Journal of

Functional Morphology
and Kinesiology

Article
Analysis of Dental Malocclusion and Neuromotor
Control in Young Healthy Subjects through New
Evaluation Tools
Barbara Isaia 1 , Martina Ravarotto 2 , Paolo Finotti 2 , Matteo Nogara 2 , Giovanni Piran 2 ,
Jacopo Gamberini 2 , Carlo Biz 3 , Stefano Masiero 2 and Antonio Frizziero 2, *
1 Studio Dentistico Isaia, Vigodarzere, 35010 Padua, Italy; barbaraisaia@hotmail.it
2 Department of Physical and Rehabilitation Medicine, University of Padua, 35128 Padua, Italy;
martina.ravarotto@studenti.unipd.it (M.R.); finottipaolo89@libero.it (P.F.); matteonogara@alice.it (M.N.);
giovanni.piran@gmail.com (G.P.); jacopo.gamberini10@gmail.com (J.G.); stef.masiero@unipd.it (S.M.)
3 Orthopaedic and Traumatology Clinic, Department of Surgery, Oncology and Gastroenterology DiSCOG,
University of Padua, 35128 Padua, Italy; carlo.biz@unipd.it
* Correspondence: antonio.frizziero@unipd.it; Tel.: +39-349-220-2338




Received: 25 October 2018; Accepted: 7 January 2019; Published: 14 January 2019


Abstract: The presence of a correlation between stomatognathic and postural systems has been
investigated by different authors trying to identify a possible influence of dental occlusion on body
posture and balance. The aim of this study was to evaluate the relationship between dental occlusion
and neuromuscular control in a healthy young population using modern evaluation tools. 25 subjects
(9 males and 16 females, aged 23 to 44) were evaluated for dental occlusion, particularly in relation to
overjet and overbite parameters, anterior and posterior crossbite, scissor bite, mandibular crowding,
molar and canine class, and deviation of the median dental line. Neuromotor control was assessed
using two different types of stabilometric platforms in both monopodalic and bipodalic equilibriums
(Prokin-B and MF-Stability, Tecnobody, Italy). All subjects were evaluated with and without cotton
rolls positioned between the upper and lower arches at the premolar level in order to temporarily
eliminate any pathological contact. In all 25 subjects, no statistically significant differences were
revealed between the evaluations performed with and without cotton rolls in all the analyzed
conditions (in static, in dynamics, with open and closed eyes). This study did not find a significant
correlation between dental occlusion and neuromuscular control in a young and healthy population.

Keywords: dental occlusion; malocclusion; stomatognathic system; posture; body balance;

neuromotor control

1. Introduction
Posture and its control has been frequently investigated by many specialists who have tried to give
a precise definition of correct posture both anatomically and functionally, leading to the development
of a specific branch of study called posturology. The term “posture” defines the position of the human
body in space and the subsequent relationship between its segments. Posture can be defined as correct
when it allows for implementing any movement with the least energy expenditure, being characterized
by the absence of asymmetric or abnormal muscular tensions and by correct relationships between the
various body segments [1,2].
Posture is not a single entity for each subject, but it refers to any “balanced position”, defined with
maximum equilibrium (stability), economy (minimum energy consumption), and comfort (minimum
stress on anatomical structures). Postural regulation requires the control of the so-called “Tonic Postural
System”, which is a cybernetic system characterized by a constant transmission of information between

