite forces measured had a mean of 312.9 N in

girls and 312.8 in boys.

Braun et al (1996)93

in USA carried out a research focused on recording bilateral

bite force in a sample of 457 individuals aged 6–20 years. In terms of the maximum bite

forced found, the mean was 78 N amongst those aged 6–8 years, and 178 N amongst

those aged 18–20 years.

Discussion

83

The levels of bite force concerning dental status in children with deciduous dentition

was assessed by Tsai (2004) 66

. The sample comprised 676 Taiwanese children aged 3–5

years. It was found that the maximum bite forces recorded ranged between 147 N and

176 N.

Bite force measurements of 2,549 northern Japanese children aged 3–17 years was

assessed by Kamegai et al (2005)67

, with all sample subjects divided into groups

according to age. Notably, the mean force ranged from 186.2 N in the case of 3–5 year

olds, and up to 545.3 N amongst 15–17 year olds.

Usui et al ( 2007)61

conducted a study with the aim of ascertaining the link between

bite force and a number of different parameters, taking a sample of individuals aged 8–

25 years old, all of whom were patients attending an orthodontic department with

malocclusion. The means of the bite force values were found to be 20.9 Kgf (204.9 N)

amongst those aged 8.6 years, but were as high as 40.7 Kgf (399.1 N) in participants

aged 25.4 years.

Su et al (2009)64

determined bite force of 201 preschool children in the age range

of 4-6 years. The average age of their studied sample was 5.2 years. Mean maximum bite

force has been reported to be 5.69 Kg and that is equal to 55.79 Newtons.

The magnitude of maximum voluntary bite forces utilizing a sample of 205 children

aged 3–6 years at school in a major UK city was determined by Mountain et al

(2011)13

. The data recorded provided a comparatively wide intra and inter-individual

disparity, with three bite force measurements ranging from 12.6 N to 353.64 N, and

providing a mean of 196.60 N.

A study with the aim of assessing the MVBF in children and adults with normal

occlusion was conducted by Sathyanarayana et al (2012)94

. With respect to children,

total 40(20 males, 20 females) aged 8-12 years with class I occlusion participated in the

study. Class I occlusion was assessed with lateral cephalogram and study models. The

mean MVBF in children was 191.17 Newtons with boys having a value of 199.2

Newtons and in girls it was 183.07 Newtons.

Previously, Shiau and Wang (1993)79

found that the maximum bite force of male

children aged 7−20 years was 31.6 kg, whereas that of females averaged 22.4 kg. Chen

Discussion

84

found the maximum bite force of male children aged 6−13 years to be 20.51 kg and that

of females to be 14.77 kg.

The Effects and Correlation of Different Studied Variables with Bite Force

There are a number of inter-related variables believed to impact the bite force of

not only children but also adults as found by studies of Braun et al (1996)73

; Rentes et

al (2002) 33

; Kamegai et al (2005)67

; Koc et al (2010)7; Mountain et al (2011). It is not

always possible to compare or generalise the influence of certain variables on bite force

on all populations or age groups as there are other confounding factors such as study

design, measurement techniques and characteristics of the sample studied as well as

sample size that could have effects on findings and prohibits generalisation on other

populations.

In this specific study, a number of factors were considered for analysis to detect

any significant correlation with the bite force magnitude in Bengalee children. These

factors are the child’s age, height, weight, BMI, gender, OP, VOR; caries experience that

is described as DMFT/dmft, DMFS/dmfs indices, MMO and food consistency evaluated

in terms of dietary habits . With these in consideration, the following section will focus

attention to analysing each of these factors with interpretations compared to the results

obtained from other related prior studies.

Bite Force in Boys and Girls- the Influence of Gender

In the present study, the mean bite force in male of age 6-8 yrs in control

group(caries free) was 8.12 kg (79.57 N) and in case group (caries affected) was 7.75 kg

(75.95 N ); in control group of 9-11 yrs was 14.19 kg (139.06 N) and in case group was

10.81kg (105.93N ) ;whereas in control group of 12-14 yrs was 23.50 kg (230.3N ) and

in case group was 15.59 kg (152.78N ) respectively. The corresponding mean bite force

value for females of same age groups were found to be lesser than that of males,

although the results were shown not to be statistically significant except for 12-14 yrs

in control group. (p > 0.05).The mean bite force for females of 6-8 yrs; 9-11 yrs and 12-

14 yrs in control group were 8.05 kg(78.89N ); 11.76(115.24N ) ;16.96(166.20N)

whereas in case group were 7.71kg(75.55N); 10.63kg(104.17N) and14.43kg(141.41N)

Discussion

85

respectively. Importantly, this finding supports the findings of other studies Serra et al

(2007)39

; Su et al (2009) 64

; Sonnesen et al (2001)20

. The study of Mountain et al

(2011)13

reported a greater bite force amongst males aged 3–6 years than females,

however these differences were also not considered statistically significant.

Moreover, and in line with our findings, the work of Sathyanaryana and

Permkumar (2012)94

emphasises a strong difference between genders in bite force, but

only amongst adults; in the case of children, this difference was not statistically

significant.

In contrast, Owais et al (2012)95

emphasised a strong link between gender and bite

force amongst three sub-groups of the sample, i.e. those subjects in late primary, early

mixed, and late mixed dentition stages children, with bite force found to be higher in

males. He took a sample of 1,011 children, with the sample divided in regard to the

developmental phase of dentition. Such factors (i.e. sample size and characteristics)

could be reasons as to why gender impacted bite force in their sample. The present

study’s sample included children in the age range of 6 to 14 yrs and attempt was made to

divide the sample according to age and dentition stage.

Koc et al (2011)96

recently reported a gender significant influence on bite force value

in a sample of 19-20 year olds. Again, it should be noted that this gender influence might

not be applicable in children.

It has been postulated that the gender differences in bite forces are the result of

anatomical variation as well as higher muscular mass in males as compared to females.

These physiological variations are not normally apparent until puberty and therefore in a

sample of children (6-14 years) it is not unusual to detect no significant differences in

bite force between boys and girls of groups aged 6-8 and 9-11 years but significant

difference observed in group comprising 12-14 years. From previous studies and current

results, it can be said that boys have higher bite forces than girls but this does not

normally show statistical significance in young children or in other words, in pre-

pubertal stage individuals.

Discussion

86

The Impact of Age on Bite Force Value

The findings of this study reaffirm that an increase in bite force is recognised

alongside an increase in age (r = 0.60, p=0.01 for 6-9 yrs; r=0.63;p=0.02 for 9-11 yrs and

r=0.74,p=0.03 for 12-14 yrs respectively), which also correlates to progression from

early mixed dentition through late mixed dentition to permanent dentition. This finding is

in agreement with several previously conducted studies by Kiliardis et al (1993)71

;

Braun et al (1996) 93

; Kamegai et al (2005)67

; Usui et al. (2007)61

; Owais et al (2012)

95 that have shown a positive correlation of age with bite force.

On the other hand, the work of Braun et al (1995)73

, who examined bite force

amongst adults aged 26–41 years, noted a lack of significant link between bite force and

that of age. In this case, it is essential to acknowledge the fact that the sample cannot be

compared with the sample of this study due to the fact that the former targets adults

while the latter targets children.

An increase in bite force with age in children can be explained by two theories.

First, as children grow with increasing age they will have higher muscle masses and thus

will have stronger bite forces as muscles are one of the essential components of bite

force. Second, as Sonneson and colleagues (2001)20

suggested that bite force increases

in children when growing from 7 to 12 years due to dental eruption through the different

dentition stages which subsequently allows for greater number of occlusal units and

higher bite forces.

Body Build and its Impact on Bite Force Magnitude

With the aim of examining the possible link between bite force and body build, it

was necessary to analyse, height, and weight, and BMI with the statistical analysis of

correlation coefficients.

Discussion

87

Child’s Weight Influences on Bite Force

It was found that there was a strong, positive link between weight and bite force

magnitude, as revealed by Pearson‘s correlation coefficient ( r =0.61, p =0.0123 for case

male and r=0.64,p=0.0245 for case female ; and r=0.67,p=0.033 for control male and

r=0.65,p=0.0312 for control female of 6-9 yrs respectively ; r =0.69, p =0.011 for case


r=0.67,p=0.037 for control female of 9-11 yrs respectively; r =0.61, p =0.008 for case


r=0.73,p=0.039 for control female of 12-14 yrs respectively). Such a finding is in

agreement with that of Owais et al (2012)95

, who stated a positive link between bite

force and body weight amongst their sample (1,011 subjects), comprising both children

and adolescents. Interestingly, the correlation coefficients were found to be at their

highest levels in the cases of those at permanent and mixed phases of dentition stages (r

= .0219 and r = 0.186 respectively).Similarly, a weak, positive correlation was found

between weight and bite force (r = 0.24) through the study of Rentes et al (2002)33

.

Moreover, the investigators further emphasised that weight is believed to have

contributed to 6% of bite force variation amongst their sample of young children.

Similarly, Mountain (2008)75

in a PhD study reported that child’s weight was found to

be a predictor variable that continued to show, following hierarchical regression

modelling, significant effects on recorded bite force and further stated that around 7% of

bite force variation was contributed by the weight of the child.

Furthermore, the study of Linderholm et al (1971)68

confirmed a small but positive

impact of weight on bite force amongst their sample comprising 79 children. Braun et al

(1995)73

agreed with the results of the present study and reported that correlation

coefficient of bite force and weight equals to 0.401 and it was the highest among all

other studied predictors. They further stated that 16% of variation in bite force can be

predicted by body weight.

Discussion

88

On the other hand, Su et al (2009)64

suggested that body build—as defined by height

and weight—showed no positive or significant impact on the bite force values reported

when considering their sample of children aged 4–6 years. Racial differences, variation

in bite force recoding systems and techniques as well as sample characteristics could

partly be the rational of this discrepancy between their findings and the present findings.

Overall, comparisons with results obtained through prior research are not without

problems and/or debates. For instance, various studies take a sample of individuals of

different genders and age groups, which can subsequently increase variation and

ultimately inhibit the interpretation and generalizability of the results gathered.

Therefore, it is not surprising to consider that experimental results are somewhat

inconsistent in terms of the impact of growth variables on maximum bite force,

especially amongst children.

Child’s Body height and Impacts on Bite Force Magnitude

Bite force and height illustrated a positive but weak correlation which is a finding

found to be in agreement with the study of Rentes et al (2002) 33

, with the suggestion

that there is a 5% variance contribution of height on bite force values in their sample,

which comprised children aged 3–5.5 years .

The study of Abu Alhaija et al (2010)97

investigated bite force amongst adults, which

subsequently highlighted a positive but not statistically significant link between bite

force and height. In a sample of growing individuals (3-10 years) there is normally a

direct relationship between age and height and therefore a correlation between height and

bite force is not unexpected as found here.

In contrast, Owais et al (2012)95

, noted a significant positive link between bite force

and height (r = 0.144, p = 0.021). Moreover, the work of Mountain et al (2011)13

has

highlighted a positive and significant link between bite force and height through the

conduct of a UK-based research with a sample of 205 children with primary dentitions.

