Full Terms & Conditions of access and use can be found athttps://www.tandfonline.com/action/journalInformation?journalCode=ycra20

CRANIO®The Journal of Craniomandibular & Sleep Practice

ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ycra20

Comparison of occlusal bite force distribution insubjects with different occlusal characteristics

Khadijah A. Turkistani , Moayyad A. Alkayyal , Mona A. Abbassy , Ayman A.Al-Dharrab , Mohammed H. Zahran , Marcello Melis & Khalid H. Zawawi

To cite this article: Khadijah A. Turkistani , Moayyad A. Alkayyal , Mona A. Abbassy , Ayman A.Al-Dharrab , Mohammed H. Zahran , Marcello Melis & Khalid H. Zawawi (2020): Comparison ofocclusal bite force distribution in subjects with different occlusal characteristics, CRANIO®, DOI:10.1080/08869634.2020.1830662

To link to this article: https://doi.org/10.1080/08869634.2020.1830662

Published online: 19 Oct 2020.

Submit your article to this journal

View related articles

View Crossmark data

ORTHODONTICS

Comparison of occlusal bite force distribution in subjects with different occlusal characteristicsKhadijah A. Turkistani BDS, DMSc a, Moayyad A. Alkayyal BDS, MScb, Mona A. Abbassy DDS, PhDa, Ayman A. Al- Dharrab BDS, MSc, MPhil, PhDc, Mohammed H. Zahran BDS, MSc, PhD c, Marcello Melis DMD, Pharm Dd,e

and Khalid H. Zawawi BDS, DSca

aDepartment of Orthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; bPrivate Practice, Jeddah, Saudi Arabia; cDepartment of Oral and Maxillofacial Prosthodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; dPrivate Practice, Cagliari, Italy; eDepartment of Orthodontics, School of Dentistry, University of Cagliari, Cagliari, Italy

ABSTRACTObjective: To analyze bite force distribution in subjects with different occlusal characteristics.Methods: This prospective study included 132 candidates (50 males, 82 females) seeking ortho-dontic treatment, who were divided into four groups based on Angle’s classification of malocclu-sion. T-Scan® III Version 7.0 was used to record their relative distribution of bite forces, which were compared using gender, Angle’s occlusal classification, overjet, overbite, space analysis, sagittal, and transverse skeletal relations variables.Results: ANOVA revealed significant differences in posterior/anterior bite force ratios between sagittal dental and skeletal relationships, overjet, and overbite groups (p < 0.05). No significant difference was found between different space analysis and transverse relationship groups (p > 0.05) or between genders (p > 0.05).Conclusion: Subjects with Class III, decreased overjet and decreased overbite displayed higher bite force in posterior teeth compared to other groups. This feature must be considered when evaluating patients with dental and periodontal pathologies that might be affected by excessive tooth stress, especially in subjects with oral parafunctions and bruxism.

KEYWORDS Dental occlusion; computerized occlusal analysis; T-Scan; bite force; occlusal balance

Introduction

Dental occlusion is defined as the contact between the upper and lower dentition when the teeth are in max-imum intercuspation [1]. In addition, the term “dynamic occlusion” is used to describe tooth contacts during mandibular movements [2]. Since the number, site, and position of the teeth are extremely variable, the possible combinations of different types of dental occlu-sion are incredibly high. Therefore, to study dental occlusion, several features have been used to try to categorize it. A very commonly used classification is Angle’s classification, which divides different types of dental occlusion based on the sagittal relationship between the upper and lower teeth. Other characteristics include the overjet (the horizontal overlap between the upper and lower incisors); overbite (the vertical overlap between the upper and lower incisors); and occlusal lateral guidance (the description of tooth contact during lateral mandibular movements) [1,2].

Different occlusal features can affect the number and the magnitude of teeth contacts, and they have also been

associated with a diverse amount of bite force [3,4]. Nonetheless, measurement of tooth contact and occlusal force is often unreliable. Qualitative occlusal measures are commonly used due to their low cost and ease of handling. They include articulating paper, articulating silk, articulating film, metallic Shimstock film, and high spot indicators [5,6]. The main limitations of such methods are the subjective assessment, the inability to identify the sequence and applied load of the contacts, the presence of saliva, and the thickness of the film [7–9].

