Archives of Oral Biology 75 (2017) 14–20

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Archives of Oral Biology

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Only severe malocclusion correlates with mastication deficiency

Pierre Bourdiola,b,* , Delphine Soulier-Peiguea,b , Pauline Lachazea,b , Emmanuel Nicolasa,b ,
Alain Wodaa,b , Martine Hennequina,b
a
Centre Hospitalo-Universitaire, Service d’Odontologie, Clermont-Ferrand, France
b
UFR Odontologie, Université d’Auvergne, Clermont-Ferrand, France

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: The relation between level of dentofacial deformity and extent of masticatory deficiency was
Received 22 March 2016 studied.
Received in revised form 1 December 2016 Design: Three groups of human young adults were formed: (i) subjects needing orthodontics plus
Accepted 3 December 2016
orthognathic surgery (SevDFD, n = 18), (ii) subjects needing orthodontic treatment only (ModDFD, n = 12),
and (iii) subjects needing no treatment (NoDFD, n = 12). For mastication tests, carrot boluses were
Keywords: collected at the deglutition time. Bolus particle size range was expressed as d50 value, which was
Masticatory deficiency
compared with the Masticatory Normative Indicator (MNI). Index of treatment need (IOTN), global oral
Masticatory normative indicator
Index of treatment need
health assessment index (GOHAI) and chewing kinematic characteristics were also recorded. We used a
Global oral health assessment index general linear model univariate procedure followed by a Student-Newman-Keuls test.
Malocclusion Results: All the SevDFD subjects showed impaired mastication with MNI above the normal limit (d50
Dentofacial deformity mean = 7.23 mm). All the ModDFD subjects but one were below this limit (d50 mean = 2.54 mm), and so
could adapt to a low level of masticatory impairment as also indicated by kinematics. IOTN indicated a
treatment need for ModDFD (3.7  0.5) and SevDFD (4.3  0.6) groups, while GOHAI values were
unsatisfactory only for SevDFD (42.6  9.2 vs. 55.3  1.9).
Conclusions: Our findings emphasize the need for an objective evaluation of masticatory function to
discern truly deficient mastication from mild impairment allowing satisfactory adaptation of the
function. However, malocclusions are known to worsen with time justifying thus their corrections as
early as possible.
© 2016 Published by Elsevier Ltd.

1. Introduction
Mastication is performed through a series of masticatory
sequences. Each sequence aims to prepare a mouthful of food to be
swallowed, and comprises a series of cycles or chewing strokes.
Each cycle is made up of a three-dimensional, basically up-and-
down, drop-shaped movement of the mandible. These cycles are
time-paced by a masticatory central generator (Dellow and Lund,
1971), which determines a cycle frequency within the sequence.
This rhythmic activity is influenced by sensory feedback derived
from, among other sources, oral mucosa and interarch contacts
with or without food particle interpositions. Complete processing
in a sequence results in a food bolus whose main properties;
particle size (Woda et al., 2010) and rheological characteristics
* Correspondence to: Centre de Recherche en Odontologie Clinique (EA 4847),
Faculté d’Odontologie (UFR), Université d’Auvergne Clermont 1, 2 rue de Braga,
63100, Clermont-Ferrand, France.
E-mail addresses: pierre.bourdiol@u-clermont1.fr, pierre.bourdiol@udamail.fr
(P. Bourdiol).
(Peyron et al., 2011) allow a safe swallow (Mishellany, Woda, Labas,
& Peyron, 2006). Achieving this mastication process relies on the
integrity and sound functioning of its components.
