Bite Force and Occlusion

Abstract

Maximum bite force is a useful indicator of the functional state of the masticatory system and the loading of the teeth, and its recordings can be performed in a relatively simple way in the clinic. However, because maximum bite-force levels vary with method, sex and age, it is important that the measurements are compared against the appropriate reference values. The level of bite force is a result of the combined action of the jaw elevator muscles modified by jaw biomechanics and reflex mechanisms. Pain limits the maximum bite force and may thus impede the measurements, but this factor may also be useful in treatment control. The maximum bite force increases with the number of teeth present. The number of occlusal tooth contacts is an important determinant for the maximally attainable bite force, explaining about 10% to 20% of the variation. The association between maximum bite force and the amount of occlusal contact is closest in the posterior region, and as a consequence, loss of molar support results in reduction of force. In contrast, malocclusions defined solely on the basis of molar and canine relationships have less influence on the level of bite force.

Full text

Bite Force and Occlusion
Merete Bakke
Maximum bite force is a useful indicator of the functional state of the
masticatory system and the loading of the teeth, and its recordings can be
performed in a relatively simple way in the clinic. However, because maxi-
mum bite-force levels vary with method, sex and age, it is important that the
measurements are compared against the appropriate reference values. The
level of bite force is a result of the combined action of the jaw elevator
muscles modified by jaw biomechanics and reflex mechanisms. Pain limits
the maximum bite force and may thus impede the measurements, but this
factor may also be useful in treatment control. The maximum bite force
increases with the number of teeth present. The number of occlusal tooth
contacts is an important determinant for the maximally attainable bite force,
explaining about 10% to 20% of the variation. The association between
maximum bite force and the amount of occlusal contact is closest in the
posterior region, and as a consequence, loss of molar support results in
reduction of force. In contrast, malocclusions defined solely on the basis of
molar and canine relationships have less influence on the level of bite force.
(Semin Orthod 2006;12:120-126.) © 2006 Elsevier Inc. All rights reserved.
Maximum bite force is one indicator of the
functional state of the masticatory sys-
tem.
1-5
The force results from the action of the
jaw elevator muscles (in turn, determined by the
central nervous system and feedback from mus-
cle spindles, mechanoreceptors, and nocicep-
tors) modified by the craniomandibular biome-
chanics.
6
Bite-Force Measurements
Bite force is most often recorded with one or two
transducers placed between pairs of opposing
teeth during clenching.
1
This is a simple, direct
method for clinical use, but it increases the bite
height and leaves the rest of the dentition sepa-
rated.
2
Pressure-sensitive sheets, thin force-sens-
ing resistors, and strain gauges in dental recon-
structions do not disturb the dental occlusion as
much, but their recordings need far more prep-
aration or computer calculation.
6-8
Recording Technique
The recorded force during maximal clenching
varies with the location of the measurement
within the dental arch and the number of teeth
included. Also, the use of coverage, splints, and
other means of protecting teeth and transducers
may influence the measurements.
2
Maximum
bite force is highest in the molar region.
7
Uni-
lateral measurement of maximum bite force in
the molar region averages between 300 and 600
Newtons (N) in healthy adults with natural
teeth.
1,2
With the transducer placed on the an-
terior teeth the measured force is about 40% of
the unilateral force recorded in the molar re-
gion, and with the transducer in the premolar
region it is about 70%. If the force is measured
bilaterally in the molar region, the recorded
force is about 40% higher than the unilateral
measurement.
2,9-12
Department of Oral Medicine, Clinical Oral Physiology, Oral
Pathology & Anatomy, School of Dentistry, University of Copenha-
gen, Copenhagen, Denmark.
Address correspondence to Merete Bakke, DDS, PhD, Department
of Oral Medicine, Clinical Oral Physiology, Oral Pathology &
Anatomy, School of Dentistry, University of Copenhagen, 20 Nørre
Allé, DK-2200 Copenhagen, Denmark. Phone: 45-35 326 554; Fax:
45-35 326 569; E-mail: merete.bakke@odont.ku.dk
© 2006 Elsevier Inc. All rights reserved.
1073-8746/06/1202-0$30.00/0
doi:10.1053/j.sodo.2006.01.005
120 Seminars in Orthodontics, Vol 12, No 2 (June), 2006: pp 120-126

