Journal of Investigative and Clinical Dentistry (2012), 3, 45–50

ORIGINAL ARTICLE
Oral Rehabilitation

Effect of complete edentulism on masseter muscle

thickness and changes after complete denture
rehabilitation: an ultrasonographic study
Parag Sudhakar Bhoyar, Surekha R. Godbole, Ram U. Thombare & Ashok J. Pakhan
Department of Prosthodontics, Sharad Pawar Dental College and Hospital, Datta Meghe Institute of Medical Sciences, Deemed University,
Wardha, Maharashtra, India

Keywords
complete denture rehabilitation,
complete edentulism, cross-sectional
thickness, masseter muscle, ultrasonography.
Correspondence
Dr Parag Sudhakar Bhoyar, 58/A
Sacchidanand Nagar, Manewada Ring Road,
Nagpur, Maharashtra 440024, India.
Tel: +91-98223-62313
Fax: +91-07152-241711
Email: dr_prgb@yahoo.com
Received 24 October 2010; accepted 15 May
2011.
doi: 10.1111/j.2041-1626.2011.00088.x
Abstract
Aim: The aim of the present study was to determine the changes in masseter
muscle thickness due to the state of complete edentulism and the effect of
complete denture rehabilitation on the masseter muscle.
Methods: Real-time ultrasonography of the masseter muscle at relaxed and
contracted states was carried out for twelve patients (six dentulous and six
completely edentulous). Edentulous patients were scanned at the time of den-
ture insertion and at the end of 3 months’ follow up.
Results: The mean masseter muscle thickness of the edentulous patients was
significantly increased after the 3-month follow-up than the thickness at the
time of denture insertion, but was significantly lower than that of the dentu-
lous patients of the same age group.
Conclusion: Within the limitations of this study, it can be concluded that
change occurs in the masseter muscle thickness after rehabilitation with com-
plete dentures in the form of increased muscle thickness. However, the thick-
ness of the muscle remains smaller than that of dentate individuals.

masseter muscle thickness and bite force magnitude.2 The

Introduction
One of the major reasons for understanding masticatory
muscle function in dentistry is the importance of these
muscles in the natural function and functional disorders
of the craniomandibular system. There is a close associa-
tion between dental occlusion and the outcome of the
action of the muscles of mastication. Both the strength
and action of the masticatory muscles are influenced by
occlusal factors. Bite force is one objective parameter for
the assessment of masticatory ability.1 The strong correla-
tion between the number of remaining teeth and bite
force confirms that the number of natural teeth is an
important factor in maintaining bite force levels. Muscle
thickness has been shown to be the major contributing
factor of bite force in adults.2
The masseter muscle is the main elevator muscle of
the mandible and plays an important role in the act of
mastication. A significant correlation is found between
masseter is a superficially placed, quadrate muscle, and is
well suited for ultrasonographic scanning.3 The parame-
ters of muscle thickness can be evaluated by using various
techniques, such as computed tomography (CT),4–7 mag-
netic resonance imaging (MRI),6,8,9 and ultrasonogra-
phy.2,6,10–12 Ultrasonography is an accurate, convenient,
easy, and inexpensive method that allows for follow-up
possibilities. Cumulative biological side-effects impose
ethical restraint on the use of CT, while MRI requires a
long exposure time.
With the loss of teeth (pathological aging13), the masti-
catory muscles are unable to function as vigorously as
when natural teeth are present. Taking this into consider-
ation, it could be hypothesized that the total loss of the
teeth (complete edentulism) changes the muscle thickness
of the masticatory muscles, along with the changes in
other parameters, such as bite force. Thus, the aim of this
study was to determine the effect of complete edentulism

ª 2011 Blackwell Publishing Asia Pty Ltd 45

Complete edentulism and masseter muscle P.S. Bhoyar et al.

on masseter muscle thickness and to establish the changes

in masseter muscle thickness after the rehabilitation of a
patient with complete dentures.

