HAVE MODIFICATIONS OF OCCLUSION AN IMMEDIATE REPERCUSSION ON THE FINE POSTURAL CONTROL SYSTEM?


L. BONNIER

SUMMARY

      To confirm our clinical experience, this work wanted to verify, on a sample of 50 patients habitually classified from clinical signs as algo-dystrophic syndromes of the temporo-mandibular joint (TMJ), that modifications of occlusion by the wearing of a bite brings about an immediate modification of some stabilometric parameters.

      In fact, just after the beginning of the wearing of the bite one observes:

- a modification (increase or decrease) of the area of the statokinesigram, in the eyes open-situation,
- a modification of the amplitude spectrum in the 0.3 Hz frequency band, in the eyes-open situation.

   Whatever be the interpretation of these facts, these results show clearly that the postural control reacts immediately to an instrumental modification of the occlusion.



INTRODUCTION

   Daily clinical observation shows, if we accept to observe it, that a modification of occlusion (dento-dental) induces evident postural modifications (1, 21) and reciprocally (4, 16). But in order to become more convincing these modifications have to be demonstrated by means of an instrumentation which prevents observer from doing any clinical test.

   I already (3) put forward the interest of posturographic recordings to precise the eventual relationship between occlusal and postural modifications, and to follow up such patients. I gave some examples of this interest of posturographic recordings, but as demonstrative as they could have been, these clinical stories were not a proof.

   In order to establish the reality of this relationship between occlusion and posture, I undertook verifying if the modification of occlusion by a bite (and of mandibular position and of muscular balance corresponding to the new occlusion) brings about an objective reply from the fine postural control system.

    This first work is concerned only with the immediate repercussions.


MATERIAL AND METHODS

   Objectivity was obtained by using a stabilometric platform, according to the standards (equipment, recording conditions and situations) of the 'Association Française de Posturologie' (8).With this apparatus, postural control from each subject can be characterized by values of several parameters which have been studied and standardized for several years by this Association, so that a subject can be classified as normal or not from a statistical point of view. (In our standard recording conditions, the position of the center of pressure of the subject on the platform is not very different from the projection of his center of gravity (9) on his support basis). Sampling frequency of the signal was 5 Hz; one minute recording; signal was filtered by a fourth order filter with a frequency cut at 2.5 Hz.


Patients

   All patients, suffering from an occlusal problem, presented a syndrome of postural dysfunction whose the occlusal origin was systematically verified according to the Meersseman (6) technic. After a first usual postural clinical examination, a thin piece of bristol (or salivary cotton according to the eventual loss of vertical dimension of occlusion) was interposed between arcades, then, after some swallowings, the same postural examination was made to see if there is a systematic variation of the postural tone in relation with the interposition; this variation must disappear when the piece of bristol is removed.


Method

   Each patient was recorded three times, at some minutes interval:

- first time in his usual state, that is to say without any modifications of any of his postural inputs, in the eyes-open condition, then in the eyes-closed condition. This time of usual intercupisdation will be referred to as «UI1».
- second time in the same conditions after being descended from the platform and having made some swallowings and some steps, in the eyes-open condition, then in the eyes-closed condition. This second time of usual intercupisdation will be referred to as «UI2». (This second recordings were made to control that recordings are reproducible for these patients. It is well known that they are reproducible, inside certain limits, for normal subjects).
- third time, finally, after puting a bite (or an occlusal gutter) between arcades and having the patient made some swallowings and some steps, in the eyes-open condition, then in the eyes-closed condition. This third time of modified intercupisdation will be referred to as «MI».

Statistics

   A statistical analysis was made of all parameters habitually studied in stabilometry, in the eyes-open and eyes-closed conditions (8.9): X-mean and and Y-mean positions, length of stabilogram, statokinesigram area, VFY and LFS parameters, Romberg's quotient, amplitude spectra of postural sway (first thirty values of the FFT, after application of the Hamming's window and normalization of the signal).
These parameters were compared, in matched samplings, by the Student's t-test.

   As the distribution of area is log-normal, comparison of different areas was made by their quotient, A1/A2, and not by soustraction, A1-A2.


