Clinical measurement of maximum mouth opening in children and its relation with different facial types

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1 Research Article Clinical measurement of maximum mouth opening in children and its relation with different facial types M. Sridhar 1 *, Ganesh Jeevanandham 2 ABSTRACT Introduction: Maximal opening of the mouth is described as the greatest distance between incisal edge of maxillary central incisor to the incisal edge of mandibular central incisor when the mouth is opened as wide as possible painlessly or as the interincisal distance plus the overbite. Maximal mouth opening (MMO) is an earliest marker in detecting any TMD. However, MMO varies considerably with age, gender, facial type, and weight. The aim of this study is to determine the correlation of MMO with age, gender, height, weight, and facial type. Material and Methods: This is a cross-sectional study conducted among 150 pediatric patients who visited Saveetha Dental College and Hospitals for their routine dental checkup. They were randomly divided into three age groups: Group I - children of age 6 8 years, Group II - children of age years, and Group III - children of age years. For each child, three readings of MMO were noted and mean of those values was considered. Age, sex, facial type, height, and weight of the children were recorded simultaneously. Pearson correlation was used to determine the relationship between the different parameters. Results: The estimated average MMO measured for girls and boys in the age group of 6 8 years was ± 1.26 mm and ± 1.19 mm, respectively, in 23 children having euryprosopic facial type. Among 26 leptoprosopic facial type children, the average MMO was ± 1.18 mm and ± 0.73 mm for girls and boys, respectively. In case of 18 children having mesoprosopic facial type, the average MMO was found to be ± 1.16 mm for girls and ± 1.20 mm for boys. The estimated average MMO measured for girls and boys in the age group of years was ± 0.38 mm and ± 0.37 mm, respectively, in 13 children having Euryprosopic facial type. Among 14 leptoprosopic facial type children, the average MMO was 46.5 ± 0.55 mm and ± 0.39 mm for girls and boys, respectively. In case of 13 children having mesoprosopic facial type, the average MMO was found to be ± 1.23 mm for girls and ± 0.52 mm for boys. The estimated average MMO measured for girls and boys in the age group of years was ± 1.44 mm and ± 0.16 mm, respectively, in 21 children having euryprosopic facial type. Among 14 leptoprosopic facial type children, the average MMO was mm and ± 1.15 mm for girls and boys, respectively. In case of 13 children having mesoprosopic facial type, the average MMO was found to be ± 1.83 mm for girls and ± 2.26 mm for boys. Conclusion: There was a significant difference in MMO between males and females, with males having higher values in all age groups. MMO is seen to increase with age in a statistically significant manner. KEY WORDS: Age, Facial types, Height, Maximum mouth opening, Weight INTRODUCTION Maximum mouth opening (MMO) is an important diagnostic procedure preliminary carried out during routine dental visit. Limited mouth opening produces difficulty in carrying out many dental procedures as prolonged mouth opening causes discomfort to patients undergoing treatment. Any reduction in Access this article online Website: jprsolutions.info ISSN: normal mouth opening is the earliest sign of problems associated with the masticatory system. Any dental infections, malignancies involving craniofacial region, fractures involving jaws, and myopathies in the head and neck region are some reasons that may contribute to the cause of reduced mouth opening. [2] Reduction in MMO requires a complete evaluation of the function of masticatory system which can be carried out by temperomandibular joint (TMJ) palpation and muscle palpation to find the preliminary cause of such occurrence. [3] 1 Department of Pedodontics, Saveetha Dental College and Hospitals, Saveetha University, Chennai, Tamil Nadu, India, 2 Department of Paedodontics, Saveetha Dental College and Hospitals, Chennai, Tamil Nadu, India *Corresponding author: Dr. Ganesh Jeevanandham, Department of Paedodontics, Saveetha Dental College and Hospitals, Saveetha University, No. 162, Poonamallee High Road, Velappanchavadi, Chennai , Tamil Nadu, India. helloganz@gmail.com Received on: ; Revised on: ; Accepted on:

2 Establishing a normal range for MMO could allow dental clinicians to objectively evaluate the treatment effects and set therapeutic goals for patients performing mandibular functional exercises. Before making diagnosis as a decreased mouth opening, normal range of mouth opening should be considered. Many researches have shown that the measurement of mouth opening varies significantly with age, gender, and race. [4] Yao et al. and Hirsch et al. came to a conclusion that MMO reduces with age and females have lower MMO when compared to males of the same age. [5] Several studies have found a relation between facial musculature and its effect on arch width and also on facial type which was the rationale behind finding a Tables 1: Facial forms present among children who took part in the study Age groups (years) Gender Number Facial forms 6 Female Male Female Male Female Male Female Male Female Male Female Male Female Male Table 2: Values of MMO in mm among children of various age groups Age groups (years) Gender Number MMO 6 Female Male Female Male Female Male Female Male Female Male Female Male Female Male MMO: Maximum mouth opening Table 3: Weight in kilograms among different age groups and different facial types Age groups (years) Gender Number Weight 6 Female Male Female Male Female Male Female Male Female Male Female Male Female Male

