CRANIO®

The Journal of Craniomandibular & Sleep Practice

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Influence of dental occlusion on postural control

and plantar pressure distribution

Benjamin Scharnweber , Frederic Adjami , Gabriele Schuster , Stefan Kopp ,

Jörg Natrup , Christina Erbe & Daniela Ohlendorf

To cite this article: Benjamin Scharnweber , Frederic Adjami , Gabriele Schuster ,

Stefan Kopp , Jörg Natrup , Christina Erbe & Daniela Ohlendorf (2016): Influence of
dental occlusion on postural control and plantar pressure distribution, CRANIO®, DOI:
10.1080/08869634.2016.1244971

To link to this article: http://dx.doi.org/10.1080/08869634.2016.1244971

Published online: 20 Oct 2016.

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CRANIO®: The Journal of Craniomandibular & Sleep Practice, 2016
http://dx.doi.org/10.1080/08869634.2016.1244971

TMJ

Influence of dental occlusion on postural control and plantar pressure

distribution
Benjamin Scharnweber DDSa, Frederic Adjami DDS, PhDb, Gabriele Schuster DDS, PhDb, Stefan Kopp
DDS, PhDb, Jörg Natrup PhDc, Christina Erbe DDS, PhDd and Daniela Ohlendorf PhDe
a
Department of Prosthodontics, School of Dentistry, “Carolinum”, Goethe-University Frankfurt/Main, Frankfurt/Main, Germany; bDepartment
of Orthodontics, School of Dentistry, Goethe-University, Frankfurt/Main, Germany; cGesellschaft für Biomechanik Münster, Münster, Germany;
d
Department of Orthodontics, School of Dentistry, University Medical Centre of the Johannes Gutenberg University Mainz, Mainz, Germany;
e
Institute of Occupational Medicine, Social Medicine and Environmental Medicine, Goethe-University Frankfurt/Main, Frankfurt/Main, Germany

ABSTRACT KEYWORDS
Objective: The number of studies investigating correlations between the temporomandibular Dental occlusion; postural
system and body posture, postural control or plantar pressure distribution is continuously increasing. control; plantar pressure
If a connection can be found, it is often of minor influence or for only a single parameter. However, distribution; force platform
small subject groups are critical. This study was conducted to define correlations between dental
parameters, postural control and plantar pressure distribution in healthy males.
Methods: In this study, 87 male subjects with an average age of 25.23 ± 3.5 years (ranging from 18
to 35 years) were examined. Dental casts of the subjects were analyzed. Postural control and plantar
pressure distribution were recorded by a force platform. Possible orthodontic and orthopedic factors
of influence were determined by either an anamnesis or a questionnaire. All tests performed were
randomized and repeated three times each for intercuspal position (ICP) and blocked occlusion (BO).
For a statistical analysis of the results, non-parametric tests (Wilcoxon-Matched-Pairs-Test, Kruskall-
Wallis-Test) were used. A revision of the results via Bonferroni-Holm correction was considered.
Results: ICP increases body sway in the frontal (p ≤ 0.01) and sagittal planes (p ≤ 0.03) compared to
BO, whereas all other 29 correlations were independent of the occlusion position. For both of the
ICP or BO cases, Angle-class, midline-displacement, crossbite, or orthodontic therapy were found
to have no influence on postural control or plantar pressure distribution (p > 0.05). However, the
contact time of the left foot decreased (p ≤ 0.001) while detecting the plantar pressure distribution
in each position.
Conclusions: Persistent dental parameters have no effect on postural sway. In addition, postural
control and plantar pressure distribution have been found to be independent postural criteria.

Introduction jaw positions.[8–16] For example, Nobili et al. [17] found

The assumption that the craniomandibular system (tempo-
romandibular system) and the whole body posture correlate
anatomically and functionally with each other has developed
recently as a subject of discussion in the area of orthodontics
diagnostics.[1–6] Presently, the masticatory system as well as
the postural and movement systems are still partly consid-
ered as autonomous functional unities.[7]
A correlation between the masticatory system and
indicators of postural control or plantar pressure distri-
bution is intensively discussed in the literature. In numer-
ous publications, a relationship has been proven to exist
between the temporomandibular system and postural
control by analyzing different dental malocclusions and
that subjects with a Class II malocclusion indicate an
anterior displaced posture, whereas subjects with a Class
III malocclusion indicate a posterior displaced posture.
Bracco et al. [18] investigated an improved lateral sway in
myocentric position by comparing various jaw relations
(centric occlusion, rest position, and myocentric posi-
tion). Michelotti et al. [19] showed that weight distribu-
tion on the foot area and the speed of body sway were not
significantly influenced by the posterior crossbite (with
and without lateral mandibular slide), occlusal conditions
(intercuspal position (ICP), blocked occlusion with cotton
rolls (BO)), or gender. Tardieu et al. [20] noted a decay
of postural control between rest position and thwarted

