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EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 13/1-2012

D. Ciavarella
1
, A. Monsurr
2
, G. Padricelli
2
,
G. Battista
1
, L. Laino
2
, L. Perillo
2
1
Department of Surgical Sciences
University of Foggia, Foggia, Italy
2
Department of Dentistry, Orthodontics and Surgery
Second University of Naples, Naples, Italy
e-mail: angmons@libero.it
Introduction
Unilateral posterior crossbite (UPCB) is an asymmetric
Keywords Adolescents; Surface electromyography;
Unilateral posterior crossbite.
ABSTRACT
Aim Unilateral posterior crossbite (UPCB) is
characterised by an inverse relationship of the upper
and lower buccal dental cusps and may involve one or
several teeth. The aim of this study was to compare the
electromyographic outcomes of patients with UPCB
and those of healthy controls.
Materials and methods Fifteen patients (mean
age 11.5 years) with UPCB and fteen healthy
controls (mean age 12 years) were examined at the
Department of Orthodontics, Second University of
Naples. Surface electromyography was performed on
patients and controls.
Results and conclusion Patients with UPCB
had less muscle activation than healthy subjects
(p<0.0001) and an asymmetric muscle activation with
89.23% muscle balancing for temporals and 83.21%
for masseters. The control group showed a 99.32%
of muscle balancing for temporals and 97.77% for
masseters. These ndings suggest that asymmetric
muscle activation may inuence maxillary and
mandibular growth in adolescents with UPCB.
Unilateral posterior
crossbite
in adolescents: surface
electromyographic
evaluation
malocclusion affecting 8-22% of children [Harrison
and Ashby 2000; Perillo et al., 2010]. This condition is
characterised by an inverse relationship of the upper
and lower buccal dental cusps and may involve one
or several teeth [Daskalogiannakis 2002]. According
to Planas [Planas, 1997] the crossbite side presents a
greater number of occlusal contacts, because it is the
preferred chewing side. However, this has not been
conrmed elsewhere (Salioni et al., 2005; Alarcon et
al., 2009]. The pathogenesis of this malocclusion is still
unknown. It may originate from altered skeletal and/or
dental growth that can induce mandibular displacement
frequently associated with lower midline deviation.
Surface electromyography is often used to study the
pathogenesis of UPCB. Some studies have shown that
UPCB was commonly related to asymmetric elevator
muscle function [Ingervall and Carlsson 1982; Ferrario
et al., 1999]. Moreover, asymmetric muscle function
induced poor occlusal contacts and temporomandibular
stress [Ciavarella et al., 2010]. Changes in masticatory
cycles and reverse chewing cycles were also reported
[Piancino et al., 2009].
The aim of this study was to compare the
electromyographic outcomes of patients with UPCB
and those of healthy controls.
Materials and methods
Fifteen patients between the ages of 9-14 (mean 11.5
years, 9 girls and 6 boys) with UPCB and fteen healthy
controls between the ages of 9-14 (mean age 12 years,
7 girls and 8 boys) were selected and examined at the
Department of Orthodontics, Second University of
Naples, Italy. The participants and parents provided
written informed consent to be involved in the study.
Exclusion criteria included Class II and III malocclusions,
open and deep-bite, oral or systemic diseases,
previous orthodontic treatment.
Four of the eight channels of a surface electromyograph
recorder (sEMG, Biopack) were employed to record
sEMG activity of anterior temporal (TA) and masseter
(MM) muscles.
This diagnostic test provided information on
the functional status of the craniomandibular
neuromuscular system and was useful in determining
the proper cranio-mandibular relationship.
To position the electrodes, subjects were requested to
close their mouths and clench.
To reduce electrode impedance, the skin was carefully
cleaned prior to electrode positioning, and recordings
were performed 56 min later, allowing the conductive
paste to adequately moisten the skin surface.
The analogue sEMG signal was amplied, digitised,
and digitally ltered.
The instrument was directly interfaced with a computer,
which presented the data graphically.
CIAVARELLA D. ET AL.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 13/1-2012
26
The signals were averaged over 25 ms, with muscle
activity of the four tested muscles espressed in
microvolts (V).
Right and left muscle activity was monitored at rest
and in maximum voluntary clench (MCV).