RESULTS

   50 subjects, 43 females and 7 males (proportion habitually observed in this category of patients (13)), mean age 40 years, range from 19 to 71 years (younger subjects were excluded) were examined. Nine patients were excluded from the cohort because their recordings were not reproducible.


Clinic

   The wearing of bite modified the muscle tone of the external rotators of inferior limbs for all patients (with a doubt for one subject).


Stabilometry

Comparison of the two first recordings (UI1 / UI2).

   Recordings are reproducible for the 41 selected patients. Except the Y-mean position, it does not exist any significant difference for any of the parameters, including for the amplitude spectra in the frequency band 0.02/0.4 Hz, characteristic of the postural control.

Comparison of second and third recordings (UI2 / MI).

   There is a significant difference (p<0.05) between areas, in the eyes-open situation (fig. 1) before (UI2) and after (MI) the wearing of the bite. This difference does not exist in the eyes-closed situation.



FIG. 1 Distribution of the quotient of areas before and after wearing a bite (UI2/MI), eyes-open situation.

   Gaussian curve of the normal distribution of random variations of areas observed for two recordings made in exactly the same conditions; confidence limits at 95%: 0.43 and 2.3.

   Bar graph of the quotients of areas observed without (UI2) and with (MI) the bite, for 41 subjects whose recordings UI1 and UI2 were perfectly reproducible.

   In this particular population, defined only by clinical criteria (occlusal and postural dysfunction), puting a bite brings about statistically significant modifications of statokinesigram areas, that either increase or decrease.

   Comparison between recordings UI2 and MI shows a statistically significant difference (p<0.05) between amplitude spectra in the frequency band 0.3 Hz for forward-backward postural sway in the eyes-open condition (fig. 2). This difference does not exist in the eyes-closed condition.



FIG. 2 Results of the Student's t-test of the comparison to zero of the amplitude spectra differences between UI2 and MI

   Abscisses: frequencies (Hz), Ordinate: Values of the Student's t according to frequencies. The straight line at 2.01 represents the limit of significance (p<0.05) for the cohort.

   A significant difference of the amplitude spectra appears in the frequency band 0.3 Hz, in the eyes-open situation (A). This is not the case in the eyes-closed situation (B).

   Forward-backward postural sway, (N= 50).



DISCUSSION

Recordings repetition (comparison UI1-UI2)

   There is no statistically significant difference among these 41 patients between values of parameters of the two first recordings, except the Y-mean position. But it is very well known that this particular parameter is not reproducible among normal subjects.

Modifications of occlusion (Comparison UI2-MI)

   There is a statistically significant difference between areas in situation UI2 and MI, in the eyes-open condition. The quotient of these areas is beyond the confidence limits at 95% of the distribution of random variations for ten subjects (fig. 1). The wearing of bite modifies immediately precision of postural control for one of four patients.

   This result is confirmed by the spectral analysis: a statistically significant difference appears in the frequency band 0.3 Hz when patients wear a bite (fig. 2). Such modification of the amplitude spectrum is habitually considered as a sign of a difference in the functioning of the fine postural control system (9).

   It is worth noting that these two effects of the bite, on area and on amplitude spectrum, appear only in the eyes-open situation but not in the eyes-closed situation. It has been known for a long time (19) that mandibular input has some relations with the functioning of the oculomotor system; in this way our results are coherent with anterior observations. Moreover, there is a topological connection between pathways of oculomotor proprioception and mandibular inputs, from the Gasser ganglion to brainstem, though, till now, no anatomical connection was demonstrated between these two pathways.

   For most of the patients one observes an abnormal peak (9) in the frequency band 0.2 Hz of the amplitude spectrum (fig. 3). This peak is found in the two recordings, UI1 and UI2, when it exists, and can not therefore be considered as an artefact. It is more acute in the eyes-closed condition and on the amplitude spectrum of left-right postural sway. This 0.2 Hz peak is related to ventilatory rhythm and appears when normal functioning of the spine is impaired (9). An interpretation which is coherent with dental clinic that notices almost constantly cervical pain in patients suffering from TMJ problems.



FIG. - 3. Mean and deciles 10 and 90 of the amplitude spectra of patients. Left-right postural sway, eyes-closed situation.

   A: time UI1; B: time UI2; C: time MI.

   Note the 0.2 Hz peak that appears on recordings UI1 and UI2, but not on the recordings MI. (N= 50).


