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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 726-731
An ultrasonographic evaluation of masseter muscle thickness in different dentofacial patterns


1 Department of Orthodontics and Dentofacial Orthopaedics, Government Dental College, University of Health Sciences, Rohtak, Haryana, India
2 Department of Orthodontics and Dentofacial Orthopaedics, Faculty of Dental Sciences, C.S.M. Medical University, Lucknow, Uttar Pradesh, India
3 Department of Radiotherapy, C.S.M. Medical University, Lucknow, Uttar Pradesh, India

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Date of Submission25-Aug-2011
Date of Decision16-Feb-2012
Date of Acceptance07-Apr-2012
Date of Web Publication3-May-2013
 

   Abstract 

Objectives: The aim of this study is to compare the masseter muscle thickness in different vertical dentofacial patterns and identify the possible sexual dimorphism and also to correlate masseter muscle thickness with craniofacial morphology using cephalometric parameters.
Materials and Methods: The masseter muscle thickness was measured using ultrasonography in 60 subjects (30 females and 30 males). Standardized lateral and posteroanterior cephalograms were taken to determine the facial morphology. The subjects were divided into three vertical pattern groups (I, II, and III) according to their Jarabak ratio: hypodivergent ( n = 20), normodivergent (n = 20), and hyperdivergent (n = 20). The sample was further subdivided into males and female subgroups.
Results: Masseter muscle thickness relaxed (MMTR) in hypodivergent group was 13.94 ± 1.51. Mean value of MMTR in normodivergent group was 12.53 ± 1.21 and the MMTR in hyperdivergent group was 11.13 ± 1.18. The mean value of masseter muscle thickness contracted (MMTC) in hypodivergent group was 15.46 ± 1.33. Mean value of MMTC in normodivergent group was 13.81 ± 1.38 and the mean value of MMTC in hyperdivergent group was 12.27 ± 1.26. MMTC showed a significant, negative correlation with mandibular plane angle and gonial angle. Posterior facial height, symphysis width, intermolar width of maxillary first molars, maxillary width, and facial width (bizygomatic width) showed significant ( P < 0.05 or P < 0.01) positive correlation.
Conclusion: The masseter muscle thickness varied among the three vertical dentofacial patterns and sexual dimorphism also existed except in the hyperdivergent group. Masseter muscle thickness was found to be negatively correlated to vertical facial pattern and positively associated with transverse craniofacial morphology.

Keywords: Dentofacial patterns, ultrasonographic thickness, masseter muscle

How to cite this article:
Rohila AK, Sharma VP, Shrivastav PK, Nagar A, Singh GP. An ultrasonographic evaluation of masseter muscle thickness in different dentofacial patterns. Indian J Dent Res 2012;23:726-31

How to cite this URL:
Rohila AK, Sharma VP, Shrivastav PK, Nagar A, Singh GP. An ultrasonographic evaluation of masseter muscle thickness in different dentofacial patterns. Indian J Dent Res [serial online] 2012 [cited 2020 Dec 4];23:726-31. Available from: https://www.ijdr.in/text.asp?2012/23/6/726/111247
Dentofacial morphology is closely related to the attached muscle activity. Embryologically, the bones that make the maxillofacial region are essentially membranous bones, and as such are more susceptible to the environmental factors, such as the stimulating influence of muscles and extra functional force, as compared with long bones of the extremities which are formed by cartilaginous ossification. [1]

Masticatory muscle activity has been investigated by electromyography (EMG) [2],[3] and by muscle strength. [4] Recently, muscle thickness has been considered as one indicator of jaw muscle activity. [5],[6] Muscle thickness may be measured using Magnetic Resonance Imaging (MRI), Computed Tomography, or Ultrasound, but for clinical examinations, ultrasonography is better than MRI and Computerized Tomography because it is a rapid and inexpensive technique, the equipment can be easily handled and transported, and it has no known cumulative biological effects. [7],[8] Ultrasonography is proven to be a reproducible, simple, and inexpensive method for accurately measuring muscle thickness, provided the operator adheres to a strict imaging protocol. [5],[9]

The possible complementary effect and the relation of masseter muscle thickness to the craniofacial morphology have not been studied previously by using lateral cephalograms and posteroanterior cephalograms. The present study was conducted with following objectives in mind:

  • To evaluate the masseter muscle thickness in different vertical dentofacial patterns and to identify the possible sexual dimorphism in muscle thickness.
  • To correlate masseter muscle thickness with craniofacial morphology using various cephalometric parameters measured on lateral cephalogram and posteroanterior cephalogram.

