SECTION EDITOR

M a s s e t e r m u s c l e f a t i g u e b e f o r e and a f t e r r e h a b i l i t a t i o n with
implant-supported prostheses
R. J a c o b s , D D S , P h D , a D . v a n S t e e n b e r g h e , MD, PhD, b and
I. N a e r t , D D S , P h D c
Faculty of Medicine, Catholic University of Leuven, Leuven, Belgium

To e s t a b l i s h w h e t h e r d i f f e r e n t i m p l a n t - s u p p o r t e d p r o s t h e t i c r e c o n s t r u c t i o n s
i n f l u e n c e j a w m u s c l e r e s i s t a n c e to c l e n c h i n g efforts, s u s t a i n e d s u b m a x i m a l ( 5 0 % )
c l e n c h i n g w a s p e r f o r m e d in t w o g r o u p s o f p a t i e n t s w h o w e r e e d e n t u l o u s in o n e or
both jaws. One group consisted of patients who were rehabilitated by means of an
o v e r d e n t u r e on t w o to f o u r i m p l a n t s c o n n e c t e d b y a bar; t h e o t h e r g r o u p c o n s i s t e d
o f p a t i e n t s w h o w e r e r e h a b i l i t a t e d w i t h an i m p l a n t - s u p p o r t e d f i x e d p r o s t h e s i s on
f o u r to s e v e n i m p l a n t s in e i t h e r t h e m a x i l l a or t h e m a n d i b l e . R e s u l t s i n d i c a t e d t h a t
after rehabilitation with implant-supported fixed reconstructions, the myoelectric
o u t p u t l e v e l i n c r e a s e d o v e r t i m e , w h i c h w a s p a r a l l e l to a h i g h e r b i t e f o r c e l e v e l .
F o r t h e o t h e r g r o u p , s u c h a t i m e - d e p e n d e n t c h a n g e in e l e c t r o m y o g r a p h i c a m p l i t u d e
did n o t occur. On t h e o t h e r hand, p o w e r s p e c t r u m a n a l y s i s r e v e a l e d a s i g n i f i c a n t
downward shift of the mean power frequency during sustained clenching after
rehabilitation with implant-supported overdentures but not with implant-supported
f i x e d p r o s t h e s e s . T h e a b s e n c e o f a s p e c t r a l s h i f t in t h e l a t t e r g r o u p p r o b a b l y
e x p r e s s e d a f e a r o f b i t i n g too h a r d a n d f r a c t u r i n g t h e p r o s t h e s i s . (J PROSTHET DENT
1995;73:284-9.)

I t has been assumed that implant-supported pros-
theses lead to an improvement of masticatory muscle per-
formance. 1One parameter of muscle performance is fatigue
resistance during sustained clenching. In a cross-sectional
study on different types of rehabilitation, fatigue occurred
in patients with natural teeth, complete dentures, and im-
plant-supported overdentures, but fatigue was not present
in patients with fixed prostheses on implants. The absence
of fatigue in patients with fixed prostheses probably
reflected a fear of biting too hard and fracturing the pros-
thesis because of the absence of periodontal feedback. 2 In
this follow-up study, the occurrence of change in fatigue
resistance after installation of implants was investigated.
Muscle fatigue has been defined in different ways and
has led to different hypotheses about the underlying
mechanisms. 3-6 Time-dependent changes in both myoelec-
tric signal amplitude and spectral parameters may be ap-
plied to monitor deterioration of muscle performance. 6 For
jaw muscles, the surface electromyogram (EMG) analyzed
by means of power spectrum analysis indicates that the
power shifts to lower frequencies when the subject is
maintaining a constant clenching level. 7 The median fre-
quency (mean power frequency, MPF) is one of the most
reliable spectral parameters to analyze such shifts. 7 The
MPF is related to the bite force level. Lower MPF values
are usually observed at higher bite force levels, ss~ Denture
wearers develop a reduced bite force compared with that of
subjects with natural dentitions. 11 After rehabilitation
with osseointegrated implant-supported prostheses, bite
force increases. I, 12-14 It could therefore be hypothesized
that the increased bite force levels for implant-supported
prostheses involve decreased MPF values.
This study investigated resistance to fatigue and shifts
in the power spectrum of the masseter muscle during a
sustained submaximal (50 %) clenching effort before and
after rehabilitation with osseointegrated implants. This
investigation determined whether masseter muscle fatigue
was dependent on the type of the prosthetic superstructure
supported by implants.