Malocclusions, which perceptibly affects patients inter-arch
contacts, are frequently increased by non-always apparent
associate skeletal defects and, this time, are considered as
dento-facial deformities (DFDs). DFDs can lead to a deficient
masticatory function (Abrahamsson, 2013; Abrahamsson, Henrik-
son, Bondemark, & Ekberg 2015; English, Bushang, & Throckmor-
ton, 2002; Hennequin, Mazille, Cousson, & Nicolas, 2015; Iwase,
Ohashi, Tachibana, Toyoshima, & Nagumo, 2006; Magalhães,
Pereira, Marques, & Gameiro, 2010; Ngom, Diagne, Aïdara-Tamba,
& Sene, 2007; Van den Braber, van der Glas, van der Bilt, & Bosman,
2001), but the relation between severity of DFD and extent of the
deficiency has not been researched. This is a crucial issue, because
DFD may lead to two quite different endpoints, either satisfactory
masticatory function through successful adaptation, or impaired
mastication because adaptation proves impossible (Mishellany-
Dutour, Renaud, Peyron, Rimek, & Woda, 2008; Woda, Hennequin,
& Peyron, 2011). Some subjects succeed in making a normal food

http://dx.doi.org/10.1016/j.archoralbio.2016.12.002
0003-9969/© 2016 Published by Elsevier Ltd.
 P. Bourdiol et al. / Archives of Oral Biology 75 (2017) 14–20 15

bolus despite being hampered by a particular DFD. These subjects
may have lowered masticatory efficiency as indicated by food bolus
granulometry measured after a limited number of cycles (Van der
Bilt, 2011), but they adapt their masticatory function, mostly by
increasing the number of chewing cycles and the duration of the
masticatory sequence (Mishellany-Dutour et al., 2008; Woda et al.,
2011). Members of this group therefore achieve a normal
functional result. By contrast, other subjects, similarly confronted
with DFD-related modifications of their masticatory apparatus, or
malocclusion, fail to adapt. These subjects, when chewing hard
food samples for instance, suffer from impaired mastication, as
shown by the fact that their food bolus is composed of coarse
particles irrespective of how many chewing cycles there are in the
masticatory sequence. Other indicators of an individual with
impaired mastication include decreased frequency when con-
fronted with food of increased hardness, and when in a group,
decreased frequency compared with healthy controls (Woda et al.,
2011).
The aim of this study was to determine what degree of DFD
severity implies true functional impairment. We hypothesized that
subjects with severe DFDs, for example needing orthodontics
combined with craniofacial surgery, would be unable to chew test
foods satisfactorily, whereas those with malocclusion, case of
moderate DFD, treated by orthodontics alone or not treated, would
be able to do so.
2. Materials and methods
2.1. Study design
In this case-control study, carried out pre-treatment, three
groups were formed: subjects with severe DFDs (SevDFD), subjects
with moderate DFDs (ModDFD), and subjects with no DFDs
(NoDFD) to act as controls. Functional evaluation was conducted in
two ways: (i) granulometry of the food bolus was evaluated using
the Masticatory Normative Indicator (MNI), an indicator of normal
versus impaired masticatory function based on the median (d50)
of the particle size of a carrot food bolus (Woda et al., 2010), and (ii)
a set of gelatine models allowed measurement of both frequency of
mastication and adaptation to increased food hardness indepen-
dently of other changes in the food rheological properties (Peyron,
Lassauzay, & Woda, 2002). The subjects were scored on two scales
for oral well-being and treatment need. Finally, interarch contact
areas were also evaluated.
2.2. Subjects
Inclusion criteria were: age above 16 and below 36 years, full
dentition not counting wisdom teeth, healthy oral mucosa and
temporo-mandibular joint, good or well-controlled general health,
and ability to understand and answer questionnaires. Subjects
were also young adults with only few intracoronal restorations or
fillings. None of them presented a dental bridge and two patients
presented a unique molar crown. Exclusion criteria were:
removable dentures, previous orthodontic or oral surgery treat-
ments, and allergy to the test foods. The required sample size was
estimated from a preliminary pilot study that measured the carrot
bolus granulometry between ModDFD (n = 10) and SevDFD (n = 10).