CONTACT  Daniela Ohlendorf  ohlendorf@med.uni-frankfurt.de

© 2016 Informa UK Limited, trading as Taylor & Francis Group
2    B. Scharnweber et al.
lateral occlusion conditions (enforced dento-dental con-
tact without the possibility for lateral excursion) with
regard to static and dynamic postural control. Hellmann
et al. [21] examined a stable sway reduction and anterior
displacement of the center of pressure (COP) in healthy
subjects who either kept the mandible at rest or performed
unilateral and bilateral maximum voluntary teeth clench-
ing, feedback-controlled biting tasks at sub-maximum bite
forces, or unilateral chewing. Baldini et al. [22] revealed a
weak correlation between mandibular position and pos-
tural sway in healthy subjects.
In contrast, Ferarrio et al. [12] tried to correlate man-
dibular positions to the sway area in women with tempo-
romandibular disorders (TMD) or unilateral Angle-Class
II malocclusion. In different dental positions (e.g. ICP, BO,
rest position), they measured changes in the COP and
concluded that TMD does not affect COP. No detectable
correlation was found by Perinetti et al. [23] between den-
tal occlusion and body posture.
In a systematic review, Michelotti et al. [24] summa-
rized that scientific evidence is missing to support a cause-
and-effect relation between dental malocclusion, head
posture, spine curvature and body sway. Perinetti et al.
[25] found significant correlations which are not clinically
relevant in 4 out of 12 studies.
While the majority of studies in the last two decades
tried to prove the influence of occlusion on static param-
eters of postural control, only a few took dynamic param-
eters, such as plantar pressure distribution, into account
[26–30]. Tecco et al. [31] tried to determine if stomato-
gnathic functions correlate with alterations in walking.
The analysis of walking was performed in rest position,
habitual occlusion, and BO. Only in BO was a significantly
higher pressure load detected in the TMD patients than in
the control subjects. Additionally, TMD subjects showed a
significantly smaller loading surface than control subjects
on equal terms under both feet. Tecco et al. [32] proved
that an artificially induced imbalance of occlusion (BO)
causes an alteration of plantar pressure distribution during
walking in female subjects. Souza et al. [33] showed a sig-
nificantly higher rearfoot and lower forefoot distribution
in TMD subjects than those in the asymptomatic group.
All of the above-mentioned studies have different
occlusal conditions in common, like rest position, ICP,
or BO (uni- or bilateral). Some even take sagittal deviation
(Angle-classes) and/or transversal malocclusion (cross-
bite) into account. Afterwards, the focus of each study
lies either in static or dynamic measurements. Only Souza
et al. [33] measured both, but did not screen patients for
malocclusions. Furthermore, the subjects in each of the
above-mentioned studies included both sexes, and three
studies were conducted only on females. All mentioned
studies above exclude children and older subjects to rule
out growing or aging influences. The average age lies
between 21 and 28.5 years, and the number of subjects
has a range of 10–95.
Due to the great diversity of studies in design, gender,
subject numbers, and occlusal parameters (permanent
or temporarily induced) as well as used measuring tech-
niques and systems, the aim of this study is to investigate
several key parameters of the dental occlusion gathered
through an analysis of the dental casts and displaying their
influence on static (postural control) and dynamic param-
eters (plantar pressure distribution). Additionally, a large
homogenous group of subjects was required. Therefore,
this study only screened male subjects to eliminate known
differences between children and older subjects as well
as differences between genders.[34–36] For example,
Abubaker et al. [34], Bush et al. [35], and Conti et al. [36]
found discrepancies among male and female subjects in
the threshold of pain, hormone balance and composition
of the connective tissue. Consequently, this study aims
to conduct correlations between dental parameters and
postural control as well as plantar pressure distribution
in a large homogenous group.
The following hypotheses were tested:
Hypothesis 1: Differences in parameters of postural
control and plantar pressure distribution can be seen
between ICP and BO. Furthermore, differences in
parameters of plantar pressure distribution appear
between ICP and BO.
Hypothesis 2: The sagittal sway and the plantar pressure
on fore- or rearfoot increase in Angle-Class II or Angle-
Class III subjects as an effect of compensation or adapta-
tion in body posture.
Hypothesis 3: The transversal sway and plantar pressure
on left or right foot in subjects with crossbite are aug-
mented due to a transversal malocclusion.
Hypothesis 4: BO causes the COP to be closer to the per-
pendicular of body center and achieves a harmonized
planter pressure distribution.
Methods
Subjects
In this study, 87 male subjects between 18 and 35 years
of age (average 25.23  ±  3.49  years) were examined. All
participants were subjectively healthy and reported no
musculoskeletal diseases. Their medical history was
screened for possible influences (e.g. pain or noises in
the temporomandibular joint (TMJ), tinnitus, orthodon-
tic treatment, neurological illness) using a questionnaire.
Another standardized questionnaire [37] was used to eval-
uate present TMD. Forty-one of the 87 subjects revealed
possible influencing variables. No orthodontic treatment
or a completed orthodontic treatment (regardless of the

