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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 44-49

Evaluation of bite force in patients with cleft lip and palate and its comparison with normal patients


Department of Prosthodontics and Crown and Bridge, Yenepoya Dental College, Mangalore, Karnataka, India

Date of Submission01-Sep-2020
Date of Decision12-Nov-2020
Date of Acceptance18-Nov-2020
Date of Web Publication26-Jun-2021

Correspondence Address:
Dr. Sanha Razdan
Department of Prosthodontics and Crown and Bridge, Yenepoya Dental College, Mangalore - 575 018, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/amhs.amhs_235_20

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  Abstract 


Aim and Objectives: This in vivo cross-sectional study aimed to measure and correlate the average and maximum bite forces between cleft and noncleft individuals. Materials and Methods: The study was conducted on thirty cleft and thirty noncleft lip and palate patients who were belonging to the age group of 14–30 years with unrepaired unilateral cleft lip and palate under treatment at the Craniofacial Center, Yenepoya Dental College, Mangalore, and G. S. R Craniofacial Center, Hyderabad, India. Dental Prescale® sheet was used to record the bite force of the patients and the test sheet was scanned with an Epson v330 color HD photo scanner, and the bite force was evaluated by an FDP 8010 analyzing system. The data were analyzed statistically by the Student's data t-test. Results: The control group had a statistically significantly higher mean pressed area on the left side (P = 0.034), maximum pressure on the left side (P < 0.001), mean maximum pressure on the right side (P = 0.024), and mean average pressure on the left side (P = 0.038). There was no statistically significant difference in the mean pressed area on the right side (P = 0.569) and average pressure on the right side of the control and study groups (P = 0.358). Conclusions: There was a statistically significant difference in the mean maximum pressure (P = 0.001) and average pressure (P = 0.039) among cleft lip and palate patients when compared with that of the control group. There was no significant difference between male and female subjects of both the groups.

Keywords: Bite force, cleft lip, cleft palate, dental Prescale®, occlusal forces, orthodontics


How to cite this article:
Bhat V, Reddy H, Razdan S, Shetty S. Evaluation of bite force in patients with cleft lip and palate and its comparison with normal patients. Arch Med Health Sci 2021;9:44-9

How to cite this URL:
Bhat V, Reddy H, Razdan S, Shetty S. Evaluation of bite force in patients with cleft lip and palate and its comparison with normal patients. Arch Med Health Sci [serial online] 2021 [cited 2021 Aug 1];9:44-9. Available from: https://www.amhsjournal.org/text.asp?2021/9/1/44/319385




  Introduction Top


Cleft is a defect that creates a gap or split in the upper lip, the roof of the mouth (palate), and this defect results when the lip and the palate do not fuse together in the second and third months of pregnancy. Within the 5th and 9th weeks of pregnancy, the face and upper lip start develop. Most clefts are picked up either at the time of the routine 20-week scan or soon after birth.[1]

The cleft can involve part or all of these areas and maybe one sided (unilateral) or affect both sides (bilateral).[2] These defects arise in about 1.7/1000 live-born babies, with an ethnic and geographic variation.

Typically, multidisciplinary care from birth to adulthood can help children with these disorders. They have higher morbidity and mortality throughout life than most unaffected individuals. Long-lasting adverse outcomes from health and social integration could occur because of the effects on speech, hearing, appearance, and cognition. Findings from some studies have revealed that there is an increased frequency of structural brain abnormalities. In addition, studies have shown that many children and their families are affected psychologically to some extent.[3]

Orofacial clefts inevitably pose a burden to the individual, the family, and the society, with substantial expenditure in terms of health and related services even though rehabilitation is possible with good-quality care. Furthermore, the standards of care for patients with cleft lip, cleft lip and palate, or cleft palate alone in both developing and developed countries remain a cause for concern.[4]

For complete rehabilitation of patients with cleft lip and palate, complete and thorough knowledge of the alterations of the stomatognathic system is necessary due to its complexities.