Sponsored by the National Fund for Scientific Research (NFWO MATERIAL AND METHODS
Belgium). Subjects
aResearch Assistant, NFWO, Department of Periodontology (lab-
oratory of Oral Physiology). Seventeen women participated in the experiment (Table
bprofessor, Department of Periodontology, The P-I Br~nemark I). All subjects denied having any known heart disease or
Chair in Osseointegration. hypertension, which might make constant clenching effort
cprofessor, Department of Prosthetic Dentistry.
Copyright | 1995 by The Editorial Council of THE JOURNALOF unsafe because of the muscle heart reflex) 5 They gave in-
PROSTHETICDENTISTRY. formed consent and ethical committee approval was ob-
0022-3913/95/$3.00 + 0. 10/1/61130 tained.

284 THE JOURNAL OF PROSTHETIC DENTISTRY V O L U M E 73 NUMBER 3

JACOBS, VANSTEENBERGHE, AND NAERT
Table I. Patient groups
A g e (yr)
No. of p a t i e n t s
Group (all w o m e n ) M e a n (SD)
ODi 10 56 (8)
FFPi 7 50 (10)
Before implant installation all patients were edentulous
in at least one jaw and wore a complete denture for more
than 10 years (Table 1). The edentulous period before im-
plant installation ranged from 0 to 32 years (mean 14 years,
standard deviation [SD] 13) for the overdenture supported
by implants (ODi) group and 1 to 26 years (mean 13 years,
SD 8) for the fixed implant-supported prosthesis (FFPi)
group.
Test group ODi consisted of 10 patients whose ages
ranged from 40 to 68 years (mean age 56 years, SD 8) at en-
try into the study. Seven of them had been rehabilitated by
means of two osseointegrated implants connected by a
straight bar, s~:rictly parallel with the hinge axis of the
mandible supporting a denture in the lower jaw. Thus the
overdenture was tissue-supported in the molar areas. The
three others had been rehabilitated by means of four
osseointegrated implants connected by a bar in the maxilla.
The antagonistic jaw had natural teeth (n = 3) or carried
a complete denture (n = 7). Test group FFPi consisted of
seven patients whose ages ranged from 34 to 62 years (mean
age 50 years, SD 10) at entry into the study. They had been
rehabilitated by means of four to seven osseointegrated
implants supporting a full fixed prosthesis in either the
upper or lower jaw opposing natural teeth (n 4) or a com-
plete denture (n 3).
For rehabilitation of the edentulous jaw with implant-
supported prostheses, principles for occlusion and articu-
lation did not differ from the conventional prosthodontic
rules proposed by Beyron. 16Simultaneous bilateral contact
in centric relation was always present.
In both test groups, the experiments were done before
implant installation and 1 or 2 years after rehabilitation
with the present prostheses to avoid jaw muscle activity
variations caused by initial adaptation to the prosthesis. 17
Experimental procedure
The subjects were seated upright in a dental chair with
the head leaning against the headrest. The masseteric my-
oelectric activity was recorded bilaterally by means of bi-
polar surface tin/lead electrodes (Dantec Medical and Sci-
entific Equipment, Skovlunde, Denmark) placed in paral-
lel to the muscle fibers of the superficial masseter muscle.
The electrode centers were 2 cm apart. To ensure repro-
ducible placement of the electrodes at future recordings in
the subjects, a grid with horizontal and oblique intersect-
ing lines was used. is A horizontal line was aligned with the
MARCH 1995
THE JOURNAL OF PROSTHETIC DENTISTRY
M e a n y e a r s of
Range Dentition edentulism (SD)
40-68 Overdenture on implants 14 (13)
34-62 Fixed prosthesis on implants 13 (8)
alar-tragus line, and the oblique intersecting line was po-
sitioned parallel to the muscle fibers of the superficial
masseter muscle. The center of the upper electrode was
placed 2 cm below the intersection, and the center of the
second electrode was located on the same line 2 cm below
this.
The skin was cleaned with ethyl alcohol and the patient
was grounded with a grounding electrode soaked in saline
solution (Dantec Medical and Scientific Equipment). At
each follow-up session, the maximal EMG amplitude
(EMGmax) when clenching bilaterally was determined dur-
ing an encouraged maximal clenching effort. Thereafter
patients had to develop an isometric contraction of the jaw
elevator muscles at 50% of EMGmax (50% maximum vol-
untary contraction [MVC]) by clenching bilaterally. Visual
feedback by means of an oscilloscope screen showing the
raw EMG amplitude allowed them to maintain a constant
amplitude level until exhaustion appeared. The investiga-
tor observed the experiments and gave the necessary feed-
back to maintain the proper raw EMG level. Corrections
rarely had to be made, and when deviations occurred they
were always smaller than 10 ttV. Subjects clenched at the
selected level for as long as possible until fatigue or pain
