Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

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Journal of Cranio-Maxillo-Facial Surgery

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Evaluation of bite force recovery in patients with maxillofacial fracture

Hamed Gheibollahi a, b, Ehsan Aliabadi a, Mohammad Saleh Khaghaninejad a,
Sona Mousavi a, Amirhossein Babaei c, d, *
a
Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Rajaei Acute Care Surgical Hospital, Shiraz University of Medical Sciences,
Shiraz, Iran
b
Department of Oral and Maxillofacial Surgery, School of Dentistry, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
c
Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
d
Resident of Otolaryngology, Otolaryngology Research Center, Department of Otolaryngology, Shiraz University of Medical Sciences, Shiraz, Iran

a r t i c l e i n f o a b s t r a c t

Article history: The aim of this study was to measure the maximum voluntary bite force and recovery time in patients
Paper received 28 August 2020 treated for different types of the maxillofacial fracture.
Accepted 18 February 2021 Patients aged between 18 and 60 years, who received surgical treatment for a single isolated fracture
Available online xxx
of the maxillofacial structure, were included in this study. Healthy individuals without any maxillofacial
abnormality were selected as the control group. Bite force (in kg) was measured at the first incisor tooth,
Keywords:
bilaterally, prior to surgery and 2 weeks, 6 weeks, 3 months, and 6 months after surgery.
Bite force
Of 120 patients, 89 (74.17%) were male and 31 (25.83%) were female. Mean patient age (±SD) was
Mandibular fracture
Maxillofacial injury
31.21 (±11.64) years. Bite forces relating to fractures of the zygomaticomaxillary complex (ZMC) with
Recovery of function involvement of the arch and zygomaticofrontal suture reached normal levels after 6 weeks (from 3.89
Iran (±1.11) to 10.82 (±1.29); p ¼ 0.296 and from 4.20 (±0.93) to 10.70 (±1.70); p ¼ 0.192, respectively). Bite
force returned to normal after 3 months in fractures of the symphysis (from 2.05 (±0.97) to 12.18 (±0.77);
p ¼ 0.222), body (from 2.21 (±1.26) to 11.9 (±0.73); p ¼ 0.750), angle (from 2.45 (±1.24) to 11.89 (±0.76);
p ¼ 0.769), condyle (from 2.45 (±1.27) to 11.25 (±0.82); p ¼ 0.968), and ZMC with and without
infraorbital rim involvement (from 3.83 (±0.93) to 11.92 (±0.84); p ¼ 0.724 and from 3.7 (±1.21) to 12.03
(±0.82); p ¼ 0.482, respectively).
Patients with ZMC fracture involving the arch and zygomaticofrontal suture require fewer follow-ups
in comparison with those with other maxillofacial fractures. Measurement of maximal bite force can help
to evaluate dentofacial deformities before and after surgical treatment.
© 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights
reserved.

1. Introduction the most common occurrence (64.7%), followed by ZMC fractures

(21.1%) (Akhlaghi et al., 2019). Another study of 730 patients with
Maxillofacial fractures result from high-energy trauma, and maxillofacial trauma between 2004 and 2010 reported the most
occur frequently. They include orbital, mandible, Le Fort, nasal common fracture to be mandibular (58.4%), followed by ZMC
complex, and zygomaticomaxillary complex (ZMC) fractures (24.1%), orbital (15.1%), and Le Fort (12.4%) (Arabion et al., 2014).
(Chouinard et al., 2016). Lalloo et al. reported the worldwide inci- Treatment of maxillofacial fractures is an important issue in the
dence of facial fracture as being 7 538 663 (98 per 100 000) in 2017. field of maxillofacial surgery (Sukegawa et al., 2019). The treatment
The estimated years of living with disability due to facial fractures strategy for maxillofacial fractures might be influenced by the
was 117 402 years (Lalloo et al., 2020). In a study of 708 maxillo- surgeon’s experience and preference, as well as the location and
facial fracture patients conducted in Iran, mandibular fracture was type of fracture (Ozkaya et al., 2009).
Maxillofacial fractures impact on the patient’s lifestyle, espe-
cially feeding (Zandi et al., 2020). It takes time for them to resume a
normal life and regular diet (Giridhar, 2016), although there is no
* Corresponding author. Student Research Committee, Neshat Street, Shiraz,
explicit reference in the literature to how long it takes for diet to
71348-43638, Iran.
E-mail addresses: Babaei93@[Link], babaei@[Link] (A. Babaei). return to normal after surgery.