The clench test was repeated three times to ascertain
stability according to the protocol developed by
Donaldson and Donaldson [1990].
The percentage of muscle balancing, called percentage
of torque (PT), was also calculated.
Statistical analysis
An intragroup comparison was made between the
mean activation of left and right sides of temporals
and masseters in the control group and cross and non
cross side of the same muscles in the UPCB group.
An intergroup comparison was performed by testing
the mean activation of temporals and masseters of
the UPCB group versus the control group at rest and
during clenching (Tables 1 and 2).
Data were evaluated on graph pad program
TAB. 1 The sEMG evaluation of temporalis and masseters at rest and maximum volontary clench (MCV).
TA: Temporal Anterior; MM: Masseter; UPCB: Unilateral Posterior CrossBite Group; HC: Healthy Control Group;
SD: Standard Deviation; SE: Standard Error of the mean. ns: not signicant - p < 0.05*
FIG. 1 Mean activation of
masticatory muscles and
percentage of torque (PT) in
Unilateral Posterior CrossBite
(UPCB) patients and healthy
controls (HC).
GROUPS SIDE MEAN(V) SD SE LOW. 95% UP. 95% P
TA UPCB REST
CROSS 2.9241 1.531 0.4419 1.951 3.897
*
NO CROSS 1.938 0.9447 0.2727 1.338 2.539
TA HC REST
R 2.5555 1.509 0.5031 1.395 3.716
ns
L 2.3333 1.414 0.4714 1.246 3.420
MM UPCB REST
CROSS 1.3875 0.5135 0.2684 1.061 1.714
ns
NO CROSS 1.858 0.9298 0.2684 1.268 2.449
MM HC REST
R 3.2222 2.224 0.7412 1.513 4.931
ns
L 3.00 2.345 0.7817 1.197 4.803
TA UPCB MCV
CROSS 104.5 42.29 12.211 77.624 131.38
ns
NO CROSS 93.25 42.093 12.151 66.505 119.99
TA HC MCV
R 173.34 38.897 12.966 143.45 203.24
ns
L 174.51 43.770 14.590 140.80 208.15
MM UPCB MCV
CROSS 128.58 83.805 24.193 75.336 181.83
ns
NO CROSS 107.00 60.670 17.514 68.452 145.55
MM HC MCV
R 234.7777 41.243 13.748 203.08 266.48
ns
L 240.1111 50.315 16.772 201.44 278.79
POSTERIOR CROSSBITE EVALUATION WITH SURFACE ELECTROMYOGRAPHY
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 13/1-2012
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performing one-way ANOVA test. Statistical
signicance was set at 0.05.
Results
Results of the intragroup comparison (i.e., activation of
temporals and masseters on both sides) in the UPCB
and control group are shown in Table 1.
The UPCB group showed statistically signicant
differences in anterior temporal rest test (p<0.05),
whereas no statistically signicant differences were
observed in the control group.
A different muscle activation between cross and non
crossbite side was seen in the UPCB group. Temporals
and masseters showed higher mean activation on the
crossbite side. These ndings were not statistically
signicant. No differences were seen in the control
group. In the UPCB group, asymmetric activation in
clench test generated 89.23% torque for temporals
and 83.21% torque for masseters. The control group
showed 99.32% torque for temporals and 97.77%
torque for masseters (Fig. 1). Surface electromyography
evaluation showed that the mean electric activity for
masseter and temporal muscles at clench was lower in
the UPCB group than in the control group (p<0.0001).
Mean muscle activity at rest showed how the UPCB
group presented lower activation of masseters than the
control group (p<0.05). The temporal means for the
UPCB and control at rest were not different (Table 2).
Discussion
The pathogenesis of UPCB is a matter of great
interest for orthodontists and oral rehabilitators. It
is well known that for an optimal muscle function,
ideal occlusal contacts are necessary. Altered occlusal
relationships have already been found to inuence the
coordination of the masticatory muscles during chewing
in adolescents and young adult women [Deguchi et al.,
1994; Deguchi et al., 1995].
Many authors have reported how patients with UPCB
have an unbalanced masticatory muscle activation.
Thus, it may inuence mandibular position during
clenching and at rest. Cooper and Rabuzzi suggested
that unbalanced masticatory muscle EMG activity was
not physiologic [Cooper and Rabuzzi, 1984].