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(minimum stress on anatomical structures). Postural regulation requires the control of the so-called
“Tonic Postural System”, which is a cybernetic system characterized by a constant transmission of
the locomotor
information apparatus
between the and centralapparatus
locomotor nervous system (CNS).
and central The latter
nervous systemreceives
(CNS). allThe
information from
latter receives
exteroceptive (tactile, visual, and auditory) and proprioceptive
all information from exteroceptive (tactile, visual, and auditory) and proprioceptive receptors,receptors, processes it, and sends
response
processes outputs to theresponse
it, and sends end effectors.
outputs Eachto thecomponent of thisEach
end effectors. system can sometimes
component be altered,
of this system can
thus modifying body balance control [3,4]. In the last few years, thanks
sometimes be altered, thus modifying body balance control [3,4]. In the last few years, thanks to to technological innovations,
knowledge
technological on innovations,
this topic has knowledge
made big steps on forward,
this topic leading
has madeto thebig
awareness that posture
steps forward, is involved
leading to the
in many musculoskeletal problems [5–9].
awareness that posture is involved in many musculoskeletal problems [5–9].
Particular attention has
Particular attention hasbeenbeenplaced
placedon onocclusal
occlusalrelationships,
relationships, trying
trying to to understand
understand whether
whether an
an altered
altered dentaldental occlusion
occlusion cancan leadlead to changes
to changes in muscular
in muscular patterns.
patterns. Various
Various studies
studies havehaveshown shown
that
that
changeschanges in mandibular
in mandibular position position
can induce can variations
induce variations
in postural in settings,
posturalshowing
settings,theshowing
existencethe of
existence
a biomechanical and neurological connection between stomatognathic and postural systemspostural
of a biomechanical and neurological connection between stomatognathic and [10,11].
systems [10,11]. The stomatognathic
The stomatognathic system is an anatomic-functional
system is an anatomic-functional complex that complex
performsthat performs
digestive, digestive,
respiratory,
respiratory, relational, and postural functions. Indeed, the skull, jaw,
relational, and postural functions. Indeed, the skull, jaw, and cervical spine constitute an inseparableand cervical spine constitute
an inseparable
functional unit,functional unit, so that
so that everything everything
that happensthat happens
in the mouthinhasthe anmouth has an
impact, impact,temporal-
through through
temporal-mandibular
mandibular joints, on the joints, on the
cervical cervical
tract, tract, thus
thus affecting theaffecting
scapular the scapular
girdle, girdle, column
the vertebral the vertebral
up to
column up to the feet, and vice versa. For this reason, stomatognathic
the feet, and vice versa. For this reason, stomatognathic dysfunctions can cause cranium-cervical- dysfunctions can cause
cranium-cervical-mandibular
mandibular alterations that inalterations that in turn
turn can generate can generate
postural imbalances postural
[12]. imbalances [12].
The
The term “occlusion” defines the relationship between maxillary and
term “occlusion” defines the relationship between maxillary and mandibular
mandibular arches,
arches, whenwhen
teeth
teeth come into contact with each other both in static conditions and during functional movements
come into contact with each other both in static conditions and during functional movements
of
of the
the temporomandibular
temporomandibular joint. This contact
joint. This contact shouldshould always
always be be uniform
uniform and and simultaneous
simultaneous on on both
both
sides,
sides, in order to give the jaw maximum stability using as many contacts as possible. Changes in
in order to give the jaw maximum stability using as many contacts as possible. Changes in
normal
normal occlusal
occlusalmorphology
morphologymay mayinduce
inducethe the jawjawtotolook
lookforfor
a stable
a stableocclusion
occlusion position, which
position, maymay
which not
correspond
not correspond to that toin which
that in the chewing
which the muscleschewingand internal
musclesstructures
and internalof the temporomandibular
structures of the
joint are used to operating in normal conditions [13]. In orthodontics,
temporomandibular joint are used to operating in normal conditions [13]. In orthodontics, all non-ideal occlusal situations
all non-
are
idealidentified
occlusalassituations
“malocclusions”, and they
are identified are usually classified
as “malocclusions”, andinto
they three
are classes,
usually according
classified to Angle’s
into three
classification (Figure 1) while the occlusal relationship between anterior
classes, according to Angle’s classification (Figure 1) while the occlusal relationship between anteriordental elements is defined by
overjet and overbite parameters (Figure 2). Each dental malocclusion
dental elements is defined by overjet and overbite parameters (Figure 2). Each dental malocclusion can cause repercussions on the
whole
can causepostural system [14].
repercussions on the whole postural system [14].

Figure 1.1.Angle
Angleclassification
classification of dental
of dental occlusions.
occlusions. NormalNormal occlusion:
occlusion: The
The first firstmolar
upper upper molar is
is displaced
displaced
distally distally
from from
the first the molar,
lower first lower molar,
for no for no
less than less
half than First-class
a cusp. half a cusp.malocclusion:
First-class malocclusion: The
The relationship
relationship
between between
molars molars
is normal is normal
but the alignment butofthe alignment
other of other
teeth is not. teeth is malocclusion:
Second-class not. Second-class
The
malocclusion:
jaw is positionedThefarther
jaw isback
positioned
than thefarther
maxilla,back than
so that the maxilla,
upper so that
incisors show upper incisors
accentuated show
protrusion
accentuated
and protrusion and
overjet. Third-class overjet. Third-class
malocclusion: The jaw ismalocclusion:
too advancedThe jaw is too
in relation advanced
to the maxilla.in(Figure
relation1 to
is
the maxilla.
inspired (Figure
by the image 1 is inspired
in the following by the image in the following link:
link: https://img.tfd.com/dorland/malocclusion.jpg).
https://img.tfd.com/dorland/malocclusion.jpg).
J. Funct. Morphol. Kinesiol. 2019, 4, 5 3 of 13
J. Funct. Morphol. Kinesiol. 2019, 4, x 3 of 13