   Materials and Methods Top


The study was performed using ultrasonography, lateral cephalograms, and posteroanterior cephalograms of 60 patients (30 males and 30 females) who reported to Department of Orthodontics and Dentofacial Orthopaedics for orthodontic treatment. The records were taken before starting the treatment. All subjects gave written consent on a prescribed format. All the subjects were in the age group of 18-24 years, with the mean age of 22.3 years. Standardized lateral cephalograms of the subjects were taken and traced to determine their facial morphology.

The data obtained from the lateral cephalograms were used to divide the subjects into three vertical pattern groups, i.e. hypodivergent (Group I), normodivergent (Group II), and hyperdivergent (Group III), on the basis of Jarabak ratio. Jarabak ratio [10] is the ratio of posterior facial height (Sella-Gonion or S-Go) to anterior facial height (Nasion-Menton or N-Me). S-Go/N-Me ratio was taken because it is a reliable measurement as it is constructed from anatomic landmarks. [11]

The subjects were further subdivided into male and female subgroups, as shown in [Table 1].
Table 1: Distribution of the study sample


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Subjects with a range of skeletal jaw discrepancies, both in the anteroposterior and vertical dimensions, were included. There was no history of previous orthodontic treatment. There were no missing teeth in the permanent dentition except third molars. Individuals with marked jaw asymmetries or craniofacial disorders and with history of trauma to dentofacial region, parafunctional habits, and temporomandibular joint (TMJ) dysfunction were excluded.

Measurement of dentofacial morphology

The lateral cephalograms and posteroanterior cephalograms of the subjects were obtained with Rotagraph plus (Model MR05, Villa System Medical, Italy) at the Department of Orthodontics and Dentofacial Orthopaedics. A round lead film of 1 mm diameter and 0.05 mm thickness was cemented with thin mixed glass ionomer cement on buccal surface of the mesiobuccal cusp of right and left maxillary and mandibular first molars, for avoiding the overlapping of image of molars on posteroanterior cephalograms.

The dentofacial morphology was evaluated by using 10 parameters. Two angular and three linear parameters were measured from lateral cephalograms and five linear measurements were made on posteroanterior cephalograms.

Measurements from lateral cephalograms included mandibular plane angle, gonial angle, posterior facial height, effective mandibular length, and symphysis width [Figure 1].
Figure 1: Cephalometric angular and linear measurements used in the study on lateral cephalogram

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The following transverse measurements were made on posteroanterior cephalogram: facial width, maxillary width, mandibular width, intermolar width of maxillary first molars, and intermolar width of mandibular first molars [Figure 2].
Figure 2: Cephalometric measurements used in the study on posteroanterior cephalogram

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Masseter muscle thickness on ultrasound

All scans were carried out in the Ultrasonography Department. Each subject was examined by the same operator using the Toshiba Ultrasound Scanner and Probe (model no. Nemio SSA-550) with a 7.5-9.0 MHz broadband transducer. A line was drawn joining the lateral commissure of the mouth to the intertragic notch of the ear, crossing the masseter muscle. A generous amount of water-soluble conductive gel was applied evenly on muscle area on the cheeks using a gauze pad. The ultrasound probe was placed on the line with a feather-like pressure. [12] The angle of the probe was adjusted to produce the strongest echo from the mandibular ramus, which was achieved when the scan plane was perpendicular to its surface. The imaging and measurements were performed bilaterally with the subjects in a supine position under two different conditions: When the teeth were occluding gently with the muscle in a relaxed position and during maximal clenching, with the masseter muscle contracted. The measurements were made directly from the image at the time of scanning [shown in [Figure 3] and [Figure 4].
Figure 3: Thickness of masseter muscle as measured on ultrasonography in relaxed state

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Figure 4: Thickness of masseter muscle as measured on ultrasonography in contracted state

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Measurement of reliability

Recording of 20 subjects was performed again after an interval of 15 days. Error variance (Se) was calculated using Dahlberg's formula [13] , where d is the difference between two recordings of an individual and n is the number of subjects. Percentage errors were calculated using the formula: % = (Se/mean) × 100%, where Se is the result from Dahlberg's formula and mean corresponds to the mean value of the total of the initial and second measurements. A paired "t" test was performed to examine the systematic error and was found non-significant for all readings.