An objective method to assess both static and dynamic dental occlusion is the T-Scan® (Tekscan Inc., South Boston, MA, USA). It allows a computerized analysis that removes operator subjective paper mark misperceptions; in addition, T-Scan® measurements are not affected by the presence of saliva [4,7,8,10]. The T-Scan® provides real-time occlusal balancing data. It can also accurately indicate the relative distribution of bite forces along the dental arch to the total force exerted by the jaws [10–14].

CONTACT Khadijah A. Turkistani katurkistani@kau.edu.sa Department of Orthodontics, Faculty of Dentistry, King Abdulaziz University, P.O. Box 80209, Jeddah 21589, Saudi Arabia

CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE https://doi.org/10.1080/08869634.2020.1830662

© 2020 Taylor & Francis Group, LLC

Qadeer et al. [15,16] assessed bite force distribution along the dental arch in subjects with Angle’s Class I occlusion, comparing post-orthodontic patients with non-orthodontic subjects, also evaluating the difference between articulating paper mark, and association with symptoms of temporomandibular disorders. Based on these data, the aim of this study was to evaluate and compare the bite force distribution among different classes of occlusion and to compare the effect of differ-ent predictor variables, including gender, overbite, over-jet, space analysis, and sagittal skeletal relationship on bite force distribution as an outcome variable. Occlusal bite force was assessed by the use of the T-Scan®.

Materials and methods

Sample size calculation

Using the G*Power3, a priori power analysis was calcu-lated with alpha level set at 0.05 and medium effect size (d = 0.30) to reach a power of 0.80 [17]. Thus, the estimated sample size of 128 patients has an 80% prob-ability of detecting a true difference (of medium effect size) among the four groups at p < 0.05.

Intra-examiner reliability

Intra-examiner reliability was tested using Cronbach’s alpha. T-scan® measurements of 10 participants were recorded twice with a one-month interval.

Data collection

The research was reviewed and approved by the Research Ethics Committee (No. 024–15). Patients seek-ing orthodontic treatment at the Faculty of Dentistry were asked to voluntarily participate in this study. The study protocol was explained to each potential subject, and signed consent was obtained for those who agreed to participate and fulfilled the following inclusion cri-teria: complete permanent teeth excluding the third molars, normal temporomandibular joint function, and absence of periodontal pathology. The exclusion criteria included a history of temporomandibular dis-order and/or orofacial pain, developmental dental or skeletal anomaly, being mentally challenged, current or previous orthodontic treatment and cast restorations, previous occlusal adjustment, tooth attrition into the dentin, and extensive occlusal restoration of three teeth or more with onlay restorations.

A total of 132 subjects (50 males and 82 females) aged between 13 and 32 years participated in the study. Among them, patients with ideal occlusion were

recruited and asked to participate in the study as a control group. Subjects were divided into four groups based on Angle’s classification of occlusion, as follows:

Group 1: Class I normal occlusion, when the mesio-buccal cusp of the upper first molar occludes with the buccal groove of the lower first molar;

Group 2: Class I malocclusion is the same as normal occlusion but characterized by crowding, rotations, and other positional dental irregularities;

Group 3: Class II malocclusions, when the mesiobuc-cal cusp of the upper first molar occludes anterior to the buccal groove of the lower first molar;

Group 4: Class III malocclusion, when the mesiobuc-cal cusp of the upper first molar occludes posterior to the buccal groove of the lower first molar. Lateral cepha-lometric images were also collected and analyzed.

Lateral cephalometric analysis

Skeletal relationships were assessed using lateral cepha-lometric radiographs. Subjects were classified as Class I, II, or III using the angle formed by points A, Nasion, and B (ANB angle). VistaDent OCTM Version 4.2.40 (Dentsply Sirona, Charlotte, NC, USA) was used for cephalometric analysis.

