Neuroscience Letters 392 (2006) 140–144

Postural stability and unilateral posterior crossbite:

Is there a relationship?
Ambrosina Michelotti a,∗ , Gerarda Buonocore a , Mauro Farella a , Gioacchino Pellegrino a ,
Carlo Piergentili b , Stefano Altobelli a , Roberto Martina a
a School of Dentistry, Department of Dental, Oral and Maxillo-Facial Sciences, Section of Orthodontics and Gnathology, University of Naples
“Federico II”, Via Pansini, 5, I-80131 Naples, Italy
b Department of Locomotor Apparatus Diseases and Emergency Surgery, University of Naples “Federico II”, Italy

Received 6 July 2005; received in revised form 2 September 2005; accepted 3 September 2005

Abstract
The aim of this study was to test the hypothesis that unilateral posterior crossbite influences postural stability of the whole body. Twenty-six
subjects (14 males and 12 females) affected with unilateral posterior crossbite were selected and compared with 52 controls matched for age and
gender. Postural stability was assessed using a stabilometric platform. The following stabilometric measurements were assessed: weight distribution
on foot area and speed of body sway. Tests were performed under two occlusal conditions: teeth in intercuspal position (ICP) and while keeping
two cotton rolls between teeth without clenching. The weight distribution on foot area and the speed of body sway were not significantly influenced
from crossbite (with and without lateral mandibular slide), occlusal conditions (ICP, cotton rolls), and gender. Therefore, the treatment of this
malocclusion in order to prevent or to treat postural disorders is not justified.
© 2005 Elsevier Ireland Ltd. All rights reserved.

Keywords: Posture; Malocclusion; Posterior crossbite; Stabilometry

The human posture is the result of positioning and orientation of
the body and limbs in equilibrium with motion and gravitation.
Postural adjustments, consisting in slight sways, include visual,
vestibular and somatosensory inputs integrated in a complex
regulatory system [10].
It has been previously demonstrated that respiration, head
and neck position, mood states, especially anxiety, can modify
posture [1,18,19,29].
Recent studies emphasize the potential role of dental occlu-
sion [7,11–14,20,22] and of trigeminal afferents in the mainte-
nance of postural control. Afferents from periodontal apparatus,
jaw muscles and TMJ converge to trigeminal nuclei. Trigeminal
nuclei have connections with vestibular nuclei [4]. Trigemi-
nal afferents have been shown to influence posture because the
anesthesia of its mandibular branch modifies postural control in
human subjects [8].
Furthermore, several studies seem to indicate that differ-
ent mandibular positions induce variations in body posture
∗ Corresponding author. Tel.: +39 081 746 2195; fax: +39 081 746 4980.
E-mail address: michelot@unina.it (A. Michelotti).
[2,23,24]. There are also studies suggesting that dental occlusion
may influence head posture [26], spine curvatures (e.g., scolio-
sis and lordosis) [5,13], and even leg length [27,28]. Clinical
anecdotal reports suggest that transversal malocclusions (e.g.,
unilateral posterior crossbite) may have the strongest impact on
body posture. However, the current scientific evidence to sup-
port this statement is very poor. An extensive literature review
published some years ago, concluded that there is no scientific
evidence to justify an occlusal correction for the treatment of
postural diseases and vice versa [21]. Although the current scien-
tific evidence for these causal relationships is weak or lacking at
all, the dental holistic approach is often followed not only by chi-
ropractors but also by several dentists and general practitioners.
According to the hypothesis that dental occlusion may influence
the whole body posture, disturbances of the functioning, such
as chewing and swallowing of the masticatory muscles can be
transmitted to distal musculature along the so-called “muscle
chains” [27,28].
In many countries, these beliefs have also been widely spread
by local magazines, television programs, and by many websites,
yielding a large number of patients seeking concomitant treat-
ment for occlusal and postural disorders.