The masticatory muscles causing the bite force or masticatory function have an impact on the mandibular shape and structure, and influence the occlusal variation and dental arch form.[5] The use of the bite force as a clinical indicator of masticatory performance has been reported in literature.[6] This parameter is correlated with craniofacial morphology;[7] gender; age;[8] temporomandibular disorders; and also with status, number, and tooth mobility. Patients submitted to orthodontic treatment, orthognathic surgery, etc., have shown the same relationship. However, there is no literature on the bite force in patients with cleft lip and palate, a valid resource for evaluation of the neuromuscular function in these patients in all occurrence. The present study aimed to measure the bite force that cleft lip and palate patients can develop, and compare these data to the values found in normal patients.

A pressure-sensitive foil has been developed for use as an assessment method (Watanabe et al., 2001).[9],[10] This system is highly preferable for assessing bite force in an epidemiological survey. Referential data on the maximum bite force would be useful in establishing oral health needs. Furthermore, the data would be a good guideline in planning a strategy of oral health.

Aim

This study aimed to measure and correlate the average and maximum bite forces between cleft and noncleft individuals.

Objectives

  • The objectives were to evaluate the average and maximum bite forces in patients with cleft lip and palate
  • To evaluate the average and maximum bite forces in normal patients
  • To compare bite force in patients with cleft lip and palate with that of normal patients.



  Materials and Methods Top


Ethical approval

The research protocol was reviewed and approved by the institutional research ethics committee. Informed consent was obtained by all patients before being enrolled in the study.

Population

The present study was conducted on thirty cleft lip and palate individuals (16 males and 14 females) and thirty noncleft lip and palate patients (13 males and 17 females) aged 14–30 years with unrepaired unilateral cleft lip and palate under treatment at the Craniofacial Center, Yenepoya Dental College, Mangalore, and G. S. R. Craniofacial Center, Hyderabad, India.

Inclusion criteria

Cleft lip patients and cleft palate patients.

Exclusion criteria

Patients with teeth missing in the posterior region and patients under orthodontic treatment.

Bite force measurement

Dental Prescale® [Figure 1] sheet was used to assess the bite force. The medium-sensitive sheet was chosen depending on its force registration capacity from 0.05 to 50 Mpa. It was then laser cut into a palate-shaped sheet on which cardboard handles were attached, and a stainless steel handle was used to support the cardboard [Figure 2]. The midline marker was incorporated in these handles [Figure 3] and [Figure 4]. Prescale® sensor of thickness 97 μm consisted of two layers: one layer of microcapsules containing a color-forming material and another layer of a color-developing material. T-scan occlusal analysis system was used to analyze the bite force [Figure 5]. The microcapsules break and release the color-forming material at various occlusal pressures above 10 kg/cm2. The color-developing material, producing a red color whose intensity depended on the occlusal load applied to the test sheet, absorbed the released color-forming material. Polyethylene terephthalate (PET) covered the two layers, ensuring that the test material is safe and waterproof for use in the oral cavity. As a precautionary measure, the glossy PET side was always facing the lower side at the time of bite registration [Figure 6].
Figure 1: Dental Prescale sheet placed in a cardboard

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Figure 2: A metal handle placed in between the cardboard for support when placed in the mouth

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Figure 3: Different layers of dental Prescale sheet

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Figure 4: Bite force recording

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Figure 5: t-scan occlusal analyzer (evolution sensor)

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Figure 6: Two-dimensional representation of the Prescale sheet in FDP 8010 analyzing system and representation of the Prescale sheet in the FDP 8010 analyzing system

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The test sheet was then scanned with an Epson v330 color HD photo scanner (Epson®, Hydrabad, India), and the bite force was evaluated by an FDP 8010 analyzing system(Fujifilm holding corporations, India) [Figure 6]. The system analyzed the intensity of the red color of each pixel (about 16 pixels/mm2), and assigned each pixel one of the 256 specific occlusal load values between 10 kg/cm2 and 130 kg/cm2. The detected pixels were displayed on a monitor for further analysis. The system could store the scanned data on the computer as it could be used later if required. The measurement tool in the software displayed readings as Prescale effective rate, pressed area, average bite force, maximum bite force, load, and measured area. The thickness of the Prescale sheet and position at which it was kept inside the patient's mouth were standardized.

The data thus obtained were analyzed statistically by the Student's data t-test.