T-Scan® measurements

T-Scan® III Version 7.0 (Tekscan Inc., South Boston, MA, USA) was used for measurements. According to the man-ufacturer’s recommendations, participants were seated in an upright position, and the proper sensor size was selected. While maintaining the handle as parallel to the occlusal plane as possible, the sensor was inserted into the subject’s mouth with the midline indicator of the plastic support placed between the upper central incisors (Figure 1). Participants were asked to perform three light chewing cycles before recording the bite force to adjust the sensitiv-ity according to the manufacturer’s instructions to obtain no more than three pink peaks at maximum intercuspation [18]. The average of three consecutive recordings at the maximum bite forces was calculated. The display was kept on the output mode of four quadrants to register the bite force distribution of each quadrant separately (Figure 2). One trained investigator performed all the recordings to avoid any inter-examiner variations.

Data management

Occlusion was categorized according to Angle’s molar classification as Class I normal occlusion, Class I, II, and III malocclusions. Overjet was categorized into three groups: decreased (< 2 mm), average (2–3 mm), and

2 K. A. TURKISTANI ET AL.

increased (>3 mm). The overbite was categorized into three groups: decreased (<10%), average (10–40%), and increased (>40%). The transverse discrepancy was categor-ized into normal, unilateral crossbite, bilateral crossbite, single tooth crossbite, and buccal (Brodie) bite. The skele-tal profile was categorized as Class I (ANB 0–4 degrees), Class II (ANB > 4 degrees), and Class III (ANB < 0 degrees).

Statistical analysis

The statistical analysis was conducted using the Statistical Package for Social Sciences version 20 (SPSS; IBM Corporation, Armonk, NY, USA). The Shapiro

Wilk’s test indicated that the data were approximately normally distributed. The frequency and percentages of the distribution by gender, occlusal classification, sagit-tal skeletal relationship, overjet, overbite, space analysis, and transverse relationship were calculated. Means and standard deviation were calculated for the following bite force ratios: posterior and anterior, right and left, right posterior and right anterior, and left posterior and left anterior ratios. ANOVA was performed to evaluate the association between these ratios (dependent variable) and gender, occlusal classification, sagittal skeletal rela-tionship, overjet, overbite, space analysis, and transverse relationship (independent variables). Post hoc multiple comparisons were performed using the Tukey-HSD

Figure 1. Full assembly of the T-scan® system with handle and USB portal connected to the film sensor.

CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3

method to detect significant intergroup differences. Bivariate comparisons were performed using the t-tests. The significance level was set at p < 0.05.

Results

The characteristics of the study sample are shown in Table 1. A total of 132 patients were included (50 males and 82 females). There was no significant difference in age between males (mean = 21.34 ± 5.15) and females (mean = 21.07 ± 4.68), p = 0.76.

After comparing T-scan® measurements of 10 parti-cipants surveyed at two separate times with a one- month interval, the results of the Cronbach’s alpha for all variables was > 0.8, which indicates good to excellent reliability.

Comparisons of the bite force ratios between males and females are shown in Table 2. No statistically sig-nificant difference was found between males and females in the posterior/anterior, right/left, right poster-ior/anterior, and left posterior/anterior bite force ratios, p > 0.05. The bite force was 3.58 (females) to 5.59 (males) times higher in the posterior teeth than the anterior teeth. The posterior/anterior bite force ratio was generally symmetrical, with no significant differ-ences between the left and the right side in either gen-der, p > 0.05.

ANOVA comparing the bite force ratio between the studied variables are shown in Table 3. ANOVA showed that there were statistically significant differ-ences between Angle’s occlusal classification and bite force ratios in the posterior/anterior and right poster-ior/anterior bite force ratios, p = 0.016, and p = 0.018, respectively. However, the left posterior/anterior bite force ratio was not significantly different between the

Figure 2. One subject’s quadrant bite force data displayed by the anterior left force % = 8.5% (dark blue flag), anterior right force % = 5.4% (red brown flag), posterior right force % = 39.4% (light blue flag), posterior left force % = 46.7% (pink flag), along with the right side 44.8% (red box at bottom) to left side 55.2% (green box at bottom force % imbalance. These percentage values from each subject comprised the comparison bite force ratios that were computed for statistical analysis.