0304-3940/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.neulet.2005.09.008
 A. Michelotti et al. / Neuroscience Letters 392 (2006) 140–144
In spite of these beliefs, little is known about the influence of
occlusal factors on body posture. For this reason, we designed a
study aiming to test the hypothesis that the unilateral posterior
crossbite could influence postural stability.
Subjects were recruited among three secondary schools of
Naples by means of a two-stage cluster sampling. All students
(n = 1680) received an informed consent to be signed by the par-
ents. Informed consent was collected from 1291 (76.8%) out of
1680 students. The sample included 1291 subjects, 708 (54.8%)
males and 583 (45.2%) females, whose ages ranged from 10.5
to 17.2 years (mean age ± S.D.: 13.2 ± 1.2 years). Exclusion
criteria were assessed by means of a questionnaire filled out
by the examiners. The following conditions were considered as
exclusion criteria: previous or current orthodontic treatments,
previous or current orthopedic treatments, facial trauma, acute
or chronic orofacial inflammatory diseases, acute or chronic ver-
tebral inflammatory diseases, spinal or lower limbs fractures,
and neurological diseases.
According to these criteria, 386 subjects, 205 (53.1%) males
and 181 (46.9%) females, were excluded from the study. Dis-
tribution of subjects according to the exclusion criteria are
summarized in the Table 1. The remaining subjects included
503 (55.6%) males (mean age ± S.D.:13.3 ± 1.2 years) and 402
(44.4%) females (mean age ± S.D.: 13.1 ± 1.2 years).
All the subjects underwent an orthodontic examination. Pos-
terior crossbite was considered when the subject had at least
one tooth of the posterior group in an irregular bucco-lingual
or bucco-palatal relationship with one or more opponent teeth.
Mandibular lateral slide has been assessed using jaw guidance
into the retruded contact position (RCP) obtained by support-
ing the chin point with the thumb and the lower border of
the jaw bilaterally with the index finger and middle finger.
When a lateral or sagittal slide occurred, its assessment was
based on visual estimate. Unilateral posterior crossbite was
found in 128 (14.1%) out of 905 subjects. Out of 128 uni-
lateral posterior crossbite subjects, 46 (36%) had mandibular
lateral slide. Thirteen out of 46 subjects gave their consent
to have a stabilometric examination to be held in the clinic.
Thereafter, 13 subjects, matched for age and gender, with uni-
lateral posterior crossbite and without mandibular slide, were
selected. Eventually, 26 unilateral posterior crossbite subjects,
with and without mandibular lateral slide (14 males and 12
females) (mean age ± S.D.: 13.73 ± 1.2 years) were selected as
cases.
Table 1
Distribution of exclusion criteria
Exclusion criteria N Percentage Gender
Female Male
Orthodontic treatments 270 69.9 133 137
Orthopedic treatments 48 12.4 23 25
Facial trauma 26 6.7 9 17
Orofacial disease 6 1.5 3 3
Vertebral disease 0 0 0 0
Fracture 34 8.8 13 21
Neurological 2 0.5 0 2
141
For each unilateral posterior crossbite subject, two subjects,
matched for age and gender, were selected randomly from the
sample. Criteria for inclusion in the control group were: molar
and canine Angle Class I, overjet and overbite within normal lim-
its, absence of unilateral and/or bilateral crossbite, and absence
of mandibular slide both in the sagittal and in the frontal planes
>2 mm. A threshold of 2 mm has been chosen based upon pre-
vious reports suggesting that such slides are risk factors for
temporomandibular disorders [25].
Postural stability was assessed by means of a stabilomet-
ric platform (Lizard, Lemax s.r.l., Como, Italy). This device
allows measurements of either the weight distribution on the
feet-supporting points and the related variations during time of
observation (posturometric measurements) or the center of body
pressure sway (stabilometric measurements). The platform con-
sists of two supporting plates, one for the left and one for the right
foot, on which reference points for feet positioning are drawn.
Each plate rests on three highly sensitive load cells placed at the
level of the three feet-supporting points: first metatarsus, fifth
metatarsus, and heel. The load cells detect the weight and send
data to a personal computer that displays real time dynamic pic-
tures (weight distribution and variations on feet points, and body
sway) as well as numerical data [3]. In this study, the following
stabilometric measurements were assessed: the weight distribu-
tion on the foot area, the speed of body sway, and the area of
body sway.
Data was acquired in intercuspal position (ICP) and while
keeping two cotton rolls between teeth (diameter 1 cm, length
3.7 cm) without clenching.
The stabilometric examinations were performed in the clinic.
The examiners taking stabilometric measurements were blind
about the case/control status of the subjects. The subject was
asked to take several steps before getting on the platform. Then
an examiner accurately placed the subject on the platform.
The subjects were asked to keep the correct position during
the whole examination looking at a point in front of them 2 m
away. During the test they were not allowed to look at the com-
puter monitor; hence, they did not receive any feedback about
their postural position.
At the first recording, the subject was asked to relax and
swallow twice and then to keep the teeth in the intercuspal posi-
tion without clenching. The recording lasted 51.2 s. After a rest
period of 30 s, two cotton rolls were placed between posterior
teeth and the subject, still standing on the platform, was asked
to swallow twice. Cotton rolls were placed between antagonist
teeth because they are expected to remove occlusal interferences
and mandibular slides along the physiological pattern of the jaw
closing movement [6]. Data was recorded again for 51.2 s. Even-
tually, the cotton rolls were removed and the subject stepped
down from the platform. The measurements recorded in ICP
and keeping two cotton rolls between teeth were always taken
consecutively in the same order.
In order to assess the method error, a pilot study was per-
formed on a sample of 26 subjects randomly selected in the
clinic. An examiner placed the subject on the platform and per-
formed all the measurements (ICP, cotton rolls) following the
same protocol of the sample study. Then, the subject was asked
142 A. Michelotti et al. / Neuroscience Letters 392 (2006) 140–144