The mean D50 values of the carrot bolus increased from
2512  380 mm to 6924  2762 mm respectively. Calculations were
based on this difference for a continuous criterion with paired
values and indicated the need at least for 9 subjects for each group
(a = 5%, b= 10%, epiR package 0.9–30). One subject dropped out
from the initially recruited sample of 31 patients. Finally 30
subjects with malocclusions and needing orthodontic treatment
alone or combined with orthognathic surgery were recruited and
divided into two groups. Assignment of consecutive patients to the
two groups was based on examination of dental inter-arch relation
and skeletal cephalometric balance (Coben, 1979, 1998). Patients
taking part in this study were submitted to orthodontic diagnosis
to determine if they were relevant to an orthodontic therapy alone
or to a combined orthodontic-orthognathic one. ModDFD patients
(n = 12) could be treated by orthodontic treatment alone. They
presented no skeletal anomalies, or only a slight one that could be
easily compensated orthodontically. They were eligible for
orthodontic treatment but declined it. SevDFD patients (n = 18)
accepted combined orthodontics and surgical treatment. The
subjects of the NoDFD group (n = 12), recruited on the same
inclusion and exclusion criteria, presented a balanced skeletal face,
with normal inter-arch relationships (molar and canine class I),
without crowding, or only a mild one limited to the anterior teeth.
The characteristics of the three groups are further described in
Table 1. All the subjects were Caucasian and consulting for the first
time. The patients were recruited over a 12-month period at the
University Hospital (CHU) Clermont-Ferrand, France. The study
was approved by the local ethics committee (CECIC: 2010/06; IRB
No. 5044). All the subjects gave their written informed consent to
participate.
FM and ANB angles were measured to differentiate group
subjects

Table 1
Values (mean  sd) of age in years, gender balance, GOHAI (global oral health assessment index), IOTN (index of treatment need) and functional area (mm2) in the three
groups: NoDFD (no treatment need), ModDFD (indication for orthodontic treatment alone), SevDFD (indication for surgical treatment). The SevDFD group comprised 15
skeletal class III (among them 5 open-bites, 4 deep-bites, 6 normal-bites), with hypomaxilla (n = 3), mandible prognathism (n = 6) and maxilla-mandible prognathism (n = 6);
The SevDFD group also comprised 2 skeletal class II (1 deep bite and 1 normal bite) and 1 skeletal class I (open-bite). ModDFD subjects (n = 12) presented no skeletal
anomalies, or only slight ones that could be easily compensated orthodontically and comprised 2 dental class III, 8 class dental II and 2 dental class I with dental crowding.
Statistics are GLM followed by SNK (p < 0.05). Different letters (a, b, c) between two values within a single line indicate a significant difference between the values. Value
ranges for Frankfort-Mandibular angle (FMA) and ANB angle are indicated in degrees. dt or sk = dental or skeletal classes.

Group NoDFD (n = 12) ModDFD (n = 12) SevDFD (n = 18)

Age  sd 23  4 26  4 26  9
Male/Female 8/4 9/3 12/6
GOHAI 57.5  3.3a 55.3  1.9a 42.6  9.2b
IOTN 1.3  0.6a 3.7  0.5b 4.3  0.6c
Functional area 389.3  47.1a 300.3  117.2a 176.9  106.9b
FM angle 19  FMA  31 19 FMA  31 19 > FMA > 31
ANB angle 4 < ANB < 7 4 < ANB < 7 4 > ANB  7
Subject’s numbers and classes 12 dt and sk Cl I 2 dt Cl III, sk Cl I 15 dt and sk Cl III
8 dt Cl II, sk Cl I 2 dt and sk Cl II
2 dt Cl I, sk Cl I 1 dt and sk Cl I
Treatment indication None Orthodontics Orthodontics + Surgery
16 P. Bourdiol et al. / Archives of Oral Biology 75 (2017) 14–20
2.3. Food samples
One natural food and three visco-elastic model foods were used
for testing. Six standardised samples of carrot (cylinders of
diameter 2 cm, height-adjusted to weigh 4.0  0.5 g) were
prepared. The three visco-elastic model foods, differing in
hardness [soft (S), medium (M) and hard (H)], and standardised
in size and shape, were prepared from gummy sweet jelly products
(Haribo1, Germany), with gelatine and water as previously
described (Veyrune, Opé, Nicolas, Woda, & Hennequin, 2013).
Model food cylinders (height 1 cm, diameter 2 cm) of each level of
hardness were tested using an Instron Universal Testing Machine
(Instron mini 55, High Wycombe, Bucks, UK) under uni-axial
compression performed at 50 mm/min with a strain of 50% of
initial sample height. Stresses were 70  20 kPa for S, 90  70 kPa
for M and 100  20 kPa for H.
