2012 Blackwell Publishing

Ltd
doi: 10.1111/j.13652!"2.2012.022#1.$
Jour na l o f
Oral Rehabilitation
%ou&nal o' (&al )ehabilitation 2012 3#* "63+",1
)e-iew .&ticle
/ental occlusion0 bod1 2ostu&e and te32o&o3andibula&
diso&de&s: whe&e we a&e now and whe&e we a&e heading 'o&
/. 4.56)7/8 58 90 :. ;.<:)(6L()8 (
=
0 > . P7)8 57::8
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@ L . >A.)/ . 5.)/ 8 5 8
9
9/e2a&t3ent o' 4a$illo'acial <u&ge&10 :4/ ;linic0 Ani-e&sit1 o' Pado-a0 ;a&&a&a0
=
P&i-ate 2&actice0 :u&in and
?
/e2a&t3ent o'
4edical0 <u&gical and Bealth <ciences0 Ani-e&sit1 o' :&ieste0 :&ieste0 8tal1
<A44.)C :he ai3 o' this in-estigation was to
2e& 'o&3 a &e-iew o' the lite&atu&e dealing with the
issue o' &elationshi2s between dental occlusion0
bod1 2ostu&e and te32o&o3andibula& diso&de&s
D:4/E. . sea&ch o' the a-ailable lite&atu&e was
2e&'o&3ed to dete&3ine what the cu&&ent
e-idence is &ega&ding: DiE :he 2h1siolog1 o' the
dental occlusion+bod1 2ostu&e &elationshi20 DiiE
:he &elationshi2 o' these two to2ics with :4/
and DiiiE :he -alidit1 o' the a-ailable clinical and
inst&u3ental de-ices Dsu&'ace elect&o31og&a2h10
kinesiog&a2h1 and 2ostu&al
2lat'o&3sE to 3easu&e the dental occlusion+bod1
2ostu&e+:4/ &elationshi2. :he a-ailable 2ostu&o
g&a2hic techniFues and de-ices ha-e not
consis tentl1 'ound an1 association between bod1
2ostu&e and dental occlusion. :his outco3e is
3ost likel1 due to the 3an1 co32ensation
3echanis3s occu& &ing within the
neu&o3uscula& s1ste3 &egulating bod1 balance.
6u&the&3o&e0 the lite&atu&e shows
that :4/ a&e not o'ten &elated to s2eci'ic occlusal
conditions0 and the1 also do not ha-e an1 detect
able &elationshi2s with head and bod1 2ostu&e. :he
use o' clinical and inst&u3ental a22&oaches 'o&
assessing bod1 2ostu&e is not su22o&ted b1 the
wide 3ajo&it1 o' the lite&atu&e0 3ainl1 because o'
wide -a&iations in the 3easu&able -a&iables o'
2ostu&e. 8n conclusion0 the&e is no e-idence 'o&
the e$istence o' a 2&edictable &elationshi2 between
occlusal and 2ostu&al 'eatu&es0 and it is clea&
that the 2&esence o' :4/ 2ain is not &elated
with the e$istence o' 3easu&able
occluso2ostu&al abno&3alities. :he&e'o&e0 the
use inst&u3ents and techniFues ai3ing to
3easu&e 2u&2o&ted occlusal0 elect&o31og&a2hic0
kinesiog&a2hic o& 2ostu&o g&a2hic
abno&3alities cannot be justi'ied in the
e-idencebased :4/ 2&actice.
G7CH()/<: occlusion0 bod1 2ostu&e0 te32o&o3an
dibula& diso&de&s0 diagnosis0 t&eat3ent
.cce2ted 'o& 2ublication 2! %anua&1 2012
8nt&oduction
:he issue o' &elationshi2s between dental occlusion0
bod1 2ostu&e and te32o&o3andibula& diso&de&s D:4/E
is a cont&o-e&sial to2ic in dentist&10 and it is o'ten a
sou&ce o' s2eculations. . desc&i2tion o' the a-ailable
knowledge about the 2h1siolog1 o' the bod1 2ostu&e+
dental occlusion &elationshi2 is 'unda3ental to discuss
the 2ossible diagnostic and the&a2eutic i32lications o'
the assess3ent o' bod1 2ostu&e in subjects with occlusal
2012 Blackwell Publishing
Ltd
abno&3alities o& 2atients with :4/. 8n 2a&ticula&0
clai3s 'o& t&eating :4/ acco&ding to 2atho2h1siological
conce2ts to co&&ect 2u&2o&ted occluso2ostu&al abno&
3alities see3 to be based on doubt'ul theo&ies. :he
in-asi-e natu&e o' such t&eat3ents &eFui&es that these
conce2ts ha-e to be 2&o-en with e-idencebased data
which account 2&o2e&l1 'o& the 2h1siolog1 o' such
&elationshi2s.
.cco&ding to the 2&o2onents o' these conce2ts0
a22&o2&iate diagnostic 2&ocedu&es and inst&u3ent ha-e
20! /. 4.5 6 ) 7 /8 58 et al.
to be ado2ted to 3easu&e sto3atognathic 'unction and
to assess its 2ossible &elation with the whole bod1
2ostu&e. :o this 2u&2ose0 se-e&al 3echanical o& elec
t&onic de-ices ha-e been utilised as 3easu&e3ent tools
in the &esea&ch setting* a3ong othe&s0 the1 include
su&'ace elect&o31og&a2h1 Ds74>E0 kinesiog&a2h1 DG>E0
2ostu&al 2lat'o&3s and 2ostu&og&a2hic de-ices. Bow
e-e&0 thei& use in the clinical setting as standalone
diagnostic tools has &aised st&ong negati-e c&iticis3
within the scienti'ic co33unit1 D1+3E. 8ndeed0 the
3ost co33on a22lication 'o& so3e o' the abo-e de-ices
is in the diagnosis o' :4/0 whe&e the1 a&e '&eFuentl1
used to diagnose occlusal abno&3alities and to 2lan
thei& i&&e-e&sible co&&ection to 3anage and e-en 2&e
-ent :4/ s132to3s D"E. <2ace does not 2e&3it a 'ull
discussion o' this 3atte& he&e0 but su''ice it to sa1 that
this a22&oach to :4/ 2&oble3s has been widel1
challenged and gene&all1 &ejected b1 the scienti'ic
:4/ co33unit1.
(wing to the lack o' knowledge &ega&ding se-e&al
as2ects o' the occlusion+bod1 2ostu&e+:4/ &elation
shi20 it see3s that caution is needed be'o&e &e'uting
the diagnostic use'ulness o' 'unctional inst&u3ental
assess3ent in the clinical setting. :he&e'o&e0 the
autho&s decided to &e-iew the a-ailable lite&atu&e on
these 3atte&s to anal1se cu&&ent scienti'ic thinking
about the 'ollowing th&ee to2ics: DiE :he 2h1siolog1 o'
the dental occlusion+bod1 2ostu&e &elationshi20 DiiE
:he &elationshi2 o' these two 'acto&s with :4/ and
DiiiE :he -alidit1 o' the a-ailable inst&u3ental de-ices
to 3easu&e the dental occlusion+bod1 2ostu&e+:4/
&elationshi2.
