Maximum clenching force of patients with moderate loss of posterior tooth support: A pilot study

Charles H. Gibbs, PhD,a Kenneth J. Anusavice, PhD, DMD,b Henry M. Young, DDS,c Jack S. Jones, DMD,d and Josephine F. Esquivel-Upshaw, DMD, MSe University of Florida, College of Dentistry, Gainesville, Fla. Statement of problem. Patients who have lost moderate posterior tooth support may also lose clenching
force as a result of sensitivity to increased loading to the remaining teeth and possibly a loss of muscle strength, because clenching forces are limited to avoid stress to the remaining teeth. Few studies have correlated moderate posterior tooth loss with maximum clenching force. Purpose. The purpose of this pilot study was to test the hypothesis that moderate loss of posterior tooth support will have a signicant effect on maximum clenching force. Material and methods. The maximum clenching force of 44 adults, ages 28 to 76 (mean 46), with posterior tooth loss was compared with the maximum clenching force of a control group of 20 healthy full dentition adults, ages 18 to 55 (mean 30), by use of a bilateral strain-gauged transducer. The transducer consisted of 2 stainless steel plates separated by a steel sphere that balanced occlusal forces between right and left sides. Acrylic resin pads were fabricated for each patient to protect the cusps of the teeth. The overall accuracy was found to be within 2.3% of full scale over a range of 0 to 4000 N (0 to 900 lbs). The calibration reliability of the system was checked frequently by use of a dead weight of 222 N (50 lbs). Clenching forces were supported by rst and second molars and second premolars when possible. The instrumentation, methods, and operator were the same for both groups. A 2-tailed Student t test ( 0.01) and a pooled estimate of the mean were used to determine possible statistical signicance. To test for possible correlations between clenching force and lost tooth support and between clenching force and age, a linear regression correlation coefcient R was calculated. Results. For the 44 subjects with posterior tooth loss, the mean clenching force was 462 N (104 lbs), with a range of 98 to 1031 N (22 to 232 lbs). This compares with a mean of 720 N (162 lbs) with a range of 244 to 1243 N (55 to 280 lbs) for the full-dentition subjects. A 2-tailed t test showed that the average difference of 258 N (58 lbs) between the 2 groups was signicant (P .01). There was only a moderate negative association between clenching strength and loss of mandibular tooth support (R 0.35). Clenching force was not well correlated with age as indicated by low R values (R 0.21, missing tooth group and R 0.03, full dentition group). Conclusion. Within the limitations of this study the maximum clenching force was less (P .01), by 258 N (58 lbs) on average, in subjects with moderate loss of posterior tooth support. Loss of maximum clenching force was associated with a modest negative correlation to the number of missing teeth in the mandibular arch (R 0.35). The range of clenching force was surprisingly large for both the missing tooth (98 to 1031 N) and full dentition (244 to 1243 N) groups. (J Prosthet Dent 2002;88:498-502.)

CLINICAL IMPLICATIONS
In this pilot study moderate loss of posterior tooth support resulted in a loss of clenching force. However, clenching force varied considerably across patients. Therefore moderate loss of posterior tooth support does not guarantee low clenching strength. Restorations may be subjected to high occlusal forces, even in patients with some missing posterior teeth.

atients who have lost posterior tooth support may also lose clenching force as a result of increased loading to the remaining teeth and possibly a loss of muscle strength because clenching forces are reduced to avoid
This study was supported through a grant from Ivoclar AG, Schaan, Liechtenstein. a Professor, Department of Oral Biology. b Professor and Chairman, Department of Dental Biomaterials. c Associate Professor, Department of Operative Dentistry. d Assistant Professor, Department of Prosthodontics. e Associate Professor, Department of Prosthodontics. 498 THE JOURNAL OF PROSTHETIC DENTISTRY