2.4. Experimental procedure
Video recording was used to evaluate the kinematic parameters
(Nicolas, Veyrune, Lassauzay, Peyron, & Hennequin, 2007). A digital
camera (SONY DCR-PC330E, Japan) positioned in front of the
subject recorded a video of facial movements. The subjects were
first asked to chew until deglutition three replicates of the model
foods of each hardness level presented in a random order. They
then chewed six replicates of carrots. The first two replicates were
used for training purposes: they were masticated and either
swallowed or spat out. For the third and fourth replicates, boluses
were spat out just before swallowing. For the fifth and sixth
replicates, the experimenter asked the subjects to spit out boluses
after 15 cycles. After spitting, the subjects rinsed their mouth to
clear it of all remaining carrot particles. These were added to the
boluses, and the whole frozen for later granulometric measure-
ments.
2.5. Bolus granulometric analysis
Each chewed carrot masticate was collected, rinsed, dried and
scanned to produce a 600 dpi image (Veyrune et al., 2013). The
images were digitally processed to evaluate food particle size and
distribution (Powdershape1, Innovative Sintering Technologies,
Switzerland). The results were expressed by a single value, the d50,
representing the granulometry of each bolus. The d50 value the
theoretical sieve size that would let 50% of the particles through, or
the median size of the particle distribution which gives the
theoretical sieves that would let 50% of the particles through. Thus
the d50 value decreased as the food boluses contained smaller
particles. The two-d50 values, recorded for each subject and each
number of cycles (at 15 cycles and at deglutition), were averaged.
Referring to the Masticatory Normative Indicator or MNI (Woda
et al., 2010), d50 values above 4 mm identified a subject with
impaired mastication.
2.6. Kinematic parameters of mastication
For gelatine, the evaluation of each kinematic parameter until
deglutition required independent reading of each video recording
by a calibrated observer who watched the recordings in a random
order. In a former validation, it was shown inter and intra-rater
reliability that gave a positive intra-class coefficient (ICC) for the
two variables recorded in the present experiment, i.e., duration of
mastication and number of cycles (Nicolas et al., 2007). Chewing
frequency was calculated as the ratio of chewing cycle number to
chewing time. The same variables were observed for carrots at 15
cycles and at deglutition.
2.7. Questionnaires for patients’ characterization
GOHAI is a questionnaire on oral health quality of life. It
comprises 12 items grouped into three fields: (i) functional, (ii)
psychosocial, and (iii) pain or discomfort. The method used in this
study was the cumulative method (GOHAI-Add). Each of the 12
questions was scored from 1 to 5. The maximum score was 60
(20 = functional field; 25 = psychosocial field; 15 = pain or discom-
fort field). This results in a final global evaluation with a value of 50
and below indicative of poor, between 51 and 56 for moderate, and
over 56 for good oral health. A validated French version was used
(Tubert-Jeannin, Riordan, Morel-Papernot, Porcheray, & Saby-
Collet, 2003). The subject’s need for orthodontic treatment was
appraised using the Index of Orthodontic Treatment Need (IOTN)
(Brooks and Shaw, 1989). The IOTN is the tool habitually used to
evaluate treatment needs. A single experimenter used dental casts
to evaluate IOTN. The scale ranged from 1 for no treatment need to
5 for maximum treatment need.
2.8. The dental arch functional areas
The functional contacts were recorded in interarch maximal
intercuspal position (Millstein, 1984) using a silicone recording
material (95 Shore-A, Hennry Schein). The silicone-bite records
were optically recorded with a flatbed scanner. The images
obtained were then analysed with the Toothshape1 software
(Innovative Sintering Technologies Ltd, Ringstrasse 29, CH-7324
Vilters, Switzerland). There were two types of interarch contact
areas, namely direct contacting zones (no gap) and almost-
contacting ones (1–500 mm). The sum of contacting and almost-
contacting areas characterising each silicone-bite record was
labelled as the dental functional area (mm2).