Ph1siolog1 o' the dental occlusion+
bod1 2ostu&e &elationshi2
:he bio3echanical and neu&ological &elationshi2s o'
the sto3atognathic s1ste3 with othe& bod1 dist&icts
ha-e been add&essed b1 a g&owing nu3be& o'
&esea&ches in &ecent 1ea&s D50 6E. :he a-ailable lite&atu&e
&e-iews suggested that the&e is a two'old need to
i32&o-e the 3ethodological Fualit1 o' the in-estiga
tions as well as to add&ess 3o&e s2eci'ic clinical
Fuestions D,+10E. 8n 2a&ticula&0 the occlusion+2ostu&e
&elationshi2s 3ust be assessed in te&3s o' a 2ossible
twowa1 e''ect0 -iI.0 occlusion a''ects 2ostu&e and
-ice-e&sa. .t 2&esent0 lite&atu&e data we&e 3ostl1 based
on the e''ects o' dental occlusion on head and bod1
2ostu&e0 while -e&1 sca&ce in'o&3ation is a-ailable on
the in-e&se e''ects o' 2ostu&e on dental occlusion. <o3e
occlusal 'eatu&es &elated with g&oss skeletal 3alocclu
sions a&e likel1 to &eFui&e 2ostu&al ada2tation at nea& as
well as &e3ote 3usculoskeletal dist&icts* so0 it should be
inte&esting to gain a bette& insight into the &elationshi2
o'0 a3ong the othe&s0 se-e&e &et&ognathis30 2&o
nounced 2&ognathis30 skeletal h12e& J h12odi-e&gence0
'acial as133et&10 with 2ostu&al ada2tation at the
ce&-ical s2ine le-el0 as well as 2ostu&al balance and
'oot leaning a&ea.
.s conce&ns the &elationshi2 between 3alocclusions
and head 2ostu&e0 a co&&elation was desc&ibed between
'eatu&es o' skeletal class 88 3alocclusions0 -iI.0 &et&uded
3andibula& 2osition and &educed 3andibula& length on
the sagittal 2lane and inc&eased ce&-ical lo&dosis D11E.
.lso0 the deg&ee o' ce&-ical lo&dosis was shown to be
associated with -e&tical c&anio'acial 3o&2holog1 and
ante&io& o-e&jet0 with skeletal class 88 ha-ing an ante
&io&ised and class 888 a 2oste&io&ised head and bod1
2ostu&e D12E. .ctuall10 no in-estigation so 'a& cont&olled
'o& the e''ect o' age as a 2ossible con'ounde&. <uch
sho&tco3ing assu3es i32o&tance in the light o' 'ind
ings that age is the 3ain 'acto& in'luencing the deg&ee
o' ce&-ical lo&dosis0 with the two -a&iables ha-ing a
di&ect 2&o2o&tional &elationshi20 -iI.0 lo&dosis inc&eases
with age D13E.
.s &ega&ds the in'luence o' dental occlusion abno&
3alities on &e3ote 3usculoskeletal dist&icts0 it was
h12othesised that jaw 2ostu&e 3a1 in'luence distal
3uscles and cause 2ostu&al ada2tations at the s2ine
co&d le-el. .3ong the occlusal 'acto&s 2otentiall1
in'luencing s2ine cu&-e and 3o&2holog10 the &ole o'
3onolate&al c&ossbite has been in-estigated in the
lite&atu&e as a &isk 'acto& 'o& as133et&ic jaw g&owth and
3uscle acti-it1 D1"0 15E. .ctuall10 des2ite the well
known o&thodontic indications to co&&ect 3onolate&al
c&ossbite in the 2aediat&ic age D16E0 e-idence is lacking
that unt&eated c&ossbite 3a1 lead to the onset and J o&
wo&sening o' 2athological t&ans-e&se as133et&1 at the
do&sal o& lu3ba& s2ine le-el. (&thodontic t&eat3ent o'
3onolate&al c&ossbite cannot in'luence0 neithe& 2osi
ti-el1 no& negati-el10 scoliosis0 which is the s2ine
2atholog1 3o&e '&eFuentl1 in-estigated in dentist&1
D#E. 8ndeed0 scoliosis has an unknown idio2athic aeti
olog1 in about #0K o' cases D1,0 1!E.
4o&e in gene&al0 the a-ailable studies 'ocused on the
association between a single occlusal 'eatu&e and a
single 2ostu&al 2a&a3ete& in non&e2&esentati-e 2o2u
lations0 in the absence o' cont&ol g&ou2s0 without blind
2012 Blackwell Publishing
Ltd
e$a3ine&s0 and with the ado2tion o' 3easu&e3ent
tools the -alidit1 o' which was not assessed. .lso0 a
causeande''ect &elationshi2 was ne-e& assessed as this
would &eFui&e longitudinal studies that a&e cu&&entl1
lacking.
:he lite&atu&e is not conclusi-e also as 'o& the
in'luence o' jaw 2ostu&e and occlusal 'eatu&es on the
'oot leaning a&ea. :he a-ailable 2ostu&og&a2hic tech
niFues and de-ices 'ailed to detect an association
between bod1 2ostu&e and dental occlusion D1#0 20E
o&0 when detected0 these we&e notabl1 s3all and with
2oo& clinical &ele-ance. ;linicall10 this 3eans that
t&ige3inal 2&io2&ioce2tion in'luencing 2ostu&e is likel1
3ediated b1 co32ensation 3echanis3s th&ough a''e&
ent 2athwa1s to the neu&o3uscula& s1ste3 &egulating
bod1 balance and 2ostu&e. .s a conseFuence0 it can be
suggested that 2ostu&og&a2hic techniFues 3a1 be
e32lo1ed 'o& the stud1 o' 2ostu&e 2h1siolog1 in the
&esea&ch setting0 but thei& clinical use'ulness in den
tist&1 is 2oo&. 4o&eo-e&0 it see3s that the e$ecution o'
cont&olled jaw 3oto& tasks has a 2ositi-e e''ect on
2ostu&e cont&ol b1 &educing bod1 swa1 a&ea0 thus
suggesting that occlusal 2&io2&ioce2ti-e 'eedback a''ects
2ostu&e cont&ol inde2endentl1 b1 the 3o&2holog1 o'
dental occlusion D21E.