Figure 2. Representation of overjet and overbite parameters. Overjet refers to the horizontal distance
Figure 2. Representation of overjet and overbite parameters. Overjet refers to the horizontal distance
between the edge of upper and lower incisors, while overbite represents the vertical distance between
between the edge of upper and lower incisors, while overbite represents the vertical distance between
the free margins of the same elements.
the free margins of the same elements.
In literature, several studies have identified a correlation between stomatognathic and postural
In literature, several studies have identified a correlation between stomatognathic and postural
systems, demonstrating that different mandibular positions can induce variations in body
systems, demonstrating that different mandibular positions can induce variations in body posture
posture [15–17]. In 1976, Funakoshi et al. analyzed the relationships between changes in head posture
[15–17]. In 1976, Funakoshi et al. analyzed the relationships between changes in head posture and the
and the functioning of chewing muscles through electromyography investigation, showing that an
functioning of chewing muscles through electromyography investigation, showing that an occlusal
occlusal interference could result in an incorrect reaction of masseter and temporal muscles, depending
interference could result in an incorrect reaction of masseter and temporal muscles, depending on
on the head position [18]. In 1992, Martensmeier et al. showed the radiographic modifications of
the head position [18]. In 1992, Martensmeier et al. showed the radiographic modifications of cervical
cervical spine curvature in the sagittal plane following orthodontic treatment for malocclusion [19].
spine curvature in the sagittal plane following orthodontic treatment for malocclusion [19].
In their work, Tardieu et al. studied the influence of a dental occlusion perturbation on postural
In their work, Tardieu et al. studied the influence of a dental occlusion perturbation on postural
control. The tests were performed in three dental occlusion conditions (rest position, maximal
control. The tests were performed in three dental occlusion conditions (rest position, maximal
intercuspal occlusion, and thwarted laterality occlusion, which represented a simulation of a dental
intercuspal occlusion, and thwarted laterality occlusion, which represented a simulation of a dental
malocclusion) and four postural conditions (static and dynamic, with eyes open and eyes closed). Their
malocclusion) and four postural conditions (static and dynamic, with eyes open and eyes closed).
results have proven that dental occlusion compromises postural control only in dynamic conditions
Their results have proven that dental occlusion compromises postural control only in dynamic
and in the absence of visual signals; in fact, sensory information related to dental occlusion appeared to
conditions and in the absence of visual signals; in fact, sensory information related to dental occlusion
become effective only during difficult postural tasks, with a growing importance when other sensory
appeared to become effective only during difficult postural tasks, with a growing importance when
signals were poor [20].
other sensory signals were poor [20].
In contrast to the aforementioned studies, other works in literature documented the absence of a
In contrast to the aforementioned studies, other works in literature documented the absence of
correlation between stomatognathic and postural systems, evaluating different parameters (equilibrium
a correlation between stomatognathic and postural systems, evaluating different parameters
with closed and open eyes, loading distribution on feet, body oscillations) and showing no significant
(equilibrium with closed and open eyes, loading distribution on feet, body oscillations) and showing
influence of dental occlusion on body posture [21,22].
no significant influence of dental occlusion on body posture [21,22].
The purpose of this study was to evaluate the presence of a possible association between
The purpose of this study was to evaluate the presence of a possible association between dental
dental malocclusions and body posture and balance in a healthy young population using modern
malocclusions and body posture and balance in a healthy young population using modern evaluation
evaluation tools.
tools.
2. Materials and Methods
2. Materials and Methods
2.1. Study Sample
2.1. Study Sample
The study sample was obtained from doctors who were specializing in Physical and Rehabilitation
The study sample was obtained from doctors who were specializing in Physical and
Medicine and Orthopedics at the University of Padua. The study group was composed of 25 subjects,
Rehabilitation Medicine and Orthopedics at the University of Padua. The study group was composed
aged 23 to 44 years, who voluntarily accepted to participate in the study. All subjects were asked if
of 25 subjects, aged 23 to 44 years, who voluntarily accepted to participate in the study. All subjects
they had sustained dental or face injuries and if they had received orthodontic treatment with braces.
were asked if they had sustained dental or face injuries and if they had received orthodontic
treatment
2.2. Subject with braces.
Examination
2.2. Subject
For eachExamination
subject, the evaluation consisted of an earlier clinical examination of the facial district,
followed
For by ansubject,
each instrumental stability examination.
the evaluation consisted of an earlier clinical examination of the facial district,
The facial
followed by anexamination
instrumentalwas performed
stability in frontal and profile views with the subject both at rest
examination.
and while smiling, evaluating different parameters.
The facial examination was performed in frontal and profile views with the subject both at rest
and In the smiling,
while frontal view (Figure
evaluating 3), the parameters.
different relationship between the eyes–nose–mouth and the facial
symmetry
In thewere evaluated.
frontal In particular,
view (Figure 3), the the relationship
relationship between
between thethe midlines of dental
eyes–nose–mouth andarches and
the facial
symmetry were evaluated. In particular, the relationship between the midlines of dental arches and
those of skeletal and soft tissue were considered. The vertical reference axis of the face was considered
J. Funct. Morphol. Kinesiol. 2019, 4, x 4 of 13

to be the
J. Funct. one passing
Morphol. through
Kinesiol. 2019, 4, 5 the tip of the nose, the upper and lower midline of incisors, and 4 ofthe
13
chin midpoint, while the bipupillar axis represented the horizontal reference axis. Any deviation
from
J. Funct.the midline
Morphol. of such
Kinesiol. 2019, parameters
4, x was considered as an asymmetry. 4 of 13
thoseThe of skeletal and soft tissue were considered.
height/width ratio of the face was also measured, The verticalwith
reference axis ofbeing
the height the face was considered
represented by the
to be
be the
distance
to the one
onepassing
between thethrough
passing throughthe
hairline thetipthe
and ofof
tip thethe
lowestnose, thethe
point
nose, upper
of the and lower
jawline,
upper and midline
while
lower the of incisors,
width
midline was and the
andchin
represented
of incisors, the
midpoint,
by
chin whilebetween
themidpoint,
distance the bipupillar
while thethe twoaxis
most
bipupillar represented
lateral
axis the horizontal
points
representedof the reference
thezygomatic
horizontal axis. In
arches. Any
reference deviation
aaxis.
normal
Any from the
population,
deviation
midline
this
from theofmidline
ratio such
has parameters
a value
of sucharound was
1.3 considered
parametersfor females as
andan1.35
was considered asymmetry.
for
as anmales.
asymmetry.
The height/width ratio of the face was also measured, with the height being represented by the
distance between the hairline and the lowest point of the jawline, while the width was represented
by the distance between the two most lateral points of the zygomatic arches. In a normal population,
this ratio has a value around 1.3 for females and 1.35 for males.