Discussion

89

Body Mass Index and Bite Force

The body mass index has been investigated in few previous studies to detect

influence of body build on bite force and it can be calculated by wt./ht.^2. The

correlation between body mass index and maximum bite force in the current study was

found to be statistically non-significant at the 0.05 level among 6-14 years children. This

finding is in agreement with the findings of Koc et al (2011)96

who reported that body

mass index variable failed to show statistically significant association with the bite force

in a sample of 34 adults. Similarly, Mountain (2008)75

reported a similar correlation in a

sample of children that proved to be non-significant.

In contrast, Lemos et al (2006)49

reported a positive correlation between bite force

and BMI. Moreover, it was observed that most of the children belonging to Case group

of different age were underweight signifying poor nutrient intake due to compromised

oral health thereby decreasing the masticatory efficiency whereas children belonging to

Control group were mostly normal weight according to categorization given by WHO.

Effect of Occlusal pattern; Vertical occlusal relationships and Maxillary posterior

teeth in contact on Bite Force.

When comparing different occlusal patterns and vertical occlusal relationships no

difference was found in the bite force attributable to any of these conditions. The

children selected in the present study were mature enough, had fully developed motor

control ability to control their masticatory muscles.

Although class I and II children among the study sample of each age group had

higher average bite forces on both sides and a higher maximum bite force than class III

children, the differences were not statistically significant(see tables in result and

observation section). This indicates that there might not be a strong relationship

between different occlusal patterns and bite force. These results are similar to the

conclusions drawn by Ahlgren (1996)98

, Ahlgren et al (1973)99

and Kiliaridis et al

(1993)71

. With respect to the vertical occlusal relationship, the bite force on both sides

Discussion

90

and the maximum bite force were highest in normal bite individuals and lowest in deep

bite individuals. These findings are in agreement with the study by van Spronsen et al

(1989)100

in children.

To study the number of maxillary posterior teeth in contact, the number of tooth contacts

was divided into three groups for measurement. Although there were no significant

differences in the bite force on the left and right sides or in the maximum bite force in

these three groups, a higher number of maxillary posterior teeth in contact were

associated with a stronger bite force. This finding is similar to the results of a study by

Ingervall and Minder (1997)101

of children aged 7−16 years.

Maximum mouth opening and its Impact on Bite Force Magnitude

In terms of the maximum mouth opening the average opening distance in 6-8 yrs

was 3.98cm and 3.86 cm for male and female in case group whereas it was 4.30 cm and

4.44cm for male and female in control group .The average opening distance in 9-11 yrs

was 4.68 cm and 4.64 cm for male and female in case group and 4.55 cm and 4.52cm

for male and female in control group whereas in 12-14 yrs it was 4.66cm and 4.78 cm

for male and female in case group and 4.98cm and 4.53cm for male and female in

control group. ANOVA showed that there was no significant difference in mean of

mouth opening of male and female of case and of control and also as per the CD no

significant difference was found between the means among male and female of each

age group and also between different age groups. Pearson Correlation Co-efficient

signified weak and non-significant correlation between MMO and MVBF for male and

female in case and control group for each age and between different age groups. This

finding is in agreement with study of Su et al (2009)64

.

On comparing the left and right bite forces of both sexes and among different ages,

we found the average bite force on the left and right sides among 6-8 yrs to be 7.91 kg

for male and 7.90 kg for female of case group on right side and 8.24 kg for male and

8.21 kg for female of control group on right side and 7.60 kg for male and 7.52 kg for

female in case on left side and 8.00 kg for male and 7.90 kg in control group on left

side respectively and with no significant differences(p>0.05). The average maximum

Discussion

91

bite force was 7.75kg for male and 7.71 kg for female in case sample whereas it was

8.12 kg for male and 8.05 kg for female in control group. Similarly, among 9-11 yrs it

was 10.83 kg for male and 10.79 kg for female of case group on right side and 14.53 kg

for male and 12.04 kg for female of control group on right side and 10.79 kg for male

and 10.48 kg for female in case on left side and 13.84 kg for male and 11.48 kg in

control group on left side respectively and with no significant differences. The average

maximum bite force was 10.81 kg for male and 10.63 kg for female in case sample

whereas it was 14.19 kg for male and 11.76 kg for female in control group. Among 12-

14 yrs it was 15.57 kg for male and 14.83 kg for female of case group on right side and

24.41 kg for male and 17.78 kg for female of control group on right side and 15.60 kg

for male and 14.40 kg for female in case on left side and 22.60 kg for male and 16.14 kg

in control group on left side respectively and with no significant differences. The average

maximum bite force was 15.59 kg for male and 14.43 kg for female in case sample

whereas it was 23.05 kg for male and 16.96 kg for female in control group.

Although no significant differences were observed in the left side and maximum bite

forces, there were major differences in the bite force on the right side. Bite force on the

right side of children aged 12-14 years was significantly larger than that of children aged

6-8 and 9-11 years. Most studies previously examined children aged ≥ 6 years and made

only limited comparisons, while our results showed that the bite forces of children aged

6-14 years significantly differed.

We measured the bite force of both the left and right sides and chose the higher value

as the maximum bite force in order to increase the accuracy of the measurement. Results

demonstrated that sex did not result in significant differences in bite force on the left and

right sides or on maximum bite force and is in agreement with study of Su et al (2009)64

.

Caries Level in the Study Sample and Impact on Dietary Habits and Bite Force

One of the objectives of the study was to ascertain the impact of different variables

on the maximum bite force of children; thus, decayed, filled or missing teeth and

surfaces were taken into account so as to allow for the analysis of the potential impacts

of the experience and severity of caries on the magnitude of bite force.

Discussion

92

It was found that there was a moderately strong, negative and statistically significant

link between scores of DFMT/dmft, DMFS/dmfs and that of bite force. Very limited

studies such as Tsai (2004)66

; Su et al (2009)64

; Mountain et al (2011)13

have been

found to have considered caries and their impacts on bite force magnitude amongst

children. Severely decayed and missing teeth are detrimental to mastication.

Su et al (2009)64

reported that bite force had no statistically significant correlation

with caries experience in a group of 201 preschool children. A possible explanation of

disagreement between our findings and Su et al findings is that they relied on dmft only

to describe caries experience whereas in the present study DMFT/dmft and DMFS/dmfs

and were used to describe caries prevalence and severity. In addition, the study sample in

Su and colleagues study comprised 201 preschool children (i.e. primary dentition), and

were selected from kindergartens whereas this study’s case sample comprised a group of

children who attended for dental treatment with the majority diagnosed with advanced

caries.

Both DMFS/dmfs and DMFT/dmft were found to be at high levels in sample cases

for specific age group (r= -0.60,p=0.012 for dmft /DMFT and r= - 0.84,p=0.033 for

dmfs/DMFS of case male for 6-8 yrs; r=-.64,p=0.018 for dmft /DMFT and r=-

0.88,p=0.038 for dmfs/DMFS of case female for 6-8 yrs ;r=-0.65,p=0.036 for dmft/

DMFT of case male and r=-0.71,p=0.029 of case female for 9-11years whereas r=-

0.85,p=0.023 for dmfs/DMFS of case male and r=-0.83,p=0.021 of case female for 9-

11years; r=-0.66,p=0.016 for DMFT of case male and r=-0.73,p=0.024 of case female

whereas r=-0.80,p=0.034 for DMFS of case male and r=-0.85,p=0.24 of case female for

12-14 years respectively). DMFS/dmfs showed higher significant negative correlation

compared to DMFT/dmft as,children of case group categorize as low and medium caries

status according to dmft/DMFT indices were seen as medium and high caries status

under dmfs/DMFS indices. This finding suggests that the severity of tooth decay may be

more important than the number of teeth exhibiting decay.

Discussion

93

Due to the fact that case group sample comprised children who were care is affected

and reported to the outpatient department of Pedodontics to receive dental treatment, it

is then to be expected that high scores of caries indices would be found. Moreover, it was

observed that female were more caries affected among the study population of specific

age group.

It should be acknowledged that there is a clear demand for increased awareness and

belief in prevention to reduce the occurrence as well as the severity of dental caries in

children. A large range of negative consequences of caries in children have been reported

as discussed earlier. This finding has only been stated in a few previous research studies

of Shiau and Wang (1993)79

; Tsai (2004)66

and Mountain et al (2011)13.In addition, as

found in the current study, dental caries and more specifically the number of decayed

surfaces has a strong and statistically significant negative correlation with bite force.

In other words, the larger the number of decayed surfaces the lower the bite force a

child can exhibit. Lower biting ability can also lead to lower chewing efficiency as bite

force is one crucial component of the mastication process. Subsequently, nutrition intake

in such a critical stage of individual’s life (i.e. childhood) might be negatively affected as

shown by work of Julien et al (1996)5; Su et al (2009)

64; Yamanaka et al (2009)

102.

A previous study showed that if children have good mastication ability, food is more

easily digested. Nutrition is important to the growth and development of children, and

digestion affects nutrition. Dietary habits are apparently changing with modernization.

With improved socioeconomic status and busy modern life of families, there has been an

increased intake of readymade food with fermentable carbohydrates among the masses.

People will choose soft food if they cannot chew effectively, eventually causing

malnutrition and insufficient fiber, mineral and vitamin intake. This statement is well –

supported with findings of the present study. Children of compromised oral health in

each age group demonstrated less biting ability compared to children of control group.

Moreover, children having diet mainly consisting of hard food demonstrated higher bite

Discussion

94

force( r=0.67 ,p=0.034 ) in comparison to children feeding on soft consistency food(r=-

0.43 ;p= 0.030 ) .

Anderson et al (2004)103

said that children usually show difficulty in eating and loss

of function which should be considered an indicator of oral problems. Therefore

functional impairment is a negative sequel of caries in children. This can be measured by

different means and one of those is the evaluation of bite force which is known to be

influential on mastication and chewing processes.

Diet has an important role in prevention of dental caries. Our target should be

customized dietary modifications rather than dietary restrictions and result of present

study will help in the process. It is mandatory for us as preventive dentists, to provide

appropriate diet counseling which is tailored for a particular individual to maximize the

compliance. Our finding can be considered as an additional supportive evidence of the

positive effects of caries free environment as examplified by control group in both mixed

and permanent dentitions ;as well as an evidence of serious negative impacts of dental

caries on function as expressed by low bite forces recorded in case study sample among

different age group.

Fundamentally, this research study’s outcomes revealed a number of key findings,

but unfortunately, although such a finding is remarkable and clinically valuable, as no

prior study has been conducted in this regard, no comparisons with other previous

studies can be drawn in terms of this specific aspect of the results. Nevertheless, the

results have shown valuable correlations of bite force with those variables studied that

agree with other published studies.

………………………………………

.

SUMMARY

Summary

95

SUMMARY

Bite force is recognized as one of the factors indicating the masticatory system’s

functional state resulting from jaw elevator muscle action, modified by cranio-

mandibular biomechanics. Mastication is a developmental function and its maturation

occurs from learning experiences. If it is adequate, it gives stimulus and proper function

for the normal development of the maxilla and mandible. Many studies have been

performed to determine the relationship between bite force and masticatory efficiency as

bite force is one of the key determinants of masticatory performance.

The evaluations of bite force have been proven to be constructive and thus widely

utilized in dentistry, with the measurement of such conducted with the aim of

determining muscular activity and jaw movements during the chewing process. These

measurements are also valuable in terms of providing reference values for studies on the

biomechanics of prosthetic devices. In addition, bite force has been considered important

in the diagnosis of the disturbances of the stomatognathic system.

