CRANIO® The Journal of Craniomandibular & Sleep Practice ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/ycra20 To evaluate whether there is a relationship between occlusion and body posture as delineated by a stabilometric platform: A systematic review C Álvarez Solano , LA González Camacho , SP Castaño Duque , T Cortés Velosa , JA Vanoy Martin & L Chambrone To cite this article: C Álvarez Solano , LA González Camacho , SP Castaño Duque , T Cortés Velosa , JA Vanoy Martin & L Chambrone (2020): To evaluate whether there is a relationship between occlusion and body posture as delineated by a stabilometric platform: A systematic review, CRANIO®, DOI: 10.1080/08869634.2020.1857614 To link to this article: https://doi.org/10.1080/08869634.2020.1857614 Published online: 24 Dec 2020 Submit your article to this journal Article views: 51 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at https://www.tandfonline.com/action/journalInformation?journalCode=ycra20 ® CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE https://doi.org/10.1080/08869634.2020.1857614 LITERATURE REVIEW To evaluate whether there is a relationship between occlusion and body posture as delineated by a stabilometric platform: A systematic review C Álvarez Solano DDS, MSc a,b, LA González Camacho DDS, MSc a, SP Castaño Duque DDS, MSc T Cortés Velosa DDS a, JA Vanoy Martin DDS a and L Chambrone DDS, MSc, PhD d,e c , a Department of Orthodontics, El Bosque University, Bogotá D.C, Colombia; bDepartment of Functional Orthopedics, Cruzeiro Do Sul University, São Paulo, Brazil; cDivision of Orthodontics and Epidemiology, El Bosque University, Bogotá D.C, Colombia; dDentistry Program, Ibirapuera University, São Paulo, Brazil; eUnit of Basic Oral Investigation-UIBO, School of Dentistry, El Bosque University, Bogotá D.C, Colombia ABSTRACT KEYWORDS Objective: To evaluate whether there is a relationship between occlusion and body posture evaluated using a stabilometric platform Methods: Observational studies that analyzed the relationship between dental occlusion (changes in mandibular position and/or dental malocclusion) and body posture evaluated with a stabilometric platform in patients older than 13 years without orthodontic or orthopedic inter vention and systemically healthy were considered eligible for inclusion PubMed, EMBASE, Science Direct, LILACS, and Google Scholar databases were searched to obtain articles published from September 2019 up to March 2020 Results: Twelve articles met the inclusion criteria, of which 66.7% showed a relationship between dental occlusion and body posture, and 33.3% found no relationship The marked heterogeneity between studies did not allow data to be combined for meta-analyses Conclusion: For the mandibular positions, the postural changes were mainly in the mediolateral direction, while in the malocclusions, they were in the anteroposterior direction Dental occlusion; posture; stabilometric platform; mandibular position; malocclusion; systematic review Introduction The first clear description of the relationship between dental occlusion and body posture was introduced by Rocabado et al in 1982 [1] This initial approach gen erated a vision of dental occlusion in integration with the other structures of the human body Determining the relationship between dental occlusion and body posture is important because maintaining a good bal ance between all anatomical components of the human body allows it to maintain energy efficiency and ergo nomics and also facilitates dynamic functions [2] The biomechanics between the head, cervical spine, and the masticatory apparatus has generated scientific debate, due to the different interrelationships that exist between them, particularly because postural problems have been observed in more than 90% of the patients with some type of malocclusion [3] In general, this possible relationship can be explained by the interaction between afferent and efferent signals that are picked up by multiple postural receptors such as the inner ear, the eyes, the plantar skin surface, and the stomatognathic system These signals will be later integrated and modu lated by the central nervous system [4] CONTACT Cortés Velosa T © 2020 Taylor & Francis Group, LLC tcortesv@unbosque.edu.co When evaluating body posture, the influence of visual input on balance control is particularly impor tant Postural stability is more easily maintained by compensatory visual signals produced by the interaction of multiple accessory or secondary pathways that link the visual pathway with multiple brain centers [5] The simplest and least invasive method used in various medical fields to assess body posture is the stabilometric platform, which allows measurement of weight distribu tion at fulcrums of the feet and related variations during the observation period (posturometric measurements) or center of the body The platform is made of two supporting plates, one for each foot (right and left), on which reference points are drawn for the positioning of the feet Each plate rests on three highly sensitive load cells positioned at the level of the three