JPOR 377 No.

of Pages 9

journal of prosthodontic research xxx (2016) xxx –xxx

Available online at www.sciencedirect.com

Journal of Prosthodontic Research

journal homepage: www.elsevier.com/locate/jpor

Original article

Masticatory function parameters in patients with

varying degree of mandibular bone resorption

Raissa Micaella Marcello-Machado a , Amália Machado Bielemann a ,

Gustavo Giacomelli Nascimento b, Luciana de Rezende Pinto c ,
Altair Antoninha Del Bel Cury d, Fernanda Faot b, *
a
Graduate Program in Dentistry, Federal University of Pelotas, Pelotas, Brazil
b
Department of Semiology and Clinics, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil
c
Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Pelotas, Brazil
d
Department of Prosthodontics and Periodontology, Piracicaba Dental School, University of Campinas, Piracicaba,
Brazil

article info abstract

Article history: Purpose: This cross-sectional study analyzes how bone resorption affects the masticatory
Received 9 February 2016 function and investigates the relation between perceived and measured masticatory
Received in revised form function.
25 October 2016 Methods: Thirty complete dentures wearers were divided in two groups according to
Accepted 2 December 2016 mandible bone atrophy based on the classification criteria from Cawood & Howell. Retention
Available online xxx and stability of the mandibular complete denture, masticatory performance (MP) indexes
(X_50 and B) and masticatory efficiency (ME, sieves 4 and 2.8) were evaluated. Geriatric Oral
Health Assessment Index (GOHAI) and Dental Impact on Daily Living (DIDL) questionnaires
Keywords:
were completed by the patients.
Mastication
Results: A strong correlation between bone atrophy and poor retention was found (P=0.0132).
Alveolar bone loss
Neither masticatory performance indexes nor GOHAI and DIDL domains showed statistical
Complete denture
differences (P>0.05) when patients were compared according to the atrophy criteria.
Edentulous jaw
Mandibular length showed a negative correlation with ME4, showing a positive association
Denture retention
(R2 =0.17, b = 0.67, P=0.029). Mandibular denture retention was significantly correlated with
Prosthodontics
MPB (P=0.01) and ME2.8 (P=0.01). GOHAI showed a positive association between the physical
and the functional domains and ME2.8 (R2 =0.17; b =1.22; P =0.02). DIDL showed a negative
association between ME4 and oral comfort domain (R2 =0.16; b = 2.94; P=0.02).
Conclusion: Mandibular bone height does not directly affect the masticatory function and is
inversely correlated with the self-perceived masticatory ability.
© 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

* Corresponding author at: Department of Restorative Dentistry, School of Dentistry, Federal University of Pelotas, Gonçalves Chaves St 457,
Center, Pelotas 96015560, RS, Brazil. Fax: +55 53 32256741.
E-mail address: fernanda.faot@gmail.com (F. Faot).
http://dx.doi.org/10.1016/j.jpor.2016.12.002
1883-1958/© 2016 Japan Prosthodontic Society. Published by Elsevier Ltd. All rights reserved.

Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
JPOR 377 No. of Pages 9
2 journal of prosthodontic research xxx (2016) xxx –xxx
1. Introduction
Complete denture wearers have a reduced masticatory
function by 50–84% compared to dentate patients [1]. Impaired
mastication can be related to the lack of stability and retention
of the prosthesis [2]. The latter is directly affected by
progressive resorption of the residual alveolar bone [3].
Additionally, the patient’s inability to use a new complete
denture, tongue mobility problems related to the height
towards the base of the mouth, muscles insertions and
salivary flow can have a negative impact on the adaptation
phase. All these factors can contribute to a poor chewing
function and pain, resulting in dissatisfied patients [4].
The success of rehabilitation with conventional complete
dentures depends directly on the intimate relationship
between the prosthesis and the anatomical structures that
support it: the residual ridge, the mucosa and the adjacent
musculature [5]. However, residual ridge resorption is chronic,
multifactorial, progressive and eventually necessitates cumu-
lative bone remodeling [6]. As a consequence, the prosthesis
loses stability and starts to move during mastication, which
frequently results in discomfort. This discomfort occurs
because the muscle insertions become more superficial, and
the mucosa presents thinner and more sensitive, resulting in
pressure ulcers, hyperplasia and denture stomatitis [3,4,6].
Clinicians frequently use panoramic radiography to define
and to monitor the severity of bone resorption in edentulous
patients. The degree of residual ridge resorption also deter-
mines the prognosis of oral rehabilitation in edentulous
patients [6], be it a conventional complete denture or
implant-supported. In addition, prolonged edentulism in
combination with low frequency of prostheses replacement
may occasionally result in the development of fibrous tissue.
This resilient tissue can interfere in the settlement, stability
and comfort of the mandibular prosthesis during chewing. The
resulting mobility of the mandibular prosthesis during chew-
ing can trigger trauma and pain in extremely resorbed bone
areas, limitation of occlusal forces, difficulties to homogenize
food. These factors directly affect the quality and masticatory
performance, especially in edentulous patients with severe
mandibular bone atrophy [7].
Some studies have indeed shown the negative influence of
bone resorption on the masticatory function and suggest that
masticatory function in complete denture wearers is limited
due to residual ridge resorption and the decrease of basal area
of the complete denture [8,9]. However, these studies catego-
rized the patients based on a clinical evaluation or based on a
morphological description of the alveolar ridge using cast
models. We present one of the first studies that compares
objectively evaluated masticatory function with the subjective
account of the patient regarding their chewing ability.
It is still debated whether the masticatory function is
influenced by residual ridge resorption in edentulous patients
and whether indexes related to objective masticatory function
are related to the self-perceived efficient chewing. This cross-
sectional clinical study evaluated the degree of mandibular
bone atrophy of edentulous patients and examined the
relation between the level of bone resorption and the
masticatory function. In addition, the indexes of masticatory
Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
function (masticatory performance and efficiency) were
compared with information related to the subjective percep-
tion of the patient (DIDL questionnaires – Dental Impact on
Daily Living and GOHAI – Geriatric Oral Health Assessment
Index) about their masticatory efficiency.
2. Material and methods
2.1. Experimental design
This cross-sectional clinical study was conducted in accor-
dance with the Declaration of Helsinki, as revised in 2008, and
reported following the Strengthening the Reporting of Obser-
vational Studies in Epidemiology guidelines [10]. This study
was approved by the Ethics Committee in Local Search (69/
2013) and included conventional dentures wearers attending
the Complete Denture Clinic at the School of Dentistry/UFPel
under treatment from February 2013 to April 2014. Patients in
good general health and wearing conventional complete
dentures for at least three months were included in the study,
if these patients showed difficulties adapting to mandibular
complete dentures.
A written informed consent form was obtained from
patients that fulfilled the inclusion criteria wherein they
agreed to the terms of research. Subsequently, radiographic
evaluations, functional tests on retention and stability of
dentures, masticatory function tests and questionnaires,
which comprise subjective evaluation of the masticatory
domain, were conducted.
The patients were categorized into two groups with non-
atrophic and atrophic jaws, based on radiographic measure-
ments. The dependent variables consisted of the evaluation of
retention and stability of the mandibular complete dentures,
masticatory efficiency and performance parameters and
questionnaires regarding the impact on daily life (DIDL) and
self-perceived oral health (GOHAI).
Sample size calculation was based on a previous study [8]
using the following parameters: smallest expected difference
between means, standard deviations of the difference be-
tween means, beta error of 10% and one-tailed alpha error of
5%. The sample size was increased by 20% to account for
potential losses and refusals. These calculations determined a
minimum of 12 participants were required per group for this
cross-sectional study.
2.2. Radiographic evaluation and categorization of
mandibular bone atrophy
After performing the digital panoramic radiographs (Roto-
graph apparatus Plus, with digital imaging plate system
Dentascan sensors with 12.7 30cm dimensions), radio-
graphic measurements related to morphology and mandib-
ular height were performed in DBSWIN software (digital
system VistaScan) by a single calibrated examiner, according
to the methodology described by Xie et al. [11] (Fig. 1A). The
measured parameters were: mandibular body length, height
in the anterior (midline) and posterior (molar region), and
superior height of the foramina (distance from the top edge
of mentonian foramen to the alveolar ridge). Based on these
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Fig. 1 – (A) Measurement of the mandibular height following Xie et al. [6]. RL1=reference line for the midline; RL2=reference line for
the measurement of the mandibular body; L1=height in the anterior region (midline); L2=mandibular body length; L3=height in
the pre molar region; L4=height in the molar region; L5=inferior height of the foramina; L6=superior height of the foramina. (B)
Radiograph of an atrophic patient; A=mandibular body length, B=height in the anterior (midline), C=height in the posterior (molar
region), and D=superior height of the foramina. (C) Radiograph measurement of a non-atrophic patient; A=mandibular body
length, B=height in the anterior (midline), C=height in the posterior (molar region), and D=superior height of the foramina.

Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
JPOR 377 No. of Pages 9
4 journal of prosthodontic research xxx (2016) xxx –xxx
parameters, the patients were classified in two groups: those
jaws considered atrophic (Fig. 1B) and non-atrophic (Fig. 1C),
according to the atrophy of the residual alveolar ridge
classification described by Cawood & Howell [12]. An
atrophic ridge is then characterized by a ridge height below
25 mm in the anterior region and below 16mm in the
posterior region.
2.3. Evaluation of retention and stability
The retention and stability of the complete dentures were
clinically evaluated according to the scores (S) 1–3 described by
Sato et al. [13]. Retention was evaluated via the dislodgement
of the prosthesis after vertical pulling on the central incisors
with the following scores: S1—Good: without dislodgement;
S2—Acceptable: dislodgement with difficulty and S3—Poor:
easy dislodgement. The stability was evaluated with the
movement induced by pressuring the first molar teeth with the
index and middle fingers, with the scores: S1—Good: within
tissue displacement 1 to 2mm; S2—Reasonable: tissue
displacement higher than in normal tissue, S3—Poor: sliding.
For analytical purposes, the obtained scores were subsequent-
ly grouped into two categories as follows: Good/Acceptable (S1
+S2) and Poor (S3).
2.4. Masticatory function
The masticatory performance was evaluated using ‘Optocal’, a
silicone mixture commonly used as an artificial food [14].
Standardized cubes with 5.6mm side were made with the
assistance of metal matrix [15,16]. The participants were
requested to masticate 17 portions of Optocal for 40 mastica-
tory cycles counted by the operator. The resulting triturated
mass was then expelled in a disposable paper filter, washed
and dried. After the test, patients rinsed their mouth with
water to ensure that all Optocal fragments were removed.
Afterwards, the particles were air-dried for at least 1 week,
sieved in a stack of up to 10 sieves with square apertures
between 5.6mm and 0.5mm.
The material contained in each sieve was weighed on a
precision scale to determine masticatory efficiency and
performance parameters. The cumulative percentages were
calculated and transferred to a Rosin-Rammler equation that
determines the median particle size based on the aperture of a
theoretical sieve through which 50% of the particles can pass
by weight (MP_X50) [15,16]. In addition, this equation provides
a “b index”, that calculates the particle size distribution to
indicate the homogeneity of the chewing (MPB Index). The
masticatory efficiency was evaluated by the weight of the
material retained in sieves 4.0 and 2.8 (ME4 and ME2.8).
2.5. Impact on Daily Lliving questionnaire (DIDL) and
Geriatric Oral Health Assessment Index (GOHAI)
After the chewing tests, the DIDL and GOHAI questionnaires
were filled in by the patients. The DIDL questionnaire is
composed of 36 questions, grouped into five domains: comfort,
appearance, pain, general performance, eating and chewing.
This evaluation measures the impact and the proportional
importance of each domain or each patient who answered
Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
each question by selecting one of three possible answers:
agree, disagree or neutral [17]. The scores for all the questions
were recorded for each patient and the total score ranges from
1 to +1.
The GOHAI questionnaire was used to assess the (self-
reported) quality of life of edentulous patients regarding their
oral health [18]. This questionnaire include 12 questions
related to oral health, which evaluate three domains: pain and
discomfort, psychosocial and psycological impact, physical
and functional. Each question in GOHAI Index presents three
possible answers: always/often; sometimes/rarely; and nev-
er—receiving the scores 1, 2 and 3, respectively.
2.6. Statistical analysis
Data were submitted to descriptive analysis to verify the
sample distribution, according to the outcome and exposure
variables in STATA 12.0 software (SataCorp, College Station,
TX, USA). Subsequently, the Bartlett test was applied to verify
variance heterogeneity for the following bone atrophy varia-
bles: edentulous maxilla period (years), edentulous mandible
period (years), mandibular length (mm), height in the anterior
region (midline) (mm), superior height of the foramina (mm)
height in the posterior region (mm). The Bartlett test was also
applied to variables related to masticatory function, namely
MPX_50 (mm), MPB (mm), ME4 (%) and ME2.8 (%). When the test
showed P>0.05, the association between the predictive
parameters of bone atrophy and its relation to masticatory
performance and efficiency was analyzed with a one-way
ANOVA. In all other cases, the Mann–Whitney test was used.
The presence of linear relations between the continuous
variables was then assessed through Spearman correlation.
Finally, the slope and intercept of the linear relation between
the correlated parameters was visualized by linear regression.
The comparisons between groups for categorical discrete
variables (retention and stability) were performed using
Fisher’s exact test. The obtained scores were subsequently
grouped into Good/Acceptable (S1+S2) and poor (S3), to
analyze the effect of mandibular prosthesis retention and
stability on outcomes related to masticatory function.
The association between mandibular bone atrophy and the
GOHAI and DIDL scores, were verified using the Mann–
Whitney test. The linearity and the association between
masticatory performance and efficiency with the different
GOHAI and DIDL domains were analyzed by Spearman
correlation, and linear regression, respectively. For all ana-
lyzes, the results were considered significant at a P value <0.05.
Linear regression was only performed when Spearman
correlation analyses presented a P-value below 0.05. The
significance level for all analyses was set at 5%.
3. Results
The total sample consisted of 30 edentulous patients, 21 (70%)
of these were women with an average age of 67.57 years (46–88)
and 9 (30%) were men with an average age of 68.55 years (63–74)
The average edentulous maxilla time was 32.6 years, while in
the mandible was 25.26 years. Table 1 shows the clinical and
radiographic predictors of bone atrophy, and the masticatory
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Table 1 – Means and standard deviations of clinical parameters and chewing outcomes according to mandible atrophy
criteria (Cawood & Howell). Masticatory performance X50; MPB, masticatory performance B; ME4.0, masticatory efficiency
sieve 4; ME2.8, masticatory efficiency sieve 2.8.
Mandible Atrophy criteria Non atrophic (n=14) Atrophic (n=16)
Clinical parameters P-value
Edentulous maxilla time (years) 24.43 (12.46) 39.75 (12.12) 0.002
Edentulous mandible time (years) 14.14 (10.76) 35.00 (14.34) <0.001
Mandible length (mm) 115.10 (6.80) 108.12 (6.90) 0.001
Height in the anterior region (mm) 27.38 (3.34) 20.03 (2.97) <0.001
Height in the posterior region (mm) 20.03 (2.41) 12.79 (3.12) <0.001
Superior height of the foramina 9.07 (5.76) 2.26 (2.40) 0.001

