## 4 Discussion  
This study was designed to evaluate the maximal bite force in patients with dental implants versus patients without dental implants, as measured by a digital bite force transducer (GM10). In addition, the influences of sex, age, and sleep/awake bruxsim on the maximal bite forces of the two groups were evaluated. Our null hypotheses were that there was no difference in the bite force in patients with or without dental implants and that the maximal bite forces of the two groups were not affected by sex, age, and sleep/awake bruxsim. Our null hypotheses were partially rejected. Bite force may be an important parameter while planning implant-supported prosthesis, especially in patients with very high occlusal loads. A high bite force capability may predict a high risk for a late component fracture. Previous research showed that the results produced by the bite fork tool used in this study are robust between tests and between testers reliability [14]. The slight variability seen between testers suggests that it is preferable for a single examiner to collect mechanical threshold values [41], a conclusion that we implemented in the present clinical trial. The measurement of the force by the bite fork was also influenced by the position at which the force was applied. In our study, the cover of the bite fork was modified by attaching an acrylic cone, which acted as an occlusal guide. This enabled the placement of the bite fork in a standardized and reproducible position. It should be noted that the reliability of bite force measurements may be influenced by individual factors that may alter the measurements including facial morphology, states of dentition, functional disturbances of the masticatory system such as the presence of pain and temporomandibular disorders, sex, age, craniofacial morphology, and occlusal factors [35]. There have been a number of studies that reported the measurement of the maximal bite force in normal subjects ranging from 244 to 859 N [42]. Interestingly, the mean maximal bite force in our study was relatively low (258.5 \(\pm\) 175.7 N). Possible explanations for this finding include the small study population and the instructions given to our patients to stop biting when they felt discomfort or pain. In addition, the use of different devices, among the studies, with different biting elements may cause variations in the bite force measurements. Figure 9: Mean maximal bite force by age and implants. Notably, the surface of the bite fork was modified in the present study, such that it came into contact with only one cusp on the maxillary molar, while in previous studies the contact area between the force transducer and the teeth was much larger. Further explanations for the lower values are that muscle fatigue and psychological factors, such as a feeling of anxiety, and other factors, such as diet, habits, and profession, may significantly influence the measured values. The mechanical properties of the bite force-recording system may affect the accuracy and precision of the bite force measurements. A histogram of the results from the current study population revealed a skewed distribution of the average bite force. The shape of the curve suggested that while there seemed to be a minimum bite force, the maximum values were more varied, thereby producing a right tail and non-normal distribution. [PERSON] et al. showed the same tendency of the minimum subjects with an \"extremely high\" occluding force [15]. The results of the study suggested that the mechanical pain threshold was lower if implants were present. Although the differences did not reach significance, dividing the bite force measurements into five groups by ascending values, revealed a clear trend line with a stronger representation of the control group (no implants) in the higher force groups. We assumed that the pain is a summary of signals from all interacting sites. The loading forces during mastication induced by the masticatory muscles were controlled by the mechanoreceptors of the periodontal ligament.