Figure 3. Facial
Facial examination in frontal view.

The
In height/width
the profile view ratio
(Figureof the face lines
4), two was also
weremeasured, with the
used to identify theheight being represented
face profile—the by the
first from the
distance between the hairline and the lowest point of the jawline, while the
glabella to the upper lip margin, and the second from the upper lip margin to the chin. The anglewidth was represented
by the distance
between between
these two lines the two
indicates most
Figure
lateral
a class points relationship
II skeletal
3. Facial
of the
examination
zygomatic thearches.
in frontalifview. profileInis aconvex,
normalor population,
a class III
this ratio has a value around 1.3
relationship if the profile is concave. for females and 1.35 for males.
In the
In the profile
profile view
view (Figure
(Figure 4),4), two
two lines were used
lines were to identify
used to identify the
the face
face profile—the
profile—the first
first from
from the
the
glabella to
glabella to the
the upper
upper lip
lip margin,
margin, and and thethe second
second from
from the
the upper
upper liplip margin
margin to to the
the chin.
chin. The
The angle
angle
between these two lines indicates a class II skeletal relationship if the profile is convex, or aa class
between these two lines indicates a class II skeletal relationship if the profile is convex, or class III
III
relationship if
relationship if the
the profile
profile is
is concave.
concave.

Figure 4. Facial examination in sagittal view.

Regarding dental occlusion, each subject was asked about previous orthodontic treatment and
previous teeth or face trauma. Clinical examination was focused on different parameters: molar and
canine classes, overjet, overbite, anterior
Figure
Figure 4. andexamination
4. Facial
Facial posterior crossbites,
examination in
in sagittal dental crowding, and deviation of
sagittal view.
view.
the upper and lower dental midline. Molar and canine classes were described using Angle’s
classification
Regarding of dental occlusion,
malocclusions each subject
(Figure wasisasked
1). Overjet about previous
the horizontal orthodontic treatment
(anterior–posterior) gap between and
previous
the labial teeth or of
surface face
thetrauma. Clinicalincisors
upper central examination
and the was focusedsurface
vestibular on different
of theparameters:
lower central molar and
incisors.
canine classes,
Overbite classes, overjet, overbite, anterior and posterior crossbites, dental crowding, and deviationthe
is theoverjet,
vertical overbite,
distance anterior
between and
the posterior
incisal crossbites,
edges of the dental
upper crowding,
and lower and deviation
incisors of
(Figure 2).
of
upper
the and lower
upper dental dental
and lower midline.midline.
Molar and canine
Molar and classes
caninewere described
classes wereusing Angle’s
described classification
using Angle’s
2.3. Instrumental Assessment of Neuromotor Control
of malocclusions
classification (Figure 1). Overjet
of malocclusions (Figureis1).the horizontal
Overjet is the (anterior–posterior) gap between
horizontal (anterior–posterior) gapthe labial
between
Stability
surface of the evaluations
upper centralwere performed
incisors and the at the
vestibularDepartment
surface of of
the Orthopedic
lower centralRehabilitation
incisors.
the labial surface of the upper central incisors and the vestibular surface of the lower central incisors. of
Overbite the
is
University
Overbite is Hospital
the vertical distance
the of
vertical Padua,
between
distanceusing
the modern
incisal
between the evaluation
edges of theedges
incisal tools
upper (Prokin-B
ofand
the lower and lower
upperincisors
and MF-Stability,
(Figure 2). Tecnobody
incisors (Figure 2).
SRL, Dalmine, Bergamo, Italy, Figure 5). Both Prokin-B and MF-Stability have two different difficulty
2.3.
2.3. Instrumental
Instrumental Assessment
Assessment of
of Neuromotor
Neuromotor Control
levels (“standard” and “advanced”); forControl
our sample, the “advanced” mode was chosen. Each
evaluation was
Stability
Stability completed were
evaluations
evaluations on theperformed
were same day. at
performed the Department
at the Department of of Orthopedic
Orthopedic Rehabilitation
Rehabilitation of the
of the
University Hospital of Padua, using modern evaluation tools (Prokin-B and MF-Stability,
University Hospital of Padua, using modern evaluation tools (Prokin-B and MF-Stability, Tecnobody Tecnobody
SRL, Dalmine, Bergamo, Italy, Figure 5). Both Prokin-B and MF-Stability have two different difficulty
levels (“standard” and “advanced”); for our sample, the “advanced” mode was chosen. Each
evaluation was completed on the same day.
J. Funct. Morphol. Kinesiol. 2019, 4, x 5 of 13

The subjects were asked to perform different tests in various conditions; in particular, the same
test
J. hadMorphol.
Funct. to be performed
Kinesiol. 2019, with
4, 5 and without cotton rolls, which were placed between antagonist 5teeth
of 13
because they were expected to remove occlusal interferences and mandibular slides along the
physiological pattern of the jaw-closing movement [7].
SRL, The
Dalmine, Bergamo,
assessments Italy,
were Figure 5). Both
randomized Prokin-B
so that some and MF-Stability
subjects have
performed twotest
each different
beforedifficulty
without
levels
cotton rolls and then with them, while other subjects did the contrary, in order to avoidchosen.
(“standard” and “advanced”); for our sample, the “advanced” mode was potentialEach
bias
evaluation was completed
due to a learning effect. on the same day.

