Comparative Analysis of Bite Force after Cranioplasty with and without Temporalis Dissection in Large Skull Defects Caused by Decompressive Craniectomy

Abstract

Introduction

Cranioplasty involves repairing the skull defect using an autologous bone flap or synthetic molds. The temporalis muscle, detached during decompressive craniectomy (DC), may be reattached to the bone flap for better cosmetic reconstruction. Along with the masseter and pterygoid muscles, the temporalis muscle significantly contributes to the human bite force. In this study, we analyze patients' bite force in which the temporalis muscle was either dissected and reattached or left undisturbed during cranioplasty.

Materials and Methods

All patients who previously underwent DC for traumatic brain injury or stroke were grouped into two, depending on the method of cranioplasty. In group 1, patients underwent temporalis muscle dissection and reattachment to the bone flap or prosthesis. In group 2, the temporalis muscle was left undisturbed. The bite force of the subjects was measured bilaterally in both groups by a gnathodynamometer before cranioplasty and 3 months after the surgery. We compared the difference in bite force of the subjects individually on both sides, preoperatively and postoperatively, as well as between the groups.

Results

This study included 36 patients over 18 years of age, with 18 patients in each group. Preoperatively, the bite force of all the subjects was decreased on the side of the DC compared with the normal side. After cranioplasty, the bite force significantly improved compared with preoperative values in both groups.

Conclusion

Temporalis dissection can be safely done during cranioplasty. There is improvement in bite force after cranioplasty with or without temporalis dissection.

 

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Keywords

decompressive craniectomy - cranioplasty - temporalis dissection - bite force

Introduction

Decompressive craniectomy (DC) is a common life-saving operation performed to decrease raised intracranial pressure in patients with traumatic brain injury (TBI)[1] [2] [3] and stroke.[4] [5] It most commonly involves removing a large part of the skull, namely fronto-temporo-parietal regions of the skull of least 12 × 15 cm in diameter.[1] The temporalis muscle is dissected off its attachment during this procedure. The exposed dura is then opened and augmented by a dural substitute or a fascia lata graft to accommodate the brain swelling. The dissected temporalis muscle is then placed over the dural substitute. The excised bone flap is stored in the anterior abdominal wall or bone bank.

Cranioplasty (CP) is the surgery performed to repair this skull defect following recovery. It involves replacing the bone flap or a prefashioned synthetic mold into the skull defect. The temporalis muscle can either be dissected off and resuspended or left undisturbed during this procedure. Electromyogram studies in the past have provided sufficient evidence of the role of the temporalis muscle and the masseter to the bite force in humans.[6] In this study, we analyze the effect of temporalis dissection and reattachment during CP on the bite force and compare it to subjects in whom the temporalis was left undisturbed over the dura.

 

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Materials and Methods

This study was a prospective study done at Government Medical College, Trivandrum, from October 2020 to October 2021. The study was done after obtaining the institution's ethics committee clearance (HEC No-03/03/2021/MCT). The study subjects consisted of patients who underwent DC for TBI or stroke. The inclusion criteria involved fully conscious, oriented, and cooperative patients in the 18 to 65 year age group without any neurobehavioral sequelae of TBI or stroke. Patients with traumatic craniofacial fractures, loss of teeth, artificial dentures, or musculoskeletal disorders were excluded from the study. All patients who underwent surgery of CP were grouped into two. Group 1 had CP with temporalis muscle dissection and reattachment, and group 2 without it. The details of the procedure in each group are described below.