Outcomes chewing P-value

X50 (mm) 4.78 (1.58) 5.10 (1.20) 0.549
MPB 9.11 (12.28) 11.85 (8.88) 0.492
ME4 (g/%) 0.71 (0.29)/19.32 0.95 (0.45)/25.50 0.111
ME2.8 (g/%) 0.46 (0.45)/11.34 0.34 (0.39)/9.26 0.468

Table 2 – Correlations between clinical parameters and chewing outcomes and linear regression for the significative
correlations (P<0.05).
Clinical parameters Chewing outcomes

Spearmann correlation Linear regression

X50 MPB ME (4) ME (2.8) X50 MPB ME (4) ME (2.8)

Edentulous maxilla time r= 0.039 0.213 0.019 0.001 – – – – –
P= 0.858 0.328 0.929 0.998

Edentulous mandible time r= 0.285 0.369 0.067 0.191 R2= 0.09 0.13 0.00 0.01
P= 0.187 0.047 0.759 0.381 b= 0.02 0.14 0.002 0.004
P= 0.10 0.05 0.610 0.327

Mandible length r= 0.420 0.235 0.525 0.359 R2= 0.13 0.03 0.17 0.12
P= 0.050 0.280 0.001 0.047 b= 0.07 0.05 0.67 0.52
P= 0.05 0.323 0.029 0.05