(cclusion0 bod1 2ostu&e and
:4/
s132to3s
:he&e a&e se-e&al conce&ns that 2&e-ent '&o3 d&awing
conclusions on the 2h1sio2atholog1 o' the &elationshi2
between occlusion and 2ostu&e and its clinical i32act*
a3ong these0 the need to 'ind a22&o2&iate 3easu&e
3ent de-ices and the lack o' 3ajo& associations
between an1 occlusal and J o& 2ostu&al 'eatu&es and
:4/ s132to3s.
.s &ega&ds the 3easu&e3ent o' occlusal and 2ostu&al
'eatu&es0 se-e&al techniFues De.g. s74>0 G>0 di''e&ent
clinical and inst&u3ental 2ostu&og&a2hic a22&oachesE
we&e 2&o2osed o-e& the 1ea&s to assess -a&ious neu&o
3uscula& -a&iables which we&e clai3ed b1 2&o2onents
to be &elated with dental occlusion and bod1 2ostu&e.
/es2ite the e''o&ts 3ade in the &esea&ch setting to assess
and i32&o-e the &eliabilit1 o' those inst&u3ental
de-ices 'o& the stud1 o' the sto3atognathic s1ste3
and the &elationshi2 with 2ostu&e D22+26E0 the1 ha-e
wellknown st&ong li3its to thei& clinical a22lication
because o' the absence o' no&3ati-e -alues cont&olled
'o& age0 se$0 weight0 height and 'acial 3o&2holog1.
4o&eo-e&0 data inte&2&etation is o'ten 3isleading owing
to the high int&a and inte&e$a3ine&s -a&iabilit1 'o&
single0 as well as &e2eated 3easu&es D2,E.
:he 3ajo&it1 o' inst&u3ental data on the sto3ato
gnathic s1ste3 we&e achie-ed with s74> &eco&dings0
which 3a1 hel2 to assess the kinesiolog1 o' 3o-e3ent
diso&de&s0 to disc&i3inate between di''e&ent t&e3o&s0
31oclonus and d1stonia0 to e-aluate gait and 2ace
diso&de&s0 to 3easu&e 2s1cho2h1sical &eaction ti3e.
:hei& use'ulness in the diagnostic and t&eat3ent 2ath
wa1s o' 2ain diso&de&s is not su22o&ted in the neu&o
logical lite&atu&e D2!E.
/es2ite thei& Fuick di''usion in the 1ea&s i33ediatel1
'ollowing thei& int&oduction on the dental 3a&ket D2#+
32E0 'ew &esea&che&s 'ocused on the &eliabilit1 and
accu&ac1 o' the -a&ious technological de-ices0 and e-en
ea&l1 lite&atu&e &e-iews suggested that 3ost autho&s
'ailed to unde&stand thei& li3its o' a22lication in
dentist&1 D33E. :he ado2tion o' cont&olled e$2e&i3ental
2&otocols can 3a&kedl1 &educe the e''ects o' non
2h1siological 'acto&s on s74> &eco&dings and 3ake
such techniFue a use'ul tool to un&a-el so3e as2ects o'
jaw ele-ato& 3uscles 'unctioning D3"E. :hus0 the 3ain0
and 2&obabl1 uniFue0 'ield o' a22lication 'o& s74> is
the &esea&ch setting0 while too 3an1 sho&tco3ings
2&e-ent '&o3 suggesting its clinical a22lication 'o&
diagnostic 2u&2oses0 es2eciall1 as conce&ns &esting
s74> -alues D35E.
.s &ega&ds the &elationshi2 between occluso2ostu&al
'eatu&es and clinical s132to3s0 the lite&atu&e has
&e2eatedl1 shown the 2oo& 2&edicti-e -alue o' occlusal
'eatu&es 'o& :4/ s132to3s in 3ulti2le -a&iable 3odels
D360 3,E. <uch a weak association with clinical s132
to3s was also shown 'o& ce&-ical s2ine cu&-e D3!E0 and
'oot leaning 'eatu&es D21E. 8ndeed0 'o& e$a32le0 e-en i'
statisticall1 signi'icant di''e&ences ha-e been &ecentl1
desc&ibed as 'o& the c&anioce&-ical 2ostu&e between
2atients with 31ogenous :4/ and health1 subjects0
such di''e&ences we&e too s3all0 -iI.0 3L3 deg&ees0 to be
judged signi'icant '&o3 a clinical -iew2oint D3#E. .lso0
it should be conside&ed that 31ogenous :4/ 2ain
3ight e-en be the &es2onsible 'o& 3uscle tone and
2ostu&al ada2tation in nea& dist&icts0 so that the clinical
use'ulness o' such in'o&3ation is -e&1 2oo&. 4o&eo-e&0
the 3ost &ecent s1ste3atic lite&atu&e &e-iews did not
su22o&t the use o' i&&e-e&sible occlusal the&a2ies 'o&
:4/ t&eat3ent and J o& 2&e-ention D"0+"3E.
/es2ite the o-e&whel3ing a3ount o' 2a2e&s sug
gesting that stud1ing dental occlusion is not a ke1 'acto&
in the :4/ 2&actice0 two 3ain lines o' &esea&ch ha-e
been ad-ancing 'o& 1ea&s0 -iI.0 the stud1 o' the
statistical association between ce&tain occlusal -a&iables
and the 2&esence o' signs and s132to3s o' :4/0 and
the atte32ts to si3ulate e$2e&i3entall1 situations o'
occlusal st&ess to -e&i'1 thei& 2otential to da3age the
:4% and 3asticato&1 3uscles.
(cclusal 'eatu&es we&e neithe& 'ound to be associated
with :4% 2&oble3s D36E no& with 3uscle diso&de&s
D""E0 but the1 should be -iewed as the 3eans th&ough
which 3uscle 'o&ces a&e t&ans3itted to the di''e&ent
st&uctu&es o' the sto3atognathic s1ste3 D"5E. .lso0 the
2&esence o' occlusal abno&3alities in 2atients with :4/
3a1 be actuall1 due to joint degene&ation and J
o& &e3odelling &esulting in an occlusal shi't D"6E.
7$2e&i3ents on hu3an and ani3al 3odels in-esti
gating the 2otential o' occlusal inte&'e&ences to 2&o
-oke :4/ signs and s132to3s showed that 2ossible
iat&ogenic abno&3alities De.g. high occlusal &esto&a
tionsE can0 at wo&st0 cause local t&au3a. :hose inte&
'e&ences de3and 2ostu&al and 'unctional ada2tation o'
3asticato&1 2atte&ns which &a&el1 lead to dental
and J o& 3asticato&1 3uscle 2ain. .lso0 when those
s132to3s occu&0 the1 see3 to be 3ainl1 t&ansient and
can be easil1 &e-e&sed th&ough &e3o-al o' the iat&o
genic inte&'e&ence. /ata '&o3 &ando3ised cont&olled
studies suggest that in health1 subjects the a22lication
o' an occlusal inte&'e&ence leads to a &eduction in the
usual 74> acti-it1 o' the 3assete& 3uscles D",E and
does not signi'icantl1 a''ect 2&essu&e 2ain th&esholds
D"!E.