fulcrums of the feet, which are the first metatarsal, fifth metatarsal, and the heel The load cells detect the weight and send data to a computer that displays dynamic images in real time that express the weight distribution and variations in the fulcrums of the feet and the body, known as swaying [6] This diagnostic tool allows body posture to be analyzed while the body is immobile (static), in motion (dynamic), or in combination This will depend on the Department of Orthodontics, El Bosque University, Bogotá D.C, Colombia 110121 2 C ÁLVAREZ SOLANO ET AL design of the study and the indications presented by the different manufacturers [5–14] In recent years, interest has grown in understanding the relationship between dental occlusion and body posture, in order to establish the influence of occlusal function on body posture and, thus, generate a clinical contribution with orthodontic, restorative, or orthope dic alternatives that might contribute to postural stabi lity in adults and children in a static or dynamic position However, although some studies have been carried out, a description of the relationship between these two entities has not been made in the context of a systematic review (SR) For this reason, the objective of this SR is to evaluate whether there is a relationship between dental occlusion and body posture as assessed by a stabilometric platform The following focused question was addressed: Is there a relationship between dental occlusion and body posture in patients with permanent dentition? Outcome measures The following outcome measures were studied: (1) Relationship between mandibular position (cen tric relation, maximum intercuspation, and man dibular rest position) and body posture, measured with the stabilometric platform (2) Relationship between dental malocclusion and body posture measured with the stabilometric platform Search strategy The following electronic databases were searched, with out language restriction: PubMed, EMBASE (Excerpta Medica Database), Science Direct, LILACS, and Google Scholar from September 2019 up to March 2020 The databases were searched using MeSH (Medical Subject Headings) terms, keywords, and Boolean operators (Figure 1) Materials and methods This systematic review was structured according to the PRISMA guidelines [15], the Cochrane Handbook for Systematic Reviews of Interventions [16], and the Check Review checklist [17] The protocol was registered in PROSPERO from the UK National Institute for Health Research, with the registration number: CRD42020128853 (http://www.crd.york.ac.uk/PROSPERO) Selection criteria Only observational studies (i.e., prospective cohort, case-control, and cross-sectional studies) were consid ered eligible for inclusion in the SR if they involved the following: a) an assessment of the relationship between dental occlusion (changes in mandibular position and/ or dental malocclusion) and body posture evaluated with a stabilometric platform; and b) patients over 13 years of age with permanent dentition without dis tinction of gender Exclusion criteria Studies were excluded from the review if they involved patients with the following: a) orthodontic or orthopedic intervention; b) a history of temporomandibular disor ders, orthopedic or otorhinolaryngological problems that affect body balance or syndromic abnormalities; and c) the presence of five or more dental restorations Study selection and data extraction Two independent reviewers (T.C.V and J.A.V.M.) evalu ated the titles, abstracts, and full texts of the articles; disagreement between the reviewers was resolved through discussion When an agreement could not be reached, a third reviewer (C.A.S.) was consulted The information from the articles was extracted and recorded considering the following data: study design, year of publication, subjects, and results obtained with the plat form and conclusions Assessment of the methodological quality of the studies The methodological quality of observational studies was assessed using a quality measurement tool specially devel oped for the purpose of this study by combining topics from the original Newcastle-Ottawa Scale (NOS) [18] (Figure 2) adapted by Chambrone et al [19–25] (i.e., the number of stars awarded for each study was used to determine its overall methodological quality), with items designed to appraise the criteria used to evaluate dental occlusion (selections of patients with and without maloc clusion) and other highly relevant domains of methodolo gical quality (i.e., sample size calculation, appropriateness of analytical statistics, management of confounders, train ing/calibration of outcome evaluators, and malocclusion exposure) Consequently, up to 14 stars could be awarded to a study, instead of the original 11 proposed by the IdenƟfied arƟcles through the databases search (n=1.769) Duplicated arƟcles (n=22) Collected arƟcles aŌer eliminaƟon of duplicates (n=1.747) Excluded arƟcles by Ɵtle and abstract (n=1.721) Selected arƟcles in full text (n=26) Selected Found IdenƟfied CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE Included Excluded arƟcles by