Technological advances in signal detection and processing have improved the quality

of the information extracted from bite force measurements. However, these

measurements are difficult and the reliability of the result depends on a number of

factors, such as gender, age, cranio-facial morphology, presence of pain and

temporomandibular disorders, periodontal support of teeth and dental status. In addition

to these physiological factors, recording devices and techniques are important factors in

bite force measurement.

When reviewing the literature on bite force and correlated factors, it becomes

apparent that there is a lack in studies concerned with the effects of influential factors

including dental decay and dietary habits on bite force in Bengalee child population

specifically.

Summary

96

Therefore, the prime aim of the present study was to determine the mean maximum

voluntary bite force of Bengalee children of Kolkata in the mixed and permanent

dentitions. Secondly, to critically assess different influencing factors on the magnitude of

children’s bite force in order to advance knowledge in relation to bite forces and their

interplay in children.

A clinical-based study is not without difficulties and challenges. Particularly,

studies involving children require special care to continuously involve them and their

parents/guardians throughout the process of the research. This difficulty was overcome

by using an appropriate child-oriented approach and methods to obtain child participant

assent and subsequently cooperation during bite force measurement.

This was a cross sectional study that comprised 421 children of both sex between

age of 6-14 years in which 49.8% were boys and 50.2 % were girls. The children were

divided into three groups according to age and dentition stage and two subgroups of case

and control of male and female on basis of caries affected and caries free dental status

respectively.

The study sample was taken from children attending the Outpatient Department of

Pedodontics & Preventive Dentistry, Guru Nanak Institute of Dental Science & Research

(Kolkata) and two selected schools in Kolkata.

The determination of MVBF was done using customized bite force meter in

accordance with the procedure adopted by Mountain, 2008 and evaluation and

correlation of different variables with bite force were analyzed statistically.

Statistical Analysis was performed with help of Epi Info (TM) 3.5.3.Descriptive

statistical analysis was performed to calculate the means with corresponding standard

deviations (s.d). Also One Way Analysis of variance (ANOVA) followed by Tukey’s

Test was performed with the help of Critical Difference (CD) or Least Significant

Difference (LSD) at 5% and 1% level of significance to compare the mean values.

Pearson Correlation Co-efficient for quantitative data and Spearman Correlation Co-

Summary

97

efficient for qualitative data were calculated to find the correlation and t-test was used to

find the significance level of the correlations. Chi-square ( 2 ) test was performed to find

the associations. p≤0.05 was taken to be statistically significant.

The MVBF in the male subgroups of control group of age 6-8 was 8.12kg (79.57

N); of 9-11 yrs was 14.19 kg (139.06 N) and of 12-14 yrs was 23.50 kg (230.3N) while

for the females the MVBF of age 6-8 was 8.05 kg (78.89N ); of 9-11 yrs was 11.76 kg

(115.24N ) and of 12-14 yrs was 16.96 kg (166.20N).

The MVBF in the male subgroups of case group of age 6-8 was 7.75 kg (75.95 N)

of 9-11 yrs was 10.81kg (105.93N) and of 12-14 yrs was 15.59 kg (152.78N) while for

the females the MVBF of age 6-8 was7.71kg (75.55N); of 9-11 yrs was 10.63kg

(104.17N) and of 12-14 yrs was 14.43kg (141.41N) respectively.

Children’s age, sex showed significant correlation with the bite force. In contrast,

body build expressed by height and weight showed a positive correlation but

nonsignificant relation with bite force (p > 0.05). In addition, poor dental status

expressed by the number of decayed, missing and filled teeth and surfaces, exhibited a

statistically significant negative correlation with the bite force (p < 0.05). Occlusal

pattern, vertical occlusal relationship, maximum mouth opening showed statistically

nonsignificant correlation with bite force (p > 0.05).Dietary habits determined by

consistency of food intake showed positive significant correlation with the bite

force(p<0.05).

As highlighted by the findings of the present study, dental condition and caries

experience are among the fundamental factors influencing bite force that has not

attracted researcher’s attention despite its importance particularly in children.

The study’s findings can serve as an additional supportive evidence in the field of

paediatric dentistry for the positive effects of treating dental caries in children and

proving that chewing function can be improved by establishing and maintaining a good

level of oral health, which is essential when striving to achieve good general health, and

subsequently enhancing the maximum bite force which a child can exert.

………………………………………

CONCLUSION

Conclusion

98

CONCLUSION

Clinical and animal experiments have demonstrated the role of masticatory muscle

function in normal and abnormal dentofacial development. Masticatory muscle strength

can be evaluated by different methods and is influenced by many variables. One such

method is the assessment of maximum voluntary bite force (MVBF).

The aim of this study was to assess MVBF in Bengalee children with caries free and

caries affected dental status. Reference values in different age groups and the

stabilization of MVBF can be used in the objective evaluation of the occlusion

evaluation of jaw muscle function and activity, diagnosis & treatment plan.

The current study is an exploratory and primary study that is considered an original

Kolkata based study of its kind. While the current study provided significant findings,

further studies with larger number of study sample can be performed to broaden the

available knowledge regarding bite force in caries free and children with carious teeth.

Improvements in the design of bite force meter can be incorporated in future studies.

However, it remains uncertain to what degree or extent the bite force and hence

masticatory efficiency deteriorates if carious teeth are left untreated. This question can be

answered in a study designed to record bite forces in a sample of children with carious

teeth who are awaiting dental treatment on different intervals before the commencement

of dental management and then to compare bite forces in a period of time.

Furthermore, there is also the need to establish whether bite force is better improved

through the extraction approach of carious teeth or the restoration of such teeth (i.e.

studies comparing different interventions).

Such a query can be resolved through the conduction of a study with a randomized,

controlled design. Information relating to children’s bite force remains essential, as this

can help to guide and assist in treatment decisions made by paediatric dentists who aim

to improve children’s dental health and general wellbeing.

Considering the sample size and methodology used in the present study the following

conclusions can be drawn:

Conclusion

99

Age and gender was an important determinant factor of maximum bite force in

the present sample of children. It value increased from 6 to 14 years; moreover

males in each groups demonstrated higher bite force compared to corresponding

females of that age group.

The maximum voluntary bite force in children was influenced by a number of

key factors including body variables. A positive correlation existed between both

body height (nonsignificant) and weight (significant) and the bite force exerted

by the child.

BMI had no direct effect on bite force and correlation was not stastically

significant.

Oral status variable such as the number of maxillary posterior teeth in contact

showed significant positive correlations with bite force in comparison to other

variables such as occlusal pattern, vertical occlusal relationship and maximum

mouth opening.

This study confirmed the presence of a significant negative impact of poor dental

status (i.e. caries experience) on a child’s maximum bite force.

The study confirmed that children with preferred hard type and texture of food

demonstrated high bite force in comparison to children on soft diet.

It must be highlighted that further research on larger population is required in this

field in order to broaden knowledge about children’s bite force and the various different

influencing key factors as well as improving it.

………………………………………

REFERENCES

References

100

REFERENCES

1. Bakke M. Bite Force and Occlusion. Seminars in Orthdontics, 2006;12:120-126.

2. Calderon, P.S., E.M. Kogawa, J.R.P. Lauris, and P.C.R. Conti.The influence of

gender and bruxism on the human maximum bite force. Journal of Applied Oral

Sciences. 2006; 14:448-453.

3. Van der bilt. Assessment of mastication with implications for oral rehabilitation.

Review article. Journal of oral rehabilitation.2011;38:754-780.

4. Daumas, Xu, & Bronlund.Human masticatory muscles. Review article.Journal of

oral rehabilitation.2005;42:414-423.

5. Julien KC, Buschang PH, Throckmorton GS, Dechow PC. Normal masticatory

performance in young adult and children. Arch Oral Biol. 1996; 41:69−75.

6. Hatch, J.P.S. Sakai, J.D. Rugh, and E.D. Paunovich.. Determinants of masticatory

performance in dentate adults. Archives of Oral Biology. 2001; 46:641-648.

7. Koc, D., A. Dogan, and B. Bek. 2010. Bite force and influential factors on bite

force measurements: A Literature Review. European Journal of Dentistry. 2010 ;

4:223-232.

8. Laura Mitchell.An introduction to orthodontics;3rd

edition.Oxford medical

publications 2004.

9. Shinogaya T, Bakke M, Thomsen CE, Vilmann A, Sodeyama A, Matsumoto M.

Effects of ethnicity, gender and age on clenching force and load distribution.

Clin Oral Invest.2001; 5:63-68.

10. Waltimo A, Könönen M. A novel bite force recorder and maximal isometric bite

force values for healthy young adults. Scand J Dent Res.1993; 101:171-175.

References

101

11. Bonakdarchian M, Askari N, Askari M. Effect of face form on maximal molar

bite force with natural dentition. ArchOral Biol . 2009; 54:201-204.

12. Castelo, P.M., M.B. Gaviao, L.J. Pereira, and L.R. Bonjardim. Masticatory

muscle thickness, bite force, and occlusal contacts in young children with

unilateral posterior crossbite. European Journal of Orthodontics.2007; 29:149-

156.

13. Mountain, G., D. Wood, and J. Toumba. Bite force measurements in children

with primary dentition. International journal of paediatric dentistry.2011

;21:112118.

14. Julien, K.C, P.H. Buschang, G.S.Throckmorton, P.C. Dechow.Normal

masticatory performance in young adults and children. Archives of Oral

Biology.1996 ;41:69-75.

15. Pereira LJ, Gaviao MBD, Bonjardim LR, Castelo PM, Van Der Bilt A. Muscle

thickness, bite force, and cranio-facial dimensions in adolescents with signs and

symptoms of temporomandibular dysfunction. Eur J Orthod. 2007;29:72- 78.

16. Farella M, Bakke M, Michelotti A, Rapuano A, Martina R. Masseter thickness,

endurance and exercise-induced pain in subjects with different vertical cranio-

facial morphology. Eur J Oral Sci.2003;111:183-188.

17. Kleinfelder JW, Ludwig K. Maximal bite force in patients with reduced

periodontal tissue support with and without splinting.

J Periodontol.2002;73:1184-1187.

18. Alkan A, Keskiner I, Arici S, Sato S. The effect of periodontitis on biting

abilities. J Periodontol.2006;77:1442-1445.

References

102

19. Kogawa EM, Calderon PS, Laurus JRP, Araujo CRP, Conti PCR. Evaluation of

maximal bite force in temporomandibular disorders patients. J Oral

Rehabil.2006;33:559-565.

20. Sonnesen L, Bakke M, Solow B. Temporomandibular disorders in relation to

craniofacial dimensions, head posture and bite force in children selected for

orthodontic treatment. Eur J Orthod.2001;23:179-192.

21. Paphangkorakit, J., and J.W. Osborn.. Effect of Jaw opening on the direction and

magnitude of human incisal bite forces. Journal of Dental

Research.1997;76:561-567.

22. Ikebe, K., T. Nokubi, K. Morii, J. Kashiwagi, and M. Furuya. Association of bite

force with ageing and occlusal support in older adults. Journal of Dentistry.

2005;33:131-137.