orthodontic outcome) qualified subjects to participate in
this study.
Subjects with reported injuries, accidents involving the
head or spine, and ongoing orthodontic treatment were
excluded from this survey.
This study was approved by the ethics committee of
the Goethe University (307/12) in Frankfurt am Main,
Germany.
Measurement system
Postural control and plantar pressure distribution were
detected using a force platform (GP MultiSens, GeBioM,
Münster, Germany) with an array of 2304 pressure sensors
on a 38.5 cm² surface. The sensor was 8 mm² with a high
sensor resolution due to two sensors per square millim-
eter. The sensors were arranged in a 48-row and 48-line
matrix with a sampling frequency of 200 Hz. After being
amplified by a high ohm-resistance multiplier, the signals
were analyzed with the software ‘GP Manager.’ The results
were displayed as a color-coded mesh.
Examination protocol
Dental casts
After taking alginate impressions (Image, Dux-Dental,
Utrecht, Netherlands) of the upper and lower jaw of each
subject, dental casts were produced. For orthodontic use,
the plaster models were trimmed three-dimensionally.
The bite was registered with wax (gebdi Dental-Products,
Engen, Germany). The dental casts were analyzed using
the Frankfurt analysis.[38] The evaluation parameters
were:
• First molar relation
• Cuspid relation
• Overjet and overbite
• Crossbite
• Midline shift/deviation
All subjects were assigned to groups, considering the
anamnesis as well as the analysis of the dental casts (Angle
classification,[39] midline shift, crossbite, orthodontic
treatment, and conspicuous anamnesis). A detailed con-
stellation is presented in Table 1.
The subject distribution is equivalent to several other
studies focusing on angle-class and crossbite prevalence.
Table 1. Distribution of subjects regarding malocclusion and possible influencing factors.
Angle class Midline shift
Class I 46 (52.9%) None 48 (55.2%)
Class II 26 (29.9%) Left 19 (21.8%)
Class III 15 (17.2%) Right 20 (23%)
       
