To evaluate whether there is a relationship between occlusion and body posture as delineated by a stabilometric platform a systematic review

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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.

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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 c,

T Cortés Velosa DDS a, JA Vanoy Martin DDS a and L Chambrone DDS, MSc, PhD d,e

a Department of Orthodontics, El Bosque University, Bogotá D.C, Colombia; b Department of Functional Orthopedics, Cruzeiro Do Sul University, São Paulo, Brazil; c Division of Orthodontics and Epidemiology, El Bosque University, Bogotá D.C, Colombia; d Dentistry Program, Ibirapuera University, São Paulo, Brazil; e Unit of Basic Oral Investigation-UIBO, School of Dentistry, El Bosque University, Bogotá D.C, Colombia

ABSTRACT

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.

KEYWORDS

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]

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 variadistribu-tions 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

CONTACT Cortés Velosa T tcortesv@unbosque.edu.co Department of Orthodontics, El Bosque University, Bogotá D.C, Colombia 110121.

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?

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

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

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

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]

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

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 8 to 10 stars

were medium quality, and studies with fewer than 8 stars

were of low methodological quality [18] (Table 1)

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

occlusion and body posture evaluated with a stabilometric platform

Results

Search results

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

Selected arcles in full text

(n=26)

Idenfied arcles through the databases

search

(n=1.769)

Collected arcles a"er eliminaon of

duplicates

(n=1.747)

Excluded arcles by tle and

abstract

(n=1.721)

Included arcles

(n=12)

Excluded arcles by inclusion and exclusion criteria

(n=14)

Duplicated arcles

(n=22)

Figure 1 Flowchart

M I C H A L A K Y S K , 2 0 1 9

N O B I L I , 1 9 9 6

R I N G O F F , 2 0 1 5

S A N C H E Z , 2 0 1 5

B R A C C O , 1 9 9 8

G O M E S , 2 0 1 4

W A K A N O , 2 0 1 1

S A N C H E Z , 2 0 1 6

B A L D I N I A , 2 0 1 3

M A R I N I I , 2 0 1 3

M I C H E L O T T I A , 2 0 0 6

P E R I N E T T I G , 2 0 0 6

Selec!on Comparability Results Sta!s!c

Figure 2 Methodological quality of the included observational studies

Table

Michalakys K

Nobili 1996 Ringoff 2015

Sánchez ‘ z

Gómes 2014 Wakano 2011 Sánchez 2016 Baldini A 2013 Marini L

Michelotti A

Perinetti G

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: 1 case and control study [6] and 11 cross-

sectional 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, 3 studies presented

moderate methodological quality [6,9,10] and 9 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 4 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 balbal-ance, 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 0 to 2 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]

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

Table

Participants/ study

Method/ platform

Michalakys et

adults 27–40

MatScan Tekscan Inc.

Baldini et

patients 17–35

Medica SpA.

Perinetti et

subjects 26–38

remain as

Static 10

Ringhof et

adults 21.8

dynamic 30

Sánchez et

subjects 33.62

Maximum intercuspation

Bracco et

subjects 20–30

Postural platform

transcutaneous electrical

Table

Participants/ study

Method/ platform

Gómes et

subjects 29.6

Dynamic 100

Wakano et

subjects 22–27.4

dynamic 40

Force platform for

Dynamic 2

Michelotti et al

subjects Cases:

Stabilometric platform

Static 51.2

Table

Sánchez et

Platform, Balance

mandible 2:

baricentrum position,

subjects Class

position 3:

subjects Class

statistically significant correlation between

a p

In accordance with the above, Sánchez et al [8]

reported that people with Class I malocclusion showed

a better ability to balance in unstable conditions

com-pared to Class II, and a trend toward better stability

compared to Class III The authors determined that

occlusal characteristics, such as crowding, midline

deviation, crossbite, and anterior open bite, influenced

the postural stability index

In these studies, two stabilometric platforms were

used, in dynamics [8] and combined [11]

Discussion

Summary of main results

Of the total of selected articles, 66.7% demonstrated

a relationship between dental occlusion (changes in

mandibular position and/or dental malocclusion) and

body posture [5,7–11,40,41] When mandibular

posi-tions were evaluated, the greatest relaposi-tionship was

found in changes in body inclination, mainly

horizon-tally with a medial or lateral inclination [5,7,10,41],

unlike malocclusions where postural changes were

mainly in the anterior-posterior direction [8,11]

Likewise, two studies used different occlusal

interfer-ences [5,13,41] that varied in terms of material and the

calculation of the experimental discrepancy generated in

each one, showing divided results

Regarding the presentation of the results, there was some diversity in the description of the postural para-meters and their evaluation condition: static [6,10,14,40], dynamic [8,9,13,41], or combined [5,7,11,39]

Quality of the evidence and limitations

The studies included in this review showed differences

in methodological quality: three were moderate [6,9,10], and nine were low [5,7,8,11,13,14,39–41] Ten articles studied mandibular position [5–7,9,10,13,14,39–41] and two articles studied dental malocclusion with body pos-ture [8,11]

The limitations in the analysis of the data were found mainly in the standardization when presenting the results

of the postural parameters: the different types of stabilo-metric platforms, the frequency units (Hertz), and the different time cuts in each session Therefore, based on all the information analyzed and the limitations presented,

a checklist was proposed to guide the researcher and the clinician on the management of dental occlusion and body posture (Table 4)

Possible biases in the review process

This review was developed in a unidirectional sense, analyzing the relationship between dental occlusion and body posture The other direction is to evaluate the relationship between body posture and dental occlusion, which is a prospective for other studies, as

in the study by Silvestrini-Biavati [42], who reported that approximately 13% of the children manifested

a pathological gait Also, among them, it is common

to find different occlusion alterations, being the most common presence of vertical anomalies, such as deep bite or open bite compared to the other occlusal defects

Performing a bidirectional review could generate a great number of variables that would make it difficult to give accurate results and could generate confusion in the research

The authors opted to consider studies in patients with temporomandibular disorders not eligible for inclusion in this SR This was determined in order

to find the relationship between dental occlusion and body posture without generating confounding variables

Some studies [30,33,43] were also found with another type of analysis, in which they disturbed body posture to see their influence on dental occlusion, which could generate more responses, but the central axis of this

Table 4 Checklist of suggestions for clinical application

Domain

Anamnesis Clinic record

What type of physical activity or sport do you do and how often do you do it?

Have you had pain or any pathology in the back, neck, hip, knees, and/or feet?

Have you had any trauma to any part of the body?

Clinical evaluation Full body pictures with postural template:

anterior frontal plane, right side, left side, and posterior plane

Observe the presence of associated facial asymmetries

Perform complementary tests on mastication, breathing, phonation, deglutition, and habits.

Use of stabilometric

platform in static position

Natural and relaxed position, bare feet, arms on the side of the trunk, and looking at a fixed point at eye level.

Use of stabilometric

platform in dynamic

position

Establish time and specific physical activity.

Intraoral exam Relate dental occlusion (mandibular

position and/or malocclusion) with body posture.

Basic knowledge of the

platform

Usefulness, method of use, interpretation

of results, and calibration.

Interdisciplinary

management

Physiotherapy, orthopedics, kinesiology, podiatry, sports medicine, and speech therapy.