23. Abanto et al. Impact of oral diseases and disorders on oral health related quality

of life of preschool children. Community Dentistry and oral

Epidemiology.2011,39:105-114.

24. Paula et al. The influence of oral health conditions, socioeconomic status and

home environment factors on schoolchildren„s self-perception of quality of life.

Health and Quality of Life Outcomes.2012; 10 (1): 6.

25. Saha, Sarkar. Prevalence and severity of dental caries and oral hygiene status in

rural and urban areas of Calcutta. J Indian Soc Pedo Prev Dent.1996;14:17-20.

26. Madhumati Chatterjee, Arup Ratan Bandyopadhyay, A Study on Nutritional

Status and Dental Caries in Permanent Teeth among School Going Girl of

Bengalee Population, India.Copyright © 2012 SciRes.

27. Bite Force and Occlusal Stress Production in Hominin Evolution: Am J Phys

Anthrop. 2013 ;151:544–557.

References

103

28. Ferrario VF, Sforza C, Zanotti G, Tartagilia GM,“Maximal bite force in healthy

young adults as predicted by surface electromyography”, J Dent. 2004;32:451-

457.

29. Bakke, M., A. Tuxen, P. Vilmann, B.R. Jensen, A. Vilmann, and M. Toft.

Ultrasound image of human masseter muscle related to bite force,

electromyography, facial morphology, and occlusal factors. Scandinavian Journal

of Dental Research.1992;100:164-171.

30. Fernandes, C.P., P.J. Glantz, S.A. Svensson, and A. Bergmark.A novel sensor to

bite force determinations. Dental Materials.2003;19(2):118-126.

31. Toro, A., P.H. Buschang, G. Throckmorton , and S. Roldan. Masticatory

performance in children and adolescents with Class I and II malocclusions.

European Journal of Orthodontics, 2006;28:112-119.

32. OW, R.K, G.E., Carlsson, and T. Jemt. Biting forces in patients with

craniomandibular disorders.The Journal of Cranio Mandibular

Practice.198;7:119-25.

33. Rentes, A.M., M.B.D. Gaviao and J.R. Amaral. 2002. Bite force determination in

children with primary dentition. Journal of oral rehabilitation.2002;29:1174-

1180.

34. Kuczmarski, R. J., Ogden, C. L., Guo, S. S., Grummer-Strawn, L. M., Flegal, K.

M., Mei, Z., Wei, R., Curtin, L. R., Roche, A. F., & John-son, C. L. CDC

Growth Charts for the United States: Meth-ods and development. Vital and

Health Statistics.2002;11:1-190.

34. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC,Walsh EK. Limits of human bite

strength. J Prosthet Dent 1986; 56: 226-229.

References

104

36. Black GV: The force exerted in the closure of the jaws. Dent Cosmos 37469,

1895.

37. McWhirter N, editor: Guinness Book of World Records. New York, Bantam

Books.1985: 669-677.

38. Patterson, C.J.W. A clinical and biomechanical investigation of single tooth dental

implants. Ph.D. thesis, University of Leeds. 1998.

39. Serra, M.D., F.R. Gambareli, and M.B. Gaviao.. A 1- year intra individual evaluation

of maximum bite force in children wearing a removable partial prosthesis. Journal of

Dentistry for Children (Chicago).2007; 74:171-176.

40. Rismanchian, M., F. Bajoghli, Z. Mostajeran, A. Fazel, and P. Eshkevori. Effects of

implants on maximum bite force in edentulous patients. Journal of Oral

Implantology.2009;35:196- 200.

41. Luraschi, J., M. Schimmel, J.P. Bernard, G.O. Gallucci, U. Belser, and F. Muller.

Mechanosensation and maximum bite force in edentulous patients rehabilitated with

bimaxillary implant-supported fixed dental prostheses. Clinical Oral Implant

Research.2012; 23:577-583.

42. Muller, F., M. Hernandez, L. Grutter, L. Aracil-kessler, D. Weingart, and M.

Schimmel. Masseter muscle thickness, chewing efficiency and bite force in

edentulous patients with fixed and removable implant-supported prostheses: a cross-

sectional multicenter study. Clinical Oral Implants Research.2012;23:144-150.

43. Carlsson, G.E.. Early in contrast to recent methods to evaluate masticatory function

in implant patients. Journal of Prosthodontic Research.2012;56:3-10.

44. Lindqvist, B., and M. Rinqvist. 1973. Bite force in children with bruxism. Acta

Odontologica Scandinavica.1973;31:255-259.

References

105

45. Calderon, P.S., E.M. Kogawa, J.R.P. Lauris, and P.C.R. Conti. The influence of

gender and bruxism on the human maximum bite force. Journal of Applied Oral

Sciences.2006;14:448- 453.

46. Bakke, M., B. Holm, and K. Gotfredsen.. Masticatory function and patient

satisfaction with implant-supported Mandibular overdentures: a prospective 5-year

study. International Journal of Prosthodontics.2002;15:575-581.

47. Muller, F., M. Hernandez, L. Grutter, L. Aracil-kessler, D. Weingart, and M.

Schimmel. Masseter muscle thickness, chewing efficiency and bite force in

edentulous patients with fixed and removable implant-supported prostheses: a cross-

sectional multicenter study. Clinical Oral Implants Research.2012;23:144-150.

48. Lepley, C.R., G.S. Throckmorton, R.F. Cean, and P.H. Buschang.Relative

Contribution of occlusion, maximum bite force, and chewing cycle kinematics to

masticatory performance.American Journal of Orthodontics and Dentofacial

Orthopedics.2011:606-613.

49. Lemos, A.D., F.R. Gambareli, M.D. Serra, R. L. Pocztaruk, M.B. Gaviao.Chewing

performance and bite force in children. Brazilian Journal of Oral

Sciences.2006;5:1101-1108.

50. Ohira, A., Y. Ono, N. Yano, and Y. Takagi. The effect of chewing exercise in

preschool children on maximum bite force and masticatory performance.

International Journal of Paediatric Dentistry.2012; 22:146-153.

51. Shiere, F.R., and R.S. Manly.The effect of changing dentition on masticatory

function. Journal of Dental Research.1952 ;31:526-534.

52. Agerberg, G., G.E. Carlsson, and M. Helkimo.Chewing ability in relation to dental

and general health. Analysis of data obtained from a questionnaire.Acta

Odontologica Scandinavica.1981; 39:147-153.

References

106

53. Tanner, J.M.Growth and adolescence. Blackwell, Oxford.1962

54. Barrera, L.M., P.H. Buschang, G.S. Throckmorton, and S.I. Roldan. Mixed

longitudinal evaluation of masticatory performance in children 6 to 17 years of age.

American Journal of Orthodontics and Dentofacial Orthopedics.2011;139:427-434.

55. Fontijn-Tekamp, F.A., A.P. Slagter, A. Van der Bilt, M.A. Van Thof, D.J. Witter, W.

kalk, and J.A. Jansen. Biting and chewing in overdentures, full dentures, and natural

dentitions Journal of Dental Research.2000;79:1519-1524.

56. Okiyama, S., K. Ikebe, and T. Nokubi. Association between masticatory performance

and maximal occlusal force in young men. Journal of Oral Rehabilitation.2003

;30:278-282.

57. Wilding, R.J.. The association between chewing efficiency and occlusal contact area

in man. Archives of Oral Biology.1993; 38:589-596.

58. Bourdiol, P., and L. Mioche. Correlations between functional and occlusal tooth-

surface areas and food texture during natural chewing sequences in humans. Archives

of Oral Biology.2000;45:691-699.

59. Ownes, S., P.H. Buschang, G.S. Throckmorton, L. Palmer, and J.

English .Masticatory performance and areas of occlusal contact and near contact in

subjects with normal occlusion and malocclusion. American Journal of Orthodontics

and Dentofacial Orthopedics.2002;121:602-609.

60. Sonnesen, L., and M. Bakke.Molar bite force in relation to occlusion, craniofacial

dimensions, and head posture in pre-orthodontic children. European Journal of

Orthodontics.2005;27(1):58-63.

References

107

61. Usui, T., S. Uematsu, H. Kanegae, T. Morimoto, and S. Kurihara. Change in

maximum occlusal force in association with maxillofacial growth. Orthodontic and

Craniofacial Research.2007;10:226-234.

62. Bakke, M., B. Holm, B.L. Jensen, L. Michler, E. Moller. Unilateral isometric bite

force in 8-68-year-old women and men related to occlusal forces. Scandinavian

Journal of Dental Research.1990; 98:149-158.

63. Yurkastas, A.A. 1965. The masticatory act. A review. Journal of Prosthetic

Dentistry.1965; 15 :248-262.

64. Su, C.M., Y.H. Yang, and T.Y. Hsieh.. Relationship between oral status and

maximum bite force in preschool children. Journal of Dental Sciences.2009

;4:32-39.

65. Pizolato, R.A., M.B.D. Gaviao, G. Berretin-felix, A.C.M. Sampaio, A.S.T. Junior.

Maximal bite force in young adults with temporomandibular disorders and bruxism.

Brazilian Oral Research.2007;21:278-283.

66. Tsai, H., and K. Sun.Growth changes of general and dental health status in

Taiwanese children from mixed to early permanent dentition. The Japanese Journal

of Pediatric Dentistry. 2004;28:311-314.

67. Kamegai, T., T. Tatsuki, H. Nagano, H. Mitsuhashi and J. Kumeta.A determination

of bite force in northern Japanese children. European Journal of orthodontics.2005;

27(1):53-70.

68. Linderholm, H., B. Lindqvist, M. Ringqvist, and A. Wennstrom.. Isometric bite force

In children and its relation to body build and general muscle force. Acta


69. Gaviao, M.B., V. G. Raymundo, A.M. Rentes. Masticatory performance and bite

force in children with primary dentition. Brazilian Oral Research.2007 ; 21:146-152.

References

108

70. Castelo, P.M., L.J. Pereira, L.R. Bonjardim, and M.B. Gaviao.Changes in bite force,

masticatory muscle thickness, and facial morphology between primary and mixed

dentition in preschool children with normal occlusion. Annals of

Anatomy.2010;192:23-26.

71. Kiliaridis, S., H. Kjellberg, B. Wenneberg, and C. Engstrom. The relationship

between maximal bite force, bite force endurance, and facial morphology during

growth. A cross- sectional study. Acta Odontologica Scandinavica.1993; 51:323-331.

72. Proffit, W.R., H.W. Fields, and W.L. Nixon.Occlusal forces in normal and long-face

adults. Journal of Dental Research.1983;62,:566-570.

73. Braun, S., H.P. Bantleon, W.P. Hnat, J.W. Freudenthaler, M.R. Marcotte, and B.E.

Johnson.A study of bite force, part 1:Relationship to various physical characteristics.

Angle Orthodontist.1995; 65:367-372.

74. Castelo, P.M. , M.B. Gaviao, L.J. Pereira, and L.R. Bonjardim. Masticatory muscle

thickness, bite force, and occlusal contacts in young children with unilateral posterior

crossbite. European Journal of Orthodontics.2007;29:149-156.

75. Mountain, G.Bite characteristics of children and the fidelity of testing methods as

they apply to toy safety. Ph.D. thesis, University of Leeds. 2008.