[Link]
1010-5182/© 2021 European Association for Cranio-Maxillo-Facial Surgery. Published by Elsevier Ltd. All rights reserved.

Please cite this article as: H. Gheibollahi, E. Aliabadi, M.S. Khaghaninejad et al., Evaluation of bite force recovery in patients with maxillofacial
fracture, Journal of Cranio-Maxillo-Facial Surgery, [Link]
H. Gheibollahi, E. Aliabadi, M.S. Khaghaninejad et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

Regular follow-ups are obligatory to verify the stability of the The subjects were seated with their heads upright in an un-
fracture (Chouinard et al., 2016). One tool for assessment of stability supported natural position, looking forward, while the measure-
and returning to a normal quality of life is measurement of maximal ments were taken. Maximum voluntary bite forces were recorded
bite force between the maxillary and mandibular teeth. This factor at the first incisor tooth, bilaterally, to the nearest 0.1 kg.
has been used to evaluate dentofacial deformities both before and
after surgical treatment (Abo Mustafa et al., 2017; Takayama et al., 2.3. Sample size
2019; Zaky et al., 2019).
Although studies have been carried out to investigate voluntary After enrollment of the participants, statistical power was
bite forces following mandibular fractures and ZMC fractures, few calculated using G*Power software, version 3.1 (Franz, Germany).
have been designed to compare bite forces in patients recovering Based on the mean and SD of the bite force before surgery
from different types of maxillofacial fracture. (2.05 ± 0.97) and after 6 months (12.15 ± 0.76) in patients with
Therefore, the aim of this prospective study was to measure symphysis fracture, the effect size and study power were calculated
maximum voluntary bite forces and recovery times in patients as 11.59 and 99.99%, respectively.
treated for different types of maxillofacial fracture.
2.4. Statistical analysis
2. Material and methods
The mean (±standard deviation) maximum bite forces were
2.1. Participants calculated and reported for each group. Student’s t-test was used to
determine any significant differences. All data were analyzed using
This prospective, analytic, caseecontrol study was conducted on SPSS software, version 24 (SPSS Incorporation, Chicago, Illinois, US).
patients referred to the Department of Oral and Maxillofacial Sur- A p-value less than 0.05 was considered statistically significant.
gery at Rajaee Hospital (affiliated to Shiraz University of Medical
Sciences), Shiraz, Iran, due to maxillofacial fracture between 3. Results
January 1, 2018 and September 31, 2019.
The study design was reviewed and approved by the Ethics Of 120 patients, 89 (74.17%) were male and 31 (25.83%) were
Committee of Shiraz University of Medical Sciences ([Link].- female. The mean (±SD) patient age was 31.21 (±11.64) years. The
[Link].1399.008). Prior to the enrollment of participants, all mean maximum bite force in the control group was 11.49 (±1.47)
patients were informed of the procedures and purpose of the study. kg.
Informed consent was then obtained from all the patients. The For all time points, the difference in mean maximum bite force
study was conducted according to the principles of the Declaration between the fractured and non-fractured side was statistically
of Helsinki (1996) and Good Clinical Practice Guidelines (1996). significant for all types of fracture (Table 2). Table 3 compares the
The inclusion criteria were: 1) patients who had received any maximum bite forces with those of the normal control group for
treatment for a single, isolated fracture of the maxillofacial struc- each time point. As shown, the bite forces in those with ZMC
tures; 2) aged 18e60 years; 3) sufficient bilateral dentition to allow fracture with arch and zygomaticofrontal suture involvement
assessment of occlusal relationships; and 4) no dentoalveolar reached normal levels after 6 weeks. In those with fractures of the
fractures. symphysis, body, angle, condyle, and ZMC (with and without
The patients were excluded if any of the following conditions infraorbital rim involvement) bite forces were normal after 3
existed: 1) temporomandibular joint dysfunction or a previous months.
history of it; 2) pretraumatic skeletal malocclusion of the jaws; 3)
abnormal growth patterns (e.g. vertical, horizontal, or transverse);
4. Discussion
and 4) multiple comminuted fractures.
An unenhanced spiral CT scan of the face with 3D reconstruction
In this study, maximum voluntary bite force in patients treated
was performed for all patients to assess the status of injury, sing a
for different types of maxillofacial fracture was measured at
16-slice CT scanner (CT emotion 16; Siemens Healthcare, Erlangen,
different time points. The results showed that maximum bite force
Germany).
following ZMC fracture with arch or zygomaticofrontal suture
A total of 100 age- and sex-matched individuals without any
involvement reached the normal level after 6 weeks. With fractures
maxillofacial fractures were selected as the control group, in order
of the symphysis, body, angle, condyle, and ZMC with or without
to compare the bite force measurements with those of the maxil-
infraorbital rim involvement, bite force was normal after 3 months.
lofacial fracture patients. All control subjects had class I skeletal and
Mandibular fracture occurs in around 70% of facial injuries. This
dental occlusion, intact incisors and first molar teeth, and no signs
type of injury can cause malocclusion or changes in occlusal forces
or symptoms of functional disorders of the craniomandibular sys-
(Naeem et al., 2017). Sometimes neurosensory disturbances due to
tem. None of the controls had any myofascial pain disorders, den-
inferior alveolar nerve injury will occur after fracture treatment
tofacial deformities, or neurosensory deficits.
(Datarkar et al., 2019). Photobiomodulation with laser is an effec-
Types of fracture, surgical treatments, and number of the pa-
tive way to manage neurosensory disturbances (Sharifi et al., 2020).
tients in each category are shown in Table 1. No mandibulomaxil-
Early treatment of mandibular fracture is important for pre-
lary or intermaxillary fixation was used for patients.
venting anatomical and cosmetic deformities, in addition to pre-
serving habitual function of the injured site (Sybil and
2.2. Bite force measurement Gopalkrishnan, 2013).
Recent studies have reported that open surgical repair is the
Bite force (in kg) was measured prior to surgery and 2 weeks, 6 most common method used to treat mandibular fractures in the
weeks, 3 months, and 6 months after surgery. Maximum isometric USA (Zavlin et al., 2018; Hassanein, 2019). A cohort study of 953
bite force measurement was performed using a bite force trans- patients with mandibular fractures concluded that old age and
ducer, with the ends covered with polypropylene tubing and smoking were independent risk factors for postoperative compli-
opened to 15 mm (Khaghaninejad et al., 2017). cations (Daar et al., 2019).
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H. Gheibollahi, E. Aliabadi, M.S. Khaghaninejad et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