Figure
Figure 5.
5. MF-Stability
MF-Stability (left
(left image)
image) and
and Prokin
Prokin (right
(right image)
image) devices,
devices, Tecnobody SRL, Italy.
Tecnobody SRL, Italy.

The subjects weredevice

MF-Stability asked is to equipped
perform different tests in various
with a stabilometric conditions;
platform in particular,
and evaluates bodythe same
posture
test hadconditions,
in static to be performed
involvingwith theand without
execution ofcotton rolls,
different which were placed between antagonist
tests:
teeth because they were expected to remove occlusal interferences and mandibular slides along the
• A stabilometric test with open eyes (Romberg’s test) that consists of keeping on the standing
physiological pattern of the jaw-closing movement [7].
station for 30 s while staring at a red spot on the monitor, during which it assesses the position
The assessments were randomized so that some subjects performed each test before without
of the body in space. The numerical value obtained is represented by the area described by the
cotton rolls and then with them, while other subjects did the contrary, in order to avoid potential bias
center of mass displacements (in mm2); the higher the value, the worse the test result.
due to a learning effect.
• A test for the evaluation of the stability limit, in which the task is to move the center of gravity
The MF-Stability device is equipped with a stabilometric platform and evaluates body posture in
towards a point indicated in the monitor; this test is useful for evaluating spatial exploration
static conditions, involving the execution of different tests:
capacity. The value obtained represents the displacement of the center of mass, expressed as a
• Apercentage of the
stabilometric total
test withdisplacement provided by
open eyes (Romberg’s thethat
test) software
consistsaccording
of keepingto the
on height of the
the standing
subject for
station (more
30 sthan
while75% is considered
staring normal).
at a red spot on the monitor, during which it assesses the position
• of Twothecomparative
body in space. stability tests, including
The numerical a bipodalic
value obtained test with open
is represented by the and
areaclosed eyes, by
described and thea
monopodalic
center of mass test comparing(inthe
displacements mm 2
balance between
); the higher the the right
value, and left
the worse thefoot. The scores are
test result.
• Aexpressed as the
test for the area described
evaluation by the limit,
of the stability centerinofwhich
mass the
displacements
task is to move (in mm ); the higher
the 2center the
of gravity
value, the worse the test result.
towards a point indicated in the monitor; this test is useful for evaluating spatial exploration
capacity.
Prokin-B is The value that
a device obtained represents
evaluates the displacement
the dynamic balance, as theof the center
subject hasoftomass,
perform expressed as
three tests
a percentage of
on an unstable platform: the total displacement provided by the software according to the height of the
subject (more than 75% is considered normal).
•• Two The first test consists
comparative of maintaining
stability the bipodalic
tests, including equilibrium
a bipodalic test withon the and
open unstable
closed platform with
eyes, and a
visual feedback, which is useful for identifying the directions of the subject’s
monopodalic test comparing the balance between the right and left foot. The scores are expressed imbalance. The
value
as provided
the area by the
described bydevice is the
the center ofstability index, that is(in
mass displacements themmdistance (expressed
2 ); the higher in cm)the
the value, between
worse
the center of
the test result.the platform and the average coordinates of the positions assumed by the center of
mass; lower scores correspond to greater stability.
• Prokin-B
A secondis acomparative
device that evaluates the dynamic
proprioceptive balance,
test gives as the subject
information has to
about bodyperform three
control tests
whilst
on anperforming
unstable platform:
a fine motor skill, in this case represented by tracking a circular trace on the monitor,
• either
The with
first testthe right foot
consists (clockwise) or
of maintaining thewith the leftequilibrium
bipodalic foot (anti-clockwise). The result
on the unstable of thiswith
platform test
is expressed as an “average trace error”, which indicates the deviation of the subject
visual feedback, which is useful for identifying the directions of the subject’s imbalance. The value from the
optimal trace,
provided by the expressed
device isas
thea stability
percentage; a low
index, thatvalue
is thecorresponds to a trace
distance (expressed in close to the ideal
cm) between the
line, thus meaning good motor and perceptive capacity.
center of the platform and the average coordinates of the positions assumed by the center of mass;
• A third
lower comparative
scores correspondmonopodalic equilibrium test consists in maintaining the dynamic
to greater stability.
• A second comparative proprioceptive testfirst
equilibrium in a monopodalic position, with
gives the right foot
information and
about then
body with the
control left.performing
whilst The result
a fine motor skill, in this case represented by tracking a circular trace on the monitor, either with
the right foot (clockwise) or with the left foot (anti-clockwise). The result of this test is expressed
J. Funct. Morphol. Kinesiol. 2019, 4, 5 6 of 13