prevented them from further clenching (endurance time).
The longest sustained contraction time was 5 minutes.
Subjective perception of fatigue or pain was recorded. In
this study, no force meter was used that would inevitably
lead to a bite rise. EMG feedback seemed appropriate to
measure force output because of the existence of a linear
relationship between integrated surface EMG of the mas-
seter and submaximal isometric muscle force. 19,20
Data collection
During the clenching effort, 1/2-second runs of the mas-
seter activity were recorded at the start and the end of the
sustained contraction. The EMG was amplified with a
bandwidth from 20 to 1000 Hz. An on-line frequency anal-
ysis was done in the 0 to 500 Hz frequency range by a
Dantec Counterpoint electromyograph (Dantec Medical
and Scientific Equipment) with a sampling frequency of
204.8 kHz. It generated the power spectral density function
and the power spectra for each 1/2-second run.
Muscle fatigue is reflected by the time course of several
myoelectric signal variables. In this study, two parameters
were chosen for data analysis. The peak-to-peak amplitude
and the MPF of all EMG signals were computed by the
285
T H E J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
350
3OO
(D
0
9 250
0
I.,.
o
.m
g 200
O~
"1:3
150
E 2 years after implants
@ 100
U.I
50
0
overdenture on implants fixed prosthesison implants
Fig. 1. With regard to peak-to-peak amplitude of Clenching effort at 50 % MVC, signif-
icant increase in myoelectric output level was noted for patients with implant-supported
fixed prostheses. Vertical bars indicate SEM for each EMG amplitude value.
built-in computer program. The amplitude represented the
maximal peak/peak amplitude of the raw EMG signal. The
MPF corresponded to the frequency at which 50 % of the
power is accumulated.
Statistical analysis
All statistical calculations were done with Microstat
software (EcoSoft, Inc., Indianapolis, Ind.). A 5% level of
significance was chosen, unless otherwise stated.
A paired t test was done in each patient group to detect
whether MPF changes during sustained clenching differed
from zero and also to evaluate the change in amplitude and
endurance after installation of implants. Pearson correla-
tion tests were applied to evaluate the relationship between
the changes in amplitude, endurance, and MPF after reha-
bilitation with implant-supported prostheses. These tests
also established the relationship between the MPF shift
and subjective perception of fatigue or pain. Finally, a
simple regression analysis was done to establish the influ-
ence of endurance time, years of edentulism, and age on the
MPF.
RESULTS
Although a large intersubject variability was noted, my-
oelectric signal parameters had a different behavior in the
patient groups. Because no significant difference appeared
between the myoelectric parameters of the left and the
right side, no further distinction was made. The mean and
standard error of the mean (SEM) of the peak-to-peak
286
J A C O B S , VAN S T E E N B E R G H E , A N D N A E R T
m
BeBl=
before implants
ear after implants
amplitude at 50 % MVC is noted in Fig. 1. To create this
figure, left and right side data were pooled. The endurance
time before and after rehabilitation with implants is indi-
cated in Fig. 2. During the 2-year follow-up period, the ODi
group showed no significant changes in amplitude or
endurance (simultaneous paired t tests). After rehabilita-
tion with a fixed prosthesis on implants, a significant
increase in signal amplitude was observed (p < 0.02, Bon-
ferroni multiple comparisons method), whereas the endur-
ance time did not change significantly.
When the relationship between changes in amplitude,
endurance, and MPF after rehabilitation with implant-
supported prostheses was tested, a significant negative re-
lationship appeared between the change in amplitude and
endurance time (Pearson correlation tests, r -0.80). In-
creasing amplitude values indeed correlated with a de-
creasing endurance time.
For the change in MPF during sustained clenching,
paired t tests indicated significant downward shifts in MPF
during a sustained clenching effort before and after reha-
bilitation with implant-supported overdentures (Table II).
This shift was also present for the other patients before re-
habilitation with implant-supported full fixed prostheses.
However, after rehabilitation, such a significant shift could
no longer be observed (Table II).
Regarding the relationship between MPF shift and sub-
jective perception of fatigue or pain during a sustained
clenching effort, no correlation could be established. It also
appeared that the endurance time, the years of edentulism,
V O L U M E 73 NUMBER 3
JACOBS, VAN STEENBERGHE, AND NAERT THE J O U R N A L OF PROSTHETIC DENTISTRY