8nte&estingl10 subjects with a :4/ histo&1 see3 to
&es2ond di''e&entl1 to iat&ogenic occlusal inte&'e&ences
co32a&ed with subjects who &e2o&ted no histo&1 o'
2&e-ious :4/ D"#E. :he 'o&3e& we&e &e2o&ted to ha-e
an inc&eased &isk o' &e2o&ting 2ain with 3uscle 2al2a
tion in &es2onse to occlusion abno&3alities 2&o-oked b1
dental 2&ocedu&es. :hese obse&-ations should be bo&ne
in 3ind when ca&&1ing out occlusal t&eat3ents such as
2&osthetic o& o&thodontic &ehabilitations0 which 3a1
in-ol-e 2e&iods o' occlusal instabilit1 De.g. te32o&a&1
&esto&ations0 inc&eases in -e&tical di3ension and teeth
shi'tingE. 6&o3 a :4/ 2&actitione&Ms 2e&s2ecti-e0 it is
clea&l1 i32o&tant to a-oid o-e&esti3ating the i32o&
tance o' these &esults0 because &es2onses to the int&o
duction o' an a&ti'icial inte&'e&ence cannot be eFuated
with the 2&esence o' :4/. Besides0 an acute e$2e&i
3ental occlusal alte&ation cannot be co32a&ed with a
clinical situation cha&acte&ised b1 the 2&esence o' a
NnonidealM dentition to which the 2atient has g&aduall1
ada2ted o-e& a 2e&iod o' 1ea&s D500 51E.
8n -iew o' the abo-e conside&ations0 atte32ts to
achie-e standa&dised 3easu&e3ents 'o& &esea&ch 2u&
2oses as well as a 3o&e sensible a22&oach to the use o'
technolog1 'o& clinical 2u&2oses 3ust be encou&aged.
5otwithstanding that0 it should be bo&ne in 3ind that
:4/ ha-e a 3ulti'acto&ial aetiolog1 and that a single
causal 'acto& can be seldo3 identi'ied0 thus suggesting
caution be'o&e h12othesising an1 causeande''ect links
based on so3e occasional weak associations between
occluso2ostu&al 'acto&s and :4/ desc&ibed in a 'ew
studies D52+5"E. (n the othe& hand0 it should also be
&e3e3be&ed that di3inishing the &ole o' occlusion in
the aetiolog1 o' :4/ is not eFual than neglecting
wellestablished occlusal conce2ts in o&thodontics and
2&osthetic dentist&10 because w&ong occlusion on
&esto&ed J t&eated dentition has the 2otential to cause
iat&ogenic t&au3a i' acute changes o' the inte&a&ch
&elationshi2 a&e 2&o-ided D550 56E.
8n su33a&10 a 3echanical a22&oach to :4/ 3an
age3ent b1 3eans o' i&&e-e&sible occlusal t&eat3ents
De.g. o&thodontics0 2&osthodontics and occlusal adjust
3entE0 which a&e o'ten &eco33ended on the basis o'
inst&u3ental assess3ents o' 2atients with :4/0 3ust
be st&ongl1 discou&aged '&o3 a scienti'ic -iew2oint and
'i&3l1 conde3ned '&o3 an ethical -iew2oint D3E.
(wing to the 2oo& knowledge on :4/ aetiolog1 at
the indi-idual le-el0 and also because o' the high
success &ates o' se-e&al conse&-ati-e a22&oaches D5,+
60E0 the standa&d o' ca&e 'o& :4/ t&eat3ent is now
based on s132to3s 3anage3ent b1 &e-e&sible and
nonin-asi-e t&eat3ents D61E. 8ndeed0 3ost 2atients
with :4/ see3 to be good &es2onde&s to uns2eci'ic
t&eat3ent &egi3ens0 because o' s132to3sM 'luctuation
and sel'li3itation0 &eg&ession to the 3ean 2heno3ena
and 2lacebo e''ect D620 63E. :he 2athological &ele-ance
o' 2u&2o&ted abno&3alities0 such as joint click sounds0
was st&ongl1 di3inished D6"E0 and the&e is g&owing
e-idence that ch&onic :4/ 2ain is &elated to cent&al
sensitisation 2heno3ena that &eFui&e a co32le$
3ultidisci2lina&1 a22&oach D65E. :hus0 :4/ a&e nei
the& occlusal no& 2ostu&al 2athologies* the1 a&e
3usculoskeletal diso&de&s needing 'o& a clinical 3an
age3ent in line with that ado2ted 'o& si3ila& diso&
de&s in othe& 'ields o' 3edicine De.g. o&tho2edics0
&heu3atolog1 and &ehabilitation 3edicineE and0 in
those 3ost se-e&e cases0 needing 'o& a 3ultidisci2lin
a&1 e''o&t to 3anage ch&onic 2ain in coo2e&ation with
othe& 2&o'essionals De.g. neu&ologists0 2s1chiat&ists and
2s1chologistsE.
/iagnostic accu&ac1 o' technological
de-ices
8n theo&10 using inst&u3ents to 3easu&e objecti-el1 an
othe&wise subjecti-e clinical 2a&a3ete& is a 'ascinating
idea that &eFui&es an u23ost attention in li'eth&eat
ening 2athologies0 whe&e an1 2otential sou&ce o'
diagnostic bias 3a1 lead to dis&u2ti-e conseFuences
and that also att&acts &esea&che&s '&o3 an1 3edical
'ields dealing with 3usculoskeletal diso&de&s0 whe&e the
lea&ning cu&-e to achie-e standa&dised clinical diagno
ses is usuall1 long and '&ust&ating.
8n 2&actice0 to be use'ul in a clinical setting0 an
inst&u3ent should ha-e both inte&nal and e$te&nal
-alidit1. :he 'o&3e& -alidit1 de&i-es '&o3 those 'acto&s
that dete&3ine the &e2eatabilit1 and technical e''icac10
while the latte& -alidit1 de2ends on the inst&u3entMs
accu&ac1 to 3easu&e the 3ain 2athological 3a&ke& Di.e.
the 2owe& to &ecognise disease -e&sus absence o'
diseaseE.
8n the 'ield o' :4/0 the 3ain 2athological 3a&ke& is
2ain. :he need to 'ind an objecti-e &elationshi2
between clinical s132to3s De.g. 2ain e-oked with
2al2ationE and inst&u3ental signs led to di3inish the
&ole and to the identi'1 bette& the indications 'o&
othe&wise technicall1 e''icacious de-ices0 such as 3ag
netic &esonance i3aging D,66!E0 on the basis o' thei&
in'luence on decision3aking and t&eat3ent2lanning
D6#0 ,0E.