inclusion and exclusion criteria (n=14) Included arƟcles (n=12) Figure Flowchart PERINETTI G, MICHELOTTI A, MARINI I, BALDINI A, SANCHEZ, WAKANO, GOMES, BRACCO, SANCHEZ, RINGOFF, NOBILI, MICHALAKYS K, 2006 2006 2013 2013 2016 2011 2014 1998 2015 2015 1996 2019 SelecƟon Comparability Results StaƟsƟc 10 11 12 13 14 Figure Methodological quality of the included observational studies original NOS scale Studies with 11 to 14 points (approxi mately 80% or more of the domains satisfactorily met) were considered of high quality; studies with to 10 stars were medium quality, and studies with fewer than stars were of low methodological quality [18] (Table 1) occlusion and body posture evaluated with a stabilometric platform Results Search results Data synthesis Data were grouped into evidence tables, and a descriptive summary was created to determine the amount of data and to study the variations in terms of characteristics and results when analyzing the relationship between dental The search strategy returned a total of 1769 articles in all of the databases, of which 1743 were excluded after review of the titles and/or abstracts The full texts of the remaining 26 documents were reviewed in more detail, but only 12 were considered eligible for inclusion in the review However, 14 Sample size calculation X X X 6 X X X X X X X X X X X X X X X X X X X X X Bracco 1996 X X Sánchez ‘ z 2015 X X Michalakys Nobili Ringoff K 2019 1996 2015 Representativeness of the subjects/ patients without malocclusion and without changes in the mandibular position Selection subjects/patients with malocclusion or with changes in mandibular position Evaluation of dental occlusion (mandibular position and malocclusion) Selection of patients with similar postural conditions Training/calibration of the evaluators of clinical results Prospective data collection and description of clear inclusion/exclusion criteria Comparability Comparability d groups (patients) depending on the design analysis Management of confounding factors (data collection and impact investigation) Results Assessment ot Me reivits 2.Assessment/criteria applied assess changes in dental occlusion (mandibular position and malocclusion) in the last blkive -up Adequate patient follow-up Statistics (1) Suitability/validity of the statistical analysis (1) Analysisunit(responserate) reported in the statistical model Total Variables Selection Table Evaluation of the methodological quality of studies X X X X X X X X X X X X X X X X X X X X X X X X X X X X X 10 X X X X X X X Gómes Wakano Sánchez Baldini Marini Michelotti 2014 2011 2016 A 2013 L 2013 A 2006 X X X X X Perinetti G 2006 C ÁLVAREZ SOLANO ET AL CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE did not meet the inclusion criteria because of the following: a) non-observational studies (n = 8) [26–33]; b) orthodon tic or orthopedic intervention (n = 3) [2,34,35]; c) a history of temporomandibular disorders (n = 1) [36]; and d) body posture evaluated with different methods than stabilo metric platform (n = 2) [37,38] (Figure 1) Included studies In total, 12 articles were included in this systematic review: case and control study [6] and 11 crosssectional studies [5,7–11,13,14,39–41], published between 1996 and 2019 The authors found studies carried out in Germany [7], Spain [8,34], Italy [6,11,13,14,39,40], Brazil [9], Japan [5], and the United States [10] Ten of the studies analyzed the relationship between mandibular position and body posture [5–7,9,10,13,14,39–41], and two studies ana lyzed the relationship between dental malocclusion and body posture [8,11] Only one study performed a sample size calculation [9] In total, 332 subjects were examined in the selected articles Study evaluation Of the 12 studies in this review, studies presented moderate methodological quality [6,9,10] and low methodological quality [5,7,8,11,13,14,39–41] One study described the calculation of the sample size [9] Another article reported the calibration of the evalua tors [7], and none of the studies followed up the sample due to the type of design of the studies selected in this review Relationship between mandibular position (mandibular rest position, centric relation, maximum intercuspation) and body posture Six of the 10 articles that evaluated the relationship between changes in mandibular position and body pos ture reported that there is a relationship between the two variables [5,7,9,10,40,41], and found no relation ship [6,13,14,39] (Table 2) Mainly three mandibular positions were analyzed: mandibular rest position, centric relation, and maxi mum intercuspation Regarding postural evaluation, all studies evaluated different postural parameters; how ever, the most observed variables were the area of bal ance, speed of balance, and displacement of the center of foot pressure in the anteroposterior and mediolateral directions Likewise, three studies evaluated changes in mandib ular position in relation to changes in weight distribution [6,10,41], of which two [10,41] found a relationship The influence of visual input on balance control was assessed in four studies that