Group 1—Cranioplasty with Temporalis Dissection and Reattachment

The procedure was done under general anesthesia in supine position with the head rotated to the opposite side of the craniectomy defect. A small linearly folded sheet was kept under the shoulder to get some head extension. After that, the cranial and abdominal incision site was cleansed and draped. The skin incision was made over the initial DC incision, and the flap was raised. The flap was dissected from all sides exposing all the bony edges of the craniectomy defect. After placing retraction sutures over the skin flap, attention was focused on the dissection of the temporalis muscle. The superior edge of the temporalis was initially palpated with a dissector and slowly incised at the superior part, where it blended closely with the underlying dura. This incision was dissected anteriorly and posteriorly to release the entire muscle from the synthetic dura ([Fig. 1A]). The muscle was dissected inferiorly, where the inferior end of the craniectomy was then exposed near the zygomatic arch. While this procedure was done at the cranial end, the second surgeon at the abdominal end harvested the bone flap from the anterior abdominal wall where it was placed during the initial DC. This bone flap was then cleaned thoroughly with betadine and saline. The bone flap was then temporarily placed over the craniectomy site, and the previous site of attachment of the temporalis muscle was marked. A linear array of small holes was created with the electric drill. The temporalis muscle was then anchored over the bone flap by passing several interrupted sutures through these newly created linear arrays of holes ([Fig. 1B]). The edges of the bone flap are then fixed to the cranium with the help of titanium plates and screws. The final construct with the anchored bone flap with the temporalis is depicted in [Fig. 1C]. A suction drain was kept over the bone, and then the skin wound was then closed in layers.

Fig. 1 (A) Intraoperative photo during cranioplasty—the temporalis muscle has been successfully separated from the underlying prosthetic dura and held by two artery forceps. (B) The autologous bone flap has been placed over the craniectomy defects. Multiple small holes have been drilled with electric drill. Multiple silk sutures have been passed through these holes and the temporalis muscle and held in suspension. (C) The sutures have been firmly tightened and temporalis muscle is resuspended to its original attachment on the autologous bone. (D) Intraoperative photo—cranioplasty performed without dissection of the temporalis with patient-specific titanium mold.

 

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Group 2—Cranioplasty without Temporalis Muscle Dissection

This method of CP is done in the same steps as mentioned above until the temporalis dissection part. In this method, after raising the skin flap, all the margins of the craniectomy are well-defined except for the inferior part, which is hidden by the overlying temporalis muscle. The temporalis muscle overlying the dural substitute (kept during the initial DC) is left undisturbed. The bone flap is harvested from the abdominal wall and thoroughly cleaned with betadine and saline. This is then anchored to the craniectomy defect by titanium plates and screws. In the case of a customized implant, it is placed directly over the defect without dissection of the temporalis muscle ([Fig. 1D]). A suction drain is kept, and the wound is closed in layers.

 

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Gnathodynamometery

The measurement of human bite force is done using a gnathodynamometer. In our case, this was done by a gnathodynamometer obtained from Safal Enteprise Inc. ([Fig. 2]) The measurements were conducted in the area of the left and right first permanent molars or the adjacent teeth (second primary molars). The participant was asked to bite on the segment of the gnathodynamometer with maximal occlusal strength. The measurement was repeated three times with an interval of 10 seconds. The mean was taken as the final value, which was determined in kilograms. The patients were then taken up for CP by any one of the methods described above, depending upon the preference of the surgeon. After the procedure, the patients were followed up in the outpatient department. Three months later, the measurements of the bite force were repeated on both sides. The difference in the bite force over both sides was compared. This procedure was followed in patients who undergo CP without temporalis dissection too. The difference in bite force was compared between the two groups.

Fig. 2 Photo of the gnathodynamometer.

 

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Statistical Analysis

All data were entered into an Excel sheet and analyzed using the statistical software SPSS version 26. The continuous variables were expressed in means and standard deviation. The qualitative variables were expressed in proportions. The mean difference in bite force before and after CP was measured in the group with and without CP using a paired sample t-test. The difference in means between the two groups was compared using the independent sample t-test.

 

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Results

There were 36 subjects enrolled in the study. There were 29 males (80.56%) and 7 females (19.45%). The mean age of the male participants was 33.76 years, whereas the females had a mean age of 39 years. Thirty patients underwent DC for TBI and six for ischemic stroke. Seventeen patients underwent CP on the left and 19 on the right. There were 18 patients in each group. No patients had any ventriculomegaly or post-DC hydrocephalus. In total, 13.89% of the population were hypertensive, 8.33% of the population were diabetic, and 2.78% of the population had history of seizures. 69.44% of people had no comorbidities. There were no postoperative complications in any group. The baseline demography of the subjects in each group is depicted in [Tables 1] and [2]. No randomization was done to select the type of CP in each subject as this was subject to surgeons' preference.