Why to have chosen this type of platform?

   Studies on the postural control show a great difference between static and dynamic situations. Nashner´s platform is well suited for studying postural control in dynamic conditions as a control system. But in static conditions what we call the fine postural control system, is not a simple one, it behaves as a dynamic non-linear system (5, 18) and inputs are at the limits of discontinuity. That is why it seems better not to study it as a simple control system by opening its feedback loops.


Random or not random presentation?

   It was necessary first to verify that recordings were reproducible in this particular subject sample, emotionalism being able to modify successive recordings (2, 7.12, 13, 14, 23, 25). This analysis shows that for nine on fifty patients (18%), recordings are not reproducible. Therefore we had to record in this order UI1 then UI2 and then MI, with the same procedures between recordings, the alone change between UI2 and MI being the pose of bite, therefore the modification of the relationship of occlusion.


Why to have selected this particular TMJ patients sampling?

   Of course another experience remains to be done with a sampling of patients with no TMJ pathology. But the present experimentation demonstrates the first step of our argument: modifications of occlusion brings about a change in the functioning of the fine postural control system.

   If another experience shows that the same holds true for a not-TMJ population this will be only an extension of this demonstration. But then it will be necessary to be preoccupied with postural modifications brought about by our works in mouth, and occluso-dentists will have to control their works by this kind of recordings.

   In the opposite case, these same therapists will be encouraged to practice such recordings that, positives, would be then the pathognomonic sign of occlusal problems.


The quality of the bite?

   One may always discuss the choice and the realization of the protheses used during this experimentation, a gutter. This objection does not appear as determinant. Never mind if the gutter is good and improves the postural control or if the gutter is bad and worsens it, the objective of the protocol being to put in obviousness that a change of occlusion modifies immediately the regulation of the postural system. But now a work has to be done on the choice of the right gutter thanks to stabilometry.


Why to have limited this work to immediate changes?

   A complementary study with recordings made at different periods remains to be done, it will bring about information as for the stability of induced modifications. But a great deal of factors intervene in the integration of necessary information for the good functioning of the fine postural control (cf. 10). A particular and more difficult protocol is needed for this kind of complementary study. Before undertaking it, it appeared indispensable, in a first step, to demonstrate immediate repercussions of the modification of the occlusion.



CONCLUSION

   Meersseman´s procedure allows us to determine patients whose postural system is affected by modifications of occlusion.

   Among these patients and when their stabilometric recordings are reliable, one observes immediat and statistically significant changes of statokinesigram areas, in the eyes-open situations, in relation with a modification of occlusion. A similar study (21), on another recording platform, showed similar results. A recent work (20) using the Fukuda´s stepping test ends to concordant conclusions.

   It remains to try understanding why areas sometimes decrease sometimes increase, that is to say why precision of the fine postural control system (24) is either improved or worsened by the wearing of a bite.

   We must not to confuse precision of postural control observed by recordings and modifications of muscles tone showed by clinical tests.

   Many works remain to be done, but according to this work´s results it is no longer possible to contest that the fine postural control system is objectively concerned by occlusion.



REFERENCES

(1) BARELLE J. J. - Les troubles occluso-fonctionnels dans le cadre des régulations posturales globales Thèse Sci.Odontol., Paris, 1971.

(2) BEATON R. D., EGAN K. J., NAKAGAWA-KOGAN H., MORRISON K.N. - Symptomes rapportés de stress en relation avec les D.C.M.: comparaison avec des hommes et des femmes sains. J Prosth Dent; 65, 289-93, 1991.

(3) BONNIER L.R. - Biomécanique générale et bonne intégration de nos traitements. Chir Dent France, 61, 53-8, 1992.

(4) CHAPMAN R. J., MANESS W.L., OSORIO J. - Modification des contacts occlusaux en fonction de la position de la tête. J Craniomandib Pract, 9, 174-9, 1991.

(5) COLLINS J.J., DE LUCA C.J. - Open-loop and closed loop control of posture: a random-walk analysis of center of pressure trajectories. Exp. Brain Res., 95, 308-18, 1993.

(6) ESPOSITO G.M., MEERSMANN J. P. - Valutazione della relazione esistante tra l´occlusione e la postura. Dentista moderno (Milano), 6, 5, 1988.