evaluated body posture when subjects kept their eyes open and/or closed [9,13,14,39]; three of these studies did not find a relationship [13,14,39] Another important aspect in the postural evaluation was presented by Ringhof et al [7], who analyzed whether the subject leaned on his two legs, on his dominant leg or on his non-dominant leg, observing that, in a biped position, the subjects balanced significantly less in the anterior-posterior and mediolat eral direction than in the dominant and non-dominant legs (p < 0.001) The authors did not find significant differences between dominant and non-dominant legs In two studies [5,13], the postural change was evalu ated when the mandibular position was modified with a manufactured occlusal interference Wakano et al [5] found a relationship between the two variables when using an experimental horizontal mandibular deviation splint, while Marini et al [13] found no relationship when using occlusal interference from to mm thick made of glass composite to disturb the intercuspal position Gómes et al [9] carried out their study considering the type of mastication of the subjects They found statistically significant differences (p < 0.05) in the area of oscillation in bilateral mastication with open eyes, in right unilateral mastication with open eyes, and from the center of pressure in the mediolateral direction in right unilateral mastication with closed eyes Another aspect presented by Bracco et al [40] was the evaluation of the mandibular position using a neuroelectric stimulation technique for the muscles called myocentric occlusal position In their study, all the analyzed subjects demonstrated variations in body posture as a consequence of the alteration of the man dibular position In general, all the studies used different stabilometric platforms: four in statics [6,9,10,14], three in dynamics [9,13,41], and three combined [5,7,39] Bracco et al [40] did not describe the type of platform used Relationship between dental malocclusion and body posture Two of the studies evaluated found a relationship between dental malocclusion and body posture [8,11] (Table 3) Nobili et al [11] based their study on the observation of the baricentrum displacement of the subjects and found a posture displaced forward in Class II, while in Class III, the posture was displaced backward 44 patients 17–35 years Cross-section 26 subjects 26–38 years Cross-section 12 adults 21.8 years approx Cross-section 10 subjects 33.62 years approx Cross-section 20 subjects 20–30 years Cross-section Perinetti et al [14] Ringhof et al [7] Sánchez et al [41] Bracco et al [40] Cross-section Baldini et al [39] Study Michalakys et al [10] Participants/ study design 20 adults 27–40 years The subjects were required to remain as stable as possible but relaxed with their arms on the sides and facing the wall Subjects remained stable and relaxed with their arms on the sides Posture assessment Each subject was barefoot on the sensor in a comfortable position with arms relaxed on the sides Mandibular position assessment Mandible in rest position (MR) Maximum intercuspation (MIC) Subject clenching on the right side (CR) Subject clenching on the left side (CL) Mandibular rest position with eyes open and closed Mandible in centric occlusion with eyes open and closed Mandibular position with cotton rolls, open and closed eyes Eyes open with mandibular rest position (eyes open RP) and with dental intercuspidal position (eyes open IP) Eyes closed with mandibular rest position (eyes closed RP) and with dental intercuspidal position (eyes closed IP) Controlled biting (150 N) Non-biting or centric relation Clinical parameters AMTI power Subjects received instructions from platform the biped and unipedal postures Static and on their dominant and nondynamic dominant legs 30 s Body balance Subjects were barefoot, arms on the Maximum platform sides, shoulders relaxed, and intercuspation (MIC) Dynamic looking at a reference point to eye Mandibular rest level m away position (MRP) using cotton rolls (8 mm thick) Postural Subjects were evaluated while on Centric occlusion platform the platform Article does not Rest position Static specify postural indications Myocentric position recorded using the transcutaneous electrical neural stimulation technique Vertical force platform Static 10 Hz 51 s DL Medica SpA Static and dynamic Method/ platform MatScan Tekscan Inc Static No Yes 13 subjects showed a reduction from the real to Yes theoretical baricentrum in myocentric occlusion The effect of exercise on balance control was Yes statistically significant for level and level (p < 0.05) Analysis of the control of the balance at rest showed differences between MRP and MIC only for level (p < 0.05) Were differences between the biped position and the dominant and non-dominant leg (p < 0.05) In biped position, the subjects balanced less (p < 0.001) There are no statistically significant differences No in the absolute mean displacement of the pressure center from the theoretical point (p > 0.05) No difference was found between RP and IP with open or closed eyes The position of the