Height in the anterior region r= 0.087 0.274 0.299 0.008 – – – – –

P= 0.691 0.205 0.165 0.716

Height in the posterior region r= 0.046 0.184 0.253 0.091 – – – – –

P= 0.834 0.399 0.243 0.677

Upper height in the foramem region r= 0.168 0.250 0.208 0.204 – – – – –

P= 0.442 0.248 0.340 0.349

function (MPX_50, MPB, ME4 and ME 2.8), following the
categorization for mandibular bone atrophy described by
Cawood & Howell [12]. Patients from the category with
mandibular atrophy had significantly longer periods of
mandibular and maxillar edentulism, along with lower
mandibular length and height, and superior height of the
foramina region (P<0.05, Mann–Whitney Test). Comparisons
between the groups, patients with atrophic mandible versus
non atrophic mandible, showed that mandibular bone
resorption does not impact the different outcomes of
masticatory function (P<0.05, One way ANOVA).
Table 2 shows the Spearman correlation test for the clinical
parameters of mandibular bone atrophy showed that then
time of mandibular edentulism was positively correlated with
the masticatory performance MPB (r=0.369, P=0.047); man-
dibular length was positively correlated with the masticatory
performance MPX_50 (r=0.420, P=0.050) and negatively corre-
lated with ME4 (r= 0525, P=0.001) and ME2.8 (r= 0359,
P=0.047). Table 2 also describes the simple linear regression
results of clinical variables that were significantly correlated
(P<0.05) with the outcomes of chewing.
Regarding the stability registered for the prosthesis in
atrophic group, the score 3 was the most prevalent (68.75%).
However, statistically significant correlation between man-
dibular bone atrophy and stability was not observed (P>0.05).
Additionally, retention score 3 was observed in 81.25% of
atrophic mandible, and it was found to be strongly correlated
with bone atrophy (P=0.0132). Table 3 shows the masticatory

Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
JPOR 377 No. of Pages 9

6 journal of prosthodontic research xxx (2016) xxx –xxx

Table 3 – Means and standard deviations of the outcomes chewing in the total sample (n=30) according to the retention and
stability criteria.

Stability Retention

Good/Reasonable (n=14) Poor (n=16) P-value Good/Reasonable (n=11) Poor (=19) P-value
X50 5.18 (1.47) 4.74 (1.38) 0.39 4.40 (1.34) 5.27 (1.36) 0.06
MPB 6.90 (4.61) 13.77 (13.29) 0.26 4.69 (2.70) 13.97 (12.0) 0.01
ME4 (g/%) 0.84 (0.42) 21.8 0.84 (0.40) 23.33 0.98 0.95 (0.28) 24.61 0.77 (0.45) 21.47 0.20
ME2.8 (g/%) 0.43 (0.41) 11.45 0.37 (0.45) 9.16 0.53 0.60 (0.41) 16.07 0.28 (0.39) 6.85 0.01

Table 4 – Scores of individual satisfaction according to the DIDL domains in the study sample according to according to
mandible atrophy criteria (Cawood & Howell).
Domain Dissatisfied Relatively satisfied Satisfied

Non-atrophic Atrophic Non-atrophic Atrophic Non-atrophic Atrophic

(n=14) (n=16) (n=14) (n=16) (n=14) (n=16)
Appearance 0 (0%) 0 (0%) 2 (14.28%) 4 (25%) 12 (85.71%) 12 (75%)
Pain 11 (78.57%) 16 (100%) 3 (21.42%) 0 (0%) 0 (0%) 0 (0%)
Oral comfort 9 (64.28%) 11 (68.75%) 4 (28.57%) 5 (31.25%) 1 (7.14%) 0 (0%)
General 0 (0%) 1 (6.25%) 3 (21.42%) 5 (31.25%) 11 (78.57%) 10 (62.5%)
performance
Eating and 2 (14.28%) 7 (43.75%) 3 (21.42%) 3 (18.75%) 9 (64.28%) 6 (37.5%)
chewing