CRANIO®: The Journal of Craniomandibular & Sleep Practice   3
[40–51] These studies show similar subject distribution
according to malocclusions regardless of their study
design or aim. The average prevalence for Class I was
60.5%, for Class II 26.4%, and for Class III 9.5%. The
average prevalence for absence of crossbite was found to
be 87.9%, for unilateral crossbite 11.5%, and for bilateral
crossbite 4.3%.[40–51]
Postural control and plantar pressure distribution
Postural control and plantar pressure distribution tests
were performed in the dental ICP and with two cotton
rolls placed in both molar regions to BO. The measure-
ments were conducted randomly. All measurements were
repeated three times.
Postural control
Participants were asked to stand barefoot in habitual pos-
ture, with arms hanging down loosely and the view fixed
at a point on the opposite wall at eye level. Subjects were
asked to keep a dental ICP during the ongoing measure-
ment. Each measurement lasted 30  s and was repeated
three times with short rest periods in between. The fol-
lowing parameters of postural sway were considered in
this study: (1) maximal excursion of frontal (forward-­
backward) and sagittal (medio-lateral) sway (mm), (2)
percentage distribution of body weight of each foot sec-
tion (forefoot left, forefoot right, rearfoot left, rearfoot
right), (3) total percentage body weight distribution of
forefoot and rearfoot, (4) percentage body weight distri-
bution between left and right foot.
Perinetti et al. [52] proved the repeatability and relia-
bility of the sway area and velocity in the rest and dental
ICPs.
Plantar pressure distribution
The plantar pressure distribution was detected while walk-
ing over the force platform. The platform was embedded
in a seven-meter-long walking pathway. After the testing
procedure was explained, all subjects were asked to do
some test runs to familiarize themselves with the process.
The evaluation parameters were:
• Maximum load of the heel (N/cm²)
• Maximum load of the pad (N/cm²)
Crossbite Orthodontic treatment Conspicuous anamnesis
None 71 (81.6%) No 36 (41.4%) No 46 (52.9%)
Left 8 (9.2%) Yes 51 (58.6%) Yes 41 (47.1%)
Right 5 (5.75%)        
Bilateral 3 (3.5%)        
4    B. Scharnweber et al.

• Maximum load of the toe area (separated in medial, parameter without a significant difference. The side-com-
central, and lateral area) parison with BO showed the same results (p ≤ 0.001 or
• Loaded area of plantar arch (mm²) 0.01). Only in subjects with Angle-class 3 (forefoot:
• Power rate (kN/s) p ≥ 0.06; rearfoot p ≥ 0.09) no significant comparisons
• Time of contact (sec) were detected. Similar to the comparison in ICP, there
• Ratio of deceleration and acceleration of COP (%) were no significant differences in patients with unilateral
and bilateral crossbite in BO except the forefoot-rear-
foot comparison for crossbite left where a significance of
Statistical analysis p ≤ 0.01 could be detected.
The data were tested for the statistical analysis with BIAS
(Epsilon-Verlag, Norderstedt, Germany). A normal dis- Plantar pressure distribution
tribution of the data were tested with the Kolmogoroff–
Table 5 contains the comparison between ICP and BO of
Smirnoff test. Since the data did not exhibit a normal
all parameters of the plantar pressure distribution. The
distribution, the different data-sets and subject groups
contact time of the left foot decreased by 3.4% (p ≤ 0.001).
were tested with non-parametric tests using the Wilcoxon
A magnification of the right plantar arch space by 16.3%
matched-pairs test and the Kruskal–Wallis tests to reveal
(p ≤ 0.02), an increase in power rate of the left foot by
significant correlation in or between groups. The results
14.7% (p ≤ 0.02) as well as a decreased contact time of
were reworked by the Bonferroni-Holm correction. The
the right foot of 1.1% (p  ≤  0.03) dropped out after the
level of significance was set to 5%.
Bonferroni-Holm correction (Figure 2).
Regarding the plantar pressure distribution in Table
Results 6, no evidence could be found providing a correlation
between dental and plantar parameters while comparing
Postural control
ICP and BO (p ≥ 0.05).
Table 2 shows all significant changes in the postural con-
trol comparing ICP and BO position. A reduction in body
sway could be detected for the frontal (p ≤ 0.01) and sagit-
tal (p ≤ 0.03) excursion (Figure 1). Frontal excursion was
reduced by 11.5% and sagittal excursion by 7.6% (Table
2). All other parameters were above the significance level
of p ≥ 0.05.
The Kruskal–Wallis test showed no significance
(p ≥ 0.05) for angle-class, midline shift, or crossbite. This
can be seen for ICP as well as for BO in Table 3.
Table 4 compares postural parameters between left
and right foot across malocclusions in ICP and BO. The
side-comparison indicates if a harmonization took place.
In ICP, significant differences were encountered for angle-
classes, midline shift, orthodontic treatment, and conspic- Figure 1.  Comparison of the frontal and sagittal excursion in
uous anamnesis (p ≤ 0.05). Crossbite was the only dental intercuspal position (ICP) and blocked occlusion (BO).

Table 2. P-values, medians and quartiles (1. /3.) of intercuspal position (ICP) and blocked occlusion (BO) for postural control.