Materials and methods

The study protocol was approved by Institutional Ethical
Committee of Datta Meghe Institute of Medical Sciences
University, Wardha, Maharashtra, India. Twelve male
patients of average build (age range: 45–55 years) were
evaluated. Six were dentate and six were totally edentu-
lous (denture wearers for the first time). Based on dental
status, the sample selected was divided into the control
group and the study group. The study group was assessed
for changes in masseter muscle cross-sectional thickness
at the end of 3 months’ follow up after denture use. A
comparison was also made between the control and study
groups to evaluate the effect of loss of dentition on mas-
seter muscle thickness.
The criteria for the selection of the sample were:
(a) healthy individuals without a history of any systemic
illness or neuromuscular disorders; (b) no pain or ten-
derness on palpation in muscles of mastication and
temperomandibular joint on both sides; (c) dentulous
individuals selected had natural dentition in both arches
Figure 1. Transducer probe held perpendicular to the skin. Angula-
up to the second molars, without any mobility and with- tion of the probe was modified until optimization of image visualiza-
out any parafunctional habits; and (d) edentulous indi- tion was obtained. Thickness measured at a site on the buccal surface
viduals selected were complete denture wearers for the where the arrangement of the masseter muscle crosses a line
first time, with complete healing of the upper and lower connecting the labial corner to the intertragic notch of the ear.
residual ridges. Dentures were constructed with balanced
occlusion (vertical dimension of occlusion was decided
using Niswonger’s method) by the same operator at the patient was asked to clench the post-canine teeth for
postgraduate clinic of the Department of Prosthodontics, 10 sec. After the identification of the muscle, a line was
Sharad Pawar Dental College, Wardha, Maharashtra, marked on the cheek with a thread deepened in dental
India. plaster extending from the corner of the mouth to the
intertragic notch of the ear (Figure 1). This procedure
was considered standard for subsequent transducer place-
Ultrasonographic recording
ments. The scannings were made at this line approximat-
All patients were informed about the study, and the ing the mid-belly cross-section.14 A generous amount of
procedure was explained at the start of the study. Real- ultrasound transducer gel (Sona Gel Ultrasound; Proto
time imaging of the thickness of the masseter muscle Pharma, Gurgaon, India) was applied on the skin to
corresponding approximately to a cross-section at the avoid tissue compression by a transducer probe at the
mid-belly level of muscle was done bilaterally on an ultra- time of scanning. The transducer was held perpendicular
sound unit (Philips En Visor C; Philips Medical Systems to the skin and to the anterior border of the muscle,
Nederland BV, Best, the Netherlands) using a 7.5-MHz avoiding excessive pressure, as the pressure exerted by the
linear-phased array transducer probe (Philips s42, Philips transducer can flatten the muscle by 50%.6 The angula-
En Visor C; Philips Medical Systems Nederland BV, the tion of the transducer was adjusted until optimum visual-
Netherlands) at the Department of Radiology, Jawaharlal ization of the muscle (i.e. best echo of the ramus) was
Nehru Medical College, Wardha, Maharashtra, India. obtained.6,15 Right-side measurements were made first,
Scannings were performed with the patients seated in a followed by the left side for every patient.
natural, upright position, with their heads relaxed and Recordings were made by the same operator to avoid
unsupported. Muscle identification was done by palpating interoperator error. For dentulous patients; measurements
its origin, insertion, and its anterior border. For that, the at relaxed state were recorded by asking the patients to

46 ª 2011 Blackwell Publishing Asia Pty Ltd

P.S. Bhoyar et al. Complete edentulism and masseter muscle

close the lips, with no contact of teeth. This was done to
avoid contraction of the muscle, which might occur with
slight interocclusal contact.16 The thickness measurements
for the contracted state were recorded by asking the
patients to maximally clench the post-canine teeth for
10 sec, at which the greatest force was found to be gener-
ated in the jaw-closing muscles.17 Measurements were
made directly from the image obtained on the monitor of
the ultrasound unit using an electronic caliper available
within the software of the ultrasound unit. Muscle thick-
ness was calculated as the mean of the three measure-
ments made at 1 cm apart, with readout to the nearest
0.1 cm (Figure 2).
Thickness measurements for edentulous patients were
performed twice, at the time of denture insertion and at
(a)
the 3-month follow-up. The readings were made with the
dentures placed in the mouth. Relaxed-state measure-
ments were made in the same way as those of the dentu-
lous patients. Thickness at the contracted state was
measured by asking the patients to bilaterally clench the
posterior denture teeth in maximum intercuspation in
centric relation for approximately 10 sec. The same
procedure was followed after 3 months follow up. The
patients were instructed to continue wearing their den-
tures without fail prior to recording the follow-up
readings.
Statistical analysis
Unpaired t-test was applied for the comparison of the
muscle thickness in the dentulous and edentulous groups.
Paired t-test was applied for the comparison between
muscle thickness in edentulous patients at the time of
insertion and muscle thickness at the 3-month follow up.
The level of statistical significance was P < 0.05.