2.9. Statistical analysis
Statistical analysis was performed using IBM SPSS1 software
(version 29). Values were expressed as mean  standard deviation,
and statistical significance was set at p < 0.05. Mean values of
kinematic parameters of mastication and bolus granulometry were
calculated for each group of subjects. To evaluate the impact of
dento-facial deformity on chewing ability, statistical analysis was
carried out to detect any differences in the mean parameters
between the three groups of patients. A general linear model
univariate procedure (GLM) was used to study the variability of
each kinetic parameter and bolus granulometry. A post hoc
Student-Newman-Keuls test (SNK) was applied when GLM
displayed significant variations. Difference in age, GOHAI and
IOTN scores between the three groups of patients was tested in the
same way. Difference in gender distribution was tested with a chi-
squared test. In addition, a multivariate linear regression analysis
was used with Age, Gender and group determined by IOTN, as
factors. In three cases, some values were missing due to inability to
chew gelatine, resulting in test refusal. The 95th percentile of the
all-group values replaced these missing values.
3. Results
3.1. Characterisation of the three groups of subjects
There were no significant differences in ages between groups.
GOHAI was above the cut-off value of 56 in the NoDFD group,
indicating good oral health. This group also displayed a low level of
treatment need. The other two groups of subjects were below the
GOHAI cut-off value. Particularly the SevDFD group for which, the
three domains of GOHAI, i.e.: Functional, Psychological and Pain/
Discomfort, evenly contributed to the large decrease of oral health
 P. Bourdiol et al. / Archives of Oral Biology 75 (2017) 14–20
assessment (75, 72, 73% of their maximum values). No significant
difference was found in the GOHAI scores between ModDFD and
NoDFD. For GOHAI, IOTN and functional area, a significant
difference was observed between SevDFD and the two other
groups, indicating poor oral health, major treatment need and less
occlusal contact for SevDFD. A significant difference between
ModDFD and NoDFD was found for IOTN (Table 1).
3.2. Granulometric evaluation with the carrot bolus
All d50 values of the carrot boluses obtained at swallowing in
SevDFD were above 4 mm. One subject in ModDFD had a d50 value
above 4 mm. All the d50 values obtained at swallowing in NoDFD
were below 4 mm (Fig. 1). A significant difference in d50 was
observed between SevDFD and the two other groups, both at
deglutition and after 15 cycles (p < 0.001), but no difference was
observed between NoDFD and ModDFD (Fig. 2). Variations of
mastication parameters were only explained by group type.
3.3. Kinematic evaluation with the carrot bolus
The number of masticatory cycles, the duration of the sequence
and the frequency of cycles within the sequence are given when
chewing up to 15 cycles and until deglutition (Table 2). The number
of masticatory cycles occurring until swallowing increased from
NoDFD to SevDFD, but the differences were not significant. By
contrast, the duration of the mastication sequence both at
deglutition (p < 0.05) and after 15 cycles (p < 0.001) depended
on the group of subjects observed (Table 2). This duration
increased significantly between NoDFD and SevDFD at deglutition
and at 15 cycles, and also between ModDFD and SevDFD at 15
cycles. No difference was seen between NoDFD and ModDFD. For
the frequency of cycles within the sequence, SevDFD differed from
the other two for both sequences ending at deglutition (p < 0.01)
and sequences ending at 15 cycles (p < 0.001), while NoDFD and
ModDFD did not differ from each other.
3.4. Kinematic evaluation with the gelatines
Cycle number increased significantly only with the hardest
gelatine products between NoDFD and SevDFD (p < 0.05); ModDFD
was not different from the other two. While chewing the two
Fig. 1. d50 values (mm) of individuals in the three groups are given on the y axis.
NoDFD (no treatment need), ModDFD (indication for orthodontic treatment alone),
SevDFD (indication for surgical treatment). The horizontal interrupted line
corresponds to the Masticatory Normative Index value (MNI). Individual subject
values were positioned on the x axis according to their corresponding group to
facilitate the reading.
17
Fig. 2. d50 values (mm) observed with the carrot bolus at deglutition and after 15
cycles (chewing strokes). Significant difference (p < 0.001) between SevDFD group
(indication for surgical treatment) and the two other groups NoDFD (no treatment
need) and ModDFD (indication for orthodontic treatment alone). ***: p < 0.001.