  Results Top


Among the total sample of sixty subjects, the minimum age was 14 and the maximum was 26 years, with a mean age of 19.6 years and a standard deviation (SD) of 2.659 [Table 1]. [Graph 1] shows the percentage of male and female within the group and also within the sex.
Table 1: Mean age

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[Table 2] shows a comparison of age of both groups. The mean age of the control group was 20.13 years with an SD of 2.187 and the mean age of the study group was 19.16 years, with an SD of 2.986. A mean age difference of 0.278 was found between both the groups which was not significant.
Table 2: Comparison of mean age in both groups

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The control group had a statistically significantly higher mean pressed area on the left side (P = 0.034), maximum pressure on the left side (P < 0.001), mean maximum pressure on the right side (P = 0.024), and mean average pressure on the left side (P = 0.038). There was no statistically significant difference in the mean pressed area on the right side (P = 0.569) and average pressure on the right side of the control and study groups (P = 0.358) [Graph 2] and [Table 3].

Table 3: Comparison between the study and control groups

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[Table 4] shows the combined pressure on both the right and left sides of the male and female groups where there was no statistically significant difference in the mean maximum pressure (P = 0.579) and average pressure (P = 0.305) [Graph 3].

Table 4: Combined right and left side measurements in male and female groups

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  Discussion Top


Mastication is crucial for the improvement and preservation of general health status. In particular, chewing ability in the elderly has been reported to influence nutritional status (Madeira, 1988; Horwath, 1989) and the general physical health (Tada et al.) of patients.[11] In addition, it was reported that chewing ability was significantly related to the quality of life in elderly Japanese subjects (Miura et al., 2000).

Some investigators have reported the comparison of bite force between denture wearers and normal dentate subjects in the dental clinics (Atkinson, et al., 1973).[12] Previously, the evaluation of bite force has been said to be difficult and its measurement has rarely been applied in epidemiological research. A pressure-sensitive foil has been developed for use as an assessment method.[10] This system is highly advantageous for assessing the bite force. The oral health needs of elderly men and women are established by referential data on the maximum bite force in the elderly, which is useful as it acts as a guideline in planning a strategy of oral health.

In the present study, unilateral cleft patients were selected as a study group with cleft not extending more than one quadrant, excluding patients who had undergone surgical and orthodontic correction. A study by Proffit et al., 1989,[13] has proved that patients who had undergone orthognathic surgery have increased bite force than before. However, a study by Thomas et al., 1995,[14] has shown no significant difference in bite force in patients before and after orthodontic treatment and hence, this criteria was excluded from this study.

In the present study, the dental Prescale sheet was used to estimate the bite force of both the groups to record complete bite force at maximum intercuspation. The test sheet was then scanned with an Epson v330 color HD photo scanner and the bite force was evaluated by an FDP 8010 analyzing system. Various other methods such as gnathodynamometer[15] can be used instead of a Prescale sheet, but the disadvantage with gnathodynamometer is that the bite force is measured at three different points for each patient. Dynamometer bite fork thickness gives rise to mouth opening while recording bite force, which is one of the most controversial factors. Fields et al.,[16] in 1986, established approximately 20 mm as the ideal mouth opening, when the first molar is used.

The values were recorded separately for the right side and left side of the mouth with the maximum pressed area on both sides separately. This gave a value of contact area for each patient, percentage of the pressed area on both left and right sides separately, and information regarding the area of contact on each side of the totally pressed area. The maximum and the average pressure applied on each side were given separately with three-dimensional graphs.

The Student's t-test was used to compare the mean pressure in the control and study groups. The control group had a statistically significantly higher mean pressed area on the left side (P = 0.034), maximum pressure on the left side (P < 0.001), mean maximum pressure on the right side (P = 0.024), and mean average pressure on the left side (P = 0.038). There was no statistically significant difference in the mean pressed area on the right side (P = 0.569) and average pressure on the right side of the control and study groups (P = 0.358); this could be because the study group consisted of unilateral cleft patients and most of the samples had missing teeth on the left side. There was a statistically significant difference in the mean maximum pressure (P = 0.001) and average pressure (P = 0.039) between both the control and study groups.

A study conducted by Miyaura et al.[17] concluded that in both male and female patients the maximum bite force of the healthy subjects was significantly higher than that of the frail subjects. There was no significant difference in the number of present teeth between the healthy and frail subjects.