jaw did not influence any postural parameter (p > 0.05) (Continued) All subjects demonstrated variations in body posture for the alteration in the mandibular position The myocentric position seems to be associated with an improvement in body posture A significant reduction in both the postural sway and the anteroposterior length was observed compared to the non-biting or centric relation condition Body balance was significantly better when dental occlusion was established in MRP and entered into force under fatigue conditions This study does not show a detectable relationship between changes in the position of the mandible with open or closed eyes and body posture Future studies should focus on the 3D analysis to clearly verify the correlation between dental occlusion and posture Results Relationship Conclusions/observations Changes in the distribution of body weight in Yes Clenching/(MIC) and occlusal instability (MIC) on the right side: 65% showed leftward are associated with changes in lateral and on the left side: 70% showed a shift to distribution of body weight the right Table Characteristics of the included studies evaluating the relationship between mandibular position and body posture C ÁLVAREZ SOLANO ET AL Method/ platform Force plate system Dynamic 100 Hz 120 s Clinical parameters Mandibular position Posture assessment assessment Volunteers were standing barefoot Non-habitual bilateral with biped support in mastication with eyes a comfortable position, heels open and closed aligned, arms along the body, and Non-habitual staring at the height of the unilateral mastication glabella at 1.5 m with eyes open and closed Wakano 15 subjects Dyjoc Board A natural upright position was used Mandibular rest et al [5] 22–27.4 years Plus SVwith the heels–shoulder width position (MRP) 2001 apart with the feet at a 458° angle Experimentally Cross-section Static and and a monitor placed m of the horizontally deviated dynamic participant mandibular position 40 Hz (EHDMP) maintained 20 s through the use of a splint (DPS) Mandibular rest position maintained by the splint (RPS) Marini et al 12 subjects Force Reference points were placed on the An occlusal interference [13] platform body in a frontal and dorsal plane was used for gait Subjects were barefoot with the Eyes open with teeth analysis arms on the sides in contact and teeth Cross-section Dynamic not in contact 2s Eyes closed with teeth in contact and teeth not in contact Michelotti 78 subjects Stabilometric Subjects maintained a correct Intercuspal position (IP) et Cases: 26 platform position throughout the Maintaining two al [6] Controls: 52 examination facing a point m in cotton rolls between Cases and Static front of them the teeth without controls 51.2 s Rest clenching period 30 s Study Gómes et al [9] Participants/ study design 20 subjects 29.6 years Cross-section Table (Continued) The results showed that an experimental occlusal interference does not modify the body posture Unilateral posterior crossbite does not influence postural stability No No statistically significant differences were No found in occlusal conditions, weight distribution, speed of body sway between subjects with and without mandibular lateral slide and the occlusal status (p > 0.05) Time showed a statistically significant difference (p < 0.05) for 20 of the 76 parameters examined Results Relationship Conclusions/observations There are statistically significant differences in Yes The different types of mastication the area of oscillation during bilateral promoted changes in the different mastication with the eyes open, in the right variables of static balance unilateral mastication with the eyes open and in the center of pressure in sense mediallateral in the right-sided mastication with the eyes closed (p < 0.05) Statistically significant differences for the area Yes Variation in tilt angle and dynamic of oscillation with eyes open and eyes closed balance is greatest in the horizontally (p < 0.05) There were significant differences deviated mandibular position and between the conditions (p < 0.05) interfered with the stability of the vertical position on an unstable platform CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE Participants/study design 25 subjects al.[11] Cross-section subjects Class III: 10 subjects subjects Class II: 20 Class I: 20 18 - 32 years Cross-section Nobili et 50 patients Study Sánchez et al [8] Method/platform Posture assessment Malocclusion assessment Results Relationship Conclusions/observations Body Balance Subjects were in a stable Occlusal characteristics: Angle classification Class I population Yes Occlusal disturbance could modify the Platform, position, barefoot with arms (Class I, II, III); prognosis; crowding ≥3 mm; showed better balance control in people with dental Balance System on the sides and shoulders deviation of the midline; diastemas; missing balance ability malocclusion The centric relation SD relaxed while the platform teeth; cross bite; open bite; overbite overjet than Class II and condition only influenced balance in Static and Dynamic was moving ≥4 mm Class III (p