Table 1. Characteristics of the study sample (n = 132).Characteristics N Percent

Gender Male Female

50 82

37.9 62.1

Dental Relationship Class I normal occlusion Class I malocclusion Class II malocclusion Class III malocclusion

26 37 38 31

19.7 28.0 28.8 23.5

Skeletal relation Class I Class II Class III

68 39 25

51.5 29.5 18.9

Overjet Decreased Average Increased

17 62 53

12.9 47.0 40.2

Overbite Decreased Average Increased

18 52 62

13.6 39.4 47.0

Space analysis Crowding Adequate Spacing

59 45 28

44.7 34.1 21.2

Transverse No Unilateral Bilateral Single tooth Buccal

103 6 6

14 3

78.0 4.5 4.5

10.6 2.3

4 K. A. TURKISTANI ET AL.

four occlusal classifications, p = 0.07. Post hoc multiple comparisons showed that the posterior/anterior bite force ratio of Class III malocclusion was significantly greater than Class I normal occlusion and Class II malocclusion, p = 0.034, and p = 0.028, respectively. The posterior/anterior bite force ratio on the right side in Class III malocclusion was also significantly greater from Class I normal occlusion and Class II malocclu-sion, p = 0.028, and p = 0.033, respectively. Post hoc tests showed no significant differences between Class I normal occlusion and Class I and II malocclusions (p > 0.05).

ANOVA showed that the posterior/anterior and right and left posterior/anterior bite force ratios were significantly different among the skeletal profiles, p ≤ 0.011. Post hoc tests showed that patients with Class III skeletal profile had significantly greater poster-ior/anterior as well as posterior/anterior right and left bite force ratio than Class I and Class II (p < 0.05). Post

hoc tests showed that there were no significant differ-ences in any of the bite forces studied between skeletal Class I and II (p > 0.05).

ANOVA for the posterior/anterior and right and left posterior/anterior bite force ratios was significant (p < 0.001). Post hoc tests showed that patients with decreased overjet had significantly greater force from those with average and increased overjet (p < 0.001), with higher bite force located in the posterior teeth. No differences were observed between patients with average and increased overjet (p > 0.05).

ANOVA was also significant among the different vertical bite relationships (p < 0.001). Patients with a decreased overbite (open bite) had significantly increased bite force ratios from those with average and increased (deep bite) overbite (p < 0.001), with higher bite force located in the posterior teeth. The bite force ratio was similar in patients with an average and increased overbite (p > 0.05).

Table 3 also shows that ANOVA did not find signifi-cant differences among patients with dental crowding, spacing, or adequate dental spacing in any of the bite force ratios studied (p > 0.05).

Since the frequency between each classification in the transverse category was large (Table 1), the sample was re-categorized into those with and without crossbite. Independent sample t-test showed that posterior/ante-rior and right and left posterior/anterior force ratios were similar between those presenting with and without crossbite, p > 0.05 (Table 3).

Table 3. Comparisons of the bite force ratio between occlusal characteristics.

Variables

Bite Force Ratio

Posterior/AnteriorPosterior/Anterior

RightPosterior/Anterior

Left

Occlusion Class I normal 3.05 (2.09) 2.91 (2.10) 3.85 (3.69)Class I malocclusion 3.84 (3.67) 4.99 (7.45) 3.85 (3.44)Class II malocclusion 3.33 (4.13) 3.43 (4.57) 3.53 (4.27)Class III malocclusion 7.25 (10.00) 7.71 (8.86) 7.72 (13.3)p-value * 0.016 0.018 0.070

Skeletal Class I 3.58 (3.07) 3.37 (4.52) 3.49 (4.23)Class II 3.29 (4.09) 3.37 (4.52) 3.49 (4.23)Class III 8.05 (10.97) 8.54 (9.56) 8.58 (14.71)p-value * 0.002 0.004 0.011

Overjet Decreased 10.73 (12.71) 11.49 (13.02) 11.97 (17.1)Average 3.27 (2.67) 3.82 (4.01) 3.4 (3.04)Increased 3.54 (3.83) 3.72 (4.57) 3.8 (4.01)p-value * <0.001 <0.001 <0.001