With thin pressure-sensitive sheets that cover
the whole dental arch, the total bite force is
twice the unilateral molar bite force.
7
In addi-
tion, measuring the bite force on a splint cover-
ing all six anterior maxillary teeth (as opposed
to a single anterior tooth) increases the maxi-
mum bite force about 25%.
13
Even though the
force level varies systematically with measuring
technique, the values recorded with different
methods are generally significantly correlated,
and the method errors are small and the repro-
ducibility is good. However, for clinical evalua-
tion it is necessary to consult reference values
obtained with the technique used.
2,7,8,14
Measurements of maximum bite force are de-
pendent on the motivation and cooperation of
the subject. Concern about damage to the teeth
during the measurement, or ongoing pain and
tenderness in the teeth, supportive structures,
temporomandibular joint or masticatory mus-
cles have a negative influence on the bite-force
measurements. Pain limits the maximum bite
force due to reflex mechanisms and impedes
maximum bite-force measurements, but this fac-
tor may also indicate a patient’s actual func-
tional capacity and, therefore, provides useful
information for the control of treatment.
15-18
For example, pain in the temporomandibular
joints from chronic arthritis and temporoman-
dibular disorders (TMD) reduces the maximum
bite forces by 40% compared with control val-
ues, probably because the pain is associated with
a reflex “splinting” reaction that limits the ability
to work against heavy loads.
15,19
Maximum bite
forces have also been shown to decrease with
increased tenderness of the temporomandibular
joint in patients with arthralgia (Fig 1).
18
In
addition, biting on a transducer may in itself
provoke or aggravate pain.
20
Jaw Elevator Muscles
The highest voluntary force generated by the jaw
elevator muscles is during maximal clenching.
Bite-force levels increase when clenching is per-
formed with increased jaw opening until about
15 to 20 mm of interincisal distance, probably
corresponding to the optimum length of the
jaw-elevator muscle sarcomeres; bite force then
decreases with further opening.
21,22
This so-
called length-tension relationship should be
considered when assessing maximum bite force
with a bite-force meter that increases bite height
and jaw separation.
There is a close positive relationship be-
tween the bite force and the electromyo-
graphic activity of the jaw elevator muscles
(the temporal, the masseter, and the medial
pterygoid muscles) during isometric contrac-
tions.
2,23-25
Due to the jaw biomechanics, a
higher level of elevator activity is required in
the anterior part of the dental arch than in the
posterior part in order to produce the same
bite force.
26
For the same individual, during
the same recording session, the level of elec-
tromyographic activity fairly accurately reflects
the level of bite force during submaximal iso-
metric contractions (Fig 2).
2
However, the re-
lationship between maximum bite forces
measured in different subjects and the corre-
sponding elevator muscle activities is much
more variable, due to differences in electrode
placements in relation to fiber direction, as
well as different anatomical and morphologi-
cal relations in terms of muscle thickness and
craniofacial dimension.
2
Analogous to the limb muscles, the volume
and cross-sectional thickness, the muscle fiber
distribution, and the training state are all corre-
lated with the maximum force of the jaw elevator
muscles.
27-32
Based on ultrasonography, com-
Figure 1. Positive, linear correlation between maxi-
mum unilateral molar bite force (in Newtons) and
tenderness of the temporomandibular joint (TMJ) in
terms of the pressure-pain threshold (PPT in kPa).
Data from 26 female patients with unilateral arthral-
gia (y⫽55.57 ⫹2.64x). Low threshold, correspond-
ing to a high level of tenderness and pain of the
temporomandibular joint, was associated with low
maximum bite force. kPa ⫽kilopascals. Reprinted
from Hansdottir and Bakke 2004
18
with permission.
121Bite Force and Occlusion