Table 1 The demography of patients included in group 1 (temporalis dissection and resuspension)

Age	Sex	Laterality	Pre-op R bite force in kilograms	Pre-op L bite force in kilograms	Post-op R bite force in kilograms	Post-op L bite force in kilograms	Time To cranioplasty (months)	Comorbidities
42	M	Right	23.33	42.67	24.33	38.67	18	Nil
16	M	Right	15.00	38.33	44.67	40.00	9	Nil
56	M	Right	17.00	22.33	19.67	25.33	17	Nil
35	M	Right	14.33	18.00	17.33	19.33	2	HTN
23	M	Right	28.00	45.00	31.33	49.33	16	Nil
21	F	Left	38.33	24.33	41.00	25.67	2	Nil
42	M	Left	42.33	41.33	44.00	41.00	11	Nil
50	F	Right	12.33	4.33	13.00	6.33	3	HTN, DM, CVA
33	M	Right	16.67	20.67	17.67	22.67	6	Nil
22	M	Left	23.67	17.67	24.67	18.33	6	Nil
27	M	Left	42.00	28.67	44.33	32.67	4	Nil
37	M	Right	25.00	32.33	28.33	39.33	14	Nil
55	M	Left	17.67	24.00	20.67	26.67	21	Nil
36	F	Left	7.33	4.50	8.33	5.00	6	Nil
24	M	Right	29.67	16.67	30.33	17.67	8	Nil
23	F	Left	16.67	7.67	22.00	8.67	5	Nil
35	M	Right	17	1.67	34.33	2.00	9	Nil
30	M	Right	34.67	24.67	41.00	28.00	26	CVA

Abbreviations: CVA, cerebrovascular accident; DM, diabetes mellitus; F, female; HTN, hypertension; L, left; M, male; Post-op, postoperative; Pre-op, Preoperative; R. right.

Table 2 The Demography of patients included in group 2 (cranioplasty without temporalis resuspension)

Age	Sex	Laterality	Pre-op R bite force in kilograms	Pre-op L bite force in kilograms	Post-op R bite force in kilograms	Post-op L bite force in kilograms	Time to cranioplasty (months)	Comorbidities
31	M	Left	34.67	19.33	42.00	42.00	18	Nil
30	M	Right	12.00	20.00	18.33	12.00	4	CVA
39	M	Left	48.33	19.00	34.33	24.33	12	CVA
24	M	Right	23.00	41.67	27.33	42.67	23	Nil
33	M	Left	54.67	28.67	59.67	29.00	28	Nil
33	M	Left	45.67	22.33	44.00	25.33	8	Nil
49	M	Right	23.33	12.67	26.33	19.33	18	CVA
35	M	Right	14.00	36.00	19.67	37.67	14	Nil
38	M	Left	50.00	27.67	46.67	28.67	11	Nil
41	F	Right	6.00	16.67	17.00	25.33	10	HTN
33	M	Left	36.00	31.67	33.33	32.00	9	Nil
31	M	Left	43.00	20.00	45.67	24.00	2	Nil
40	F	Left	2.00	0.80	6.67	1.00	22	Nil
31	M	Left	39.00	34.67	42.67	37.67	16	Seizure
21	M	Left	41.33	32.00	18.67	19.33	2	Nil
48	M	Right	31.00	37.67	40.33	40.67	4	DM, HTN
26	M	Right	2.67	5.00	3.67	7.00	21	CVA
62	F	Right	15	19.00	14.67	17.67	8	DM, HTN

Abbreviations: CVA, cerebrovascular accident; DM, diabetes mellitus; F, female; HTN, hypertension; L, left; M, male; Post-op, postoperative; Pre-op, preoperative; R, right.

Group 1

There were 18 patients in this group. Among them, there were 14 males and 4 females. The mean age of the participants in this group was 33.72 years (standard deviation [SD]: 11.8 years). The mean duration from DC to CP in this group was 9 ± 7.22 months. Seven patients underwent CP on the left side, and 11 patients underwent CP on the right side. The preoperative mean bite force in this group was 21.17 (SD: 9.37) on the operated side and 25.25 (SD: 13.85) on the nonoperated side. The mean bite force improved to 25.55 (SD: 11.6) on the operated side and 27.43 (SD: 14.1) on the nonoperated side. The difference is depicted in the box plot in [Fig. 3]. The improvement was analyzed statistically using paired sample t-test and was found to be statistically significant for both the operated side (p = 0.023) as well as the nonoperated side (p = 0.001; [Table 3]).