Overbite Decreased 9.71 (12.71) 10.30 (13.01) 11.06 (16.94)Average 3.69 (2.84) 4.17 (4.09) 3.91 (3.28)Increased 3.32 (3.66) 3.66 (4.60) 3.45 (3.71)p-value * <0.001 <0.001 <0.001

Space analysis Crowding 4.81 (6.93) 5.31 (7.08) 4.64 (7.3)Adequate 3.33 (3.00) 3.25 (2.88) 4.08 (4.36)Spacing 4.98 (7.01) 6.07 (9.08) 5.66 (10.81)p-value * 0.367 0.143 0.676

Crossbite No 4.63 (5.92) 5.23 (7.11) 4.77 (6.32)Yes 3.32 (5.88) 3.14 (3.80) 4.30 (10.42)p-value ** 0.297 0.131 0.760

Data is presented as mean ± Standard deviation; *ANOVA; **t-test.

Table 2. Comparisons of the bite force ratio between males and females.

RatioMale

(n = 50)Female

(n = 82)Mean

Difference p-value

Posterior/ Anterior

5.59 (8.25) 3.58 (3.71) 2.02 0.108

Right/Left 1.01 (0.32) 1.08 (0.36) 0.07 0.254Right Posterior/

Anterior5.65 (7.55) 4.23 (5.89) 1.43 0.228

Left Posterior/ Anterior

6.22 (10.75) 3.72 (3.96) 2.50 0.102

Data is presented as mean ± Standard deviation.

CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5

Discussion

This study investigated the relative bite force distribu-tion of different Angle’s malocclusions using T-scan®. Additionally, the effect of gender, sagittal and transverse skeletal relationship, overjet, overbite, and space analy-sis were studied. The choice to categorize the subjects based on Angle’s occlusal classification among the numerous different occlusal features was due to the widespread use of such classification both in the clinical and research contexts; thus, such an approach does not replace the need for proper occlusal analysis of each tooth during dental examination.

Previous studies have compared the relationship between maximum bite forces with Angle’s occlusal classification [4,19–21]. Some of these studies did not find a relationship between bite force and sagittal dental relationship; however, these studies only measured the bite forces on the posterior teeth [4,21]. For example, Sathyanarayana et al. [21] evaluated the maximum voluntary bite force of subjects with Angle’s Class I normal occlusion compared to subjects with Class I and Class II malocclusions. Bite force was measured at the first premolar and first molar regions using a bite force meter, and they did not find any relationship between the groups. Similarly, Araújo et al.]19] evalu-ated the bite force of 100 university students with dif-ferent types of dental occlusion. They found that bite forces were not different between the right and left sides; however, bite forces were different in subjects with Angle’s Class I normal occlusion compared to subjects with Class II and III malocclusions. Still, no difference was found between students with Class I normal occlu-sion and students with Class I malocclusion. Their results are in line with the current study findings, where Class III subjects (both dental and skeletal) gen-erally displayed a higher bite force in the posterior teeth compared to the other occlusal classes, although such difference did not always reach statistical significance. Roldan et al. [20] longitudinally studied the bite force of children and adolescents between the ages of 7 and 17 years and found that malocclusion had a detrimental effect on bite force. However, their sample did not include Class III patients. It must be said that the afore-mentioned studies specifically evaluated maximum bite force by the use of a pressure transducer put between the teeth being assessed. Although such experiments mea-sured bite force, they did not measure bite force distri-bution on the entire dentition, as the current study did.

In the current study, there was no difference in bite force distribution between males and females. Furthermore, a significant relationship was found between bite force ratio and sagittal dental and skeletal

relationships. Also, patients with negative overjet and open bite showed an increase of bite force distribution in the posterior teeth. The amount of dental spacing or crowding did not affect the bite force ratio. Even though bite force ratios were different between the transverse relationship categories, such difference did not reach statistical significance. This could be attributed to the small number of patients in these categories.