:he sa3e &easoning should be done to de'ine the
clinical use'ulness o' s74>0 G> and 2ostu&al 2lat'o&3s0
which a&e e-en cha&acte&ised b1 a doubt'ul inte&nal
-alidit1. Besides0 se-e&al wo&ks in the lite&atu&e showed
that such techniFues ha-e a low accu&ac1 to disc&i3
inate between 2atients with :4/ and as132to3atic
subjects D2,0 330 ,1+,3E. :hei& ado2tion as diagnostic o&
e-en t&eat3ent2lanning tools in 2atients with :4/
cannot be justi'ied due to a too high 2e&centage o' 'alse
2ositi-es0 which is u2 to !0K 'o& se-e&al 2a&a3ete&s
De.g. s74> -alues at &est0 all kinesiog&a2hic 2a&a3ete&s
and all 2ostu&al 2lat'o&3 -a&iablesE D,30 ,"E.
/es2ite such sho&tco3ings0 the lite&atu&e also
showed that s74> 3a1 'ind 2&o3ising a22lication in
the clinical setting b1 conside&ing onl1 so3e selected
2a&a3ete&s0 and in 2a&ticula& the 3a$i3u3 clenching
le-els. 8ndeed0 acco&ding to the 2ain ada2tation 3odel
and its integ&ation D,50 ,6E0 2ain a''ects negati-el1
3oto& units &ec&uit3ent and causes a &eduction in
3a$i3u3 3uscle 'o&ce with &es2ect to no&3al 2h1s
iological 'unctioning. <tanda&dised a22&oaches unde&
cont&olled e$2e&i3ental conditions allow &eco&ding
&eliable and &e2eatable 3easu&e3ents D2"E0 with
acce2table -alues o' sensiti-it1 and s2eci'icit1 'o& s74>
-alues du&ing 3a$i3u3 clenching D,"E. <tanda&dised
s74> in labo&ato&1 settings showed a sensiti-it1 o'
!6K and a s2eci'icit1 o' #2K to disc&i3inate between
2atients with :4/ and those with neck 2ain D,,E. .lso0
so3e s74>based inde$es o' 3uscle 'unctioning De.g.
3uscle to&Fue inde$E 3a1 ha-e acce2table accu&ac1 to
&ecognise 2atients with di''e&ent )/; J :4/ diagnoses
D,!E0 but the1 cannot identi'1 as132to3atic subjects
D,#E. 8n -iew o' the abo-e0 it can be suggested that e-en
74> de-ices ado2ted in cont&olled labo&ato&1 settings0
which a&e able to 2&o-ide ancilla&1 'indings to the
clinical assess3ent0 cannot be used as standalone
diagnostic tools.
.s 'o& clinical techniFues 'o& 2ostu&al assess3ent and
as 'o& 2ostu&og&a2hic inst&u3ents0 such as 2ostu&al and
ba&o2odo3et&ic 2lat'o&3s0 the lite&atu&e 2&o-ided no
data on thei& s2eci'icit1 and sensiti-it1 in dentist&1. :he
3ost co32&ehensi-e &e-iew 2ublished so 'a& concluded
that the use'ulness o' such inst&u3ents J techniFues in
dentist&1 is -e&1 2oo& D,3E. :he e$a3ined 2a2e&s we&e
o' low Fualit1 on a-e&age0 with a 2oo& 3ethodological
design0 and 2ostu&og&a2h1 'ailed to be &eliable and
accu&ate to inte&ce2t :4/ 2atients0 with onl1 two o' 21
2a2e&s 'inding a highe& betweeng&ou2 D2atients with
:4/ -e&sus cont&olsE di''e&ence in the 3ain outco3e
2a&a3ete& than the withing&ou2 -a&iance o' the sa3e
2a&a3ete& D,3E. :hose two studies assessed &es2ecti-el1
an as133et&1 inde$ o' the bod1 swa1 a&ea on 2ostu&al
2lat'o&3s to be used in cont&olled labo&ato&1 settings
D!0E0 and so3e clinical 2a&a3ete&s 'o& the t&unk
2ostu&al anal1sis on the sagittal 2lane D!1E. :he clinical
signi'icance o' such 'indings is 1et to be de'ined. :hus0
in gene&al0 the wide 3ajo&it1 o' the studies0 e-en i'
so3e autho&s clai3ed 2ositi-e conclusions on the use o'
2ostu&al 2lat'o&3s that we&e not su22o&ted e-en b1
thei& own stud1Ms 'indings D!20 !3E0 did not su22o&t the
use o' clinical 2ostu&al assess3ent and 2ostu&og&a2hic
de-ices in dentist&1 D1#0 !"+!6E.
.n i32o&tant 2oint to &e3a&k is the&e it see3s to be
a st&ong di''e&ence between the conce2ts unde&l1ing
the use o' elect&o31og&a2h10 G> and 2ostu&og&a2h1
in the &esea&ch setting and the co33e&cial abuse
cha&acte&ising thei& ado2tion in the clinical setting.
8ndeed0 the latte& is too o'ten based on 2&esu32ti-e
2atho2h1siological theo&ies ai3ing to justi'1 the need
'o& i&&e-e&sible and e$2ensi-e occlusal t&eat3ents. :he
scienti'ic co33unit1Ms sce2ticis3 towa&ds the 2otential
use'ulness o' technological de-ices in the :4/ 'ield
conce&ns thei& ado2tion as standalone diagnostic tools
to inte&ce2t 2u&2o&ted occlusal and 2ostu&al abno&3al
ities that0 in the use&sM intentions0 need to be co&&ected.
<uch a t12ical chain o' e-ents0 which cha&acte&ises
so3e socalled 2hiloso2hies to a22&oach the dental
2&o'ession De.g. neu&o3uscula& dentist&10 dental kine
siolog1 and osteo2ath1E is not scienti'icall1 sound and is
a sou&ce o' unjusti'ied o-e&t&eat3ents0 with subseFuent
huge biological and 'inancial costs. :he biological0
2s1chosocial and social conseFuences as well as the
clinical i32lications o' such beha-iou&s 3ust be con
side&ed 'o& debate as a g&owing 3edical legal 2&oble3
D3E. (n the othe& hand0 it 3ust be bo&ne in 3ind that
an adhoc use o' technological de-ices 'o& &esea&ch
2u&2oses still &e3ains 'unda3ental to get dee2e& into
the knowledge o' the sto3atognathic s1ste3Ms 2h1siol
og1. .lso0 a 3ajo& sho&tco3ing o' so3e clinical
h12otheses is that0 while st&ong e32hasis has been
2ut on 2&o2osing occlusal a22&oaches to co&&ect bod1
2ostu&e0 onl1 a 'ew in'o&3ation has been gathe&ed on
the 2otential use'ulness o' t&eating bod1 2ostu&e to
o2ti3ise jaw 'unction and 3anage :4/ s132to3s and
on the &elati-e use'ulness o' co&&ecting occlusion 'o&
2ostu&al diso&de&s with &es2ect to othe& s1ste3ic
a22&oaches 2&o2e& o' the e-idencebased &ehabilitation
3edicine. :his 3eans that0 acco&ding to so3e dental
2&o'essionals0 dentists see3 to ha-e al3ost the whole
task o' disco-e&ing and t&eating 2ostu&al diso&de&s0
which is likel1 to be a biological nonsense.