Table 2
Values (mean  sd) of cycle number (or chewing stroke number) at deglutition and
values of duration in second and frequency (cycle number/sequence duration in
hertz) at deglutition and after 15 cycles when chewing raw carrots in the three
groups: NoDFD (no treatment need), ModDFD (indication for orthodontic treatment
alone), SevDFD (indication for surgical treatment). GLM followed by SNK; p < 0.05).
Statistics are GLM followed by SNK; p < 0.05). Different letters (a, b, c) between two
values within a single line indicate a significant difference between the values.
Group NoDFD (n = 12) ModDFD (n = 12) SevDFD (n = 18)
Deglut. cycle number 30.3  15.3 34.4  12.3 37.4  18.3
Deglut. duration 18.0  7.1a 21.0  6.8ab 25.3  11.8b
15 cycles duration 9.75  1.6a 9.0  1.3b 11.35  2.8c
Deglut. frequency 1.70  0.30a 1.63  0.20a 1.48  0.25b
15 cycles frequency 1.57  0.24a 1.69  0.21a 1.39  0.28b
hardest gelatine products, sequence duration increased signifi-
cantly from NoDFD to SevDFD and from ModDFD to SevDFD
(p < 0.001); NoDFD and ModDFD did not differ significantly.
Whatever the gelatine being chewed, frequency increased
between NoDFD and ModDFD and between ModDFD and SevDFD
(p < 0.001).
Hardness effect was strong, and induced a significant increase
in both cycle number and sequence duration (p < 0.001). This
increase depended on the group of subjects (p < 0.001), SevDFD
being the most affected and NoDFD the least. Also, the increase in
hardness significantly influenced masticatory frequency (p < 0.05)
indiscriminately in all the groups (Table 3).
4. Discussion
Many previous studies have suggested that malocclusion
patients suffer from functional impairment, particularly concern-
ing mastication (Magalhães et al., 2010; Ngom et al., 2007). Our
study suggests, however, that a section of this population, namely
ModDFD subjects, can adapt to their level of dysfunction. All the
ModDFD subjects but one had a d50 value below MNI cut-off, i.e. a
median particle size above 4000 mm, showing that they succeeded
in making a normal food bolus. In addition, their cycle frequency
when chewing carrots did not differ from that of NoDFD subjects,
also indicating that they had a normal mastication function. These
findings are at variance with the decreased masticatory perfor-
mance reported in most previous studies (Ngom et al., 2007;
Picinato-Pirola, Mestriner, Freitas, Mello-Filho, & Trawitzki, 2012).
However, these earlier studies measured masticatory performance
and not final food bolus state. When evaluating masticatory
performance, mastication is interrupted before swallowing,
18 P. Bourdiol et al. / Archives of Oral Biology 75 (2017) 14–20
Table 3
Values (mean  sd) of cycle number at deglutition and values of duration (second) and frequency (cycle number/sequence duration, in hertz) at deglutition and after 15 cycles
when chewing gelatine food models with three different hardness levels in the three groups: NoDFD (no treatment need), ModDFD (indication for orthodontic treatment
alone), SevDFD (indication for surgical treatment). Statistics are GLM followed by SNK; p < 0.05). Different letters (a, b, c) between two values within a single line indicate a
significant difference between the values.
Gelatine food models Cycle number
Sequence duration
Frequency
generally after 15 cycles. The evaluation of their bolus did not,
therefore, take into account the adaptation occurring in patients
with mildly impaired mastication. The subjects with mildly
impaired mastication adapt their masticatory behaviour mostly
by increasing the number of cycles so as to successfully reach a
normal particle size in the bolus (Feldman, Kapur, Alman, &
Chauncey, 1980; Mishellany-Dutour et al., 2008; Peyron, Mis-
hellany, & Woda, 2004; Woda, Mishellany, & Peyron, 2006). In
addition, a significantly increased final particle size can still be
considered normal if the median particle size is below a certain
MNI value, 4 mm for the carrots and 3.7 mm for Optosil (Witter,
Woda, Bronkhorst, & Creugers, 2013; Woda et al., 2010). This is
probably why the only study measuring bolus at deglutition time
and not masticatory performance at 15 cycles was also the only one
that did not find any difference between patients and controls
(English et al., 2002).