to step down from the platform and to make several steps. After
2 min, the subject was replaced on the platform and the record-
ing in ICP and keeping two cotton rolls between teeth were
performed again. The method error (ME) for all these √measure-
ments was assessed by means of the formula ME = (
d2 /2n)
where d is the difference between the two measurements and
n is the number of recordings. Systematic differences between
replicate measurements were tested with paired Student’s t-test
setting the alpha error at 0.1.
Data was analyzed using conventional statistical methods.
Normality of data was tested using the Kolmogorov–Smirnov Fig. 1. Mean values (+S.D.) of speed of body sway in subjects with and without
test. If necessary, data were log-converted. mandibular slide. Data were log-converted.
Data were evaluated using the analysis of variance for
repeated measures (ANOVA). The depending variables were
the index of asymmetry of weight distribution and the speed
of body sway. The index of asymmetry of weight distri-
bution was assessed by means of the formula: AI = abs
[(a − b)/(a + b) × 100] where a is the total weight on left foot
and b is the total weight on the right foot. The factor within-
subject was occlusal condition (two levels: ICP and cotton rolls).
The factors between-subjects were gender (two levels; male and
female), crossbite (two levels: present and absent), and slide
(two levels: present and absent).
Mauchly’s test of sphericity for repeated measures was com-
puted. In case of violation in assumption of sphericity, degrees Fig. 2. Mean values (+S.D.) of index of asymmetry in subjects with and without
of freedom were corrected with Greenhouse–Geisser epsilon. mandibular slide.
If necessary multiple post hoc comparisons were executed
by Student–Newman–Keuls test. Significance level was set at (F = 0.1; p = 0.976), occlusal status (F = 1.2; p = 0.283), and gen-
p < 0.05. der (F = 0.2; p = 0.965).
The statistical analysis was made using the software Table 3 shows mean values of the speed of body sway reported
SPSS12.0 for Windows. during occlusal conditions, occlusal status (case and control),
The mean method error was 5.5% for the index of asym- and gender. No statistically significant differences were found
metry of weight distribution, 7.8% for the speed of body sway in the values of the speed of body sway between occlusal con-
and 29.2% for the area of body sway. There was no systematic ditions (F = 0.4; p = 0.544), occlusal status (F = 0.3; p = 0.600),
error for duplicate stabilometric measurements (Student’s t-test; and gender (F = 0.2; p = 0.632).
p > 0.1). Since the method error for the area of body sway was
Table 2
high, only the weight distribution on the foot area and the speed
Mean values (S.D.) for the index of asymmetry of weight distribution (%)
of body sway were considered in this study.
Post hoc power analysis was carried out setting the alpha Occlusal condition Occlusal status Gender Mean S.D. N
error at 0.05, and considering a 5% change in the index of Intercuspal position Case Female 6.9 5.3 12
asymmetry of weight distribution as the main variable being Male 6.5 7.4 14
clinically relevant. The power of our statistical tests was Total 6.7 6.4 26
87%. Controls Female 7.8 5.4 24
No statistically significant differences were found in occlusal Male 8.9 7.2 28
conditions (ICP, cotton rolls) (F = 0.4; p = 0.550), in weight dis- Total 8.4 6.4 52
tribution (F = 0.8; p = 0.910), and in speed of body sway (F = 1.2; Total Female 7.5 5.3 36
p = 0.269) between subjects with and without mandibular lateral Male 8.1 7.3 42
Total 7.8 6.4 78
slide (Figs. 1 and 2). Therefore, mandibular lateral slide does
not influence the stabilometric measurements considered in this Cotton rolls Case Female 7.6 4.7 12
study. For this reason, data from subjects affected with cross- Male 6.1 5.5 14
Total 6.8 5.1 26
bite without lateral mandibular slide and crossbite with lateral
mandibular slide were pooled. Controls Female 7.7 5.8 24
Male 8.7 6.6 28
Table 2 shows mean values of the index of asymmetry of
Total 8.3 6.2 52
weight distribution reported during occlusal conditions, occlusal
status (case and control), and gender. No statistically signif- Total Female 7.7 5.4 36
Male 7.9 6.3 42
icant differences were found in the values of the index of Total 7.8 5.9 78
asymmetry of weight distribution between occlusal conditions
 A. Michelotti et al. / Neuroscience Letters 392 (2006) 140–144 143