76. Williams, W.N., S.B. Low, W.R. Cooper, and C.E. Cornell.The effect of periodontal

bone loss on bite force discrimination. Journal of Periodontology.1987; 58:236-

239.

77. Kampe, T., T. Haraldson, H. Hannerz, and G.E. Carlsson.Occlusal perception and

bite force in young subjects with and without dental fillings. Acta Odontologica

Scandinavica.1987;45: 101-107.

References

109

78. Helkimo, E., G.E. Carlsson, and M. Helkimo.Bite force and state of dentition. Acta


79. Shiau,Y.Y., J.S. Wang.The effects of dental condition on hand strength and

maximum bite force. Journal of Cranio Mandibular Practice.1993;11:48-54.

80. Olthoff, L.W., W. Van Der Glas, and A. Van der Bilt.. An influence of occlusal

vertical dimension on the masticatory performance during chewing with maxillary

splints. Journal of Oral Rehabilitation.2007; 34:560-565.

81. Tortopidis, D., M.F. Lyons, R.H. Baxendle, and W.H. Gilmour.. The variability of

bite force measurements between sessions, in different positions within the dental

arch. Journal of Oral Rehabilitation.1998; 25:681-686.

82. Fernandes, C.P., P.J. Glantz, S.A. Svensson, and A. Bergmark.A novel sensor to bite

force determinations. Dental Materials.2003;19 (2):118-126.

83. Ortug, G. 2002. A new device for measuring mastication force. Annals of

Anatomy.2002; 184:393-396.

84. Castelo, P.M., L.J. Pereira, L.R. Bonjardim, and M.B. Gaviao.. Changes in bite

force, masticatory muscle thickness, and facial morphology between primary and

mixed dentition in preschool children with normal occlusion. Annals of

Anatomy.2010;192: 23-26.

85. Shinogaya, T., M. Bakke, C.E. Thomsen, A. Vilmann, and M. Matsumoto.Bite force

and occlusal load in healthy young subjects- a methodological study. European

Journal of Prosthodontics and Restorative Dentistry.2000; 8:11-15.

86. http://www.tekscan.com/occlusal-analysis-system#applications.

87. Kerstein, R.B.T-Scan II„s Computerized Occlusal Analysis Brings Your Practice Into

the Future, Contemporary Esthetics.1999:90-94.

References

110

88. Kerstein, R. B.Current Applications of Computerized Occlusal Analysis in Dental

Medicine. General Dentistry.2001; 49:521-530.

89. Mahoney, D.Refining Occlusion with Muscle Balance to Enhance Long-term

Orthodontic Stability. International Journal of Orthodontics.2004;15:1-6.

90. Garg, A. K.Analyzing Dental Occlusion for Implants: Tekscan's T-Scan III. Dental

Implantology.2007;19:66-70.

91. James Heitzman & Robert L. Early History 1000 BC –AD 1202. Worden 1989.

92. Helle, A., T. Tulensalo, and R. Ranta. Maximum bite force values of children in

different age groups. Proceedings of the Finnish Dental Society.1983;79:151-154.

93. Braun, S., W.P. Hnat , J.W. Freudenthaler, M.R. Marcotte, K. Honigle , and B.E.

Johnson. A study of maximum bite force during growth and development. Angle

Orthodontist. 1996;66:261-264.

94. Sathyanarayana, H.P., and S. Premkumar.Assessment of Maximum Voluntary Bite

Force in children and adults with normal occlusion. International Journal of

Pharmaceutical Science and Health Care.2012; 2:64-70.

95. Owais, A., M. Shaweesh, and E. Abu Alhaija.Maximum occlusal bite force for

children in different dentition stages. European Journal of Orthodontics.2012;10:42-

48.

96. Koc, D., A. Dogan, and B. Bek. 2011. Effect of gender, facial dimensions, body mass

index and type of functional occlusion on bite force. Journal of Applied Oral

Science.2011 ;19(3): 274-279.

97. Abu Alhaija, E.S., I.A. Al zo„ubi, M.E. Al Rousan, and M.M. Hammad. Maximum

occlusal bite forces in Jordanian individuals with different dentofacial vertical skeletal

patterns. European Journal of Orthodontics.2010 ;32:71-77.

References

111

98. Ahlgren J. Mechanism of mastication: a quantitative cinematographic and

electromyographic study of masticatory movements in children, with special

reference to occlusion of the teeth. Acta Odontol Scand. 1966;24:44.

.

99. Ahlgren JG, Ingervall BF, Thilander BL. Muscle activity in normal and postnormal

occlusion. Am J Orthod. 1973;5:445−456.

100. Van Spronsen, P.H., W.A. Weijs, J. Valk, B. PrahL-Andersen, and F.C. Van

Ginkel. Comparison of jaw-muscle bite force cross-sections obtained by means of

magnetic resonance imaging and high-resolution scanning. Journal of Dental

Research.1989; 68:1765- 1770.

101. Ingervall B, Minder C. Correlation between maximum bite force and facial

morphology in children. Angle Orthod. 1997; 67:415−424.

102. Yamanaka, R., R. Akther, M. Furuta, R. Koyama, T. Tomofuji, D. Ekuni, N.

Tamaki, T. Azuma, T. Yamamoto, and E. Kishimoto. Relation of dietary

preference to bite force and occlusal contact area in Japanese children. Journal of

Oral Rehabilitation.2009;36:584-591.

103. Anderson, H.K., B.K.Drummond, and W.M. Thomson.Changes in aspects of

children„s oral-health-related quality of life following dental treatment under

general anaesthesia.International Journal of Paediatric Dentistry.2004;14:317-325.

…………………………………………..

APPENDIX

List of Abbreviations BMI Body Mass Index.

Case Caries affected children

Control Caries free children

Dmft Decayed, missing and filled primary teeth.

dmfs Decayed, missing and filled surfaces in primary teeth.

DMFT Decayed, missing and filled surfaces in permanent teeth.

DMFS Decayed, missing and filled surfaces in permanent teeth.

FC Food consistency

FIG. figure

ht. height

Kg kilogram, unit of force

MVBF Maximum voluntary bite force

MPTC Maxillary posterior teeth in contact

MMO Maximum mouth opening

N Newton , unit of force.

OP Occlusal pattern

r Correlation Coefficient

VOR Vertical occlusal relationship

wt. weight

yrs years

Sl.n

o

AGE(

YRS)

AGEG

ROU

P

GEN

DER

GRO

UP

BODY

HT(

CM)

BODY

WT.

BMI

OP

VOR

MM

O(C

M)

MPT

C

dmft

DMFT

dmfs

DMFS

MVB

F O

N R

(KG

)

MVB

F O

N L

(KG

)

MVB

F

FC

4 12 3 1 2 143.4 39.3 19.11147681 1 2 4.3 5 1 1 22.27 20.2 21.235 129 12 3 1 2 143.4 39.3 19.11147681 1 2 4.3 5 1 1 9.93 20.2 15.065 112 14 3 1 2 156.8 38.1 15.49647282 1 1 3.8 5 2 2 20.1 19.93333333 20.01666667 120 12 3 1 2 147 37 17.12249526 1 1 5.4 5 2 2 18.93 19.5 19.215 115 12 3 2 2 143 42.8 20.93011883 1 1 4.8 5 2 3 21.5 21.93333333 21.71666667 12 13 3 1 2 151.9 40.9 17.72587818 1 1 4.7 4 3 3 20.06666667 20.06666667 20.06666667 16 14 3 1 2 157.8 49.3 19.79852888 1 1 5.4 5 3 3 18.56666667 16.53333333 17.55 1

11 14 3 2 2 155 48 19.97918835 1 1 5.2 2 3 10 17.27 17.43 17.35 11 12 3 1 2 147 38.6 17.86292748 1 1 4.9 3 4 7 18.33333333 18.1 18.21666667 13 14 3 1 2 160 67.3 26.2890625 1 1 5.1 4 4 4 21.06666667 18.9 19.98333333 1

27 14 3 1 2 159.3 48 18.91514548 1 1 4.9 5 4 4 13.8 17.93333333 15.86666667 15 13 3 2 2 141.8 49 24.36933164 2 2 5.1 4 4 10 16.4 15.5 15.95 1

13 13 3 2 2 151 48 21.05170826 1 1 4.6 3 4 6 17.5 17.06666667 17.28333333 114 12 3 2 2 146 39.6 18.5775943 1 1 4.3 4 4 8 17.6 16.93 17.265 216 14 3 2 2 157.9 51.9 20.81627889 1 1 5.3 4 4 11 15.13 13.53 14.33 224 12 3 2 2 146 39.6 18.5775943 1 1 4.3 4 4 9 17.6 17.03333333 17.31666667 211 14 3 1 2 159.3 45.8 18.04820131 1 1 4.2 4 5 5 18.53333333 17.56666667 18.05 113 13 3 1 2 149.1 34.3 15.42903745 2 3 4.1 3 5 5 16.60333333 16.56666667 16.585 112 12 3 2 2 147.1 38.7 17.88486307 1 1 4.8 3 5 18 15.6 14.96666667 15.28333333 122 14 3 2 2 157.9 51.9 20.81627889 1 1 5.3 4 5 8 19.2 19 19.1 132 13 3 2 2 154.1 63 26.52987917 1 1 4.7 3 5 14 15.57 14.56666667 15.06833333 214 14 3 1 2 151.9 52.6 22.79660617 1 1 4.9 4 6 10 16.10333333 14.66666667 15.385 29 13 3 2 2 158.5 35 13.93187314 1 2 4.8 3 6 12 18.63 17.2 17.915 1

23 12 3 2 2 151.7 39.7 17.25120139 1 1 4.6 3 6 13 17.63 17.36666667 17.49833333 131 12 3 2 2 146 40.5 18.99981235 1 1 4.3 2 6 11 13.67 12.53333333 13.10166667 134 14 3 2 2 161 68 26.2335558 1 1 4.8 3 6 6 11.5 11.03333333 11.26666667 29 14 3 1 2 157.3 42.8 17.29761887 1 1 5.1 3 7 13 16.26666667 15.46666667 15.86666667 1

22 14 3 1 2 171.8 52.6 17.82130181 1 2 4.6 4 7 7 17.63 19.6 18.615 126 12 3 1 2 146 39 18.29611559 3 1 5.1 1 7 7 10.17 13.3 11.735 128 13 3 1 2 153.2 40 17.04285938 3 2 5.1 4 7 7 15.57 17.16666667 16.36833333 132 13 3 1 2 151.9 52.6 22.79660617 1 1 4.7 3 7 7 16 16.6 16.3 118 13 3 2 2 146.5 38 17.70550618 1 1 4.9 2 7 16 16.87 16.2 16.535 129 13 3 2 2 156 34 13.97107166 1 1 4.3 2 7 16 8.93 12.5 10.715 235 14 3 2 2 155 55 22.89281998 1 1 5.2 3 7 11 14 14.03333333 14.01666667 118 13 3 1 2 151.9 41.9 18.15927373 1 1 4.9 3 8 10 17.53333333 16.5 17.01666667 119 14 3 1 2 155 65 27.05515088 1 1 4.7 4 8 8 15.4 18.36666667 16.88333333 14 14 3 2 2 153.4 60 25.49767206 1 1 4.9 3 8 16 15.23 15.4 15.315 2