   Results Top


Masseter muscle thickness in relaxed state (MMTR) is given as Mean ± SD (mm) [Figure 5].
Figure 5: Masseter muscle thickness in relaxed state (MMTR), Mean ± SD (mm)

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Figure 6: Masseter muscle thickness in contracted state (MMTC), Mean ± SD (mm)

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Masseter muscle thickness in contracted state (MMTC) is given as Mean ± SD (mm) [Figure 6]

  • Mandibular plane angle and gonial angle showed significant (P < 0.01) negative correlation with MMTC for the total sample.
  • Posterior facial height, symphysis width, intermolar width of maxillary first molars, maxillary width, and facial width (bizygomatic width) showed significant (P < 0.05 or P < 0.01) positive correlation with MMTC for the total sample.
  • Effective mandibular length and intermolar width of mandibular first molars showed low level of correlation with MMTC.
[Table 2] shows that in Hypodivergent group (Group I) the mean MMTR and MMTC of males was significantly higher than females (P<0.01). In Normodivergent group (Group II) also the levels of mean MMTR in males was significantly higher than females (P<0.01). In Hyperdivergent group (Group III) the value of MMTR was more in males than females but it is not statistically significant (P>0.05). This is evident from [Table 3] that for each sex comparing the Hypodivergent with Normodivergent, Hypodivergent with Hyperdivergent and Normodivergent with Hyperdivergent the difference in mean MMTR and MMTC was significant (P<0.05 or P<0.01). But when comparing the mean MMTR of Normodivergent females (Group IIb) with Hyperdivergent females (Group IIIb) no significant difference was found (P>0.05).
Table 2: Intragroup comparison depicting sexual dimorphism of masseter muscle thickness (mm) in relaxed state (MMTR)

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Table 3: Intergroup comparison for sexes, masseter muscle thickness (mm) in relaxed state (MMTR) and masseter muscle thickness (mm) in contracted state (MMTC)

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   Discussion Top


In the present study, the masseter muscle was always easily identified on sonograms as a homogenous structure lying adjacent to the echogenic band of mandible. [9] Ultrasonography of masseter muscle is a reliable, reproducible, simple, and rapid method, as long as the operator adheres to a strict protocol. [5],[9]

In the present study, only masseter muscle thickness was measured because of the fact that in the group of masticatory muscles, the masseter muscle seems to represent the functional capacity of the masticatory apparatus and is said to have major influence on the transverse growth of the midface and the vertical growth of the mandible. [5],[12] Also, masseter muscle is a superficial muscle and can be easily recorded on ultrasonography. However, other muscles of mastication also contribute to the interaction between muscle and facial morphology, [14] and their influence might have biased the relation found between the masseter muscle and facial morphology.

In the present study, the subjects were made to lie in supine position. This approach gives the examiner a good access for the probe. This method was in contrast to some other studies, [15] where the subjects were made to sit in an upright position with their heads in natural position or their Frankfort Horizontal plane plane parallel to the floor, but was consistent with studies by Satirogluo et al.[16] and Ariji et al.[17]

Thickness of masseter muscle (relaxed and contracted) in vertical dentofacial patterns and its association to the gender of subjects

The results of this study show that there is a large variation in masseter muscle thickness among individuals, during both relaxation and contraction [Table 4]. These differences in adult subjects regarding masseter muscle thickness could be explained by the fact that there are differences in the fiber-type and fiber-size composition of the masseter muscle. Various factors have been proposed to account for inter-individual variation in fiber-type composition of skeletal muscle. Some of these factors relate with the level of physical activity, [18],[19] genetic factors, [20],[21] and an influence of sex hormones. [22] Although the fiber profile of an individual muscle results from the influence of multiple factors as mentioned above, one of the most important factors contributing to the sex difference in masseter muscle fiber-type composition may be male and female sex hormones. In female masseter muscle, type I and IM fibers constituted a larger percentage of cross-sectional area and number than in males. Whereas in the male masseter muscle, the cross-sectional area and number of type II fibers were larger than in the female masseter muscle. [23] Contrary to Tuxen's findings, Ringqvist [24] found no divergence between the fiber size of male and female masseter and temporalis muscles. Other factors which may be attributed to inter-individual variation are the racial, ethnic differences, different dietary habits and technique variation, etc.
Table 4: Masseter muscle thickness, Mean±SD (mm), in relaxed state (MMTR) and contracted state (MMTC)

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Relationship of masseter muscle thickness with craniofacial morphology