as an “average trace error”, which indicates the deviation of the subject from the optimal trace,
expressed as a percentage; a low value corresponds to a trace close to the ideal line, thus meaning
good motor and perceptive capacity.
• A third comparative monopodalic equilibrium test consists in maintaining the dynamic
J. Funct. Morphol. Kinesiol. 2019, 4, x 6 of 13
equilibrium in a monopodalic position, first with the right foot and then with the left. The result
is expressed as a stability index—that is, the distance (in cm) between the center of the platform
is expressed as a stability index—that is, the distance (in cm) between the center of the platform
and the average coordinates of the positions assumed by the center of mass; the lower the score,
and the average coordinates of the positions assumed by the center of mass; the lower the score,
the greater the stability.
the greater the stability.
2.4.
2.4. Statistical
Statistical Analysis
Analysis
For
Forthe statistical
the analysis
statistical procedure,
analysis since nosince
procedure, evaluated subjects reported
no evaluated significant
subjects reported malocclusion,
significant
amalocclusion,
comparison of data was performed
a comparison between
of data was the normal
performed betweencondition andcondition
the normal the stateand
withthe
cotton
state rolls
with
placed between the dental arches. The results obtained with and without rolls were compared
cotton rolls placed between the dental arches. The results obtained with and without rolls were through
the Wilcoxon
compared signed-rank.
through the Wilcoxon signed-rank.

3.
3. Results
Results
3.1. MF-Stability
3.1. MF-Stability
•• Open-eyesstability
Open-eyes stabilitytest
testwith
withand
andwithout
withoutcotton
cottonrolls
rolls
The whole
The whole sample
sample ofof subjects
subjects did
did not
not exhibit
exhibit statistically
statistically significant
significant differences
differences between
between the
the
results obtained
results obtained with
with and
and without
without rolls,
rolls, since
since the
the average
average score
score obtained
obtained without
without rolls
rolls was
was 125.088
125.088
±63.737) while
((±63.737) while that obtained with rolls was was 137.495 ±92.666) (Figure
137.495 ((±92.666) (Figure 6). Therefore, there were no no
statistically significant
statistically significant differences
differencesbetween
betweenthe thetwo
twotests
tests(p
(p== 0.7048).
0.7048).

Figure 6. Graph
Figure 6. Graph showing
showing the
the scores
scores obtained
obtained with
with the
the MF-Stability
MF-Stability device
device at
at the
the open-eyes
open-eyes stability
stability
test
test with
with and
and without
without cotton
cotton rolls.
rolls.

• Open-eyes stability limit test with and without cotton rolls

• Open-eyes stability limit test with and without cotton rolls
The average scores reported by the whole sample were 81.124 (±15.787) for the test without rolls
The average scores reported by the whole sample were 81.124 (±15.787) for the test without rolls
and 84.364 (±6.094) for that with rolls, with a test median, respectively, of 85.170 and 84.770 (Figure 7).
and 84.364 (±6.094) for that with rolls, with a test median, respectively, of 85.170 and 84.770 (Figure
These results show no statistically significant differences between the two evaluations (p = 0.4386).
7). These results show no statistically significant differences between the two evaluations (p = 0.4386).
J. Funct. Morphol. Kinesiol. 2019, 4, 5 7 of 13
J. Funct. Morphol. Kinesiol. 2019, 4, x 7 of 13

J. Funct. Morphol. Kinesiol. 2019, 4, x 7 of 13

Figure
Figure 7.
Figure Graph
7. 7.
Graph showing
Graph showingthe
showing thescores
the scoresobtained
scores obtained with
obtained with the
with MF-Stability
the MF-Stability
the device
deviceatat
MF-Stabilitydevice the
atthe open-eyes
theopen-eyes
open-eyes stability
stability
stability
limit
limit test
test with
with and
and without
without cotton
cotton rolls.
rolls.
limit test with and without cotton rolls.

•• • Monopodalic
Monopodalic
Monopodalic evaluation
evaluationwith
evaluation withand
with andwithout
and without rolls
without rolls
rolls
TheThe
The whole
wholesample
whole sampleexhibited
sample exhibitedno
exhibited nosignificant
no significant differences
significant differences between
differences between
betweenthethe results
theresults obtained
resultsobtained
obtained with
with
with and
and
and
without rolls
without
without (p = 0.7187);
rolls(p(p= =0.7187);
rolls the
0.7187);the average
theaverage score
average score of the evaluation
score of the evaluation performed
evaluationperformed without
performedwithout rolls
withoutrolls was
was
rolls 368.729
368.729
was 368.729
±(±119.993),
((±119.993),
119.993),while
while that
whilethat of
thatof the
ofthe evaluation
theevaluation performed
evaluation performed withrolls
performed with
with rollswas
rolls was378.385
was 378.385 (±150.530)
378.385(±150.530)
(±150.530) (Figure
(Figure 8).
8).8).
(Figure

Figure 8. 8.Graph
Figure Graphshowing
showing the
the scores
scores obtained with the
obtained with the MF-Stability
MF-Stabilitydevice
deviceatatthe
themonopodalic
monopodalic
evaluation
evaluationwith
withand
andwithout
withoutrolls.
rolls.
Figure 8. Graph showing the scores obtained with the MF-Stability device at the monopodalic
evaluation with and without rolls.
J. Funct. Morphol. Kinesiol. 2019, 4, 5 8 of 13
J. Funct. Morphol. Kinesiol. 2019, 4, x 8 of 13