In the present study, the T-scan® was used to analyze the bite forces simultaneously on the teeth. This repre-sents the strength of this study since the validity and reliability of the T-scan® has been studied extensively [3,12,13,22–25]. It has many clinical applications in dentistry for the evaluation of dental occlusion in the case of orthodontics, prosthodontics, restorative treat-ments, and equilibration of dental appliances, with higher accuracy compared to commonly used articulat-ing papers and other measuring methods [7,8,12,13].

A comparison of this study’s results with other stu-dies where the T-Scan® was used for the evaluation of dental occlusion could not be made because no other similar trials used the same method of assessment to compare different Angle’s classes of occlusion. On the other hand, the current study has a major limitation in the fact that, although the sample size of the entire sample was calculated, it was not equally distributed among the studied groups. In addition, the use of occlu-sal indicators inevitably alters tooth contacts; therefore measurements of bite force distribution may not neces-sarily characterize actual occlusion [26,27]. However, since such indicators are inevitable for the evaluation of dental occlusion, the choice of the T-Scan® is reason-ably the most suitable to quantify occlusal forces, espe-cially when using the new high definition sensor with very low variability of force reproduction over multiple closures [13].

The increase of bite force in the posterior teeth in subjects with Class III malocclusion, decreased overbite, and decreased overjet must be considered when evalu-ating patients with dental and periodontal conditions that might be affected by excessive tooth stress (implant placement, tooth mobility, risk of tooth fracture). This is particularly relevant in subjects with oral parafunctions and bruxism. Obviously, the need for treatment must be specifically evaluated in each patient with an occlusal analysis of each tooth during dental examination.

In this study, only static occlusion in the intercuspal position was evaluated. However, dental occlusion is also characterized by functional movements, especially during mastication, that were not assessed. Since the T-Scan® allows such measurements, this could be an interesting topic to investigate in future studies.

6 K. A. TURKISTANI ET AL.

Conclusion

Some occlusal features, such as dental and skeletal Angle’s Class, overjet, and overbite can affect bite force distribution; specifically, Class III subjects (both dental and skeletal), subjects with decreased overjet and sub-jects with a decreased overbite (open bite) generally displayed a higher bite force in the posterior teeth com-pared to the other groups. This feature must be consid-ered when evaluating patients with dental and periodontal pathologies that might be affected by exces-sive tooth stress, especially in subjects with oral paraf-unctions and bruxism.

Acknowledgments

This project was funded by the Deanship of Scientific Research (DSR), King Abdulaziz University, Jeddah, Saudi Arabia, under grant no. (514/165/1436). The investigators, therefore, acknowledge, with thanks, DSR technical and finan-cial support.

The authors also would like to thank Professor Mohammad S. Al-Zahrani for his valuable comments and statistical advice.

Disclosure statement

The authors have no conflict of interest.

ORCID

Khadijah A. Turkistani BDS, DMSc http://orcid.org/0000- 0001-8603-4305Mohammed H. Zahran BDS, MSc, PhD http://orcid.org/ 0000-0003-2599-1552

References

[1] Davies S, Gray RM. What is occlusion? Br Dent J. 2001;191(5):235–238, 241–235.

[2] Panek H, Matthews-Brzozowska T, Nowakowska D, et al. Dynamic occlusions in natural permanent dentition. Quintessence Int. 2008;39(4):337–342.

[3] Al-Rayes NZ, Hajeer MY. Evaluation of occlusal con-tacts among different groups of malocclusion using 3D digital models. J Contemp Dent Pract. 2014;15 (1):46–55.

[4] Sonnesen L, Bakke M. Molar bite force in relation to occlusion, craniofacial dimensions, and head posture in pre-orthodontic children. Eur J Orthod. 2005;27 (1):58–63.

[5] Forrester SE, Presswood RG, Toy AC, et al. Occlusal measurement method can affect SEMG activity during occlusion. J Oral Rehabil. 2011;38(9):655–660.

[6] Sharma A, Rahul GR, Poduval ST, et al. History of materials used for recording static and dynamic occlu-sal contact marks: a literature review. J Clin Exp Dent. 2013;5(1):e48–53.

[7] Kerstein RB. Articulating paper mark misconceptions and computerized occlusal analysis technology. Dent Implantol Update. 2008;19(6):41–46.