puted tomography, and magnetic resonance im-
aging, the thickness of the resting masseter
alone explains 55% of the variation of maximum
bite forces.
33
Anthropometric Factors and Craniofacial
Form
Age, sex, and probably stature account for a part
of the variation of the maximum bite force. The
jaw closing force increases with age and
growth,
34,35
stays fairly constant from about 20
years to 40 or 50 years of age, and then de-
clines
36,37
(Fig 3). The maximum bite force is
generally higher in men than in women because
of men’s larger jaw dimensions.
4,12,36-38
In addi-
tion, the muscle fibers may also differ between
the sexes, as the greater bite force in men seems
to correspond with a greater diameter and cross-
sectional area of the type II fibers in the masse-
ter muscle.
39
The maximum bite force also varies with skel-
etal craniofacial morphology, decreasing with
increasing vertical facial relationships, the ratio
between anterior and posterior facial height,
mandibular inclination, and gonial angle.
40-45
It
has been proposed that bite force reflects the
geometry of the lever system of the mandible.
That is, the elevator muscles appear to have
Figure 2. Positive, linear correlation between unilateral, molar bite force (in Newtons) at submaximal contrac-
tions (12.5, 25, 37.5, 50, 62.5, 75 and 87.5% of maximum bite force) and ipsilateral and contralateral anterior
temporalis (above) and superficial masseter (below) activities, recorded by surface electromyography (in
␮
V).
Average values from seven healthy control subjects. The elevator activities increased with increasing levels of bite
force. Reprinted from Bakke et al., 1989
2
with permission.
122 M. Bakke

greater mechanical advantage when the ramus is
more vertical and the gonial angle relatively
acute.
41
However, the interaction is probably
more complex because craniofacial form seems
to be determined, at least in part, by the biome-
chanics of the masticatory muscles. Thus, analy-
ses of structures by computed tomography have
shown that the jaw elevator muscles exert influ-
ence on their adjacent local skeletal sites by
mechanical stresses,
46
and that the maximum
electromyographic activity in the jaw elevator
muscles during clenching is highest in subjects
with a square facial type.
47
Occlusal Factors
There is a significant positive correlation be-
tween the maximum bite force and the number
of teeth present.
36,37,48
With increasing levels of
clenching, the occlusal tooth contact between
the maxillary and mandibular dental arches be-
comes closer. For example, with an increase of
the clenching level from 30% to 100% the oc-
clusal contact area is doubled.
49
Due to the bio-
mechanics of the jaw elevator muscles and the
lever system of the mandible, the occlusal force
is greater on the molars than on the incisors
7
(Table 1). Correspondingly, occlusal tooth con-
tacts are most frequent in the posterior re-
gion.
7,36
The number of occlusal contacts is a stronger
determinant of muscle action and bite force
than the number of teeth present.
36
The occlu-
sal contacts have been shown to determine 10%
to 20% of the variation of maximum bite force
in adults, and the association between maximum
bite force and contacts is higher in the posterior
region (r, 0.40-0.60) than in the anterior re-
gion.
4,36,44
One way to explain the correlation
between occlusal contacts and bite force is that
“good” occlusal support (ie, force distributed
over many teeth) may result in stronger or more
active jaw elevator muscles that can develop
higher bite force. Another explanation could be
Figure 4. Linear correlation between maximum bilat-
eral bite force (in Newtons) and number of posterior
teeth in the mandibular arch without opposing tooth
contact. The maximum level of clenching force de-
creased with loss of occlusal support. Data from 39
adults with one or more missing teeth distal to the
canines. The transducer, consisting of four strain
gauges in an electrical bridge, was positioned for max-
imum molar support on both sides. Reprinted from
Gibbs et al. 2002
52
with permission from The Editorial
Council of the Journal of Prosthetic Dentistry.
Figure 3. Relation between unilateral molar bite
force, age and gender in 122 healthy subjects (59
males and 63 females) with full complement of teeth
(fourth order polynomial regression lines). The max-
imum bite force (in Newtons) was lower in women
than in men and it increased until the second decade
and decreased again, especially after the fifth decade.
Redrawn after the data in Bakke M, Holm B, Jensen
BL et al. 1990.
36
Table 1. Relative Distribution of Maximum Bite
Force and Occlusal Tooth Contact in the Maxillary
Dental Arch*
Mean ⫾SD
(%)
Occlusal Force (On all
teeth in the group, in
percentage of the total
bite force)
Occlusal Tooth Contact
(Percentage of teeth
with contact, of all
teeth in the group)
Incisors 3 ⫾332⫾30
Canines 4 ⫾279⫾31
Premolars 12 ⫾7 100 ⫾0
Molars (third
molars
excluded)
78 ⫾8 100 ⫾0
*Values for tooth group on both sides in 17 healthy young
adults. Data from Shinogaya et al.
7
123Bite Force and Occlusion