stress to the remaining teeth. Few studies have correlated moderate tooth loss with maximum clenching force. In one extreme, the loss of all teeth greatly compromises maximum clenching force. In 1 study, denture wearers, even with good ridges, could exert only 156 N (35 lbs) on average,1 compared with healthy adults with complete dentition who produced a mean clenching force of 720 N (162 lbs).2 On the other extreme, clenchers and the Alaskan Eskimos, with heavy chewing demands to soften seal skin, can have clenching forces
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far above average. Waugh3 reported clenching forces up to 1547 N (348 lbs) in the Alaskan Eskimo. A world record clenching force of 4333 N (975 lbs) was recorded for a man with a clenching habit.1 Several previous investigations have studied the variation in clenching forces in relation to loss of tooth support. Braun et al4 found no effect by missing anterior and posterior teeth in 142 dental students, ages 26 to 41. However, none of these subjects exhibited more than the absence of one tooth in any quadrant, and all subjects with absent posterior teeth had a xed or removable prosthesis in place. Tsuga et al5 found a moderate correlation between the number of remaining teeth and maximal unilateral clenching force in a large sample of 80-year-old Swedes. Helkimo et al6 studied unilateral clenching force in 125 Skolt Lapps, ages 15 to 65, and found a decrease in clenching force with increasing age, which they suggest was probably due to the marked age-dependent deterioration of the dentition. Bakke et al7 studied 122 students, staff, and pediatric patients with a minimum of 24 teeth at a Danish dental college. Using unilateral clenching measurements, they concluded that occlusal parameters determined 10% to 20% and that age only contributed 3% to 15% of the variation in clenching force. In contrast, this study investigates changes in maximal bilateral clenching force as a result of loss of posterior teeth. A previous study8 showed that maximum clenching force is generated at an increased vertical dimension of occlusion of 10 to 20 mm. Instrumentation placed between the teeth may actually enhance clenching force somewhat over the force that would be generated at the vertical dimension of occlusion. Therefore force transducers between the teeth should not compromise the subjects clenching force because of a moderate increase in vertical dimension of occlusion. Tortopidis et al9 compared clenching forces at 3 different locations and found consistently that clenching forces were greatest when measured bilaterally on posterior teeth. Forces were less when measured between anterior teeth or unilaterally on posterior teeth. Tortopidis et al9 also reported that maximum clenching force was relatively consistent over 3 recording sessions, suggesting that a single recording for each subject should be adequate for this study. Average maximum clenching forces reported in healthy, full-dentition subjects for this study should be similar to those reported by other studies that provide comparable bilateral posterior tooth support. This would support the concept that clenching force is limited by tooth support/muscle strength and not by discomfort of the instrumentation. Previous studies by Braun et al4 and Hidaka et al10 provided comfortable bilateral support with their transducers and reported relatively high clenching strengths, similar to values reported previously2 for subjects with good occlusion by use of the instrumentation of this study. Unilateral
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clenching forces can be quite high in healthy, full-dentition adults. Waltimo and Kononen11 reported average maximal clenching forces of 847 N in 15 men and 597 N in 15 women. Clenching force varies considerably, even in healthy adults with a full dentition. In a study of 20 healthy, full-dentition adults, maximum clenching force ranged from 244 to 1243 N (55 to 280 lbs).2 Therefore average values may provide a general trend and may be useful for statistical comparisons between groups but may not be good predictors for individual patients.

MATERIAL AND METHODS

Forty-four adult subjects, 33 female and 11 male, were recruited from persons seeking a xed partial denture at the Graduate Prosthodontics Clinic at the University of Florida. Ages ranged from 28 to 76 years, with an average of 46.4 years and standard deviation of 10.3 years. These subjects had healthy periodontal tissues and showed no evidence of tooth mobility. The subjects presented with one or more missing posterior (distal to the canine) teeth. Informed consent was obtained from each subject after the nature of the procedures and possible discomforts and risks had been fully explained. In an early visit to the clinic, the subjects maximum clenching force was measured by use of a strain-gauged transducer1 (University of Florida, Gainesville, Fla). The transducer consisted of 2 stainless steel plates separated by a steel sphere that balanced occlusal forces between right and left sides. Four strain gauges (Model EA-13060PB-350; Micro-Measurements, Raleigh, NC) were mounted on one of the 2 plates: 2 above and 2 below. The 4 strain gauges were wired in a full electrical bridge circuit. The electrical output was additive in bending and offsetting in extension or contraction, so that effects of temperature change were minimized. The overall linearity and reproducibility were found to be within 2.3%, over a 0 to 4000 N (0 to 900 lbs) range with an Instron universal testing machine (Model No 1125; Instron Corp, Canton, Mass.). Three transducers were available for this project and allowed as many as 3 patients to be recorded per day. The transducers were sterilized with ethylene oxide after each recording session. Sterilization required a turnaround time of 1 day. The interocclusal separation between the posterior teeth was approximately 12 mm. Manns et al8 showed that maximum clenching force is greatest at an increased vertical dimension of occlusion of 10 to 20 mm. Therefore, the values reported in this study are believed to be a better measure of the patients maximum clenching force than if the measurements had been made at the vertical dimension of occlusion. Output from the transducer was displayed on a digital voltmeter (Model No. 22-174; Tandy Corp, Fort Worth, Texas) in view of the
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Fig. 1. Clenching strength versus loss of posterior tooth support.