;onclusions
8n conclusion0 the&e is no e-idence 'o& the e$istence o' a
2&edictable &elationshi2 between occlusal and 2ostu&al
'eatu&es0 and it is clea& that the 2&esence o' :4/ 2ain is
not &elated with the e$istence o' 3easu&able occluso
2ostu&al abno&3alities. :he&e'o&e0 the use inst&u3ents
and techniFues ai3ing to 3easu&e 2u&2o&ted occlusal0
elect&o31og&a2hic0 kinesiog&a2hic o& 2ostu&og&a2hic
abno&3alities cannot be justi'ied in the e-idencebased
:4/ 2&actice.
.ll theo&ies a22a&entl1 su22o&ting the clinical i32li
cations o' assessing dental occlusion+bod1
2ostu&e+
:4/ &elationshi2 did not stand u2 to se&ious sc&utin10
and the1 a22ea& to be a clinical nonsense. :he
ado2tion o' inst&u3ental de-ices to assess dental
occlusion and bod1 2ostu&e has to be &ese&-ed to
st&ictl1 cont&olled &esea&ch settings0 with the ai3 to
cla&i'1 the 3ain doubts conce&ning the high inte&indi
-idual -a&iabilit1 o' the occlusion+bod1 2ostu&e+:4/
&elationshi2. (nl1 then0 h12othesistested clinical sug
gestions could be d&awn.
:he a-ailable e-idence suggests that the conse
Fuences o' occlusal o-e&t&eat3ents ai3ing to sol-e
:4/ 2ain and thei& &elated biological0 'inancial and
2s1chosocial costs ha-e to be 3o&e clea&l1 de'ined '&o3
a 3edical legal -iew2oint0 -iI.0 2&o'essional liabilit1
2&o'iles. 6&o3 an ethical -iew2oint0 all 2&actitione&s
in-ol-ed in the 3anage3ent o' 2atients with :4/
ha-e to &ecognise thei& &ole o' ca&e2&o-ide&s 2u&suing
the 2atientsM inte&ests within the bounda&ies o' e-i
dencebased 3edicine.
)e'e&ences
1. >&eene ;<. :he etiolog1 o' te32o&o3andibula& diso&
de&s: i32lications 'o& t&eat3ent. % (&o'ac Pain.
2001*15:
#3+105.
2. )inchuse /%0 )inchuse /%0 Gandasa31 <. 7-idencebased
-e&sus e$2e&iencebased -iews on occlusion and :4/. .3 %
(&thod /ento'ac (&tho2ed. 2005*12,:2"#+25".
3. 4an'&edini /0 Bucci 4B0 4ontagna 60 >ua&da5a&dini L.
:e32o&o3andibula& diso&de&s assess3ent: 3edicolegal con
side&ations in the e-idencebased e&a. % (&al )ehabil.
2011*3!:101+11#.
". ;oo2e& B;0 Gleinbe&g 8. 7stablish3ent o' te32o&o3andibula&
2h1siological state with neu&o3uscula& o&thosis t&eat3ent
a''ects &eduction o' :4/ s132to3s in 313 2atients.
;&anio.
200!*26:10"+11,.
5. -anMt <2ijke& .0 ;&euge&s 5B0 B&onkho&st 740 G&eulen ;4.
Bod1 2osition and occlusal contacts in late&al e$cu&sions:
a 2ilot stud1. 8nt % P&osthodont. 2011*2":133+136.
6. Hakano <0 :akeda :0 5akaji3a G0 Gu&okawa G0 8shiga3i G.
7''ect o' e$2e&i3ental ho&iIontal 3andibula& de-iation on
d1na3ic balance. % P&osthodont )es. 2011*55:22!+233.
,. .&3ijo (li-o <0 B&a-o %0 4agee /%0 :hie 54)0 4ajo&
PH0 6lo&es4i& ;. :he association between head and
ce&-ical 2ostu&e and te32o&o3andibula& diso&de&s: a
s1ste3atic &e-iew. % (&o'ac Pain. 2006*20:#+23.
!. .&3ijo (li-o <0 4agee /%0 Pa&'itt 40 4ajo& P0 :hie 54). :he
association between the ce&-ical s2ine0 the sto3atognathic
s1ste30 and c&anio'acial 2ain: a c&itical &e-iew. % (&o'ac Pain.
2006*20:2,1+2!,.
#. Banke B.0 4otschall 70 :u&2 %;. .ssociation between
o&tho2edic and dental 'indings: what le-el o' e-idence is
a-ailableO % (&o'ac (&tho2. 200,*6!:#1+10,.
10. 4ichelotti .0 6a&ella 4. 4alocclusion and bod1 2ostu&e.
8n: 4an'&edini /0 ed. ;u&&ent conce2ts on
te32o&o3andib ula& diso&de&s. Be&lin: Puintessence
Publishing* 2010:
2!3+2#3.
11. Go&b3ache& B0 7gge&s<t&oede& >0 Goch L0 Gahl5ieke B.
;o&&elation between ano3alies o' the dentition and
2athol ogies o' the loco3oto& s1ste3: a lite&atu&e &e-iew.
% (&o'ac (&tho2. 200"*65:1#0+203.
12. <olow B0 <onnesen L. Bead 2ostu&e and 3alocclusions. 7u&
% (&thod. 1##!*20:6!5+6#3.
13. /oual %40 6e&&i %0 Laude 4. :he in'luence o' senescence on
c&anio'acial and ce&-ical 3o&2holog1 in hu3ans. <u&g )adiol
.nat. 1##,*1#:1,5+1!3.
1". .la&con %.0 4a&tin ;0 Pal3a %;. 7''ect o' unilate&al 2oste&io&
c&ossbite on the elect&o31og&a2hic acti-it1 o' hu3an
3asti cato&1 3uscles. .3 % (&thod /ento'ac (&tho2.
2000*11!:32!+
33".
15. Gilic 50 Giki .0 (kta1 B. ;ond1la& as133et&1 in
unilate&al 2oste&io& c&ossbite 2atients. .3 % (&thod
/ento'ac (&tho2.
200!*133:3!2+3!,.