Results
The mean cross-sectional thickness of the masseter muscle
in relaxed and contracted states at the left and right sides
is summarized in Table 1 for six dentulous patients and
six edentulous patients with dentures at the time of inser-
tion and at 3 months’ follow up. When muscle thickness
was compared for the edentulous patients at the time of
insertion and after 3 months, no statistically-significant
difference was observed for the left side at the relaxed
state. However, a statistically-significant difference was
(b) observed for the right side at the relaxed state. A compar-
ison of the mean cross-sectional muscle thickness in the

Table 1. Mean cross-sectional thickness of masseter muscle in relaxed

and contracted states at left and right sides for six dentulous patients
and six edentulous patients with dentures at the time of insertion and
at the 3-month follow up

Mean Standard
Groups Side (cm) deviation

Dentulous patients Relaxed Left 1.55 0.11

state Right 1.51 0.09
Contracted Left 1.86 0.10
state Right 1.77 0.13
Edentulous patients Relaxed Left 0.85 0.12
at the time of state Right 0.92 0.23
Figure 2. (a) Cross-sectional thickness of the muscle was calculated denture insertion Contracted Left 1.05 0.12
as the mean of the three measurements made at 1 cm apart. Relaxed state Right 1.08 0.15
state. (+ Length) = 1.06 cm; (· Length) = 1.04 cm; ( Length) = Edentulous patients Relaxed Left 0.94 0.11
0.659 cm. (b) Cross-sectional thickness of the muscle was calcu- at 3-month follow up state Right 1.00 0.14
lated as the mean of the three measurements made at 1 cm apart. Contracted Left 1.19 0.11
Contracted state. (+ Length) = 1.19 cm; (· Length) = 1.15 cm; state Right 1.25 0.09
( Length) = 0.877 cm.

ª 2011 Blackwell Publishing Asia Pty Ltd 47

Complete edentulism and masseter muscle
contracted state at the time of insertion and at 3 months’
follow up for edentulous patients showed statistically-
significant differences on both sides. There was an
increase of 10% and 8% in the relaxed state at 3 months’
follow up on the left and right sides, respectively, and
13% and 15% in the contracted state on the left and right
sides, respectively. The mean masseter muscle thickness of
edentulous patients was significantly increased after the
3-month follow up than the thickness at the time of den-
ture insertion. However, the mean masseter muscle thick-
ness of the edentulous patients was significantly lower
than that of the dentulous patients.
Discussion
Ultrasound has been proven to be an accurate and practi-
cal method in previous studies by calculating intraopera-
tor error.14,18 The use of a 7.5-MHz scanning probe
indicates higher accuracy when compared with a 5-MHz
scanning probe14 for the difference between the actual
measurements of the muscle and the ultrasound scanning
measurements. Kubota et al.14 measured the intraoperator
error of 3.2–3.6% and proved the reproducibility of ultra-
sonography, thus the intraoperator error was not
recorded for proof of reproducibility.
The follow-up period of 3 months in this study was
based on the assumption of Müller et al.19 that with
changes in vertical dimension, the sarcomere length of
the muscle changes progressively to restore optimal work-
ing length and maximal bite force at 3 months. Various
researchers3,10,14,15,20,21 have investigated masseter muscle
thickness in dentate individuals, however different values
were recorded. The abovementioned mainly orthodontic
studies involved dentate patients only. The results of the
present study might not be directly comparable to the
studies conducted at the various sites of the masseter (e.g.
most upper level, upper level, middle level, lower level,
and most lower level). Differences in age and ethnicity,
variations in the frequency of the scanning probe, and the
patient position, rather than the site alone, are also
important parameters for consideration.
When a comparison was made between insertion and
follow up for edentulous patients, no statistically-signifi-
cant difference was observed for the left side at the
relaxed state. However, a statistically-significant difference
was observed for the right side at the relaxed state. This
might be due to the possibility of unilateral chewing,
despite instructions given for bilateral chewing. Findings
of the dentulous patients in the present study are near
the values recorded by Kubota et al.,14 who measured
muscle thickness at the mid-belly cross-section. The
increased thickness of the muscle observed at the contrac-
tion might be due to the reduction in the vertical height
48
P.S. Bhoyar et al.
of the muscle and increase in the diameter of the muscle
fibre by sliding of the actin and myosin filaments over
each other17 by the sliding filament mechanism.22
A muscle thickness investigation carried out for the
edentulous patients showed significantly lower values
than their dentulous counterparts. This reduction in
thickness can be attributed to the atrophic changes in the
masticatory muscle with the loss of teeth. Kohyama
et al.23 found that the integrity of natural dentition is
one of the major variables that can alter food acceptabil-
ity. Missing natural dentition has been associated with a
reduced acceptability of foods. Avoiding hard food could
reduce muscular activity during chewing. Weak muscle
contraction might compensate for poor chewing perfor-
mance by lengthening both the chew cycle and sequence
duration. An increase in the number of chews occurs to
compensate for chewing efficiency per chew. Miralles
et al.24 observed the changes in the influence of periph-
eral and/or central neural mechanisms in edentulous
patients. With the changes in the functional conditions of
muscles, there is adaptation in muscle tissue, particularly
muscle fibres.25 It has been reported that these appear to
be due to the reduction in fast-twitch fibres in individu-
als who have lost their natural dentition.4 The size of
fast-twitch fibres significantly correlate to bite force and
are primarily designed for maximum biting effort.26 This
change has been attributed to the altered functional
demand, with atrophy of these fibres as a consequence of
tooth loss.4
In the present investigation, values at the 3-months
follow up for the contracted state were found to be sig-
nificantly increased than the values at the time of inser-
tion. Müller et al.19 mentioned that the changes in the
vertical dimension have both short and less immediate
effects on the capacity of muscles to exert maximum
tension. The immediate effect is a function of optimum
working length of the sarcomeres. The less immediate
effect results from the capacity of the muscles to graft
in new sarcomeres in series on the elongated muscle
restoring the optimum working length. The ability of
the muscle to add to new sarcomeres progressively
restores the optimum working length, and thereby, max-
imum bite force. Thus, the edentulous muscle might
need to utilize more available masticatory muscle fibers
to maintain the necessary force required for mastication.
Goldspink shares the view of muscle adaptability in
terms of changes in the functional length of muscles by
the addition or removal of sarcomeres to adjust the
muscle length of muscle fibers optimum for force gener-
ation, velocity, and thus, power output.27 They men-
tioned that the age-related changes in masticatory
muscle length would be expected to result in a decrease
in muscle mass, and thus, atrophy. They advised the
ª 2011 Blackwell Publishing Asia Pty Ltd
P.S. Bhoyar et al. Complete edentulism and masseter muscle