In the present study, on comparison of the bite force within the control group to check if there is any difference in bite force between the male and female subjects, there was no significant difference, but some contradictory results have been reported by some authors. For example, in a study done by Sipert et al.,[15] the bite force was significantly reduced in men with cleft when compared with the noncleft group and there was no significant difference in the female group. A study conducted by Ferrario et al. (2004)[18] found no significant left–right differences on maximum bite force, whereas, in the present study, there was a significant difference on the left and right sides, which is because of the missing teeth on one side in cleft individuals. Ferrario et al. also observed that the lowest bite force was recorded with the incisors (40%–48% of the maximum single-tooth bite force) and the largest force was recorded with the first molar in both sexes. Bite forces were more in men than in women (P < 0.002), and they increased monotonically along the arch until the first or second permanent molar (P < 0.0001). However, in the present study, we did not record bite force for each tooth separately, but we had analyzed forces on the right and left sides. Waltimo and Könönen,[19] in 1993, observed that the bite force on the incisal area could be limited by the periodontal ligament sensitivity and not by the muscle strength, hence significant differences were reported on the maximum bite force between genders in the posterior area of the mouth only for the molar region. Raadsheer et al.,[20] when measured bite force between canines also, did not find differences between genders. Some authors[20] stated that due to increased muscle strength in males, they present a higher maximum bite force. However, no significant difference was found in the present study when we tried to compare the difference between both sexes with the same age group, and this would be because of a limited sample size. Bakke et al.[21] found that the thickness of the masseter muscle and the bite force showed a positive correlation. In the present study, we did not evaluate muscle activity because it differs from individual to individual, but to avoid bias, we had selected the same age group so that the muscle activity can also coincide. A study done by Kiliaridis et al.[8] has shown that stress increases as age increases.

In the present study, the significant difference in mean values between the control and study groups may be due to the reduced occlusal contact in cleft patients. The less occlusal forces in cleft patients affect the chewing efficiency and speech of patients. Even though patient needed surgical and orthodontic correction of the cleft, prosthetic rehabilitation was indicated for missing teeth. Tumrasvin et al. (2006)[22] conducted a study to evaluate patients' masticatory function after removal partial denture (RPD) treatment by comparing that of the RPD replaced side with that of their opposite dentulous side having unilateral edentulous area replaced with a distal extension RPD opposing a complete natural dentition, while, the maxillary and mandibular dentitions were intact on the opposite side. They evaluated the masticatory performance based on mixing ability index and bite force. They concluded that the mean mixing ability index and the mean maximum bite force of the RPD-replaced side were significantly lower than that of the dentulous side.

A study done by Miyaura et al.[17] assessed the biting abilities and concluded that the bite forces of the fixed partial, removable partial, and complete denture wearers were 80%, 35%, and 11%, respectively, when expressed as a percentage of the subjects with natural dentition. These studies suggest that the possible restoration of the cleft patients with a fixed prosthesis will be a better option to increase the bite force and chewing efficiency. This will aid in the even distribution of forces and speech and also social well-being.

Limitations

  • Small sample size
  • There are variations in the size of cleft for each individual, so it cannot be standardized.
  • It was not possible to standardize and study the palatal vault of surgically corrected cleft palate patients and normal patients so that parameter was not considered.



  Conclusion Top


Within the limitations of the present study and based on the results obtained, it may be concluded that patients with unilateral cleft lip and palate have a decrease in maximum isometric bite force when compared with that of normal subjects. Further studies must be carried out to know whether this reduction is related or not to the presence of the cleft per se.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mossey PA, Little J, Munger RG, Dixon MJ, Shaw WC. Cleft lip and palate. Lancet 2009;374:1773-85.  Back to cited text no. 1
    
2.
Christensen K, Juel K, Herskind AM, Murray JC. Long term follow up study of survival associated with cleft lip and palate at birth. BMJ 2004;328:1405.  Back to cited text no. 2
    
3.
Nopoulos P, Langbehn DR, Canady J, Magnotta V, Richman L. Abnormal brain structure in children with isolated clefts of the lip or palate. Arch Pediatr Adolesc Med 2007;161:753-8.  Back to cited text no. 3
    