The ModDFD group in the present study showed some signs of
adaptation to a mildly impaired function. They displayed a cycle
frequency lower than that of NoDFD when chewing gelatines.
Although the differences were not significantly different, the
subjects in the ModDFD group displayed an increased number of
cycles and duration of the sequence compared with NoDFD when
chewing carrots. Another mode of adaptation could be a change in
the timing during the sequence. This can be deduced from the
kinematics recorded when chewing carrots. A significantly shorter
time to reach the fifteenth cycle was associated with a non-
significant increased frequency. By contrast, at deglutition, the
duration was slightly increased and the frequency slightly
decreased compared with NoDFD. A possible interpretation is
that to chew a hard food like carrots, the non-significant decreased
efficiency, shown by d50 at 15 cycles, is offset by an increased cycle
frequency at the beginning of the mastication sequence.
This study confirms that SevDFD subjects are unable to
compensate for their deficient occlusion during mastication. The
SevDFD subjects had clearly impaired mastication as shown by two
main criteria: (i) the individual d50 of SevDFD subjects was always
above MNI cut-off and (ii) the cycle frequency when chewing
either carrots or gelatines was significantly lower in SevDFD than
in NoDFD. The SevDFD subjects appear similar to patients or
subjects displaying severe mastication impairment. For instance,
MNI, with either carrots or Optosil1, has shown impaired
mastication in edentates with different types of complete denture,
in patients wearing several types of partial dentures, in persons
with Down syndrome, and in persons with healthy mastication
wearing an occlusal splint (Berteretche, Frot, Woda, Pereira, &
Hennequin, 2015; Witter et al., 2013; Woda et al., 2010). Other
proofs of mastication impairment in SevDFD subjects derived from
the decreased frequency observed in groups such as elderly
persons eating hard foods, persons with TMD or with Down
syndrome (Feldman et al., 1980; Hennequin et al., 2015;
NoDFD (n = 12) ModDFD (n = 12) SevDFD (n = 18)
Soft 22.3  6.3 24.0  9.4 22.5  11.0
Medium 29.5  9.0 30.2  14.1 32.9  13.9
Hard 37.1  10.4a 40.4  18.5ab 47.3  21.9b
Soft 14.7  4.6 16.5  5.1 17.4  7.6
Medium 19.3  6.2a 21.2  7.9a 25.9  9.7b
Hard 25.1  7.2a 29.1  12.7a 34.7  13.1b
Soft 1.54  0.19a 1.42  0.21b 1.22  0.22c
Medium 1.54  0.18a 1.40  0.22b 1.21  0.19c
Hard 1.48  0.14a 1.39  0.19b 1.19  0.25c
Mishellany-Dutour et al., 2008; Woda et al., 2011). Persons with
multiple untreated carious lesions are other documented examples
of masticatory impairment (De Souza Barbosa, De Morais Tureli,
Nobre-Dos-Santos, Puppin-Rontani, & Duarte Gaviao, 2013)
characterized by an increase in frequency (Decerle, Nicolas, &
Hennequin, 2013).
Impaired mastication in our SevDFD subjects was not due to
having fewer teeth, tooth number being similar in all the groups,
but rather to interarch discrepancy, as indicated by the signifi-
cantly reduced functional area (Henrikson, Ekberg, & Nilner, 1998;
Magalhães et al., 2010; Picinato-Pirola et al., 2012). Although
number of teeth can be correlated with mastication efficiency
(English et al., 2002; Feldman et al., 1980; Kohyama, Mioche, &
Bourdiol, 2003; Luke and Lucas, 1985), what really matters is the
number of teeth making contact with opposing teeth. This is why
functional areas during interarch occlusion were measured. It is
well known that the larger the functional area the better the
masticatory efficiency (Luke and Lucas, 1985; Owens, Bushang,
Throckmorton, Palmer, & English, 2002). The poor masticatory
performance of the SevDFD subjects could, therefore, be explained
not only by the reduction of their functional areas and/or the
number of occluding pairs of teeth (Abrahamsson, 2013; Henne-
quin et al., 2015; Magalhães et al., 2010) but also by the low value of
the chewing forces (Di Palma, Gasparini, Pelo, Tartaglia, & Sforza,
2010; Julien, Bushang, Throckmorton, & Dechow, 1996; Lepley,
Throckmorton, Ceen, & Bushang, 2011; Saifuddin, Miyamoto, Ueda,
Shikata, & Tanne, 2003) and the small lateral amplitude of their
masticatory cycles (Wilding, 1993).