16. Pa2ado2oulos 4.0 >kiaou&is 8. . c&itical e-aluation o'
3etanal1ses in o&thodontics. .3 % (&thod /ento'ac (&tho2.
200,*131:5!#+5##.
1,. Bu&well )>. .etiolog1 o' idio2athic scoliosis: cu&&ent con
ce2ts. Pediat& )ehabil. 200"*6:13,+1,0.
1!. Hang H%0 Ceung BC0 ;hu H;0 :ang 5L0 Lee G40 Piu
C et al. :o2 theo&ies 'o& the etio2athogenesis o'
adolescent idio2athic scoliosis. % Pediat& (&tho2. 2011*31D1
<u22lE:<1"+ <2,.
1#. Pe&inetti >. /ental occlusion and bod1 2ostu&e: no detectable
co&&elation. >ait Postu&e. 2006*2":165+16!.
20. Pe&inetti >. :e32o&o3andibula& diso&de&s do not co&&elate
with detectable alte&ations in bod1 2ostu&e. % ;onte32 /ent
P&act. 200,*5:60+6,.
21. Bell3ann /0 >iannako2oulos 550 Blase& )0 7be&ha&d L0
<chindle& B%. :he e''ect o' -a&ious jaw 3oto& tasks on bod1
swa1. % (&al )ehabil. 2011*3!:,2#+,36.
22. ;ast&o'lo&io :0 8ca&di G0 :o&sello 60 /e&egibus .0 /ebe&na&di ;0
B&acco P. )e2&oducibilit1 o' su&'ace 74> in the hu3an
3assete& and te32o&alis 3uscle a&eas. ;&anio.
2005*23:130+
13,.
23. ;ast&o'lo&io :0 6a&ina /0 Bottin .0 Piancino 4>0 B&acco
P0 4e&letti ). <u&'ace 74> o' jaw ele-ato& 3uscles: e''ect
o' elect&ode location and inte&elect&ode distance. % (&al
)ehabil.
2005*32:"11+"1,.
2". ;ast&o'lo&io :0 B&acco P0 6a&ina /. <u&'ace elect&o31og&a2h1
in the assess3ent o' jaw ele-ato& 3uscles. % (&al
)ehabil.
200!*35:63!+6"5.
25. Leitne& ;0 4ai& P0 Paul B0 Hick 60 4itte&3aie& ;0 <1cha : et
al.
)elaibilit1 o' 2ostu&og&a2hic 3easu&e3ents in the assess3ent
o' i32ai&ed senso&i3oto& 'unction in ch&onic low back 2ain.
% 7lect&o31og& Ginesiol. 200#*1#:3!0+3#0.
26. <u-inen :80 4al3be&g %0 6o&ste& ;0 Ge322ainen P. Postu&al and
d1na3ic 3assete& and ante&io& te32o&alis 3uscle 74>
&e2eatabilit1 in se&ial assess3ents. % (&al )ehabil. 200#*36:
!1"+!20.
2,. Glasse& >/0 (keson %P. :he clinical use'ulness o'
su&'ace elect&o31og&a2h1 in the diagnosis and
t&eat3ent o' te32o &o3andibula& diso&de&s. % .3
/ent .ssoc. 2006*13,:,63+,,1.
2!. Pull3an <L0 >oodin /<0 4a&FuineI .80 :abbal <0 )ubin 4.
;linical utilit1 o' su&'ace 74>. )e2o&t o' the
the&a2eutics and technolog1 assess3ent subco33ittee
o' the .3e&ican .cad e31 o' 5eu&olog1. 5eu&olog1.
2000*55:1,1+1,,.
2#. 4o1e&s )7. :e32o&o3andibula& 3uscle cont&action
2atte&ns in .ngle ;lass 880 di-ision 1 3alocclusions*
an elect&o31o g&a2hic anal1sis. .3 % (&thod.
1#"#*35:!3,+!5,.
30. ;a&lsoo <. 5e&-ous coo&dination and 3echanical
'unction o' the 3andibula& ele-ato&s* and
elect&o31og&a2hic stud1 o' the acti-it10 and an
anato3ic anal1sis o' the 3echanics o' the 3uscles.
.cta (dontol <cand <u22l. 1#52*10:1+132.
31. P&uIanski <. :he a22lication o' elect&o31og&a2h1
to dental &esea&ch. % .3 /ent .ssoc. 1#52*"":"#+6!.
32. %ankelson B. 7lect&onic cont&ol o' 3uscle
cont&action+a new clinical e&a in occlusion and
2&osthodontics. <ci 7duc Bull.
1#6#*
2:2#+
31.
33. Lund %P0 Hid3e& ;>0 6eine %<. Qalidit1 o'
diagnostic and 3onito&ing tests used 'o&
te32o&o3andibula& diso&de&s. % /ent )es.
1##5*,":1133+11"3.
3". <-ensson P. 7''ects o' hu3an jaw3uscle 2ain on
so3ato senso&1 and 3oto& 'unction: e$2e&i3ental
studies and clinical i32lications. (donto. /oct.
:hesis0 .a&hus Ani-e&sit10 .a&hus* 2000.
35. Baba G0 (no C0 ;la&k >:. 8nst&u3ental
a22&oach. 8n: 4an'&edini /0 ed. ;u&&ent conce2ts
on te32o&o3andibula& diso&de&s. Be&lin: Puintessence
Publishing* 2010: 223+236.
36. Pullinge& .>0 <elig3an /.. Puanti'ication and
-alidation o' 2&edicti-e -alues o' occlusal -a&iables in
te32o&o3andibula& diso&de&s using a 3ulti'acto&ial
anal1sis. % P&osthet /ent.
2000*!
3:66+
,5.
3,. 4an'&edini /0 Pe&etta )0 >ua&da5a&dini L0 6e&&onato >.
P&edicti-e -alue o' co3bined clinicall1 diagnosed
b&u$is3 and occlusal 'eatu&es 'o& :4% 2ain. ;&anio.
2010*2!:105+113.
3!. Qissche& ;40 /e Boe& H0 LobbeIoo 60 Babets LL0
5aeije 4. 8s the&e a &elationshi2 between head
2ostu&e and c&anio3an dibula& 2ainO % (&al )ehabil.
2002*2#:1030+1036.
3#. .&3ijo(li-o <0 )a22o2o&t G0 6uentes %0 >adotti 8;0
4ajo& PH0 Ha&&en < et al. Bead and ce&-ical
2ostu&e in 2atients with te32o&o3andibula& diso&de&s.
% (&o'ac Pain. 2011*25:1##+20#.
"0. 6o&ssell B0 Galso 70 Goskela P0 Qeh3anen )0
Puukka P0 .lanen P. (cclusal t&eat3ents in
te32o&o3andibula& diso& de&s: a Fualitati-e s1ste3atic
&e-iew o' &ando3iIed cont&olled t&ials. Pain.