250

200

(D
150
B
"-"
0 before implants
0
r-

ear after implants

= 100
0 2 years after implants

50

0
overdenture on implants fixed prosthesis on implants
Fig, 2. For endurance time, differences did not reach level of significance, although for
ODi group, tendency toward lowered endurance time appeared 2 years after rehabilitation
with implant-supported prostheses. Vertical bars indicate SEM for each endurance time.

and age at the moment of observation did not influence the Table II. Spectral shift after sustained clenching before
behavior of the MPF (simple regression analysis). and after rehabilitation with implants
M e a n shift
DISCUSSION (SEM)* t Value p Value
In accordance with the previous cross-sectional study on
Group ODi
jaw muscle fatigue, 2 the amplitude of the myoelectric out-
Before rehabilitation 13.7 (4.2) 3.19 <0.01t
put and the resistance to fatigue, as assessed by endurance
1 year after rehabilitation 26.4 (10.3) 2.55 <0.01t
time and MPF, were compared between different patient 2 years after rehabilitation 10.0 (5.4) 1.95 <0.05#
groups. In the present follow-up study, patients were mon- Group FFPi
itored before and after installation of implants. Before rehabilitation 11.9 (4.7) 2.49 <0.05#
The large intersubject variability, noted for the ampli- 1 year after rehabilitation 13.6 (8.6) 1.56 >0.10
tude and MPF values, corresponds well to that of previous 2 years after rehabilitation 10.0 (5.4) 0.76 >0.10
reports.S, 21This variability may be related to differences in
*Values for the left a n d the right sides were pooled.
craniofacial morphologic features, 22 differences in bite tLevel of significance is reached.
force level, 19, 20 or variations in the masseter muscle fiber
type composition. 3
Although it has been shown that occlusal forces increase
after rehabilitation with implant-supported overdentures in the lower jaw. Force build-up with such a prosthetic re-
in the mandible, 23this result could not be confirmed in this construction has not yet been evaluated.
experiment. During the 2-year follow-up period, patients in This observation concerning the increased EMG ampli-
the ODi group showed no significant changes in amplitude tude for the edentulous patients after rehabilitation by
or endurance. These findings correspond well to the obser- means of an implant-supported fixed prosthesis corre-
vations made in three subjects (mean age 52 years, SD 10; sponds well with observations of previous reports. Indeed,
age range 43 to 46 years) who wore a denture in the maxilla in edentulous patients, rehabilitation with fixed osseointe-
opposed to natural teeth in the lower jaw. In these patients, grated implant-supported prostheses led to bite force lev-
no significant changes in amplitude or endurance occurred els ranging from 111 to 335 N. 1,12-14 The results also indi-
during the 2-year follow-up period. Furthermore, it has to cated a negative relationship between the change in ampli-
be mentioned that 3 of 10 patients were rehabilitated with tude and endurance. Increasing amplitude values indeed
an overdenture in the upper jaw opposed to a full denture correlated with a decreasing endurance time.