patient. Calibration of the system was checked frequently by use of a dead weight of 222 N (50 lb). Autopolymerizing acrylic resin (TMJ Fossa & Tray Acrylic; TMJ Instrument Co Inc, Norco, Calif.) was placed on the 4 occlusal surfaces of the transducer. The transducer was placed inside a sandwich bag, and then the bagged unit was placed between the subjects teeth. The sandwich bag prevented the acrylic resin from bonding to restorations and reduced the odor of the acrylic from reaching the patient. It also prevented saliva from contacting the transducer. The acrylic resin hardened so that the load would be distributed over the surface of the tooth in an effort to avoid tooth fracture. Occlusal forces were supported by rst molars, second molars, and second premolars bilaterally, when possible. When teeth were missing, the transducer was positioned for maximum posterior tooth support. After the acrylic resin had hardened, the patient was asked to rst clench gently, then moderately, then hard, and then maximally to make sure that there was no discomfort before clenching maximally. No patient complained of discomfort, and no teeth or restorations were damaged during the study. The digital readout, showing the clenching force, was placed in view of the subject because this feedback appeared to help the subject achieve a higher force. Each patient was asked to clench maximally approximately 5 times. The highest number was recorded. Clenching forces were recorded for 1 session. The single session appeared justied in light of a study by Tortopidis et al,9 who reported that there was little difference in maximal clenching force among measurement values determined at 3 different sessions. At a follow-up visit, study casts were made as part of treatment for the xed partial denture. These study casts were used to determine missing posterior teeth in both
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arches. Loss of posterior tooth support could result from loss of a posterior mandibular tooth or loss of a posterior maxillary tooth. Loss of third molars was not included, except in one situation where the third molar had been moved mesially to replace the missing second molar. In this situation, the third molar was considered as a second molar. Five of the 44 subjects did not proceed with treatment; therefore no study casts or missing tooth data were available for these 5 subjects. The plots of clenching strength versus missing teeth data (Figs. 1 and 2) are based on 39 of the 44 subjects. Clenching force data of the 44 subjects missing posterior teeth were compared with similar data from 20 healthy subjects with full dentition between the ages of 18 and 55 (mean 29.8 years, standard deviation 11.0 years), which were reported previously.2 Both groups were recorded with the same instrumentation, procedure and by the same investigator. A 2-tailed Student t test ( 0.01) and a pooled estimate of the mean was used to determine possible statistical signicance. To test for possible correlations between clenching force and lost tooth support and between clenching force and age, a linear regression correlation coefcient R was calculated. A large sample size was not available to this project to control for possible confounding factors, such as age, sex, facial structure, and muscle size. Therefore this project was considered a pilot study.

RESULTS
The mean maximum clenching strength was 462 N (104 lbs), with a range of 98 to 1031 N (22 to 232 lbs) for the 44 subjects with 1 or more missing posterior teeth. This was signicantly less (P .01) than the mean clenching force of 720 N (162 lb), with a range of 244 to 1243 N (55 to 280 lbs) reported previously for a
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Fig. 2. Clenching strength versus loss of posterior teeth in both arches.

group of 20 healthy subjects with a full dentition2 (Table I). Neither group showed a signicant age relationship to clenching strength as measured by the linear regression correlation coefcient R (R 0.21 for missing tooth group, R 0.03 for full dentition group). Clenching strength was plotted against loss of posterior tooth support in 39 of the 44 subjects, where models of the dental arches were available (Fig. 1). Clenching strength showed a modest negative association with loss of posterior tooth support in the mandibular arch, on the basis of a linear regression analysis with the correlation coefcient (R 0.35). When clenching strength was plotted against the number of missing teeth in both arches, a weaker negative association resulted (R 0.27) (Fig. 2).

Table I. Maximum bite strength in N (lbs)

Group Average SD Range

44 Subjects with moderate loss of tooth support 20 Healthy subjects with full dentition

462 (104)

240 (54)

981031 (22232)

720 (162)

293 (66)

2441244 (55280)

