Assessment of Bite Force in Bengalee Children and its Correlation

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
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
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
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
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.
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
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 & 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=0.913Class-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=0.517Class-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=0.317Class-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

Assessment of Bite Force in Bengalee Children and its Correlation

Assessment of Bite Force in Bengalee Children and its Correlation

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