Median 1.Quartile 3.Quartile

ICP BO ICP BO ICP BO p-Value
Frontal excursion (mm) 11.67 10.33 9.00 8.00 14.33 13.67 0.01
Sagittal excursion (mm) 17.67 16.33 15.00 13.67 22.33 20.33 0.03
Forefoot right (%) 15.67 15.33 11.33 11.67 20.00 20.33 0.56
Forefoot left (%) 21.33 21.67 17.67 18.00 26.00 26.33 0.67
Rearfoot right (%) 28.00 27.67 21.67 22.67 33.00 32.67 0.60
Rearfoot left (%) 34.67 34.00 29.67 30.00 39.00 38.33 0.85
Forefoot (%) 36.67 38.00 30.00 30.67 45.67 45.00 0.41
Rearfoot (%) 63.00 62.00 54.33 55.00 70.00 69.67 0.56
Left (%) 56.33 56.67 53.33 52.67 59.33 60.67 0.55
Right (%) 63.00 43.33 54.33 39.33 70.00 47.33 0.45
Note: p-values in bold remain significant after Bonferroni-Holm correction.
 CRANIO®: The Journal of Craniomandibular & Sleep Practice   5

Table 3. Influence of malocclusion on postural control in intercuspal position (ICP) and blocked occlusion (BO) (Kruskal-Wallis-Test).
Angle class Midline shift Crossbite Angle class Midline shift Crossbite
p-Value p-Value p-Value p-Value p-Value p-Value
Parameter ICP BO
Frontal excursion (mm) 0.98 0.38 0.59 0.99 0.61 0.65
Sagittal excursion (mm) 0.95 0.82 0.76 0.47 0.54 0.11
Forefoot right (%) 0.97 0.57 0.96 0.29 0.72 0.70
Forefoot left (%) 0.44 0.99 0.36 0.84 0.98 0.53
Rearfoot right (%) 0.93 0.84 0.38 0.83 0.90 0.54
Rearfoot left (%) 0.52 0.88 0.25 0.70 0.61 0.26
Forefoot (%) 0.79 0.80 0.65 0.38 0.88 0.93
Rearfoot (%) 0.85 0.78 0.66 0.39 0.91 0.93
Left (%) 0.99 0.95 0.32 0.64 0.67 0.49
Right (%) 0.99 0.86 0.30 0.65 0.67 0.49

Table 4. P-values of the side comparison between left and right foot of weight distribution to reveal harmonization (Wilcoxon-Matched-
Pairs-Test).
Orthodontic Conspicuous
Angle class Midline shift Crossbite treatment anamnesis
Bilat-
1 2 3 None Left Right None Left Right eral No Yes No Yes
Intercuspal position
Forefoot right vs. left 0.001 0.001 0.02 0.001 0.001 0.001 0.001 0.15 0.62 0.50 0.001 0.001 0.001 0.001
Rearfoot right vs. Left 0.001 0.001 0.001 0.001 0.03 0.04 0.001 0.11 0.12 0.25 0.001 0.001 0.001 0.001
Left vs. right foot 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.11 0.06 0.50 0.001 0.001 0.001 0.001
Forefoot vs. rearfoot 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.04 0.06 0.25 0.001 0.001 0.001 0.001
Blocked occlusion
Forefoot right vs. left 0.001 0.001 0.06 0.001 0.01 0.001 0.001 0.08 0.81 0.75 0.001 0.001 0.001 0.001
Rearfoot right vs. left 0.001 0.001 0.09 0.001 0.01 0.001 0.001 0.25 0.12 0.50 0.001 0.001 0.001 0.001
Left vs. right foot 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.04 0.06 0.50 0.001 0.001 0.001 0.001
Forefoot vs. rearfoot 0.001 0.001 0.001 0.001 0.001 0.001 0.001 0.01 0.06 0.25 0.001 0.001 0.001 0.001
Note: p-values in bold remain significant after Bonferroni-Holm correction.