Table 1
Surgical treatment for each type of fracture.

Type of fracture Treatments Number of

patients

Symphysis fracture d bounded by vertical lines distal to the canine teeth Occlusion and reduction, and fixation with two miniplates 15
Condyle fracture d area of the condylar process superior to the ramus region Occlusion with open reduction and internal fixation 15
(retromandibular incision)
Body fracture d from the distal symphysis to a line coinciding with the alveolar border of the Occlusion and reduction, and fixation with one miniplate 15
masseter muscle (usually including the third molar)
Angle fracture: triangular region bounded by the anterior border of the masseter muscle to the Occlusion and reduction, and rigid fixation with two 15
posterosuperior attachment of the masseter muscle (usually distal to the third molar) miniplates (one Champy and another in the border)
(intraoral approach)
ZMC fracture with infraorbital rim involvement Reduction and fixation with one miniplate, and reduction of 15
infraorbital rim with or without fixation
ZMC fracture without infraorbital rim involvement Reduction and fixation with one miniplate 15
ZMC fracture with zygomaticofrontal suture involvement Reduction and fixation with one miniplate; 15
zygomaticofrontal suture was reduced and fixed with one
orbital miniplate
ZMC fracture with arch involvement Open reduction and fixation, with one miniplate and 15
reduction of arch fracture

ZMC: zygomaticomaxillary complex.