MARCH 1995 287

THE J O U R N A L OF P R O S T H E T I C D E N T I S T R Y
Another approach to evaluating masseter muscle perfor-
mance is monitoring fatigue phenomena t h a t appear dur-
ing sustained clenching efforts. During sustained clench-
ing, a significant downward shift of the M P F p a r a m e t e r
occurred, which can be related to fatigue. 7,10, 21 After reha-
bilitation in the i m p l a n t - s u p p o r t e d fixed prosthesis group,
however, such a shift could not be established. T h e latter
finding could eventually be related to the lower E M G lev-
els noticed during submaximal clenching. The forces de-
veloped are known to be lower t h a n those t h a t occur dur-
ing chewing, which probably expresses the fear of causing
damage to the implants or the prosthetic reconstruction
during the experimental conditions. 24
In this study, the reported values for endurance time
were somewhat higher t h a n those reported for natural
dentitions, 25 b u t no significant difference in endurance
time could be established between the patient groups or
within one group after rehabilitation with implants. The
actual experimental setup, which involved regular verbal
encouragements, may have enhanced the endurance time.
In addition, some difficulties were encountered in motivat-
ing patients to exert real maximal outputs. A fear of frac-
ture of implants or prostheses was sometimes expressed.
The endurance time during isometric contractions is re-
lated to the fiber type composition of the muscle. 26 Lower
clenching forces involve fatigue-resistant type I fibers and
are also associated with a long endurance t i m e s Thus the
longer endurance time observed in this study could also be
explained b y the lower clenching levels exerted. T h e lim-
iting factor to the sustained clenching effort was somewhat
different between the p a t i e n t groups. Before rehabilitation
with implants, some patients reported muscle fatigue
(10%) or pain caused by pressure of the denture on the
mucosa (20 % ) as the limiting factors of their clenching ef-
fort. The other patients had neither pain nor fatigue dur-
ing clenching. After rehabilitation, patients in the ODi
group did not perceive greatly different sensations: 60%
noted no pain, 20% had muscle fatigue, and 20% contin-
ued to report pressure of the opposing denture on the mu-
cosa. In contrast, patients in the F F P i group reported mus-
cle fatigue (42.8 % ) or fear of clenching any further (28.6 % )
as limiting factors of the sustained clenching effort. The
rehabilitation of edentulous patients by means of implant-
supported fixed prostheses involves an immediate load
transfer through the implants to the jaw bone instead of a
negative periodontal feedback, which is associated with in-
creased bite force levels compared with those of denture
wearers.I, 12-14During the sustained submaximal clenching
effort, these patients develop lower bite forces, expressing
their fear of causing damage to the implants or the
prosthetic reconstruction. 24 Dentures, on the other hand,
are tissue-supported and during sustained clenching a
compression of the soft tissues is involved, which stimu-
lates the periodontal mechanoreceptors in the gingiva of
both upper and lower jaw. Thus it may not be surprising
288
JACOBS, VAN S T E E N B E R G H E , AND N A E R T
t h a t several patients with a m a n d i b u l a r overdenture op-
posing a full denture reported pain in the anterior maxil-
lary region instead of masseter muscle pain.
Clinically, it was observed t h a t after rehabilitation with
i m p l a n t - s u p p o r t e d overdentures no real changes appeared
in the p a r a m e t e r s t h a t monitored masseter muscle fatigue.
On the other hand, after rehabilitation with implant-sup-
p o r t e d fixed prostheses, patients exhibited an increased
E M G amplitude during a brief clenching effort. Neverthe-
less, during sustained submaximal clenching, a spectral
shift t h a t monitored fatigue remained absent, which might
indicate the p a t i e n t s ' fear of clenching too hard and frac-
turing the prosthetic reconstruction.
CONCLUSIONS
The limited sample size does not allow one to draw any
definitive conclusions, but observations from this study are
important with regard to masseter muscle behavior after
rehabilitation with implants.
1. Spectral analysis offers quantitative information
about masticatory performance of patients rehabilitated or
not rehabilitated by means of osseointegrated implants.
2. After rehabilitation with i m p l a n t - s u p p o r t e d overden-
tures no real changes appeared in the parameters t h a t
monitored masseter muscle fatigue. A significant down-
ward shift of the spectral p a r a m e t e r s for patients with an
overdenture on implants was related to the phenomenon of
fatigue.
3. In patients with i m p l a n t - s u p p o r t e d fixed prostheses
no such shift occurs, and they expressed a fear of possibly
biting too hard and fracturing the prosthetic reconstruc-
tion.
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JACOBS, VAN STEENBERGHE, AND NAERT THE JOURNAL OF PROSTHETIC DENTISTRY

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DEPARTMENT OF PERIODONTOLOGY
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