Moreover, no
Moreover, nosignificant
significantdifferences
differenceshave
havebeen
beenfound
foundbetween
betweenthe tests
the performed
tests with
performed thethe
with leftleft
or
right foot.
or right foot.
•• Bipodalic evaluation
evaluation with
with open
open and
and closed
closed eyes,
eyes, with
with and
and without
without rolls
rolls
better balance
The results show that the subjects had better balance when
when they
they performed
performed the
the test
test without
without rolls,
rolls,
even if this difference is not statistically significant
significant (p = 0.5980). Indeed, the open-eyes test performed
without rolls reported scores ranging from 2.250 to 321.410, while the same test performed with rolls
reported scores ranging from 32,710 to to 356,010
356,010 (Figure
(Figure 9).
9).

Figure 9.
Figure Graph showing
9. Graph showing the
the scores
scores obtained
obtained with
with the
the MF-Stability
MF-Stability device
device at
at the
the bipodalic
bipodalic evaluation
evaluation
with open eyes without and with rolls.
with open eyes without and with rolls.

At the
At the bipodalic
bipodalicevaluation
evaluationwithwithclosed
closedeyes,
eyes,the scores
the ranged
scores rangedfrom 11.890
from to 1703.030
11.890 when
to 1703.030 the
when
subjects performed the test without rolls and from 48,840 to 740,290 when the test was performed
the subjects performed the test without rolls and from 48,840 to 740,290 when the test was performed with
rolls (Figure
with 10); even
rolls (Figure in thisincase,
10); even this no significant
case, difference
no significant was found
difference (p = 0.287).
was found (p = 0.287).
J. Funct. Morphol. Kinesiol. 2019, 4, 5 9 of 13
J. Funct. Morphol. Kinesiol. 2019, 4, x 9 of 13

Figure
Figure 10. Graph showing
10. Graph showing the
the scores
scores obtained
obtained with the MF-Stability
with the MF-Stability device
device at
at the bipodalic evaluation
the bipodalic evaluation
with closed eyes without and with rolls.
with closed eyes without and with rolls.
3.2. Prokin-B
Prokin-B
•• Bipodalic
Bipodalic stability
stability test
test with
withand
andwithout
withoutrolls
rolls
The results
results obtained
obtained by the
the whole
whole sample
sample show more
more stability
stability in the
the test
test performed
performed with
with rolls
rolls
than in the one performed without rolls, reporting an average score of 1.072
in the one performed without rolls, reporting an average score of 1.072 (±0.508) ( ± 0.508) with rolls and
and
(±0.452)without
of 0.955 (±0.452) withoutrolls
rolls(Figure
(Figure 11).
11). However,
However, thisthis difference
difference is not
is not statistically
statistically significant
significant (p =
(p = 0.1179).
0.1179).
• Proprioceptive evaluation through foot-ankle circling with and without rolls
This test consisted in the execution of three clockwise turns with the right foot and three
anticlockwise turns with the left foot. The average score reported during the test performed without
rolls was 48.671 (±18.432), while the one reported during the test performed with rolls was 47.819
(±27.096), showing no statistically significant differences (p = 0.4693) (Figure 12).
• Monopodalic stability evaluation with and without rolls
The results obtained by the whole sample with and without rolls are quite similar (p = 0.7017),
with an average score of 1.328 (±0.687) at the test performed without rolls and of 1.376 (±0.854) at the
test performed with rolls (Figure 13).
• Bipodalic stability test with and without rolls
The results obtained by the whole sample show more stability in the test performed with rolls
than in the one performed without rolls, reporting an average score of 1.072 (±0.508) with rolls and
ofFunct.
J. 0.955Morphol.
(±0.452) without
Kinesiol. 2019, rolls
4, 5 (Figure 11). However, this difference is not statistically significant (p13=
10 of
0.1179).

J. Funct. Morphol. Kinesiol. 2019, 4, x 10 of 13

Figure 11. Graph showing the scores obtained with the Prokin-B device at the bipodalic stability test
with and without rolls.

• Proprioceptive evaluation through foot-ankle circling with and without rolls

This test consisted in the execution of three clockwise turns with the right foot and three
anticlockwise turns with the left foot. The average score reported during the test performed without
rolls Figure
was 48.671 (±18.432),
11. Graph showing while the one
the scores reported
obtained with during the test
the Prokin-B performed
device with rolls
at the bipodalic wastest
stability 47.819
(±27.096), showing no statistically
with and without rolls. significant differences (p = 0.4693) (Figure 12).

12.Graph
Figure 12. Graphshowing
showing thethe
scores obtained
scores with the
obtained Prokin-B
with device atdevice
the Prokin-B the proprioceptive evaluation
at the proprioceptive
through foot-ankle circling with and without rolls.
evaluation through foot-ankle circling with and without rolls.