that strong elevator muscles, with resulting
harder biting and vigorous function, cause bet-
ter occlusal support and increased number of
contacts. Both explanations are probably rele-
vant. However, we cannot be sure which is the
cause and which is the effect. Not unexpectedly,
strong correlations (r, 0.60-0.70) occur between
the number of occlusal contacts and the ampli-
tude of the electromyographic activity in the
masseter muscle during maximum voluntary
contraction and in the occlusal phase during
chewing.
50
Dental Status, Prostheses, and Implants
Reduced bite force has often been ascribed to
deficiencies in the dentition, but neither re-
duced periodontal attachment nor tooth decay
seem to influence maximum bite force.
37,51
However, even moderate loss of posterior tooth
support results in loss of clenching force
52
(Fig
4). Because the amount of occlusal contact on
the posterior teeth is the most important of the
occlusal parameters, tooth loss in the molar re-
gion has a greater influence on the level of
maximum bite force than loss in the anterior
part of the dental arch.
36
When the function of the masticatory system
is reduced due to loss of occlusal support, re-
movable prostheses do not compensate enough
to maintain the previous level of maximum bite
force
53-55
(Fig 5). However, if complete dentures
are converted into implant-supported overden-
tures the maximum bite force is almost doubled,
corresponding to about two thirds of the value
obtained for dentate subjects.
56-58
Because re-
ceptors in the periodontal ligament modify the
activity of the masticatory muscles, and thus the
bite force, their function in the edentulous jaw
and with implants must be taken over by other
receptors, such as mucosal and periosteal mech-
anoreceptors, as well as intraosseous nerve end-
ings.
Malocclusion
Most bite force studies have been comprised of
subjects with a full complement of teeth, Angle
Class I molar occlusions, and no dysfunction.
However, there has long been an interest in how
maximum bite force influences the develop-
ment of facial morphology and malocclusions
(eg, the overeruption of posterior teeth in the
development of anterior open bite) and in the
planning of orthodontic treatment.
14,41,42
It has
also been shown that both bite force and occlu-
sal tooth contact most often are reduced tempo-
rarily during orthodontic treatment.
59
Malocclusions are often associated with re-
duced maximum bite force.
17,35,60,61
Therefore
orthodontic treatment may be needed to im-
prove function.
35
However, the bite force does
not seem to vary between Angle malocclusion
types.
62
At the same time children with unilat-
eral posterior cross bites have been reported to
have both lower maximum bite forces and lower
numbers of occlusal contacts than children with-
out malocclusions.
35
The same difference of bite
force and occlusal contact is found between
adults subjects with anterior open bite and sub-
jects without malocclusion, but not in young
children.
40,63,64
Generally, there is not the same
systematic relation between malocclusion and
maximum bite force as with occlusal contact and
maximum bite force. In subjects with malocclu-
sion the reduced maximum bite force is proba-
bly related more to the effect of occlusal contact
Figure 5. Maximum bite force in different states of
dentition and with dental prostheses. Good dentition:
normal posterior occlusal support; Compromised
dentition: loss of posterior support and no removable
prosthesis, Partial denture: either upper or lower par-
tial denture; Complete dentures: both upper and
lower complete dentures. The maximum bite-force
values from the groups with compromised dentition,
partial denture and complete dentures are shown in
percentage of the recorded values in adults with good
dentition (100%). The fewer the natural teeth
present, the lower the maximum bite force. Drawn
after the data in Miyaura et al. 2000 (thin pressure-
sensitive sheets in 500 adults
53
) and Shinkai et al.
2001 (bilateral force transducer in 731 adults
54
).
124 M. Bakke

and the biomechanics of the jaws and mastica-
tory muscles than to the classification of mor-
phological occlusion per se. As a consequence it
may be useful to routinely assess the occlusal
contact together with the morphological occlu-
sion of the teeth, and also take both into con-
sideration when planning and evaluating orth-
odontic treatment.
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