21 13 3 2 2 158.5 35 13.93187314 1 2 4.8 3 8 12 18.93 17.2 18.065 125 13 3 2 2 147.8 39.8 18.21940559 2 2 5.3 3 8 12 18.1 17.73333333 17.91666667 17 12 3 1 2 141.6 35 17.45587156 2 2 4.7 2 9 17 14.43 13.66666667 14.04833333 2

15 12 3 1 2 163.7 51.8 19.33002434 1 1 4.6 3 9 21 14.00333333 12.33333333 13.16833333 124 13 3 1 2 151.3 58 25.33670515 2 2 4.1 3 9 17 18.1 14.56666667 16.33333333 231 14 3 1 2 143.2 33.7 16.43402203 1 1 5.3 4 9 15 14.2 13.93333333 14.06666667 228 12 3 2 2 147.8 55 25.17757054 1 1 4.7 3 9 18 13.8 9.2 11.5 233 13 3 2 2 140.6 42 21.24607201 1 1 5.1 1 9 28 9.93 8.733333333 9.331666667 219 12 3 2 2 151.7 39.7 17.25120139 1 1 4.1 2 10 18 17.07 15.53333333 16.30166667 15 13 3 1 2 150.1 40.9 18.15356496 1 1 5.2 2 11 21 15.6 15.06666667 15.33333333 18 12 3 1 2 142.3 33.6 16.59317438 1 1 4.8 3 11 18 14.67 13.1 13.885 2

21 14 3 1 2 160.9 45 17.38202722 1 1 4.1 3 11 11 19.2 16.56666667 17.88333333 130 12 3 1 2 141.6 35 17.45587156 2 2 4.7 2 11 17 11.5 13.66666667 12.58333333 210 14 3 2 2 153.6 57 24.15974935 1 2 5.4 2 11 34 14.37 13.87 14.12 230 12 3 2 2 141.9 57 28.30805722 2 2 3.9 2 11 23 8.4 7.433333333 7.916666667 210 13 3 1 2 143.2 33.7 16.43402203 1 1 5.7 4 12 15 14.2 13.93333333 14.06666667 21 12 3 2 2 148 38 17.34842951 1 1 4.8 3 12 22 11.6 11.16666667 11.38333333 23 14 3 2 2 152.8 43 18.41712124 1 1 4.3 2 12 32 10.23 8.366666667 9.298333333 2

Sl.n

o

AGE(

YRS)

AGEG

ROU

P

GEN

DER

GRO

UP

BODY

HT(

CM)

BODY

WT.

BMI

OP

VOR

MM

O(C

M)

MPT

C

dmft

DMFT

dmfs

DMFS

MVB

F O

N R

(KG

)

MVB

F O

N L

(KG

)

MVB

F

FC

27 14 3 2 2 154.6 65 27.19533278 1 1 4.9 2 12 36 10.17 9.266666667 9.718333333 216 12 3 1 2 149.6 38.3 17.11337184 1 1 3.8 2 13 27 10.76 10.63333333 10.69666667 225 14 3 1 2 149 38 17.11634611 1 1 4.3 2 13 15 10.5 12.83333333 11.66666667 235 13 3 1 2 152.7 31.8 13.63794849 1 1 4.7 1 13 29 8.566666667 8.366666667 8.466666667 22 13 3 2 2 157 32 12.98227109 1 1 4.1 2 13 28 10.3 9.066666667 9.683333333 2

17 13 3 2 2 149.3 47 21.08522513 1 3 5.2 3 13 23 14.23 11.73333333 12.98166667 233 12 3 1 2 163.7 51.8 19.33002434 1 1 4.6 3 14 21 14 12.5 13.25 234 12 3 1 2 149.6 38.3 17.11337184 2 1 3.6 3 14 17 16.43333333 15.56666667 16 18 12 3 2 2 151 52 22.80601728 1 1 5.3 4 14 32 16.33 16.1 16.215 1

26 14 3 2 2 152.8 53 22.70017269 1 1 4.4 1 14 33 10.5 9.433333333 9.966666667 217 13 3 1 2 152.7 31.8 13.63794849 1 1 4.7 2 15 31 8.34 8.206666667 8.273333333 223 12 3 1 2 149.7 38.7 17.26900695 2 3 4.3 2 15 21 17.6 14.23333333 15.91666667 27 12 3 2 2 145 43 20.45184304 1 1 5.2 4 17 36 15.8 14.5 15.15 1

20 12 3 2 2 146 39.6 18.5775943 1 1 5.1 3 17 20 15.45 14.8 15.125 16 12 3 2 2 143.7 39.6 19.17704334 2 2 4.6 3 28 28 14.1 13.2 13.65 17 8 1 1 2 138.3 32.5 16.99 1 1 4.4 6 3 3 9.13 8.56 8.845 26 7 1 1 2 118.7 21.8 14.59 1 1 4.1 6 1 1 - 9.46 8.63 9.045 1

17 7 1 1 2 121.6 19.7 13.32 2 2 4.3 6 1 1 1 1 7.53 6.66 7.095 232 7 1 2 2 118.9 20.7 14.64 1 1 3.8 5 1 1 1 1 11.8 11.13 11.465 121 9 2 1 2 129.3 27.9 16.68 1 2 4.3 3 1 1 1 2 8.84 8.96 8.9 210 10 2 2 2 135.3 30.5 15.5 1 1 3.9 2 11 1 11 1 12.16 12.26 12.21 11 8 1 1 2 128.1 25.8 15.72 1 1 3.8 4 1 3 1 3 6.2 5.96 6.08 2

20 10 2 1 2 133.8 29.7 16.58 1 1 4.9 4 1 5 2 9 14.5 14.49 14.495 130 11 2 2 2 139.1 47.2 24.39 1 1 5.2 3 1 5 1 11 11.8 11.32 11.56 28 11 2 2 2 139.8 29.8 15.96 2 1 4.6 4 1 7 1 9 13.1 13.1 13.1 18 11 2 1 2 139.7 31.2 15.98680883 1 1 3.2 2 1 9 2 14 8.86 8.79 8.825 2

19 10 2 2 2 138.5 32.5 16.94 1 1 4.8 3 1 9 2 14 7.9 7.8 7.85 231 10 2 2 2 138.2 33.5 17.53 1 1 5.1 2 1 9 2 13 8.76 8.34 8.55 28 6 1 2 2 108.4 17.7 15.06 2 1 4.1 3 10 29 6.46 5.9 6.18 2

20 8 1 2 2 129.3 28.3 16.93 1 1 3.8 4 10 11 9.26 8.83 9.045 122 6 1 2 2 115.3 22.7 17.07 1 1 4.5 4 10 12 10.16 9.7 9.93 131 6 1 1 2 116.1 20.7 15.35 1 1 4.1 3 10 1 15 1 8.2 10.26 9.23 29 8 1 1 2 138.3 32.5 16.99 3 2 3.9 2 10 4 33 4 4.66 4.2 4.43 2

22 7 1 1 2 118.5 22.9 16.35 1 1 3.9 2 10 5 25 6 5.5 7.86 6.68 218 6 1 2 2 121.7 32.5 21.94 2 2 4.2 2 11 28 5.36 6.36 5.86 230 6 1 2 2 116.1 20.7 15.35 1 1 4.1 4 11 19 7.2 7.2 7.2 132 7 1 1 2 119.5 24.9 17.43 1 1 3.7 2 11 1 24 1 7.66 8.76 8.21 22 8 1 1 2 125 24 15.36 1 1 3.9 3 11 2 21 2 4.43 3.93 4.18 2

29 7 1 1 2 121.7 18.9 12.76 1 1 4.7 4 11 1 20 2 6.7 9.33 8.015 16 7 1 2 2 120.6 21.8 14.98 1 1 4.5 5 11 2 27 2 8.3 7.5 7.9 2

16 8 1 2 2 138.3 27 16.99 3 2 3.9 6 11 2 31 4 9.2 4.63 6.915 210 8 1 1 2 132.2 25 17.74 1 3 3.6 2 11 5 28 5 3.76 3.36 3.56 223 8 1 1 2 129.3 28.3 16.93 2 2 3.6 2 11 5 30 6 4.53 5.53 5.03 224 8 1 2 2 129.3 28.3 16.93 1 1 4.8 2 12 19 7.2 6.53 6.865 226 6 1 2 2 115.6 20.5 15.34 1 1 4.9 3 12 16 7.73 7.43 7.58 133 6 1 1 2 129.3 27 16.14 1 2 3.9 2 12 22 6.7 5.43 6.065 13 7 1 1 2 121.7 28.9 19.51 2 2 4.2 2 12 4 24 4 4.53 3.96 4.245 2

15 7 1 2 2 121.7 17.8 19.51 2 1 4.2 2 12 4 26 4 4.73 4.63 4.68 225 8 1 2 2 126.4 24.8 15.52 1 1 4.6 4 13 31 5.56 5.56 5.56 128 8 1 2 2 126.5 26.3 16.43 1 3 3.3 2 13 27 5.8 5.13 5.465 234 7 1 1 2 118.9 20.7 14.64 1 1 3.8 2 13 12 7.9 7.2 7.55 135 8 1 1 2 127.3 21 12.95 1 1 4.6 4 13 14 8.4 8.2 8.3 230 8 1 1 2 127.9 28.3 17.29 1 1 4.8 5 13 1 27 1 7.76 8.36 8.06 224 7 1 1 2 122.7 21.9 14.54 1 3 3.1 2 13 3 29 4 11.56 5.5 8.53 127 7 1 2 2 122.7 21.9 14.54 1 3 3.7 2 14 31 6.53 6.06 6.295 2

Sl.n

o

AGE(

YRS)

AGEG

ROU

P

GEN

DER

GRO

UP

BODY

HT(

CM)

BODY

WT.