1###*!3:5"#+560.
"1. ;la&k >:0 :suki1a3a C0 Baba G0 Hatanabe :. <i$t1eight
1ea&s o' e$2e&i3ental occlusal inte&'e&ence studies: what
ha-e we lea&nedO % P&osthet /ent. 1###*!2:,0"+,13.
"2. 6o&ssell B0 Galso 7. .22lication o' 2&inci2les o' e-idencebased
3edicine to occlusal t&eat3ent 'o& te32o&o3andibula& diso&
de&s: a&e the&e lessons to be lea&nedO % (&o'ac Pain.
200"*1!:#+22.
"3. Goh B0 )obinson P>. (cclusal adjust3ent 'o& t&eating and
2&e-enting te32o&o3andibula& joint diso&de&s. % (&al )eha
bil. 200"*31:2!,+2#2.
"". Landi 50 4an'&edini /0 :ognini 60 )o3agnoli 40 Bosco
4.
Puanti'ication o' the &elati-e &isk o' 3ulti2le occlusal
-a&iables 'o& 3uscle diso&de&s o' the sto3atognathic s1ste3.
% P&osthet /ent. 200"*#2:1#0+1#5.
"5. Pe&etta )0 4an'&edini /. 6utu&e 2e&s2ecti-es in :4/ 2h1sio
2atholog1. 8n: 4an'&edini /0 ed. ;u&&ent conce2ts on te32o
&o3andibula& diso&de&s. Be&lin: Puintessence Publishing*
2010:153+16!.
"6. /e Boe-e& %.0 ;a&lsson >70 Glinebe&g 8%. 5eed 'o&
occlusal the&a21 and 2&osthodontic t&eat3ent in the
3anage3ent o' te32o&o3andibula& diso&de&s. Pa&t 88: tooth
loss and 2&osth odontic t&eat3ent. % (&al )ehabil.
2000*2,:6",+65#.
",. 4ichelotti .0 6a&ella 40 >allo L40 Qelt&i .0 Palla <0 4a&tina ).
7''ect o' occlusal inte&'e&ence on habitual acti-it1 o' hu3an
3assete&. % /ent )es. 2005*!":6""+6"!.
"!. 4ichelotti .0 6a&ella 40 <teenks 4B0 >allo L40 Palla <.
5o e''ect o' e$2e&i3ental occlusal inte&'e&ences on 2&essa&e
2ain th&esholds o' the 3assete& 3uscles in health1 wo3en.
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200!*35:""6+"53.
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incidence o' de3and 'o& te32o&o3andibula& diso&de&
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53. Gi&-eska&i P0 %a3sa :. Bealth &isk '&o3 occlusal inte&'e&ences
in 'e3ales. 7u& % (&thod. 200#*31:"#0+"#5.
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2lanta& a&ch. % Bod1w 4o- :he&. 2011*15:2"2+250.
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3anage3ent o' te32o&o3andibula& diso&de&s. (&al 4a$illo
'ac <u&g ;lin 5o&th .3. 200!*20:1#,+210.
5!. Glasse& >/0 >&eene ;<. (&al a22liances in the 3anage3ent o'
te32o&o3andibula& diso&de&s. (&al <u&g (&al 4ed (&al Pathol
(&al )adiol 7ndod. 200#*10,:212+223.
5#. 4an'&edini /0 Piccotti 60 >ua&da5a&dini L. B1alu&onic acid in
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63+1,1.
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62. >&eene ;<0 >odda&d >0 4acaluso >40 4au&o >. :o2ical &e-iew:
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65. <tohle& ;<. :e32o&o3andibula& joint diso&de&s + the -iew widens
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Ph1siol Pha&3acol. 1##1*6#:6!3+6#".
(; ; L A< 8 (5 0 P (< : A) 7 0 . 5 / : 7 4P () (4.5/8 BAL . ) / 8 < () /7 ) < 215
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a new 3odel. % (&o'ac Pain. 200,*21:263+2,!.
,,. 6e&&a&io Q60 :a&taglia >40 Lu&aghi 670 <'o&Ia ;. :he use
o' su&'ace elect&o31og&a2h1 as a tool in di''e&entiating
te32o &o3andibula& diso&de&s '&o3 neck diso&de&s. 4an
:he&.
200,*12:3,2+3,#.
,!. /wo&kin <60 Le&esche L. )esea&ch diagnostic c&ite&ia
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/iso&d. 1##2*6:
301+355.
,#. :a&taglia >40 4o&ei&a )od&igues da <il-a 4.0 Bottini <0
<'o&Ia ;0 6e&&a&io Q6. 4asticato&1 3uscle acti-it1 du&ing
3a$i3u3 -olunta&1 clench in di''e&ent &esea&ch diagnostic
c&ite&ia 'o& te32o&o3andibula& diso&de&s D)/; J :4/E g&ou2s.
4an :he&. 200!*13:"3"+""0.
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!1. 5icolakis P0 5icolakis 40 Piehslinge& 70 7benbichle& >0
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dibula& diso&de&s and 2oo& 2ostu&e. ;&anio. 2000*1!:106+112.
!2. B&acco P0 /e&egibus .0 Piscetta ). 7''ects o' di''e&ent jaw
&elations on 2ostu&al stabilit1 in hu3an subjects. 5eu&osci
Lett. 200"*356:22!+230.
!3. ;uccia .0 ;a&adonna ;. :he &elationshi2 between the
sto3atognathic s1ste3 and bod1 2ostu&e. ;linics D<ao PauloE.
200#*6":61+66.
!". Li22old ;0 /anesh >0 Bo22e >0 /&e&u2 B0 Backenbe&g L.
<agittal s2inal 2ostu&e in &elation to c&anio'acial 3o&2holog1.
.ngle (&thod. 2006*,6:625+631.
!5. <'o&Ia ;0 :a&taglia >40 <oli3ene A0 4o&gun Q0 Gas2&anski1
))0 6e&&a&io Q6. (cclusion0 ste&nocleido3astoid 3uscle acti-
it10 and bod1 swa1: a 2ilot stud1 in 3ale ast&onauts. ;&anio.
2006*2":"3+"#.
!6. 4ichelotti .0 6a&ella 40 Buonoco&e >0 Pelleg&ino >0 Pie&
gentili ;0 4a&tina ). 8s unilate&al 2oste&io& c&ossbite associ
ated with leg length ineFualit1O 7u& % (&thod. 200,*2#:
622+626.
;o&&es2ondence: /aniele 4an'&edini0 /e2a&t3ent o' 4a$illo'acial
<u&ge&10 :4/ ;linic0 Ani-e&sit1 o' Pado-a0 Qia 8ngolstadt 30 5"033
4a&ina di ;a&&a&a D4<E0 8tal1. 73ail: daniele.3an'&e d iniWtin.it