[8] Kerstein RB, Radke J. Clinician accuracy when subjec-tively interpreting articulating paper markings. CRANIO®. 2014;32(1):13–23.

[9] Saracoglu A, Ozpinar B. In vivo and in vitro evaluation of occlusal indicator sensitivity. J Prosthet Dent. 2002;88(5):522–526.

[10] Afrashtehfar KI, Qadeer S. Computerized occlusal ana-lysis as an alternative occlusal indicator. CRANIO®. 2016;34(1):52–57.

[11] Kirveskari P. Assessment of occlusal stability by mea-suring contact time and centric slide. J Oral Rehabil. 1999;26(10):763–766.

[12] Andrus R, Qian F, Schneider R. et al. Comparison of results of traditional occlusal adjustment technique with computer-aided occlusal adjustment technique. Adv Dent Tech. 2019;1(2):43–53.

[13] Kerstein RB, Lowe M, Harty M, et al. A force reproduc-tion analysis of two recording sensors of a computerized occlusal analysis system. CRANIO®. 2006;24(1):15–24.

[14] Qadeer S, Abbas AA, Sarinnaphakorn L, et al. Comparison of excursive occlusal force parameters in post-orthodontic and non-orthodontic subjects using T-Scan® III. CRANIO®. 2018;36(1):11–18.

[15] Qadeer S, Kerstein R, Kim RJ, et al. Relationship between articulation paper mark size and percentage of force measured with computerized occlusal analysis. J Adv Prosthodont. 2012;4(1):7–12.

[16] Qadeer S, Yang L, Sarinnaphakorn L, et al. Comparison of closure occlusal force parameters in post- orthodontic and non-orthodontic subjects using T-Scan® III DMD occlusal analysis. CRANIO®. 2016;34(6):395–401.

[17] Faul F, Erdfelder E, Lang AG, et al. G*Power 3: a flexible statistical power analysis program for the social, beha-vioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–191.

[18] Jeong MY, Lim YJ, Kim MJ, et al. Comparison of two computerized occlusal analysis systems for indicating occlusal contacts. J Adv Prosthodont. 2020;12(2):49–54.

[19] Araújo SC, Vieira MM, Gasparotto CA, et al. Bite force analysis in different types of angle malocclusions. Revista CEFAC. 2014;16:1567–1578.

[20] Roldan SI, Restrepo LG, Isaza JF, et al. Are maximum bite forces of subjects 7 to 17 years of age related to malocclusion? Angle Orthod. 2016;86(3):456–461.

[21] Sathyanarayana HP, Premkumar S, Manjula WS. Assessment of maximum voluntary bite force in adults with normal occlusion and different types of malocclusions. J Contemp Dent Pract. 2012;13 (4):534–538.

[22] Trpevska V, Kovacevska G, Benedeti A, et al. T-scan III system diagnostic tool for digital occlusal analysis in orthodontics - a modern approach. Pril (Makedon Akad Nauk Umet Odd Med Nauki). 2014;35 (2):155–160.

[23] Liu CW, Chang YM, Shen YF, et al. Using the T-scan III system to analyze occlusal function in mandibular reconstruction patients: a pilot study. Biomed J. 2015;38(1):52–57.

CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 7

[24] Agbaje JO, Casteele EV, Salem AS, et al. Assessment of occlusion with the T-Scan system in patients under-going orthognathic surgery. Sci Rep. 2017;7(1):5356.

[25] Ayuso-Montero R, Mariano-Hernandez Y, Khoury- Ribas L, et al. Reliability and validity of T-scan and 3D intraoral scanning for measuring the occlusal con-tact area. J Prosthodont. 2020;29(1):19–25.

[26] Helms RB, Katona TR, Eckert GJ. Do occlusal contact detection products alter the occlusion? J Oral Rehabil. 2012;39(5):357–363.

[27] Mitchem JA, Katona TR, Moser EAS. Does the presence of an occlusal indicator product affect the contact forces between full dentitions? J Oral Rehabil. 2017;44 (10):791–799.

8 K. A. TURKISTANI ET AL.