BMI

OP

VOR

MM

O(C

M)

MPT

C

dmft

DMFT

dmfs

DMFS

MVB

F O

N R

(KG

)

MVB

F O

N L

(KG

)

MVB

F

FC

23 7 1 2 2 118.5 22.9 16.35 2 2 3.9 2 14 16 8.2 7.43 7.815 229 7 1 2 2 121.7 18.9 12.76 1 1 4.3 4 15 28 5.2 5.26 5.23 217 10 2 1 2 137.5 31.4 16.6 1 1 4.7 3 2 4 14.56 14.54 14.55 123 10 2 1 2 134.8 32.8 18.05 1 1 5.1 4 2 4 14.56 14.54 14.55 133 8 1 2 2 127.3 21 12.95 2 2 4.7 5 2 3 11.03 9.56 10.295 126 6 1 1 2 114.9 23.7 17.95 1 1 4.5 5 2 1 2 1 11.56 10.63 11.095 13 8 1 2 2 127.4 25.8 15.89 1 1 4.3 2 2 1 5 1 7.23 6.53 6.88 1

31 6 1 2 2 114.9 23.7 17.95 1 1 4.5 5 2 1 2 1 10.4 9.7 10.05 135 8 1 2 2 126.5 26.3 16.43 1 1 4.6 6 2 1 8 1 11.93 11.46 11.695 111 11 2 2 2 139.7 31.2 15.98 1 3 4.2 2 2 3 12 4 10.8 10.23 10.515 12 7 1 2 2 119.6 21.8 15.24 2 2 4.7 6 2 4 8 4 9.53 9.06 9.295 14 9 2 2 2 133.9 30.9 17.23 1 1 4.8 3 2 4 2 4 14.6 14.2 14.4 1

35 9 2 2 2 133.9 30.9 17.23 1 1 4.8 3 2 4 2 2 14.6 14.2 14.4 129 10 2 2 2 137.6 29.6 15.63 1 1 4.7 2 2 6 4 8 9.95 9.56 9.755 123 9 2 2 2 132.4 27.9 15.91 1 1 4.6 3 2 7 4 16 7.73 7.23 7.48 23 10 2 1 2 131.6 29.8 17.20697333 2 2 4.1 3 2 8 3 11 8.12 7.98 8.05 29 9 2 1 2 132.2 26.7 15.27736135 1 1 4.7 2 2 8 4 10 8.53 8.42 8.475 1

24 9 2 1 2 131.2 27.9 16.29 1 1 4.6 2 2 8 4 10 8.53 8.42 8.475 134 10 2 1 2 132.7 30.5 17.32 1 2 4.7 3 2 8 2 13 12.33 12.32 12.325 15 9 2 2 2 132.2 28.1 16.07 2 2 3.8 2 2 8 2 13 11.33 10.93 11.13 2

14 11 2 2 2 141.3 34.2 17.12 1 1 4.9 4 2 8 3 11 11.8 11.2 11.5 220 10 2 2 2 136.9 32 17.07 1 3 4.9 3 2 8 4 10 11.3 10.9 11.1 217 6 1 2 2 108.7 28.9 15.06 1 2 4.4 2 3 7 4.73 9.7 7.215 11 6 1 2 2 114.6 19.5 14.84 1 1 4.5 4 3 1 3 2 6.6 5.86 6.23 25 6 1 2 2 111.3 18.9 15.25 1 1 4.2 5 3 1 9 1 9.86 10.53 10.195 1

10 7 1 2 2 116.7 17.7 14.53 1 1 4.7 5 3 1 11 1 9.3 8.73 9.015 125 10 2 2 2 137.4 33.6 17.79 2 2 4.1 3 3 10 5 11 8.13 8.12 8.125 16 10 2 2 2 137.5 31.4 16.6 1 1 4.7 3 3 11 3 14 11.8 11.7 11.75 1

24 9 2 2 2 135.2 31.8 17.04 1 1 4.3 2 3 11 4 17 5.56 5.49 5.525 216 7 1 1 2 116.7 19.8 14.53 1 1 4.7 5 3 2 6 2 10.8 10.1 10.45 122 11 2 1 2 140 33.5 17.09 3 2 4.5 3 3 2 3 5 14.98 14.98 14.98 110 9 2 1 2 132.2 28.1 16.0784215 1 1 5.1 4 3 6 5 16 6.59 6.49 6.54 215 11 2 1 2 143.7 36.8 17.82109078 2 2 4.7 2 3 6 5 18 9.67 9.63 9.65 225 9 2 1 2 132.2 28.1 16.07 2 1 4.8 1 3 6 5 16 6.59 6.49 6.54 221 11 2 2 2 145.3 38.3 18.14 1 1 5 2 3 6 5 16 9.5 9.33 9.415 24 11 2 1 2 139.8 34.3 17.55010735 1 1 5.4 3 3 7 4 11 11.89 11.79 11.84 1

33 10 2 1 2 139.4 32.6 16.77 2 1 4.3 3 3 7 4 11 11.56 11.57 11.565 115 11 2 2 2 137.5 33.7 17.82 1 1 4.7 2 3 7 4 11 13.8 13.36 13.58 128 10 2 1 2 136.5 31.4 16.85 1 2 4.4 3 3 8 3 8 9.87 9.86 9.865 130 11 2 1 2 137.5 31.4 16.60826446 1 1 4.9 2 3 8 4 17 12.57 12.39 12.48 211 9 2 1 2 133.9 30.9 17.23444591 1 1 3.8 3 3 9 4 17 5.57 5.53 5.55 226 9 2 1 2 129.8 25.6 15.19 1 1 4.6 2 3 9 4 17 5.57 5.53 5.55 27 10 2 1 2 134.5 31.4 17.35741629 1 1 4.2 3 3 5 9.35 9.42 9.385 1

14 9 2 1 2 132.9 27.1 15.34331951 1 1 4.6 3 3 3 9.96 9.95 9.955 118 9 2 2 2 128.5 29.6 19.68 1 1 4.7 3 3 5 9.3 8.9 9.1 19 8 1 2 2 131.9 29.5 16.95 1 1 5.1 6 4 8 10.9 10.03 10.465 1

14 6 1 2 2 129.3 27 16.14 1 1 4.3 2 4 12 9.2 10.46 9.83 134 7 1 2 2 119.5 24.9 17.43 1 1 4.3 6 4 6 11.53 12.4 11.965 121 6 1 2 2 114.9 23.7 17.95 1 1 4.6 5 4 8 11.5 10.8 11.15 114 7 1 1 2 121.7 28.9 19.51 2 1 3.5 6 4 1 18 1 9.4 8.3 8.85 225 8 1 1 2 126.5 26.3 16.43 1 1 4.6 4 4 1 15 1 10.76 3.56 7.16 127 6 1 1 2 115.3 22.7 17.07 1 1 5.2 6 4 5 - 9.6 10.4 10 118 9 2 1 2 132.2 28.1 16.07 1 1 4.8 2 4 8 6 15 7.73 7.69 7.71 27 8 1 2 2 132.2 28.5 16.3 1 1 4.9 6 5 13 11.76 11.2 11.48 1

13 6 1 1 2 108.4 15.7 8.64 1 2 4.7 5 5 1 24 1 10.76 10.66 10.71 1

Sl.n

o

AGE(

YRS)

AGEG

ROU

P

GEN

DER

GRO

UP

BODY

HT(

CM)

BODY

WT.

BMI

OP

VOR

MM

O(C

M)

MPT

C

dmft

DMFT

dmfs

DMFS

MVB

F O

N R

(KG

)

MVB

F O

N L

(KG

)

MVB

F

FC

4 8 1 2 2 115.9 33.8 25.16 2 2 3.9 4 5 2 28 2 8.3 8.4 8.35 18 6 1 1 2 108.7 17.8 15.06 1 1 4.2 5 5 4 18 9 6.73 7.66 7.195 2

18 6 1 1 2 114.1 19.5 14.97 1 1 4.4 3 5 5 20 8 8.63 8.26 8.445 24 6 1 1 2 118.9 20.7 14.64 1 1 4.3 3 6 1 13 1 7.5 6.43 6.965 1

12 6 1 1 2 118.3 30 21.43 1 1 3.9 5 6 1 15 1 11.33 10.46 10.895 113 6 1 2 2 108.7 20.7 15.06 2 1 4.2 5 6 2 15 2 6.73 6.36 6.545 221 8 1 1 2 124.8 28.9 18.55 1 1 5.1 3 6 3 14 5 6.73 9.2 7.965 212 6 1 2 2 129.3 19.8 16.14 2 1 3.7 2 7 2 28 2 5.2 5.1 5.15 219 6 1 1 2 119.5 20.7 14.49 1 1 4.6 4 7 3 18 7 9.23 6.66 7.945 111 6 1 1 2 116.1 20.7 15.35 1 1 4.1 3 8 2 24 2 5 5.76 5.38 120 8 1 1 2 127 25.8 15.99 1 1 4.5 5 8 2 22 3 8.66 8.26 8.46 211 6 1 2 2 116.1 29.5 15.35 1 1 4.1 3 8 2 24 2 4.9 5.86 5.38 219 8 1 2 2 127 25.8 15.99 1 1 4.5 5 8 2 22 3 9.23 9.2 9.215 15 6 1 1 2 129.3 27 16.14 2 1 3.9 4 8 4 14 6 8.46 7.43 7.945 1

15 7 1 1 2 133.3 31 17.44 1 1 4.2 5 9 1 29 1 9.46 9.46 9.46 12 10 2 2 2 132.2 28.5 16.3 1 1 4.7 2 1 9 1 12 9.96 9.2 9.58 2

33 10 2 2 2 132.2 28.5 16.3 1 1 4.7 2 1 9 1 12 9.96 9.2 9.58 228 6 1 1 2 112.9 19.8 15.53 1 1 5.1 5 9 2 10 3 7.7 11.3 9.5 12 10 2 1 2 134.8 31.9 17.55540685 1 1 4.5 4 4 7 9.12 9.1 9.11 1

13 10 2 2 2 136.7 32.5 17.39 1 1 4.8 3 4 7 11.1 11.2 11.15 11 10 2 1 2 137.5 31.4 16.60826446 1 1 4.8 4 5 10 8.78 8.67 8.725 1

12 9 2 2 2 129.3 24.6 14.71 1 1 4.3 3 5 10 8.3 8.1 8.2 129 11 2 1 2 132.2 28.1 16.07 2 1 4.9 3 1 2 16.67 16.59 16.63 126 10 2 2 2 135.8 37.2 20.17 1 1 4.4 3 10 14 7.56 7.23 7.395 21 9 2 2 2 128.9 28.5 17.15 1 1 4.5 2 11 24 7.9 7.2 7.55 2

32 9 2 2 2 128.9 28.5 17.15 1 1 4.5 2 11 24 7.9 7.2 7.55 219 11 2 1 2 136.3 28.5 15.34 2 2 4.8 4 2 3 15.6 15.59 15.595 135 11 2 1 2 137.8 38.9 20.48 1 1 4.9 3 2 5 14.88 14.88 14.88 13 11 2 2 2 142 33.7 19.34 2 2 4.8 4 2 3 13.2 13.06 13.13 1

34 11 2 2 2 142 33.7 19.34 2 2 4.8 4 2 3 13.2 13.06 13.13 131 10 2 1 2 132.9 27.1 15.34331951 1 1 4.8 4 3 5 13.33 13.33 13.33 132 11 2 1 2 143.7 36.8 17.82109078 1 1 3.9 4 3 6 14.56 14.57 14.565 128 11 2 2 2 134.9 46.3 25.44 1 1 4.9 4 3 5 14.49 14.32 14.405 112 9 2 1 2 130.9 28.7 16.74952917 2 2 4.3 2 4 5 8.5 8.35 8.425 127 10 2 1 2 133.7 32.5 18.18 1 1 5.1 2 4 5 8.5 8.35 8.425 113 10 2 1 2 137.5 31.4 16.60826446 1 1 4.9 3 5 9 11.66 11.63 11.645 122 9 2 2 2 129.5 29.6 17.65 1 1 4.5 2 5 11 8.89 8.56 8.725 15 11 2 1 2 141.5 37.6 18.77910824 1 1 5.1 2 6 8 13.67 13.65 13.66 1

16 11 2 2 2 134.6 37 20.42 1 1 4.9 2 6 8 14.2 14.3 14.25 116 11 2 1 2 139.4 32.6 16.77 3 3 4.8 3 7 13 10.57 10.54 10.555 227 11 2 2 2 139.4 44.8 23.05 1 1 4.8 3 7 9 13.8 13.56 13.68 19 11 2 2 2 141.9 40 19.86 1 1 4.7 4 8 13 9.1 8.73 8.915 26 11 2 1 2 142.9 38.9 19.04956854 1 1 4.9 4 9 12 12.79 12.75 12.77 17 10 2 2 2 134.8 31.9 17.55 1 1 4.2 4 9 13 12.6 12.5 12.55 1

17 11 2 2 2 142.3 33.4 16.49 2 1 5.1 2 9 12 11.8 11.3 11.55 21 8 1 2 1 126.4 24.8 15.52235219 1 1 4.6 3 8.56 8.1 8.33 12 8 1 2 1 121.3 21.8 14.81613382 1 1 3.8 2 7.6 7.23 7.415 13 7 1 2 1 123.7 22.6 14.76961042 2 2 2.9 2 8.1 7.86 7.98 14 6 1 2 1 114.6 20.5 15.60934307 1 1 4.2 1 6.2 5.6 5.9 25 6 1 2 1 115.6 19.5 14.5921385 1 1 4.1 5 9.63 9.4 9.515 16 8 1 2 1 123.5 27.9 18.29238309 1 1 3.9 5 9.5 8.9 9.2 17 7 1 2 1 118.7 21.8 15.47230635 2 1 4.3 4 7.73 7.1 7.415 28 8 1 2 1 132.2 25.5 14.59073837 2 1 4.4 3 7.3 7.2 7.25 19 6 1 2 1 112.7 20.5 16.14009286 3 3 3.3 2 5.53 5.73 5.63 2

10 6 1 2 1 108.7 17.8 15.0647148 1 1 3.8 4 8.26 8.4 8.33 1

Sl.n

o

AGE(

YRS)

AGEG

ROU

P

GEN

DER

GRO

UP

BODY

HT(

CM)

BODY

WT.