Fig. 3 Box plot showing the mean bite force in patients before and after cranioplasty with temporalis dissection. Note the marginal improvement in bite force in the postoperative bite force in this group.

Table 3 Paired t-test to assess the statistical difference between the bite force on the operated and nonoperated side before and after the cranioplasty

	Operated side—mean bite force		Paired t-test	Nonoperated side—mean bite force		Paired t-test
	Preoperative	Postoperative		Preoperative	Postoperative
Group 1 with temporalis dissection	21.17 (SD: 9.37)	25.55 (SD: 11.16)	p = 0.023	25.25 (SD: 13.85)	27.43 (14.1)	p = 0.001
Group 2 without temporalis dissection	20.17 (SD: 10.19)	23.92 (SD: 11)	p = 0.032	32.4.1 (SD: 15.83)	32 (SD 15.36)	p = 0.829

Abbreviation: SD, standard deviation.

 

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Group 2

There were 18 patients in this group. Among them, there were 15 males and 3 females. The mean age of the participants in this group was 35.83 years (SD: 9.85 years; p = 0.56). The mean time duration for CP after DC was 12 ± 7.7 months in this group. Ten patients underwent CP on the left side, and eight patients underwent CP on the right side. The preoperative mean bite force in this group on the operated side was 20.17 (SD: 10.19) and 32.4 (SD: 15.83) on the nonoperated side. The mean bite force improved to 23.92 (SD: 11) on the operated side and 32 (SD: 15.36) on the nonoperated side. The difference is depicted in the box plot in [Fig. 4]. The improvement in bite force after CP within the group was statistically significant on paired sample t-test for the operative side (p = 0.001) but not on the nonoperative side (p = 0.829; [Table 3]). There were no postoperative complications in this group.

Fig. 4 Box plot showing the mean bite force in patients before and after cranioplasty without temporalis dissection. There is improvement in bite force in the postoperative bite force in this group also.

The mean difference in preoperative and postoperative bite force in group 1 was 4.38 (SD: 7.45) and 3.75 (SD: 6.83) in group 2. This difference was compared using an independent sample t-test and was not statistically significant (p = 0.794).

 

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Discussion

Methods of CP after DC described in the literature have been diverse. Several types of CP materials have been described ranging from autologous bone grafts to prosthetic materials like titanium, PEEK, ceramic molds, etc. The essential surgical steps of the procedure are more or less the same except for the part which deals with the temporalis muscle is concerned.[7] Some surgeons prefer to meticulously dissect the plain between the muscle and the underlying dura and reattach the muscle to the autologous bone or newly paced cranial prosthesis during CP,[8] [9] [10] while others may not try this maneuver in fear of causing damage to the underlying brain resulting in an intracerebral hematoma.[7] Temporalis muscle resuspension during CP has been shown to have a better cosmetic outcome,[11] but the value of this procedure in the improvement of bite force has not been studied well in adults. Jin et al studied the effect of temporalis reflection on cerebral blood flow, symmetry, and functional independence after CP.[12] They found no difference in the cranial symmetry between individuals in whom the temporalis muscle was reflected or not. However, they noted a significant improvement in cerebral blood flow and functional independence scale in patients in whom the temporalis was reflected and reattached during CP. Martini et al evaluated the role of temporalis osteosynthetic fixation upon bite force in children who underwent correction of craniosynostosis.[13] Their study included children with craniosynostosis in whom only a fronto-basal advancement was necessary to correct the cranial deformity. In their cohort, only the anterior belly of the temporalis was detached and reattached. In our study, we examine the effect of entire temporalis muscle detachment and refixation performed during CP on the stomatognathic system, a study that has not been performed so far.

The maximal voluntary bite force is a vital determinant of masticatory function.[14] It is defined as the forces exercised by the muscles of mastication in normal occlusion.[15] The bite force is used to evaluate oral function in relation to occlusal factors,[16] [17] dentition,[18] [19] dental prostheses,[20] [21] implant treatment,[22] [23] orthognathic surgery,[24] [25] oral surgery,[26] temporomandibular disorders,[27] [28] and neuromuscular disease.[29] It has considerable influence on the masticatory performance of the individuals.[30] There is a significant correlation between bite force and muscle activity, and the amount of muscle contraction is an indication of how forcefully an individual can bite[14] and a superior masticatory system leads to a stronger bite force.[31] The temporalis muscle is one of the vital muscles of mastication.[32] [33] The anterior and the middle fibers act to elevate the mandible, whereas the posterior fibers retract the mandible. Balance activity occurs in all three parts of the temporalis muscle (anterior, middle, and posterior) at rest and during habitual clenching, and the posterior part of the muscle plays a dominant role during clenching with the mandible in the retruded position.[34] The temporalis resuspension, hence, seems logically essential in restoring the normal bite force after CP.