Table 2
Mean maximum bite force on the fractured and non-fractured side for all time points.

Site of fracture Fractured Non-fractured p-value

Mean (SD) Mean (SD)

Symphysis 8.11 (0.14) 9.46 (0.14) <0.001

Body 8.15 (0.14) 9.19 (0.14) <0.001
Angle 8.02 (0.16) 9.15 (0.16) <0.001
Condyle 7.94 (0.17) 9.26 (0.17) <0.001
ZMC without infraorbital rim involvement 8.78 (0.13) 10.25 (0.13) <0.001
ZMC with infraorbital rim involvement 8.82 (0.12) 10.09 (0.12) <0.001
ZMC with arch involvement 8.87 (0.09) 9.85 (0.09) <0.001
ZMC with zygomaticofrontal suture involvement 8.98 (0.09) 10.0 (0.09) <0.001

ZMC: zygomaticomaxillary complex.

Maximum bite force is an excellent criterion with which to One study investigated the maximum bite force after rigid in-
evaluate restoration of the skeletal structure and masticatory ternal fixation of mandibular fractures with microplates or mini-
function (Sybil and Gopalkrishnan, 2013). In our study, maximum plates. The authors followed up the patients with body,
bite force was lower than the normal range in all patients, which parasymphyseal, and symphyseal fractures of the mandible, and
could be due to trauma to the masticatory muscles or iatrogenic evaluated bite forces after the 1st, 2nd, 4th, and 6th week.
trauma during surgery. In addition, previous studies have reported Compared with the control group, bite forces were significantly
that the patient’s willingness to bite hard is low at this period decreased in the two groups over the study period until the 6th
because they are afraid to use their jaws forcefully. week, but the difference between the two groups was not statis-
In a study by Kumar et al., it was reported that after ORIF of tically significant. They recommended measurement of bite force
mandibular fracture, the bite force was less than that of a healthy for clinical evaluation of bone union (Ahmed et al., 2016).
person for 6 weeks postoperatively (Kumar et al., 2013). Jain et al. compared the effectiveness of three-dimensional
In a recent study, Anand et al. compared the effect on bite force versus standard titanium miniplates for the management of ante-
of the combination of microplate and miniplate with two standard rior mandibular fractures. They measured the bite force at weekly
miniplates for fixation of mandibular fractures in the interfor- intervals for 6 weeks. They found that, after 6 weeks, the clinical
aminal region. They found that in patients operated with one outcomes, including bite force, were similar in both groups (Jain
microplate and one miniplate bite force did not reach the normal and Kerur, 2019).
range after 3 months. By using two miniplates, after 1 month the Sybil et al. evaluated bite force in patients treated for mandib-
bite force in the central incisor region was equal to the normal ular fractures. They reported that mandibular fractures temporarily
range. In our study, patients recovered after 3 months (Anand et al., reduced the maximum bite forces. Fractures of the condyle and
2018). angle had the strongest impact on bite force, with a longer period of
Another study by Zaky et al. was conducted to compare use of a normalization required (Sybil and Gopalkrishnan, 2013).
combination of one microplate and one miniplate versus two In a study by Panchanathan et al., the functioning of the
miniplates, for management of parasymphyseal mandibular frac- masticatory muscles (masseter and temporalis) after ZMC fractures
tures, by biting force measurement. The results showed that the was evaluated by measuring electromyography (EMG) and bite
difference between both study groups was not statistically signifi- force. The authors concluded that, based on EMG and bite force, the
cant. They reported that a 3-month follow-up period was sufficient masticatory function returned to near normal ranges 3 months
for assessment of the patients’ recovery and for them to regain their after the operation (Panchanathan et al., 2016).
normal biting force. This was in line with the results of our study on This study had some advantages, one of the most important of
patients with symphysis fracture (Zaky et al., 2020). which was its comparison all types of mandibular fracture. Another

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H. Gheibollahi, E. Aliabadi, M.S. Khaghaninejad et al. Journal of Cranio-Maxillo-Facial Surgery xxx (xxxx) xxx

Table 3
The trend in maximum bite force for each group.