BMI

OP

VOR

MM

O(C

M)

MPT

C

dmft

DMFT

dmfs

DMFS

MVB

F O

N R

(KG

)

MVB

F O

N L

(KG

)

MVB

F

FC

11 7 1 2 1 124.6 19.8 12.75349175 1 1 3.9 3 7.53 7.46 7.495 112 8 1 2 1 138.3 32.5 16.99178486 2 2 4.3 5 11.46 10.3 10.88 113 8 1 2 1 133.3 28.9 16.26438117 3 3 4.1 3 7.16 6.3 6.73 214 7 1 2 1 114.6 19.5 14.8479117 1 1 3.9 4 7.93 7.93 7.93 115 6 1 2 1 108.4 15.7 13.36106534 1 1 4.3 3 6.03 5.43 5.73 21 6 1 1 1 116.1 20.7 15.35698309 1 1 4.3 2 7.56 6.93 7.245 12 7 1 1 1 121.7 22.9 15.46159616 1 1 3.9 2 8.4 8.33 8.365 13 8 1 1 1 128.1 25.8 15.72249432 1 1 3.8 5 9.5 9.2 9.35 14 7 1 1 1 119.8 24 16.72236142 1 1 3.5 2 4.46 6.9 5.68 25 8 1 1 1 129.3 25.3 15.13294562 1 1 4.5 4 8.53 8.3 8.415 16 8 1 1 1 142 33 16.36580044 1 2 3.9 6 13.6 13.26 13.43 17 8 1 1 1 132.2 25 14.30464546 1 1 3.5 2 7.2 6.5 6.85 28 7 1 1 1 133.3 31 17.44622202 2 2 4.2 1 6.53 6.1 6.315 19 8 1 1 1 121.7 28.9 19.51266939 2 2 3.7 1 7.26 7.06 7.16 19 8 1 1 1 121.7 28.9 19.51266939 2 2 3.7 1 7.26 7.06 7.16 1

10 8 1 1 1 129.3 31 18.54234443 2 2 4.2 4 9.5 8.73 9.115 111 6 1 1 1 127.3 21 12.95873138 1 1 2.9 2 5.53 4.9 5.215 212 6 1 1 1 118.9 20.7 14.64221017 1 1 3.9 2 8.3 7.66 7.98 113 6 1 1 1 118.3 30 21.43639571 1 1 3.5 5 11.2 10.83 11.015 114 8 1 1 1 129.3 27 16.14978386 1 1 4.2 2 8.06 6.5 7.28 215 7 1 1 1 119.5 24.9 17.43666953 1 1 4.1 3 8.5 8.2 8.35 11 10 2 2 1 138.3 32.5 16.99178486 1 1 5.2 4 15 14.46 14.73 12 10 2 2 1 142.9 50 24.48530661 1 2 4.9 3 15.63 14.76 15.195 13 9 2 2 1 144.3 42 20.17049834 1 1 4.2 3 16.2 15.56 15.88 14 9 2 2 1 132.2 39 22.31524692 1 1 3.8 4 13.16 13.06 13.11 15 11 2 2 1 142 33.7 16.71295378 2 2 4.8 2 10.43 10.83 10.63 26 10 2 2 1 138.3 43 22.48143844 1 1 5.1 3 12.6 11.46 12.03 17 9 2 2 1 132.2 28.5 16.30729583 1 1 5.1 2 12.53 12.2 12.365 18 11 2 2 1 142.9 38.7 18.95162732 1 1 4.7 3 14.3 12.8 13.55 19 10 2 2 1 138.3 32.5 16.99178486 1 1 4.9 4 15.73 14.8 15.265 1

10 9 2 2 1 128.9 28.5 17.15295804 1 1 4.7 2 9.6 8.73 9.165 211 11 2 2 1 139.8 29.8 15.24761513 2 2 4.3 2 8.1 7.76 7.93 212 10 2 2 1 140.9 34.5 17.3778926 3 3 4.1 1 7.16 6.53 6.845 213 10 2 2 1 135.3 30.5 16.66112206 1 1 3.9 1 7.16 6.5 6.83 214 11 2 2 1 141.9 33.7 16.73651804 1 1 4.8 3 12.16 12.26 12.21 115 9 2 2 1 148 38.7 17.66800584 1 1 4.3 2 10.96 10.63 10.795 11 10 2 1 1 137.5 31.4 16.60826446 1 1 4.8 4 21.83 20.93 21.38 12 10 2 1 1 134.8 31.9 17.55540685 1 1 4.5 4 15.2 14.5 14.85 13 10 2 1 1 131.6 29.8 17.20697333 2 2 4.1 3 12.8 12.46 12.63 14 11 2 1 1 139.8 34.3 17.55010735 1 1 5.4 3 19.66 19.03 19.345 15 11 2 1 1 141.5 37.6 18.77910824 1 1 5.1 2 13.76 12.93 13.345 26 11 2 1 1 142.9 38.9 19.04956854 1 1 4.9 4 22.03 21.83 21.93 17 10 2 1 1 134.5 31.4 17.35741629 1 1 4.2 3 15.43 15.23 15.33 18 11 2 1 1 139.7 31.2 15.98680883 1 1 3.2 2 9.16 8.66 8.91 29 9 2 1 1 132.2 26.7 15.27736135 1 1 4.7 2 7.93 7.23 7.58 2

10 9 2 1 1 132.2 28.1 16.0784215 1 1 5.1 4 15.23 14.43 14.83 111 9 2 1 1 133.9 30.9 17.23444591 1 1 3.8 3 16.03 15.06 15.545 112 9 2 1 1 130.9 28.7 16.74952917 2 2 4.3 2 11.53 11.2 11.365 213 10 2 1 1 137.5 31.4 16.60826446 1 1 4.9 3 11.4 9.7 10.55 114 9 2 1 1 132.9 27.1 15.34331951 1 1 4.6 3 13.8 13.4 13.6 215 11 2 1 1 143.7 36.8 17.82109078 2 2 4.7 2 12.3 11.13 11.715 21 13 3 2 1 152.3 49 21.12497839 1 2 5.4 4 17.9 17.76 17.83 12 13 3 2 1 149.3 38 17.04762883 1 1 3.5 4 23.5 21.5 22.5 13 13 3 2 1 159.3 65.2 25.6930726 1 2 4.5 5 23.65 21.23 22.44 14 13 3 2 1 152.8 40 17.13220581 2 2 3.3 2 14.23 11.93 13.08 2

Sl.n

o

AGE(

YRS)

AGEG

ROU

P

GEN

DER

GRO

UP

BODY

HT(

CM)

BODY

WT.

BMI

OP

VOR

MM

O(C

M)

MPT

C

dmft

DMFT

dmfs

DMFS

MVB

F O

N R

(KG

)

MVB

F O

N L

(KG

)

MVB

F

FC

5 12 3 2 1 162.5 61.9 23.44142012 3 3 4.7 2 15.13 14.16 14.645 26 13 3 2 1 157 32 12.98227109 1 1 4.1 2 11.9 11.76 11.83 27 13 3 2 1 153.9 45.3 19.12585956 1 1 6.1 5 30.03 25.33 27.68 18 14 3 2 1 152.8 53 22.70017269 1 1 4.4 1 10.5 9.43 9.965 29 14 3 2 1 152.4 88 37.88896467 2 1 4.1 2 10.4 10.96 10.68 2

10 12 3 2 1 147.8 54.7 25.04023834 1 1 4.7 5 14.66 13.03 13.845 111 14 3 2 1 151.9 53 22.96996439 1 1 4.4 1 10.5 9.43 9.965 212 13 3 2 1 154.1 61.7 25.98243722 1 1 4.8 6 24.33 22.26 23.295 113 12 3 2 1 141.9 57.8 28.70536328 2 2 3.9 3 15.1 14.03 14.565 214 14 3 2 1 153.6 63.4 26.87242296 1 1 5.2 5 22.7 19.86 21.28 115 12 3 2 1 146 40.5 18.99981235 1 1 5.2 5 22.17 19.43 20.8 11 12 3 1 1 147.9 37 16.91474193 1 1 5.2 4 22.46 20.03 21.245 12 12 3 1 1 149.7 39 17.40287522 1 1 4.9 4 23 21.96 22.48 13 13 3 1 1 153.6 44 18.64963108 1 1 5.3 5 24.4 24.03 24.215 14 12 3 1 1 147 42.5 19.66773104 1 1 5.1 4 24.4 19.66 22.03 25 12 3 1 1 151 48.6 21.31485461 1 1 5.4 3 20.8 19.23 20.015 16 13 3 1 1 157.8 51.3 20.60171464 1 1 4.9 2 17 15.06 16.03 27 12 3 1 1 146 39 18.29611559 1 1 4.9 4 27.1 24.43 25.765 18 14 3 1 1 160.9 56 21.6309672 1 1 5.3 6 33.1 29.03 31.065 19 13 3 1 1 155.6 40.9 16.89289656 2 2 4.6 3 18.26 18.43 18.345 2

10 13 3 1 1 159.8 43.5 17.03474775 1 1 4.7 4 19.2 17.96 18.58 111 14 3 1 1 158.1 53 21.20372337 1 1 5.1 5 25.33 27.33 26.33 112 14 3 1 1 153.6 65 27.55059136 1 1 5.2 5 31.56 29.4 30.48 113 13 3 1 1 149 38 17.11634611 1 1 4.3 2 18.2 17.67 17.935 214 14 3 1 1 159.3 48 18.91514548 1 1 4.9 6 34.3 30.23 32.265 115 12 3 1 1 146 39 18.29611559 1 1 4.9 4 27.1 24.63 25.865 1

research on bite force (mds thesis of dr. roshni maurya)

Healthcare