Ferrario et al. showed that in healthy patients there was
no difference between right and left side activation,
whereas in unilateral posterior crossbites patients,
the muscles appeared to contract with altered and
asymmetric patterns [Ferrario et al., 1999].
UPCB is usually present at a young age suggesting
that primary teeth occlusion starts the timing of oral
development control (TMJ/muscle/occlusion). Normally
young patients use both sides to chew on. Using just
half of the oral system may trigger growth imbalance.
With uneven chewing the masticatory muscles receive
asymmetrical activation. Masticatory muscles on
the working side become larger and stronger than
those on the balanced side. All these alterations may
cause change in primary and secondary occlusion,
generating UPCB [Ciavarella et al., 2009]. Neurologic
impulses are generated by the periodontal ligament
(PDL), considered a periphereal oral receptor and may
modulate muscle contraction. PDL is directly connected
to the mesencephalic trigeminal nucleus [Lund, 1999;
Yokomizo, 2005] and to the trigeminal motor neurons
and interneurons [Yokomizo, 2005]. In this way all
impulses starting from PDL may inuence muscle
contraction generating asymmetric activation and
modication of the masticatory cycle.
Piancino et al. showed how patients affected by
UPCB often have reverse chewing cycles [Piancino et
al., 2011]. Reverse chewing cycles are substantially
TAB. 2 Mean activation of masticatory muscles (V) at rest and maximum volontary clench (MCV).
SE: Standard Error of the mean - CI: Condence Interval p < 0.05* - p<0.0001**
GROUPS SIDE MEAN(V) SE MEDIAN MIN MAX 95% CI P
Rest
TA activation
UPCB (Cross/Non Cross) 2.431 0.27 2.1 0.8 6.3 1.86-2.99
ns
HC (R/L) 2.444 0.33 2.0 1.0 5.0 1.73-3.15
MM activation
UPCB (Cross/Non Cross) 1.622 0.15 1.5 0.5 3.6 1.29-1.94
*
HC (R/L) 3.111 0.52 2.0 1.0 7.0 2.007-4.215
MCV
TA activation
UPCB (Cross/Non Cross) 98.875 8.5 96 31 169 81.27-116.47
**
HC (R/L) 173.925 9.46 166.05 135.8 286.00 153.95-193.91
MM activation
UPCB (Cross/Non Cross) 117.79 14.77 102.00 13.00 242.00 87.21-148.37
**
HC (R/L) 237.44 10.53 236.50 178 322 215.21-259.68
CIAVARELLA D. ET AL.
EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 13/1-2012
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different from normal ones; reverse cycles are narrow,
the closing trajectory is near the vertical line or it may
be displaced on the opposite side of the bolus, and the
opening and closing trajectories may cross each other
[Throckmorton et al., 2001].
The outcomes of this paper showed that the unilateral
posterior crossbites patients compared to the healthy
controls had asymmetric activation of muscles with a
lower percentage of torque at rest and a lower muscle
activation at clench.
These data were consistent with those found by other
authors [Ingervall and Thilander 1975; Egermark-
Eriksson et al., 1990] supporting the functional
association between muscle activation and occlusal
contact modications. Many investigations compared
the bite force in children with UPCB and control groups
showing that the maximum bite forces and number
of teeth in contact were signicantly lower in children
with UPCB when [Sonnesen et al., 2001; Rentes et al.,
2002; Castelo et al., 2007; Sonnesen and Bakke 2007].
In patients with UPCB a greater but not signicant (p <
0.05) TA and MM activation on the crossbite side was
found but this nding was not in agreement with the
literature. Many authors showed that, during maximum
clenching, on the crossbite side, the masseter was
less active whereas the anterior temporal showed a
signicantly higher EMG value than the same muscles
on the non-cross bite side [Kecik et al., 2007; Andrade
Ada et al., 2009].
Conclusion
This study showed that patients with UPCB presented
muscle weakness and an asymmetric activation at rest
and clench with higher sEMG activity on the crossbite
side.
The ndings suggested that asymmetric muscle
activation may inuence mandibular growth and tooth
position in adolescents. However, more investigations
to draw conclusions are needed.
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