function parameters, categorized according to the mandibular

denture retention and stability. Only the complete denture
retention interfered significantly in the chewing outcomes,
with significant greater values for MPB (P=0.01) and lower for
ME 2.8 (P=0.01). Patients with mandibular dentures with
retention score 3 (S3) were also unique in the sense that they
were associated with the following DIDL domains: pain
(P=0.048), general performance (P=0.037) and eating and
chewing (P=0.022).
Statistical differences (P>0.05) between atrophic and non-
atrophic mandibles were not found for any of GOHAI and DIDL
domains. Table 4 shows the individual predictors of patient
satisfaction scores for each DIDL domain in the study sample,
according to mandibular atrophy. The percentage of dissatis-
faction with mandibular denture was higher than 50% for the
domains pain and oral comfort. Table 5 shows the correlations
between the GOHAI and DIDL domains and the outcomes of
masticatory function and the values obtained by linear
regression to determine the association between the correlat-
ed variables. MPX_50 was negatively correlated and associated
with the psychosocial and psychological impact GOHAI
domain (Correlation: r= 0370, P=0.049; Regression:
b = 0.49, P=0.05) while ME2.8 was positively correlated and
associated to the physical and functional GOHAI domain
(Correlation: r=0.412, P=0.050; Regression: b =1.22, P=0.02).
Considering the DIDL scores, statistically significant correla-
tions and associations were exclusively found between the
chewing outcome ME4 and the following domains: oral
comfort (Correlation: r= 0405, P=0.026; Regression:
b = 2.94, P=0.02); general performance (Correlation: r=
0305, P=0.049; Regression: b = 4.84, P=0.049) and eating
and chewing (Correlation: r=0.362, P=0.048; Regression:
b =3.82, P=0.04).
4. Discussion
Even if treatment with conventional dentures is successful,
the long-term prognosis is not favorable, especially in the
mandible. This is mainly due to progressive bone resorption,
and depends on the patient’s adaptation to overcome the
limitations of the diminished masticatory ability. It is well-
established in literature that dentures do not fully restore the
lost masticatory function, and denture wearers have about
30% of the masticatory performance of dentate patients [19].
Hence, denture wearers need to perform a greater number of
masticatory cycles (up to 7 times more), especially those with
reduced mandibular height (9–15mm), in order to halve the
original particle size of test food (ME 2.8) [15].
Progressive bone resorption is thought to be one of the main
factors that impair masticatory function in edentulous
patients with clinically adequate prostheses [20]. So far, the
relationships between the mandibular height in edentulous
patients, successful treatment and satisfaction levels have
only been evaluated subjectively in complete dentures and
mandibular implant overdentures wearers [21]. Likewise,
masticatory function of objective parameters were not
correlated with overall satisfaction ratings provided by the
patient and professionals through a visual scale [22].
In our study, the edentulous maxillary and mandibular
time periods were higher in patients with atrophic jaws. These
patients showed lower mandibular length, lower height of the
anterior and posterior regions, and lower upper height at the
foramen region, all of which indicate advanced stage bone
resorption. The quantification of these significant anatomical
changes (p<0.05) enables distinction through mandibular

Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
JPOR 377 No. of Pages 9

journal of prosthodontic research xxx (2016) xxx –xxx 7

Table 5 – Spearman correlations and linear regression between GOHAI and DIDL domains and outcomes chewing (Bold
values indicate P-value<0.05.).

Chewing outcome

Spearman Correlation Linear Regression

X50 MPB ME (4) ME (2.8) X50 MPB ME (4) ME (2.8)

GOHAI domain
Pain and discomfort r= 0.115 0.079 0.224 0.206 – – – – –
P= 0.600 0.676 0.234 0.343

Psychosocial and psychological impact r= 0.370 0.226 0.177 0.331 R2= 0.17 0.01 0.03 0.05
P= 0.049 0.299 0.349 0.122 b= 0.49 0.01 0.52 0.64
P= 0.05 0.86 0.35 0.22

Physical and functional r= 0.236 0.137 0.082 0.412 R2= 0.07 0.02 0.01 0.17
P= 0.278 0.469 0.658 0.050 b= 0.25 0.17 0.289 1.22
P= 0.14 0.47 0.65 0.02

DIDL domain
Appearance r= 0.241 0.154 0.208 0.355 – – – – –
P= 0.268 0.416 0.268 0.096