3 relation between MMO and different facial type in this study. [6] The aim and objective of this study are to obtain a normal range mouth opening of children without any strain or masticatory disturbances and to establish its relationship with age, gender, height, weight, and different facial types present among children. MATERIALS AND METHODS This cross-sectional study was carried out in 150 pediatric patients visiting Saveetha Dental College and Hospitals for routine dental checkups by obtaining informed consent from their parents or guardians accompanying them. Age, gender, height, weight, facial type, and MMO were recorded, and the values were tabulated and statistically analyzed for finding the significance of the study. The sample size was determined on the basis of previous studies among conducted Indian population regarding measurement of MMO. [7] Inclusion Criterion The following criteria were included in the study: Children with no history of jaw, head, or facial trauma having fully erupted maxillary and mandibular central incisors. Children with no history of pain in the jaw, face, or neck, either at rest or during function. Children with no history of bruxism. Children with no facial or dental abnormalities. Children with no history of TMJ sounds. Children with no dental prosthesis on anterior teeth (missing anterior teeth). Exclusion Criteria The following criteria were excluded from the study: Children with missing maxillary or mandibular incisors. Children with broken maxillary or mandibular incisors due to any reason. Children with severe orthodontic problems. Children with muscular and neurological disorders and craniofacial deformities. Children with neck pain and systemic diseases which alters normal mouth opening. Depending on age, participants were categorized into three groups: 1. Group 1: Age group 6 8 years. 2. Group 2: Age group years. 3. Group 3: Age group years. Patient s age, gender, facial type, and MMO were recorded. Patient s medical history and questions regarding TMJ problems were asked to the parents and guardians. TMJ was then palpated for detecting any abnormal clicking sounds, deviation of the mandible, and other conditions associated with limited mouth opening. The amount of mandibular opening was measured using the distance between the incisal edges of upper and lower anterior teeth. MMO was measured using modified Vernier caliper with the child s head placed in upright position and held up against the wall. Children were asked to open their mouth as wide as possible, and the maximum distance from the incisal edge of the maxillary central incisor to incisal edge of mandibular central incisor at the midline was measured. Three readings for MMO were taken to obtain an accurate value and to rule out any measuring error. Child s age, gender, height, and weight were also recorded simultaneously. Height was measured in terms of centimeters using inch tape mounted on the wall. Weight was measured using weighing machine by asking the child to stand on the machine by removing their chappals or shoes which is tabulated in Tables 3 and 4. Morphological facial length from nasion to gnathion and morphological facial width (bizygomatic width) Table 4: Reveals height in mm among different age groups and facial types Age groups (years) Gender Number Height 6 Female Male Female Male Female Male Female Male Female Male Female Male Female Male

4 were measured using sliding caliper. From these two values, facial index is calculated using belowmentioned formula: Facial Index = Morphological Facial Length Morphological Facial Width 100 Based on the calculated facial index, facial type was determined using Martin and Sallers scale. [8] Euryprosopic: Mesoprosopic: Leptoprosopic: The measurements of MMO were compared among children of different age groups and facial types. Similarly, correlation between the MMO and sex, body weight, and height was also calculated. Pearson correlation was used to determine the relationship between the different parameters. RESULTS MMO was measured in girls and boys in the age range of 6 12 years Tables 1 and 2. The estimated average MMO measured for girls and boys in the age group of 6 8 years was ± 1.26 mm and ± 1.19 mm, respectively, in 23 children having euryprosopic facial type. Among 26 leptoprosopic facial type children, the average MMO was ± 1.18 mm and ± 0.73 mm for girls and boys, respectively. In case of 18 children having mesoprosopic facial type, the average MMO was found to be ± 1.16 mm for girls and ± 1.20 mm for boys. The estimated average MMO measured for girls and boys in the age group of years was ± 0.38 mm and ± 0.37 mm, respectively, in 13 children having euryprosopic facial type. Among 14 leptoprosopic facial type children, the average MMO was 46.5 ± 0.55 mm and ± 0.39 mm for girls and boys, respectively. In case of 13 children having mesoprosopic facial type, the average MMO was found to be ± 1.23 mm for girls and ± 0.52 mm for boys. The estimated average MMO measured for girls and boys in the age group of years was ± 1.44 mm and ± 0.16 mm, respectively, in 21 children having euryprosopic facial type. Among 14 leptoprosopic facial type children, the average MMO was mm and ± 1.15 mm for girls and boys, respectively. In case of 13 children having mesoprosopic facial type, the average MMO was found to be ± 1.83 mm for girls and ± 2.26 mm for boys. On statistical analysis for calculating Pearson coefficient using Chi-square test, P value obtained is <0.5, hence the study is considered to be statistically significant. DISCUSSION The present study revealed MMO in children of 6 8, , and years of age group. In our study, the interincisal distance has been used as a measurement of MMO. [9-11] An advantage of the incisal edge distance is that the measuring point is relatively more consistent, permanent, and more easily determined. The reason why interincisal distance was measured is depicted from the study conducted by Wood and Branco [12] where comparison between direct (intraoral method) and indirect method (extra oral method) revealed that direct method was more reliable. There are two limitations in our study. First, the study included children visiting the hospital for their routine checkups. This limits our study to certain group of children from a particular remote area or locality. Second, no radiographs which reveal TMJ were not taken into account. This reduces the number of children taking part in the study, thus decreasing the sample size. Our study reveals that there is a gradual increase in MMO with advancing age. In a study done by Hirsch et al., Cortese et al., and Vanderas, [13,14] where MMO was found to be directly correlated with age, the results of our study were also in accordance to their results. Furthermore, relationship between the gender and MMO was considered in our study. The results of our study were in accordance with the results of the study conducted by Pullinger et al., who observed that the maximum passive jaw opening was 2.7% wider in males compared to females. [15] However, on the other hand, Abou-Atme et al., in his study, reported that there was no gender difference in the measurement of MMO in children between the age of 4 and 15 years. [16] The present study revealed a significant correlation of MMO with height and weight. Similar results were obtained by a study conducted by Agerberg who found a weak correlation of MMO with height and weight. [17] Contrary to this, Rothenberg [18] observed a positive correlation between MMO values in relation to weight and height in subjects in age group 4 and 14 years. One characteristic finding which was evident in this present study was the higher MMO values in normal faced or mesoprosopic individuals among all age groups. At present, however, it is difficult to propose the exact mechanism responsible for this increase in MMO. This study, in combination with several clinical expertises, can serve as an available approach for clinical decision-making in diagnosing divergence and diseases related to the function of the masticatory system by knowing the normal range of MMO in individuals of a particular age group. 3072