Table 3 class II malocclusion. Neither different occlusion conditions

Mean values (S.D.) for the speed of body sway modify center of foot pressure. Also in the present study, an
Occlusal condition Occlusal Gender Mean S.D. N asymmetric malocclusion (i.e., unilateral posterior crossbite) has
status (mm/s) been evaluated. Our findings are consistent with the findings of
Intercuspal position Case Female 53.4 67.3 12 Ferrario et al. showing that different occlusal conditions did not
Male 42.7 53.0 14 influence postural stability.
Total 47.6 59.1 26 In other studies Bracco et al. [2] found that in subjects free
Controls Female 23.5 22.0 24 from malocclusions, different jaw relations influence body pos-
Male 38.6 50.3 28 ture. In particular, the so-called myocentric jaw position [15–17]
Total 31.6 40.2 52 caused a reduction in the body sway and an improvement of
Total Female 33.4 44.1 36 weight distribution on the foot area. Our findings, however, can-
Male 40.0 50.7 42 not be compared with those of Bracco et al. [2], firstly because
Total 37.0 47.6 78 they did not investigate patients with malocclusions, and sec-
Cotton rolls Case Female 50.0 63.2 12 ondly because we have not assessed the myocentric occlusion.
Male 42.7 55.2 14 In our opinion, the potential relationship between occlusion
Total 46.0 58.0 26
and posture has low biological plausibility since in healthy sub-
Controls Female 18.9 60.0 24 jects (i.e., free of parafunctional activities) the teeth get in contact
Male 45.6 62.7 28 for a very limited amount of time (i.e., chewing and swallowing
Total 33.3 47.7 52
activities), which usually does not exceed 20–30 min per day.
Total Female 29.3 38.7 36 Conclusions of the present study may be summarized as
Male 44.7 60.0 42
follows: the unilateral posterior crossbite does not influence pos-
Total 37.6 51.3 78
tural stability. The treatment of this malocclusion to prevent or
to treat postural disorders is not justified.

The computerized stabilometry is a simple and not invasive Acknowledgements

method used in several medical fields to investigate body pos-
ture. In the last decades, many dentists are using this equipment
in their practice because malocclusions, particularly posterior
crossbite malocclusions, have been supposed to influence body
posture. To our knowledge, this is the first study investigating
the relationship between postural stability and unilateral poste-
rior crossbite and the results do not support the hypothesis that
posterior crossbite (with and without lateral slide) has any effect
on weight distribution on the foot area, and on the speed of body
sway.
Our findings are not consistent with the so-called muscle
chains theory, according to which abnormal occlusal contacts
can cause “imbalances” in the locomotor apparatus [3] resulting
in postural asymmetries [9]. Indeed, the application of cot-
ton rolls in patients affected with unilateral posterior crossbite,
which are supposed to minimize the impact of incongruous
occlusal contacts [6] and to remove mandibular slides, did not
have any effect on the stabilometric measurements assessed in
the present study.
Other studies have been carried out in order to study the
potential relationship between stomatognathic and postural
apparatus by means of the stabilometric platform.
Ferrario et al. [6] investigated the relationship between occlu-
sion and center of foot pressure variation. Ten women with an
asymmetric (unilateral) Angle class II malocclusion, 10 women
with temporomandibular disorders, and 10 healthy women (con-
trol group) were examined. Stabilometric examinations were
performed in rest position, centric occlusion, maximum clench-
ing, with two cotton rolls placed between posterior teeth and
maximum clenching on two cotton rolls. The results suggested
that the modification of center of foot pressure was not influ-
enced by temporomandibular disorders or by asymmetric Angle
Supported by a grant from Italian Ministry for University and
Scientific Research. We are grateful to Jean Paul Goulet for his
helpful suggestions.
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