Table 5. P-values, medians and quartiles (1./3.) of intercuspal position (ICP) and blocked occlusion (BO) for plantar pressure distribution.
Median 1.Quartile 3.Quartile
ICP BO ICP BO ICP BO p-Value
Toe right (N/cm²) 22.73 23.97 15.13 14.90 30.6 32.63 0.66
Toe left (N/cm²) 21.73 22.17 15.10 13.93 29.6 31.20 0.96
Lateral right pad (N/cm²) 1936 18.80 14.13 14.27 26.43 25.73 0.62
Lateral left pad (N/cm²) 19.23 17.67 13.27 13.83 27.97 27.43 0.14
Central pad right (N/cm²) 22.13 21.87 17.90 17.33 28.23 29.53 0.61
Central pad left (N/cm²) 20.83 21.47 16.90 16.37 30.13 29.23 0.24
Medial pad right (N/cm²) 11.80 11.17 6.67 7.67 18.40 14.70 0.12
Medial pad left (N/cm²) 11.80 11.43 6.67 6.03 18.40 17.47 0.57
Plantar arch right (mm) 1429.33 1707.00 981.33 939.00 2240.00 2176.00 0.02
Plantar arch left (mm) 1706.67 1600.00 1066.67 1024.00 2176.00 2176.00 0.95
Heel right (N/cm²) 17.47 19.03 13.40 14.07 22.10 23.67 0.18
Heel left (N/cm²) 18.83 19.67 15.47 16.27 24.53 23.63 0.46
Power rate right (kN/s) 6.10 6.33 4.53 4.73 8.40 8.93 0.19
Power rate left (kN/s) 6.03 7.07 4.87 5.27 8.37 8.77 0.02
Deceleration right (%) 84.33 85.00 72.67 71.33 100.00 102.33 0.84
Deceleration left (%) 94.67 95.00 79.33 75.00 108.67 112.00 0.52
Contact right (s) 0.87 0.86 0.82 0.80 0.97 0.96 0.03
Contact left (s) 0.89 0.86 0.81 0.80 0.97 0.95 0.001
Note: p-values in bold remain significant after Bonferroni-Holm correction.

Table 7 compares plantar pressure distribution parameters
between left and right foot across malocclusions in ICP and
BO. Only one significant change could be detected for the
dental groups in Table 7. The differences in pressure load of
the heel in ICP in terms of side-comparison were significant
(p ≤ 0.001). In patients without orthodontic treatment, the
pressure load of the heel as well as the deceleration is also
remarkably altered in ICP (p ≤ 0.001). Focusing influences
on plantar pressure distribution in BO, no significant changes
were found.
6    B. Scharnweber et al.

Figure 2. Comparison of the contact times of the right and left
foot in intercuspal position (ICP) and blocked occlusion (BO).
Conclusions
For the analysis, all subjects were assigned to groups by the
means of the anamnesis as well as the analysis of the dental
casts. This subject distribution is equivalent to results of
other studies for all Angle-classes and crossbite.[40–51]
The results of the present study show the impact of
occlusal parameters (permanent and temporary) on pos-
tural control and plantar pressure distribution. Concerning
postural control, a reduced frontal and sagittal sway could
be recorded when comparing ICP and BO, while dental
parameters had no effect. Therefore, the conclusion can
be drawn that blocking occlusion leads to sway reduction.

Table 6. Influence of malocclusion on plantar pressure distribution in intercuspal position (ICP) and blocked occlusion (BO) (Kruskal–Wal-
lis test).
Angle class Midline shift Crossbite Angle class Midline shift Crossbite
p-Value p-Value p-Value p-Value p-Value p-Value
Parameter ICP BO
Toe right (N/cm²) 0.68 0.42 0.23 0.17 0.95 0.10
Toe left (N/cm²) 0.42 0.21 0.44 0.04 0.29 0.25
Lateral right pad (N/cm²) 0.45 0.99 0.77 0.05 0.95 0.23
Lateral left pad (N/cm²) 0.23 0.33 0.67 0.09 0.85 1.00
Central pad right (N/cm²) 0.13 0.14 0.54 0.05 0.10 0.83
Central pad left (N/cm²) 0.94 0.52 0.91 0.48 0.71 0.32
Medial pad right (N/cm²) 0.14 0.07 0.26 0.50 0.50 0.18
Medial pad left (N/cm²) 0.14 0.07 0.26 0.98 0.26 0.43
Plantar arch right (mm) 0.91 0.68 0.99 0.85 0.30 0.70
Plantar arch left (mm) 0.51 0.52 0.95 0.13 0.17 0.55
Heel right (N/cm²) 0.51 0.91 0.37 0.98 0.94 0.63
Heel left (N/cm²) 0.93 0.43 0.50 0.66 0.44 0.65
Power rate right (kN/s) 0.32 0.26 0.16 0.15 0.11 0.08
Power rate left (kN/s) 0.23 0.75 0.80 0.88 0.79 0.11
Deceleration right (%) 0.16 0.89 0.81 0.21 0.65 0.80
Deceleration left (%) 0.13 0.44 0.77 0.14 0.54 0.70
Contact right (s) 0.84 0.60 0.97 0.88 0.93 0.52
Contact left (s) 0.83 0.75 0.98 0.84 0.96 0.80