5 An increased sample size and a wider range of ages should be examined in future research, including other underlying factors, such as the length, width, and angle of the mandible, to confirm and elaborate on these findings. Limitation 1. Horizontal movement of mandible was not taken into consideration. 2. Sample size was small. 3. Distribution of study sample in a particular region. CONCLUSION There was a significant difference in MMO between boys and girls, with boys having the higher values in all age groups. MMO was seen to increase with age in a statistically significant manner. Significantly increased value of MMO was observed in mesoprosopic facial type in comparison to euryprosopic and leptoprosopic facial type in each age group. REFERENCES 1. Fatima J, Kaul R, Jain P, Saha S, Halder S, Sarkar S. Maximum mouth opening of Kolkata children. J Clin Diagn Res 2016;10:ZC Kumar A, Dutta S, Singh J, Mehta R, Hooda A, Namdev R. Clinical measurement of maximal mouth opening in children: A pioneer method. J Clin Pediatr Dent 2012;37: Dworkin SF, LeResche LL. Research diagnostic criteria for temporomandibular disorders: Criteria, examinations and specifications, critique. J Craniomandib Dis Facial Oral Pain 1992;6: Boozer CH, Ferraro EF, Weinberg R. The effects of age, race and sex on the interincisal measurement. Ann Dent 1984;43: Yao KT, Lin CC, Hung CH. Maximum mouth opening of ethnic Chinese in Taiwan. J Dent Sci 2009;4: Mathew CF, Elaine S, Chun-His C. Relationship between dental arch width and vertical facial morphology in untreated adults. Eur J Orthod 2008;30: Kumar A, Mehta R, Goel M, Dutta S, Hooda A. Maximal mouth opening in Indian children using a new method. J Cranio Max Dis 2012;1: Martin R, Saller K. Lehrbuch der Anthropologie in systematicsher Darstellung, Band I. Stuttgart: Gustav Fischer; p Mezitis M, Rallis G, Zachariades N. The normal range of mouth opening. J Oral Maxillofac Surg 1989;47: Cox SC, Walker DM. Establishing a normal range for mouth opening: Its use in screening for oral submucous fibrosis. Br J Oral Maxillofac Surg 1997;35: Weinstein IR. Normal range of mouth opening. Letters to the editor. J Oral Maxillofac Surg 1984;42: Wood GD, Branco JA. A comparison of three methods of measuring maximal opening of the mouth. J Oral Surg 1979;37:175e Cortese SG, Oliver LM, Biondi AM. Determination of range of mandibular movements in children without tempero mandibular disorders. Cranio 2007;25: Vanderas AP. Mandibular movements and their relationship to age and body height in children with or without clinical signs of craniomandibular dysfunction: Part IV. A comparative study. J Dent Child 1992;59: Pullinger AG, Liu SP, Low G, Tayt D. Differences between sexes in maximum jaw opening when corrected to body size. J Oral Rehabil 1987;14: Abou-Atme YS, Chedid N, Melis M, Zawawi KH. Clinical measurement of normal maximum mouth opening in children. Cranio 2008;26: Agerberg G. Maximal mandibular movements in young men and women. Sven Tandlak Tidskr 1974;67: Rothenberg LH. An analysis of maximum mandibular movements, craniofacial relationships and temperomandibular joint awareness in children. Angle Orthod 1991;61: Source of support: Nil; Conflict of interest: None Declared 3073