In the present study, masseter muscle thickness in contracted condition was taken to reveal the relationship between the muscle thickness and dentofacial morphology. This was because of the fact that in the literature, the relaxed muscle thickness has been considered less accurate, owing to higher susceptibility to the pressure with which the transducer is placed on the cheek. [5],[25]

In the present study, the mandibular plane angle and gonial angle showed significant ( P < 0.01) negative correlation with MMTC [Table 5]. The masseter and medial pterygoid muscles insert into the region of gonial angle, and the contractile power of these muscles influences the mandibular base. The skeletal growth and form depends on many factors, and mechanical loading by muscle is one of the very important factors. [26] Contraction of masticatory muscle generates mechanical load which can affect the bone growth in the adjoining region. When the masseter and internal pterygoid muscles contract, their pull tends to deform the angle of the mandible in the upward direction. Under the influence of microstrain patterns, the convex surface of angle of mandible tends to become minutely more concave with respect to its resting shape. This stimulates the osteoblastic activity and addition of bone matrix at the periosteal surface, gradually producing a more acute angle. [27] Owing to the above facts, as the muscle activity increases, as suggested by increase in ultrasonographic thickness of masseter muscle, the gonial angle decreases.
Table 5: The rank correlation of masseter muscle thickness (mm) in contracted state (MMTC) for males and females and of total subjects with respective craniofacial morphology parameters

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Posterior facial height showed significant ( P < 0.01) positive correlation with MMTC. This finding is in accordance with the work of Kiliaridis and Kailebo [5] and Bakke et al., [6] who found that most correlations between masseter thickness and facial dimensions indicated a negative relation between muscle thickness and vertical facial height.

The possible explanation of correlation of masseter muscle thickness with vertical dentofacial morphology is that the forces produced by the passive stretching of the masseter muscle affect the skeletal growth pattern and dental eruption. In hyperdivergent subjects, the weaker forces possibly produced by passive stretching of hypofunctional muscles resulted in more eruption of the upper molars and less inhibition of periosteal bone apposition in the angular region, thus leading to vertical growth. [28] According to Proffit and Fields, [29] it is possible that the lower bite force in hyperdivergent people might allow greater eruption of the posterior teeth than might occur otherwise, and so is directly related to the excessive tooth eruption and backward rotation of the mandible often seen in such subjects. The results in the present study show that the thickness of masseter muscle is the highest in hypodivergent followed by normodivergent and is the minimum in hyperdivergent. this finding support the positive correlation between masseter thickness and Jarabak ratio..

Symphysis width showed significant ( P < 0.05 or P < 0.01) positive correlation with MMTC. Bushang et al.[30] stated that the stresses resulting from occlusion of the anterior teeth is compensated by bony deposition on the lingual symphyseal surface. Given the positive correlation observed with the thickness of the masseter muscle and the thickness of the mandibular symphysis, it can be understood that the stimulating influence of masticatory pressure applied to bone tissue is important in the development of bone thickness at mandibular symphysis.

Intermolar width of maxillary first molars, maxillary width, and facial width (bizygomatic width) showed significant (P < 0.05 or P < 0.01) positive correlation with MMTC. This shows that subjects with thick muscle have broader faces and wide arches. The association between masseter muscle thickness and craniofacial width appears to be positive. [5],[15] This is in agreement with the studies by Kiliaridis and Katsaros, [31] where they stated that the functional capacity of the masticatory muscles may be considered as one of the factors influencing the width of the maxillary dental arch. The increased loading of the jaws due to masticatory muscle hyperfunction may lead to increased sutural growth and bone apposition, resulting in an increased transversal growth of the maxilla and broader bone bases for the dental arches. [32]

The following conclusions were drawn from the study:

  • The masseter muscle thickness varied among three vertical dentofacial patterns, with hypodivergent group having the maximum thickness followed by normodivergent, and was the minimum in hyperdivergent group. The masseter muscle thickness was more in males as compared to females in their respective groups.
  • Increase in the thickness of masseter muscle increases the sagittal growth, while limiting the vertical growth of jaws. Masseter muscle thickness had a positive correlation with facial width, maxillary width, symphyseal width, and intermolar width of maxillary first molars. This helps us to conclude that masseter muscle thickness has a positive influence on the transverse growth of the face and symphyseal width.


 
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Correspondence Address:
Ajit K Rohila
Department of Orthodontics and Dentofacial Orthopaedics, Government Dental College, University of Health Sciences, Rohtak, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111247

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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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