Fully automated 3D volumetric analysis of masticatory muscles in a pediatric population: A CT-based normative morphometric study

The masticatory muscles play a fundamental role in craniofacial growth and development, yet normative volumetric data encompassing all four muscles across the full pediatric age range remain poorly characterized. The aim of this study was to establish age- and sex-specific normative reference values for the volumetric development of masticatory muscles in a normal pediatric population (0–17 years) using a fully automated 3D segmentation method. This retrospective, cross-sectional study included 258 normal pediatric individuals stratified into four age groups based on biomechanical milestones (0–5, 6–9, 10–13, and 14–17 years). Bilateral volumes of the masticatory muscles were automatically calculated using TotalSegmentator in the 3D Slicer environment. Two-way analysis of variance and Bonferroni post-hoc tests were applied. All muscles showed significant volume increases with age (p < 0.001), with the masseter demonstrating the greatest increase (199%). No sex differences were observed in 0–5 years; significant male-favoring differentiation began from 6 to 9 years. The temporalis muscle exhibited a biphasic sex differentiation pattern, with no significant difference at 10–13 years despite significance at 6–9 and 14–17 years. The highest sex-related effect sizes were observed in the pterygoid muscles (medial pterygoid ηp² = 0.176; lateral pterygoid ηp² = 0.160). Bilateral asymmetry analyses revealed left-sided favoring in the masseter, a lateralization trend in the temporalis (exploratory), right-sided favoring in the medial pterygoid, and sex-specific lateralization in the lateral pterygoid. These findings provide a large-scale CT-based normative reference for pediatric masticatory muscles, demonstrating muscle-specific volumetric patterns and variable sex differentiation, with normative ranges supporting clinical decision-making in dentistry, craniofacial surgery, and pediatric radiology.