• Monopodalic stability evaluation with and without rolls

The results obtained by the whole sample with and without rolls are quite similar (p = 0.7017),
with an average score of 1.328 (±0.687) at the test performed without rolls and of 1.376 (±0.854) at the
test performed with rolls (Figure 13).
J. Funct. Morphol. Kinesiol. 2019, 4, 5 11 of 13
J. Funct. Morphol. Kinesiol. 2019, 4, x 11 of 13

Figure 13. Graph showing the scores obtained with the Prokin-B device at the monopodalic stability
Figure 13. Graph showing the scores obtained with the Prokin-B device at the monopodalic stability
evaluation with and without rolls.
evaluation with and without rolls.
4. Discussion
4. Discussion
The aim of this study was to investigate the presence of a possible association between dental
The aim of
malocclusions andthis study
body was to
posture andinvestigate
balance inthe presence
static of a possible
and dynamic association between dental
conditions.
malocclusions and body posture and balance in static and dynamic conditions.
In the literature, many studies have analyzed this topic, often reporting conflicting results. Indeed,
someIn of the
theseliterature, many studies
articles confirm such an have analyzed
association, while thisothers
topic,show
oftennoreporting
correlation.conflicting results.
Indeed,
For some
example,of these articlesetconfirm
Michelotti al. claimsuch
thatanthere
association,
is no reasonwhiletoothers
performshow no correlation.
occlusal and orthodontic
For example, Michelotti et al. claim that there is no reason
treatment to treat or prevent postural imbalances or the alteration of spine curvatures to perform occlusal and[23].
orthodontic
On the
treatment to treat or prevent postural imbalances or the alteration of spine
contrary, Martensmeier demonstrated that patients with class I and II malocclusion exhibit a significant curvatures [23]. On the
contrary, Martensmeier
improvement demonstrated
of cervical spine curvature that patients
following with class
orthodontic I and [19].
treatment II malocclusion exhibit a
significant improvement of cervical spine curvature following
None of the subjects enrolled in our work showed significant dental malocclusions.orthodontic treatment [19].
Many of them
None of the subjects enrolled in our work showed significant dental
reported a recent history of receiving orthodontic corrective treatment in the past, and this can malocclusions. Many of
partly
them reported a recent history of receiving orthodontic
explain the lack of serious occlusal pathologies in the examined population. corrective treatment in the past, and this can
partly
In explain
the presentthe lack of serious
study, we used occlusal
modern pathologies
evaluation intools
the examined
to assess population.
posture and balance. Other
In the present study, we used modern evaluation
studies in the literature have reported the use of the same or other similar tools to assess posture and balance.
devices, Other
both to assess
studies in the literature have reported the use of the same or other similar
postural control in different conditions and as potential rehabilitation tools [24–27]. However, no other devices, both to assess
postural
work control in different
has previously investigatedconditions and as between
the relationship potentialdental
rehabilitation
occlusiontools [24–27].
and body However,
balance by using no
othermodern
such work has previously investigated the relationship between dental occlusion and body balance
devices.
by using such modern
The results we achieved devices.
from our study sample do not show a statistically significant difference
The results we achieved
between all the stabilometric evaluationsfrom our study samplewith
performed do not
andshow a statistically
without cotton rollssignificant
positioneddifference
between
between all the stabilometric evaluations performed
the dental arches, both in bipodalic and monopodalic equilibrium. with and without cotton rolls positioned
between
As bodythe dental
balance arches, both
derives in bipodalic
from and monopodalic
the interaction equilibrium.
between different systems, including the visual
As body balance derives from the interaction between
one, we also tried to investigate if the correlation between dental occlusion different systems,
and including
neuromotor thecontrol
visual
one, we also tried to investigate if the correlation between dental occlusion
could be modified by visual control. Anyhow, the scores obtained during the tests performed with and and neuromotor control
could becotton
without modifiedrollsbydidvisual control.
not change Anyhow,
with open orthe scores
closed obtained
eyes. during are
These results theintests performed
contrast with
with those
and without cotton rolls did not change with open or closed eyes. These results are in contrast with
those obtained by Tardieu et al., who demonstrated that the presence of dental contact worsens
stabilometric control only when visual control is absent [20].
J. Funct. Morphol. Kinesiol. 2019, 4, 5 12 of 13

obtained by Tardieu et al., who demonstrated that the presence of dental contact worsens stabilometric
control only when visual control is absent [20].

5. Conclusions
This study showed no statistically significant correlations between dental occlusion and
neuromuscular control in young and healthy individuals. Such an absence of association was observed
in all the conditions we tested (stable and unstable platforms, open or closed eyes, bipodalic and
monopodalic support).
The main limitations of this study are represented by the limited sample and the absence of a
radiological examination to support clinical evaluation.
However, we suggest that the tests we performed and the high-quality evaluation tools we
employed in this study may be useful for future research to evaluate subjects with malocclusion before
and after orthodontic treatment, even athletes during the execution of specific sporting gestures.

Author Contributions: B.I. conceived and designed the study, carried out the evaluations and collected the data.
M.R. contributed to design the study and perform the evaluations. P.F. contributed to the interpretation of the
results and wrote the manuscript with input from all authors. M.N. contributed to perform the evaluations,
collect data and draft the text. G.P. and J.G. analysed the data and contributed to the interpretation of the results.
C.B. and S.M. verified the analytical methods and supervised the project. A.F. designed and directed the project,
and contributed to the interpretation of the results. All authors discussed the results and contributed to the
final manuscript.
Funding: This research received no external funding.
Conflicts of Interest: The authors declare no conflict of interest.

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