SevDFD patients should obviously have treatment for aesthetic
reasons, but these results also confirm and underline that SevDFD
patients needed to be treated to improve their masticatory
function. Though not studied in this work, it is important to state
that there is no immediate improvement of the masticatory
efficiency in the first months that follow the surgery. As shown by
Iwase et al. (2006), the functional benefit of a combined
orthodontic and surgical approach appears more than one year
later. This is probably due to the time needed to learn a new
masticatory praxis for the patient to master the new anatomical
conditions.
The ModDFD group in this study, eligible for orthodontic
treatment alone, spontaneously adapted to their moderate degree
of masticatory impairment. Such subjects might nevertheless need
treatment for several reasons: (i) there could be a difference in
mastication impairment according to the malocclusions types, but
the small sample of this study did not allow their differentiation,
and the literature is conflicting on this topic (Magalhães et al.,
2010; Owens et al., 2002; Toro, Buschang, Throckmorton, & Roldán,
2006); (ii) In our study the patients were young adults. Functional
impairment can worsen with time and ageing. Moderate,
adaptable mastication impairment may later turn into severe
 P. Bourdiol et al. / Archives of Oral Biology 75 (2017) 14–20
functional failure as already suggested (Harris and Behrents, 1988;
Harris, 1997). Orthodontic treatment may therefore be needed as a
preventive intervention, and (iii) aesthetic and self-esteem
considerations are the main motivational factors for orthodontic
treatment, and malocclusion appears to be a secondary factor in
the patient demand (Feu, Cardoso Abdo Quintao, & Augusto
Mendes Miguel, 2010; Samsyonova and Broukal, 2014). Lack of any
functional impairment does not, however, mean a patient’s
demand for treatment is ill founded.
The questionnaire results obtained from the SevDFD group
were exactly what could be expected, reflecting a much-impaired
quality of life and oral health and a very high treatment need. For
the ModDFD group, the results were more surprising: there was an
expected high IOTN but an unexpected good score on quality of life
and oral health. Most previous studies reported both high
treatment needs and low scores for quality of life and oral health
in these types of patients (Andiappan, Gao, Bernabe, Kandala,
Donaldson, 2015). The design of this study probably explains this
surprising result. The subjects in the ModDFD group declined
treatment. We can infer that they were untroubled by their
aesthetic appearance, and as shown by our results, that they had
little or no functional concerns. Professionals analysing morpho-
logical features from dental casts filled out the IOTN questionnaire.
Facial aesthetics and functional components cannot both be readily
appraised from dental casts: the IOTN by itself does not encompass
the patient’s self-evaluation and may tend to amplify the
indication for treatment for patients who can mostly adapt to
slight masticatory impairment and may be satisfied with their
appearance
5. Conclusion
Patients with impaired mastication were characterized by a
high IOTN, decreased interarch functional areas and decreased
quality of life. Subjects with a low level of masticatory impairment
and/or moderate malocclusion were able to adapt. Though
characterized by a high level of IOTN, these subjects expressed a
near-satisfactory quality of life, which is probably why they were
not seeking treatment. The study emphasizes the need for the
objective evaluation of masticatory function so as to separate true
impairment from mild, harmless impairment that allows com-
pensatory adaptation. Nevertheless, aesthetic demand corre-
sponds to a patient seeking a satisfactory betterment of his
appearance allowing assertion of his self-evaluation. Malocclusion
are known to worsen with age which justifies their corrections and
maintenance, as early as possible, through orthodontic therapy
considered this time a preventive therapeutic.
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