Table 7. Side-comparison between left and right foot of plantar pressure distribution.
Orthodontic Conspicuous
Angle class Midline shift Crossbite treatment anamnesis
Right vs. left 1 2 3 None Left Right None Left Right Bilateral No Yes No Yes
Intercuspal position
Toe (N/cm²) 0.57 0.44 0.39 0.72 0.08 0.18 0.33 1.00 0.62 0.50 0.11 0.80 0.30 0.59
Lateral pad (N/cm²) 0.82 0.47 0.42 0.05 0.12 0.55 0.71 0.74 0.62 0.50 0.79 0.54 0.51 0.31
Central pad (N/cm²) 0.62 0.39 0.36 0.81 0.68 0.67 0.63 0.38 0.81 0.75 0.13 0.44 0.91 0.72
Plantar arch (mm²) 0.75 0.54 0.03 0.29 0.08 0.55 0.90 1.00 0.31 1.00 0.66 0.51 0.91 0.75
Heel (N/cm²) 0.001 0.90 0.50 0.46 0.08 0.02 0.03 0.55 0.19 1.00 0.001 0.34 0.09 0.05
Power rate (kN/s) 0.20 0.39 0.05 0.94 0.24 0.41 0.47 0.15 0.44 0.50 0.26 0.14 0.66 1.00
Deceleration (%) 0.01 0.69 0.28 0.29 0.42 0.05 0.03 0.84 0.44 1.00 0.001 0.74 0.13 0.16
Time of contact (s) 0.17 0.64 0.67 0.70 0.74 0.03 0.29 0.58 0.37 1.00 0.32 0.29 0.05 0.93
Blocked occlusion
Toe (N/cm²) 0.06 0.76 0.28 0.69 0.14 0.26 0.26 0.55 0.62 0.25 0.04 0.78 0.14 0.95
Lateral pad (N/cm²) 0.60 0.39 0.80 0.70 0.51 0.55 0.92 0.84 0.62 0.50 0.54 0.83 0.52 0.33
Central pad (N/cm²) 0.54 0.94 0.01 0.90 0.80 0.35 0.79 0.19 0.44 0.25 0.36 0.81 0.92 0.38
Plantar arch (mm²) 0.81 0.15 0.72 0.88 0.14 0.73 0.45 0.94 0.81 0.25 0.43 0.78 0.72 0.35
Heel (N/cm²) 0.05 0.53 0.64 0.96 0.68 0.01 0.46 0.25 0.31 1.00 0.50 0.23 0.52 0.17
Power rate (kN/s) 0.13 0.50 0.39 0.64 0.19 0.35 0.49 0.84 0.44 1.00 0.90 0.59 0.93 0.45
Deceleration (%) 0.05 0.41 0.23 0.53 0.57 0.11 0.33 0.25 0.44 1.00 0.17 0.40 0.36 0.18
Time of contact (s) 0.87 0.09 0.22 0.78 1.00 0.49 0.41 1.00 0.06 0.25 0.05 0.34 0.84 0.37
Note: p-values in bold remain significant after Bonferroni-Holm correction.
 CRANIO®: The Journal of Craniomandibular & Sleep Practice   7
The percentage weight distribution remains unchanged
for permanent and temporary occlusion parameters.
While blocking occlusion provokes reduction in body
sway, no significant influence of dental parameters on
plantar pressure distribution was found. When taking a
closer look at the upright stance as well as walking behav-
ior, a functional balance of the alignment of limbs and
muscle activity in joints was achieved. Remaining in a
stable position, as well as during motoric tasks, is always
linked to muscular work. This is only possible through
interaction of many muscles and is described as a kinetic
chain, myofascial train or muscular system feedback loop.
[53–56] A smooth cooperation between these chain links
enables a functional, balanced, and economical execution.
If the individual muscular balance is disturbed, several
neuromuscular mechanisms attempt to compensate
for this. The experimentally provoked BO measurably
changes the compensation mechanism, which results in
reduced excursion of frontal and sagittal sway, compared
to ICP. The ICP seems to be associated with a muscular
imbalance of the TMJ, which has been adapted over time,
due to a preferred chewing side.[57,58] Blocking occlu-
sion with cotton rolls could cause a muscular adjustment,
which supports a descending compensation mechanism
that results in less muscular work. The consequence
is a decreased frontal and sagittal sway. Also, Baldini
et al. [22] assumed the sway area to be the ‘most sensitive
parameter.’ These findings are in accordance with those of
Bracco et al. [18], who observed reduced excursion in the
frontal plane in the myocentric position. However, these
results are in contradiction to those of Michelotti et al.
[19], who found no significant influence between ICP and
BO. Hellmann et al. [21] describe the sway reduction as
an involved stiffening phenomenon that was attributed to
the common physiological repertoire of postural control
and might optimize the stability of posture during feed-
back-controlled biting tasks.