Type of fracture Time Mean (SD) Mean difference (SD) p-value

Symphysis Baseline 2.05 (0.97) 9.43 (0.351) <0.001

2 weeks 4.22 (0.95) 7.26 (0.351) <0.001
6 weeks 9.96 (1.12) 1.52 (0.351) <0.001
3 months 12.18 (0.77) 0.69 (0.351) 0.222
6 months 12.15 (0.76) 0.66 (0.351) 0.258
Body Baseline 2.21 (1.26) 9.27 (0.355) <0.001
2 weeks 4.59 (0.90) 6.89 (0.355) <0.001
6 weeks 9.94 (1.06) 1.55 (0.355) <0.001
3 months 11.9 (0.73) 0.41 (0.355) 0.750
6 months 12.13 (0.80) 0.64 (0.355) 0.310
Angle Baseline 2.45 (1.24) 9.03 (0.360) <0.001
2 weeks 3.88 (1.21) 7.60 (0.360) <0.001
6 weeks 9.71 (0.86) 1.77 (0.360) <0.001
3 months 11.89 (0.76) 0.40 (0.360) 0.769
6 months 12.16 (0.95) 0.67 (0.360) 0.272
Condyle Baseline 2.45 (1.27) 9.03 (0.356) <0.001
2 weeks 3.73 (1.17) 7.75 (0.356) <0.001
6 weeks 9.86 (0.68) 1.62 (0.356) <0.001
3 months 11.25 (0.82) 0.23 (0.356) 0.968
6 months 12.43 (0.82) 0.94 (0.356) 0.044
ZMC without infraorbital rim involvement Baseline 3.7 (1.21) 7.78 (0.356) <0.001
2 weeks 5.39 (1.11) 6.09 (0.356) <0.001
6 weeks 10.41 (1.07) 1.07 (0.356) 0.015
3 months 12.03 (0.82) 0.54 (0.356) 0.482
6 months 12.41 (0.55) 0.92 (0.356) 0.051
ZMC with infraorbital rim involvement Baseline 3.83 (0.93) 7.65 (0.362) <0.001
2 weeks 5.87 (1.35) 5.62 (0.362) <0.001
6 weeks 10.46 (1.21) 1.02 (0.362) 0.026
3 months 11.92 (0.84) 0.43 (0.362) 0.724
6 months 12.06 (0.78) 0.57 (0.362) 0.452
ZMC with arch involvement Baseline 3.89 (1.11) 7.59 (0.365) <0.001
2 weeks 5.66 (1.23) 5.82 (0.365) <0.001
6 weeks 10.82 (1.29) 0.66 (0.365) 0.296
3 months 12.09 (0.89) 0.60 (0.365) 0.407
6 months 11.89 (0.76) 0.40 (0.365) 0.779
ZMC with zygomaticofrontal suture involvement Baseline 4.20 (0.93) 7.28 (0.383) <0.001
2 weeks 6.34 (1.68) 5.14 (0.383) <0.001
6 weeks 10.70 (1.70) 0.78 (0.383) 0.192
3 months 12.36 (0.80) 0.87 (0.383) 0.112
6 months 11.30 (0.83) 0.18 (0.383) 0.992

ZMC: zygomaticomaxillary complex.

advantage was the measurement of bite force at several time Research of Shiraz University of Medical Sciences (grant number:
points, which allowed determination of the optimum length of 98-01-03-20300). The authors would like to thank Shiraz Univer-
follow-up period. sity of Medical Sciences, Shiraz, Iran, and also the Center for
One of the limitations of this study was a lack of measurement of Development of Clinical Research of Nemazee Hospital and Dr
bite force for the premolar and molar teeth in each group. We Nasrin Shokrpour for editorial assistance.
suggest further studies with a larger sample size, in addition to
electromyographic studies on the masticatory muscles.
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