maintenance of facial height to impose stretch on the
muscle not only to improve appearance, but also to
improve muscle mass and function of masticatory
muscles. They also found that stretch on the muscle
increases the protein synthesis in the muscle and the
muscle mass, and there is release of muscle growth
factor, which is upregulated by physical activity and
controls the local repair of the muscle, preventing
muscle fiber atrophy. Oral rehabilitation with complete
dentures restores the vertical dimension of the face, thus
might be exerting the stretch on the masseter muscle,
increasing protein synthesis for adjusting muscle fibre
length, as well as the cross-sectional area.
In the present study, ultrasonography technique had
certain limitations. With ultrasonography, muscle thick-
ness can be measured, but the force exerted by the muscle
on the adjacent structure cannot be measured. Therefore,
other instruments, such as pressure transducers that can
record muscle force, should be used in conjunction with
ultrasonography to correlate muscle thickness with effect.
Although muscle thickness is a physiological attribute, the
clinical measurement of thickness is influenced by the
patient’s compliance. Technique-related factors, such as
pressure of the scanning probe on muscle, angulation of
the probe, and accurate identification of the muscle image
influenced the measurements. A more extensive longitudi-
nal study with a longer follow-up period involving a lar-
ger number of patients is required to give more definite
conclusion.
In conclusion, there is a decrease in masseter muscle
thickness in edentulous individuals, and there are subse-
quent changes occurring in muscle thickness after rehabil-
itation with complete dentures in the form of increased
muscle thickness. However, the thickness of the muscle
remains smaller than that of dentate individuals.
Acknowledgments
The authors thank Associate Professor Pankaj Banode
(Department of Radiology, Jawaharlal Nehru Medical
College, Datta Meghe Institute of Medical Sciences,
Deemed University, Wardha, Maharashtra, India) for
guiding the ultrasound scanning technique, and Assistant
Professor Amol R. Gadbail (Department of Oral and
Maxillofacial Pathology, Sharad Pawar Dental College and
Hospital, Datta Meghe Institute of Medical Sciences,
Deemed University, Wardha, Maharashtra, India) for
editorial help.

6 Dupont AC, Sauerbrei EE, Fenton Ultrasound image of human masseter

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