Considering plantar pressure distribution, a decreased
contact time of the left foot is the only significant param-
eter when comparing ICP and BO. While walking, a
decreasing contact time implies a shorter stand phase on
the left foot while the walking speed increases. Therefore, a
velocity effect manifests itself. Since it is a single significant
parameter in plantar pressure distribution, it is inadmis-
sible to assume a change in walking behavior, especially
involving merely a brief contact time with the ground. No
evidence can be found when correlating malocclusions
with plantar pressure distribution.
Similarly, no proof of a relationship was found between
Angle-class malocclusions and the sagittal sway or plantar
pressure distribution. Furthermore, significant influence
between transversal sway in the frontal plane and plantar
pressure distribution in patients with crossbite was found.
In brief, only a blocking occlusion leads to significant
changes between ICP and BO when considering plan-
tar pressure distribution. As already stated, permanent
dental parameters have no impact on plantar pressure
distribution, merely blocking occlusion. Similar findings
were discovered by Tecco et al. [31] in TMD patients. The
results of their study assume that the major influence is
based on BO and that TMD trigger compensation mecha-
nism causing higher muscular work and changes become
evident. The results show correlating effects between BO
and postural control. By blocking occlusion with cotton
rolls, individual compensation mechanics were triggered
to keep the body in balance and should have improved
postural and harmonized plantar pressure distribution.
Regardless whether the patients were in ICP or BO, in
terms of postural control, no enhancement was crucial
except for patients with crossbite. These results are in con-
trast to Büntemeyer [59], who detected a minor positive
effect on postural control in the absence of crossbite.
Another purpose of this study was to investigate the
harmonious weight distribution and plantar pressure distri-
bution comparing both foot sides. When comparing right
and left sides in patients with crossbite, only the postural
parameters are harmonious and independent from ICP or
BO. These findings are inconsistent with those of Cuccia [60],
who found that patients with malocclusion are ‘generating
an imbalance of load distribution on feet during walking.’
Since there was no correlation between parameters of
postural and plantar pressure distribution, the conclusion
has to be drawn that postural control and plantar pressure
distribution are independent of each other, and a relation-
ship has to be disproved. Therefore, further studies are
needed with different populations (e.g. elderly subjects,
only females, children) and must be analyzed separately.
The body static and dynamic are regulated multifactori-
ally by interdependent control mechanics, so it is clear
that using only one measuring system does not justify the
complexity of the entire compensation mechanics.
This study showed a reduction in body sway in the frontal
and sagittal plane in healthy male subjects when the occlu-
sion was blocked compared to maximum intercuspal contact.
Further studies are required to establish standard values for
postural control and plantar pressure distribution parameters
to be able to evaluate and interpret them.
Author contributions
BS, SK, CE and DO made substantial contributions to the
conception and design of the manuscript. BS, FA, GS, CE,
8    B. Scharnweber et al.
JN and DO made substantial contributions to the con-
struction of the measurement protocol. All authors have
read and approved the final manuscript.
Disclosure statement
No potential conflict of interest was reported by the authors.
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