Pain r= 0.007 0.063 0.305 0.023 – – – – –

P= 0.737 0.744 0.101 0.915

Oral comfort r= 0.044 0.234 0.405 0.161 R2= 0.01 0.02 0.16 0.02
P= 0.842 0.281 0.026 0.462 b= 0.17 0.01 2.94 0.74
P= 0.66 0.81 0.02 0.57

General performance r= 0.311 0.244 0.305 0.406 R2= 0.11 0.01 0.13 0.10
P= 0.148 0.261 0.049 0.050 b= 1.29 0.03 4.84 4.04
P= 0.07 0.78 0.049 0.09

Eating and chewing r= 0.157 0.118 0.362 0.227 R2= 0.08 0.01 0.13 0.06
P= 0.473 0.544 0.048 0.296 b= 0.85 0.48 3.82 2.44
P= 0.13 0.53 0.04 0.19

height classification following Cawood and Howell [12]. This
classification has not yet been correlated to different outcomes
in previous studies that categorize patients according to
mandibular height [15,21,23]. These significant changes are
the main anatomical factors responsible for dissatisfaction in
patients with atrophic mandibles. Moreover, these patients
commonly have a knife edge ridge which inherently causes
painful stimuli when subjected to masticatory loads. This
condition results in limitations to the exercised bite force and
difficulty in adapting to complete dentures because of pain.
Consequently, atrophic patients report diminished oral
comfort in the DIDL questionnaire (Table 5).
From a functional point of view, all patients showed a
masticatory function that can be considered extremely poor,
regardless of the degree of mandibular atrophy (Table 1). This
was also observed in the edentulous population studied by De
Lucena et al. [22]. In the latter case, denture wearers were able
to chew on average 32.71% of the test food portion until
reaching 2.8 sieve. Our clinical study shows that the bone
atrophy in the edentulous patients did not modify the chewing
edentulous profile, as assessed based on the mandibular
height. Therefore, it is possible to relate parameters of
masticatory function to the period of edentulism, the
mandibular length (Table 2) and to the retention of the
mandibular prosthesis (Table 3).
The neuromuscular ability depends on the period of
edentulism, and mainly affects the coordinated activity of
the tongue and orofacial muscles. This study found a positive
correlation between the masticatory performance test (MPB)
and the duration of edentulism. This indicates that the patient
with prolonged prosthetic experience has a worse food
homogenization, and is possibly caused by changes in the
support tissues after loss of teeth, resulting in unstable
prostheses—and eventually loss of the prostheses [24].
Consequently, denture wearers develop an inability to
perform greater number of chewing cycles before swallowing,
and therefore it is crucial to monitor the period of edentulism.
Some studies [25,26] only correlate satisfaction and patient
experience with complete dentures related to age and do not
consider the duration of edentulism.
The masticatory performance is also intimately related to
the particle size selection and the ability to triturate food
homogeneously in the oral cavity. When taking the mandibu-
lar length into consideration, there is a negative association
with the ME4 and ME2.8 values. This shows that the
edentulous patients with lower mandibular length achieve

Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
JPOR 377 No. of Pages 9
8 journal of prosthodontic research xxx (2016) xxx –xxx
better food trituration only in the early chewing stages.
Consequently, food particles were not reduced to levels
associated with acceptable masticatory performance. The
latter can be explained by the positive association found
between mandibular length and the MPX_50 results.
Our results also indicate that the mandibular complete
denture stability was unrelated to mandibular atrophy and
masticatory function. These results contradict Hummonen
et al. [23] who described a significant association between
severe residual ridge resorption and poor chewing ability, low
satisfaction with the prosthesis and poor mandibular com-
plete denture stability, in a study with exclusively female
patients. In addition, this study differently evaluated the
mandibular height following the criteria from Xie et al. [6], for
categorization between severe and mild resorption, based on
the location of the mental foramen.
Furthermore, our study has shown that the worst score
for the mandibular complete denture retention was strongly
associated with bone atrophy (P =0.0132) and outcomes
related to chewing (Table 3). Moreover, they were associated
with the pain (P =0.048), general performance (P =0.037) and
eating and chewing domains in the DIDL questionnaire
(P =0.022), evidencing that these patients experience severe
discomfort in their daily lives. Regarding objective mastica-
tory function, it was also observed that patients with poor
retention of mandibular complete dentures showed a worse
food homogenization (66.4%) and lower masticatory efficien-
cy ME2.8 (53.3%) (Table 3). This can be explained by the
dependency of the retention on factors such as the extent of
the prosthesis, muscle insertion heights, peri-oral muscle
action and mucosa resilience and sensitivity and of the
mucosa and the alveolar ridge shape, next to other
anatomical factors such as the anterior and posterior
mandibular height and thickness [3].
Thus, our study indicates that the worst factor that impairs
masticatory function is the movement of the mandibular
prosthesis in the opposite direction. The result is that the
prosthesis displacement ends up competing with food
pulverization while running the masticatory cycles. Conse-
quently, edentulous patients are unable to efficiently homog-
enize food and effectively triturate the test food particles to
half of their original size (ME 2.8). This confirms the results
from a kinesiographic study in edentulous patients, which
concluded that these patients may have difficulty in position-
ing their dentures during food trituration, because the closing
phase during the masticatory cycle execution is longer than
the other phases of the masticatory cycle [7].
When the overall score and domains GOHAI and DIDL
questionnaires for the atrophic and non atrophic groups were
compared, no statistical differences were found. Irrespective
of the groups, patients reported more dissatisfaction with the
DIDL domains pain (atrophic 78.57% and 100% non-atrophic)
and oral comfort (non-atrophic 64.28% and 68.75% atrophic)
(Table 4). This indicates that for edentulous patients, the
greatest concern in their daily living is to have a comfortable
mandibular prosthesis that gives painless support and reten-
tion, and not the poor masticatory efficiency. The high
percentage of dissatisfaction related to pain in atrophic
patients may be related to bone height in the mental foramen
region. This height was on average four times smaller than for
Please cite this article in press as: R.M. Marcello-Machado, et al., Masticatory function parameters in patients with varying degree of
mandibular bone resorption, J Prosthodont Res (2016), http://dx.doi.org/10.1016/j.jpor.2016.12.002
non-atrophic patients (Table 1), indicating that this group has
a greater pain sensitivity by using prostheses.
Additionally, the GOHAI physical domain and the DIDL oral
comfort domain were strongly associated with predictor
outcomes for chewing quality ME_2.8 and ME_4 respectively
(Table 5). These correlations show that the quantification of
masticatory efficiency is strongly associated with subjectively
quantified outcomes relating to the patient’s chewing ability.
In this sense, it is also related to the fact that the mandibular
prosthesis is not easily displaced during eating and talking,
causing embarrassment. In this context, we like to emphasize
the findings by Jacobson & Krol [5] that prosthesis retention
contributes dramatically to prosthesis acceptance by the
patient.
The negative correlation between the GOHAI psychosocial
domain and MP_X50 outcomes emphasizes the important role
of the patient’s perception about their chewing performance. It
shows that physical or anatomical factors are not solely
responsible for acquiring effective masticatory parameters
that are considered acceptable by the patient. In fact, it appears
that patient compliance may partially influence their chewing
performance with regards the food reduction. This in turn,
may be related to the pain that patients experience during
chewing. Our results also suggest that the patient’s self-
evaluation tends to be more optimistic about the performance
of their chewing ability than indicated by objective masticato-
ry tests. This perception is commonly reported by denture
wearers [16], since most edentulous patients assess their
chewing favorably in stark contrast with their objectively low
masticatory performance.
Future research on other factors that influence chewing
such as salivary flow, maximum bite force, data on the
chewing cycle and swallowing threshold would be interesting
to clarify the impairment masticatory process in edentulous
patients. Our results also indicate that other methods of
mandibular bone atrophy classification, either radiographi-
cally or clinically, are necessary to optimize categorization
according to the specific situation of the patients.
5. Conclusions
This study indicates that mandibular bone atrophy does not
interfere directly with the masticatory function of edentulous
patients. Our study also found a significant correlation
between mandibular length and masticatory function, along
with correlations and associations between objective and
subjective assessments of parameters that qualify chewing
function. Finally, the oral comfort domain in the DIDL
questionnaire shows the best correspondence to objective
measurements of masticatory function.
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