4.
WHO Human Genetics Programme Global Strategies to Reduce the Health-Care Burden of Craniofacial Anomalies: Report of WHO Meetings on International Collaborative Research on Craniofacial Anomalies. Geneva: World Health Organization; 2002. Available from: https://apps.who.int/iris/handle/10665/42594. [Last accessed on 2020 Aug 28].  Back to cited text no. 4
    
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Tsunori M, Mashita M, Kasai K. Relationship between facial types and tooth and bone characteristics of the mandible obtained by CT scanning. Angle Orthod 1998;68:557-62.  Back to cited text no. 5
    
6.
Tate GS, Throckmorton GS, Ellis E 3rd, Sinn DP, Blackwood DJ. Estimated masticatory forces in patients before orthognathic surgery. J Oral Maxillofac Surg 1994;52:130-6.  Back to cited text no. 6
    
7.
Miralles R, Hevia R, Contreras L, Carvajal R, Bull R, Manns A. Patterns of electromyographic activity in subjects with different skeletal facial types. Angle Orthod 1991;61:277-84.  Back to cited text no. 7
    
8.
Kiliaridis S, Kjellberg H, Wenneberg B, Engström C. The relationship between maximal bite force, bite force endurance, and facial morphology during growth. A cross-sectional study. Acta Odontol Scand 1993;51:323-31.  Back to cited text no. 8
    
9.
Miura H, Watanabe S, Isogai E, Miura K. Comparison of maximum bite force and dentate status between healthy and frail elderly persons. J Oral Rehabil 2001;28:592-5.  Back to cited text no. 9
    
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Tada A, Miura H. Systematic review of the association of mastication with food and nutrient intake in the independent elderly. Arch Gerontol Geriatr 2014;59:497-505.  Back to cited text no. 11
    
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Atkinson HF, Ralph WJ. Tooth loss and biting force in man. J Dent Res 1973;52:225-8.  Back to cited text no. 12
    
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Proffit WR, Turvey TA, Fields HW, Phillips C. The effect of orthognathic surgery on occlusal force. J Oral Maxillofac Surg 1989;47:457-63.  Back to cited text no. 13
    
14.
Thomas GP, Throckmorton GS, Ellis E 3rd, Sinn DP. The effects of orthodontic treatment on isometric bite forces and mandibular motion in patients before orthognathic surgery. J Oral Maxillofac Surg 1995;53:673-8.  Back to cited text no. 14
    
15.
Sipert CR, Sampaio AC, Trindade IE, Trindade AS Jr. Bite force evaluation in subjects with cleft lip and palate. J Appl Oral Sci 2009;17:136-9.  Back to cited text no. 15
    
16.
Fields HW, Proffit WR, Case JC, Vig KW. Variables affecting measurements of vertical occlusal force. J Dent Res 1986;65:135-8.  Back to cited text no. 16
    
17.
Miyaura K, Morita M, Matsuka Y, Yamashita A, Watanabe T. Rehabilitation of biting abilities in patients with different types of dental prostheses. J Oral Rehabil 2000;27:1073-6.  Back to cited text no. 17
    
18.
Ferrario VF, Sforza C, Serrao G, Dellavia C, Tartaglia GM. Single tooth bite forces in healthy young adults. J Oral Rehabil 2004;31:18-22.  Back to cited text no. 18
    
19.
Waltimo A, Könönen M. A novel bite force recorder and maximal isometric bite force values for healthy young adults. Scand J Dent Res 1993;101:171-5.  Back to cited text no. 19
    
20.
Raadsheer MC, van Eijden TM, van Ginkel FC, Prahl-Andersen B. Contribution of jaw muscle size and craniofacial morphology to human bite force magnitude. J Dent Res 1999;78:31-42.  Back to cited text no. 20
    
21.
Bakke M, Tuxen A, Vilmann P, Jensen BR, Vilmann A, Toft M. Ultrasound image of human masseter muscle related to bite force, electromyography, facial morphology, and occlusal factors. Scand J Dent Res 1992;100:164-71.  Back to cited text no. 21
    
22.
Tumrasvin W, Fueki K, Ohyama T. Factors associated with masticatory performance in unilateral distal extension removable partial denture patients. J Prosthodont 2006;15:25-31.  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

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



 

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