Several techniques of temporalis muscle fixation have been proposed during craniotomy closure. The most commonly employed method worldwide was described by Spetzler and Lee, which proposed the fixation of temporalis muscle and fascia to a superior cuff of the leftover rim of temporalis muscle and fascia during initial craniotomy.[35] Other techniques described involve suturing the temporalis fascia to microscrews inserted above[36] or below[37] the superior temporal line, suturing the muscle to contourable titanium strut plate[38] [39] and trans-osseous reconstruction of temporalis muscle by suturing it to the newly drilled holes.[40] In our series, the anchoring was done similar to the method described by Brunori et al, which is by drilling holes through the bone and suturing the muscle to it.[40] Our technique described in group 1 is very similar to the one described earlier by Spetzler and Lee. In group 2, we placed the bone flap in a “pericranial on lay” fashion described earlier by Gordon et al.[41]

There are several authors who do not agree with the idea of temporalis resuspension. They would abstain from dissecting the intensely adherent temporalis muscle from the synthetic dura. In our study, this was not a problem as we used a double layer of synthetic dura (G Patch, Surgiwear Inc.) during the initial DC. This method, which was described earlier by our institution as well as by other researchers, was found to facilitate CP with ease as the plain between the two dural prostheses is easy to dissect.[42] [43]

The normal occlusive bite force in adults depends on age,[44] dentition,[45] and gender.[46] Females have lower bite forces compared with males due to lower jaw surfaces and a decrease in muscle mass. There is generally not much difference between the two sides in an individual, as determined by the previous authors.[46] In our cohort, the occlusive force determined by gnathodynamometery on the nonoperated side was normal.

There was a significant difference in bite force between the operated and nonoperated sides. This difference in bite force is presumed to be due to the temporalis muscle dysfunction precipitated by the temporalis dissection performed during the initial DC. Oikawa et al described the retrograde temporalis dissection method, which preserves the deep temporal nerves and arteries during the procedure, thereby reducing the atrophy in the postoperative period.[47] In our institution, we usually perform DC as a life-saving procedure in an emergency. The temporalis is usually reflected down along with the scalp as a myocutaneous flap with an electrocautery. This might have added to the temporalis muscle dysfunction and the consequent low bite force on the operated side.

There was an improvement in bite force on both the operated and nonoperated sides in both the groups with and without temporalis dissection. The difference in the means between groups was not statistically significant. The improvement in the side of the temporalis resuspension (group 1) might be due to remodeling of the original structure of the stomatognathic system.

Limitations

This was a study with a small sample size that examined the role of temporalis dissection and reattachment and its influence on the bite force of individuals. No proper randomization technique was employed in this study as it involved several neurosurgeons who preferred their own technique of CP. A larger sample size and proper randomization would have been more appropriate to reveal a statistical difference in bite force between the two methods.

The patients enrolled in this study were diverse in age and gender. It is not appropriate to have a blanket value of bite force as a standard, as considerable variability exists between groups and within each group. However, we give a rough estimate of the fact that there is some improvement in bite force, comparing it with the preoperative values. The cosmetological factor, which is considered to be the main factor while evaluating the outcome of CP, was not analyzed. However, earlier studies have shown that no significant difference in cranial symmetry occurs between the two choices of temporalis dissection.[12] Although we have not evaluated it scientifically, based on our wide experience in managing TBI and performing CP, we concur with the findings of this study.

 

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Conclusion

The temporalis reflection and reattachment during CP is safe. There is a trend toward improvement in bite force in patients either with or without temporalis resuspension following CP. A larger number of patients is required in each group to quantify a meaningful difference in bite force between either of the methods of CP.

 

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Conflict of Interest

None declared.

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Publication History

Article published online:
09 May 2025