DISCUSSION
Braun et al4 measured clenching strength bilaterally in 142 university students and found the average to be 738 N (166 lbs), with a range of 342 to 1280 N (77 to 288 lbs) by use of a pressurized rubber tube transducer. These values correspond closely with the values reported for adults with good occlusion 720 N (162 lbs) on average, to a range of 244 to1243 N (55 to 280 lbs) reported in this study (Table I). The rubber tube transducer of the Braun et al4 study allowed the teeth to have good bilateral support, as did the customized acrylic pads for the transducer of this study. Hidaka et al,10 using a pressure-sensitive lm bilaterally, between anterior and posterior teeth, reported maximum clenching forces above this range. They reported a mean of 1181 N (265 lbs), with a standard deviation (SD) of 351 N (79 lbs). Their study concluded that the occlusal contact area increased in parallel with clenching force. A few subjects in this study produced very low clenching forces of 98, 151, and 156 N (22, 34, and 35 lbs). In
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these subjects, bulging of the supercial masseter muscles was estimated by manual palpation while the subject clenched maximally on the transducer as compared with when the subject clenched maximally in the intercuspal position. In all 3 of these subjects, the masseter muscles were narrow and produced little bulge, indicating low muscle strength. It did not appear that the presence of the transducer limited their willingness to clench maximally. Studies with unilateral transducers also reported that clenching forces varied considerably across subjects; however, clenching force values were generally lower than in studies with bilateral transducers. Tsuga et al,5 in a study of 80-year-old Swedes, noted a range of 13 to 663 N in men and 6 to 655 N in women. Some denture wearers were included in this study, which account for the low end of the ranges. A moderate correlation was found between the number of remaining teeth and the maximal clenching force in this elderly group. Helkimo et al6 reported a mean of 444 N, SD 157 N for right-side clenching in a group of 125 Skolt Lapps ages 15 to 65. They reported a decrease in clenching force with increasing age, which they attributed to the marked age-dependent deterioration of the dentition in this special group. Bakke et al7 studied unilateral clenching force in 122
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students, staff, and pediatric patients with a minimum of 24 teeth at a Danish dental college. They reported unilateral clenching forces of about 480 N, SD 130 N. The current and previous studies report an average decrease in clenching force with tooth loss. Perhaps the most surprising and important nding is the large variation of clenching strengths in most populations. For example, some subjects of this study, with missing posterior teeth, had greater clenching force than the fulldentition subjects, as indicated by the overlapping force ranges (98 to 1031 N tooth loss group, 244 to 1243 N full dentition group). Therefore it is anticipated that restorations in subjects, even with some missing posterior teeth, may be subjected to unexpectedly high occlusal forces.

CONCLUSIONS
Within the limitations of this study, maximum clenching strength was signicantly less, 258 N (58 lbs), P .01, on average in subjects with moderate loss of posterior tooth support. Loss of maximum clenching strength was modestly correlated with the loss of posterior tooth support in the mandibular arch (R 0.35) and less correlated with the number of missing posterior teeth in both arches (R 0.27). The wide range of clenching strengths demonstrated by both the subjects with missing teeth and the subjects with full dentition indicate that some persons, even some with missing teeth, may be able to produce a high clenching force and unexpected high stress within restorations.
REFERENCES
1. Gibbs CH, Mahan PE, Mauderli A, Lundeen HC, Walsh EK. Limits of human bite strength. J Prosthet Dent 1986;56:226-9.

2. Gibbs CH, Mahan PE, Lundeen HC, Brehnan K, Walsh EK, Holbrook WB. Occlusal forces during chewing and swallowing as measured by sound transmission. J Prosthet Dent 1981;46:443-9. 3. Waugh LM. Dental observations among Eskimo. VII. Survey of mouth conditions, nutritional study and gnathodynamometer data, in most primitive and populous native villages in Alaska. J Dent Res 1937;16:355-6. 4. Braun S, Bantleon HP, Hnat WP, Freudenthaler JW, Marcotte MR, Johnson BE. A study of bite force, part 1: relationship to various physical characteristics. Angle Orthod 1995;65:367-72. 5. Tsuga K, Carlsson GE, Osterberg T, Karlsson S. Self-assessed masticatory ability in relation to maximal bite force and dental state in 80-year-old subjects. J Oral Rehabil 1998;25:117-24. 6. Helkimo E, Carlsson GE, Helkimo M. Bite force and state of dentition. Acta Odontol Scand 1977;35:297-303. 7. Bakke M, Holm B, Jensen BL, Michler L, Moller E. Unilateral isometric bite force in 8-68-year-old women and men related to occlusal factors. Scand J Dent Res 1990;98:149-58. 8. Manns A, Miralles R, Palazazi C. EMG, bite force, and elongation of the masseter muscle under isometric voluntary contractions and variations of vertical dimension. J Prosthet Dent 1979;42:674-82. 9. Tortopidis D, Lyons MF, Baxendale RH, Gilmour WH. The variability of bite force measurement between sessions, in different positions within the dental arch. J Oral Rehabil 1998;25:681-6. 10. Hidaka O, Iwasaki M, Saito M, Morimoto T. Inuence of clenching intensity on bite force balance, occlusal contact area, and average bite pressure. J Dent Res 1999;78:1336-44. 11. Waltimo A, Kononen M. A novel bite force recorder and maximal isometric bite force values for healthy young adults. Scand J Dent Res 1993;101:171-5. Reprint requests to: CHARLES H GIBBS, PHD DEPARTMENT OF ORAL BIOLOGY; BOX 100424 COLLEGE OF DENTISTRY UNIVERSITY OF FLORIDA GAINESVILLE, FL 32610 FAX: 352-392-2361 E-MAIL: cgibbs@dental.u.edu Copyright 2002 by The Editorial Council of The Journal of Prosthetic Dentistry. 0022-3913/2002/$35.00 0 10/1/129062

doi:10.1067/mpr.2002.129062

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