(7) FERREY G. - Psychosomatique des sensations vertigineuses et du déséquilibre. In: P.M. Gagey & B. Weber (Eds) Posturologie. Régulation et déreglements de la station debout , Masson, Paris, 1995.

(8) GAGEY et al. - Huit leçons de posturologie. Association Française de Posturologie, 4, avenue de Corbéra 75012 Paris.

(9) GAGEY P.M., WEBER B. - Posturologie. Régulation et déreglements de la station debout., Masson, Paris, 1995.

(10) GAGEY P.M., BENAIM Ch., BIZZO G., HABIF M., MAILLY A., MARTINERIE J, MARUCCHI C., PEZARD L., ROUGIER P., WEBER B., ZAMFIRESCO F. - Contrôle des oscillations et du tonus postural par l´entrée visuelle du système postural fin. In: P.M.Gagey & B. Weber (Eds) Entrées du système postural fin, Masson, Paris, 1995.

(11) GAGEY P.M., TOUPET M. - Communication personnelle (2 Journée francophone de posturologie, à paraitre)

(12) GRABER G. - Psychische Einflüsse auf die Fonction des Kausysteme Dtsch Zahnarztl Z, 47, 155-6, l992.

(13) KROGSTAD B.S., DAHL B.L., ECKERSBERG T., OGAARD B. - Différences sexuelles dans la symptomatologie provenant des muscles masticateurs. Oral Réhabilitation, 19, 435-40, 1992.

(14) LEVITT S.R. - Valeur pronostique de l´échelle d´évaluation de l´A.T.M. pour détecter des problèmes psychologiques et des désordres non A.T.M. chez les patients à troubles temporo-mandibulaires. J Craniomandib Pract, 8, 225-33, 1990.

(15) LOTZMANN U., KOBES L.W.R., RUDOLPH W., PAULA M. J. - Der Einflus des Okklusion auf die Kopfhaltung Wahrend Anhaltender Press phasen. Dtsch Zanhartztl Z, 44, 162-4, 1989.

(16) MAKOFSKY H., SEXTON T., DIAMOND D., SEXTON M. - Effets de la posture de la tête sur la position de contact musculaire révélée par le T Scan systeme d´analyse occlusale. J Craniomandib Pract., 9, 316-21, 1991.

(17) MARBACH J.J. - Le profil psychologique des SADAM est-il un mythe ou une réalité ? Oral Rehabilitation, 19, 545-60, 1992.

(18) MARTINERIE J., GAGEY P.M. - Chaotic analysis of the stabilometric signal. In: M.Woolacott & F. Horak (Eds) Posture and gait: control mechanisms.. University of Oregon Books, Portland, Tome I, 404-7, 1992.

(19) MEYER J. - Participation des afférences trigéminales dans la régulation tonique posturale orthostatique. Intéret de l´examen systèmatique du système manducateur chez les sportifs de haut niveau. Thèse Dent., Université R.Descartes, Paris, 1977.

(20) PERRAUD M., VILLECHEVROLLE O., VIENNE J-Y., HOORNAERT A., UNGER F., MAINETTI J-L. - Influence de la modification de l´occlusion sur la posture et l´oculomotricité. In: P.M.Gagey & B Weber (Eds) Entrées du système postural fin, Masson, Paris, 1995.

(21) PURICCELLI R., TORNO M., MIGLIERINA S. - Modification de la posture provoquée par un traitement mandibulo-orthodontique chez douze patients présentant un S.A.D.A.M. Critique de la posturologie, 63, 1-6, Association Française de Posturologie 4 avenue de Corbéra 75012 Paris, 1995.

(22) SOUTHARD T.E., SOUTHARD K.A., TOLLEY E.A. - Variation de l´intensité des contacts proximaux avec les changements de posture. J Dent Res; 69, 1776-9, 1990.

(23) SOUTWELL J., DEARY I.J., BEISSLER P. - La personnalité et l´anxiété des patients présentant des troubles A.T.M. Oral Rehabilitation, 17, 239-43, 1990.

(24) WEBER B., BENAIM C., GAGEY P.M., HABIF C., MARUCCHI C., ZAMFIRESCO F. - Correctives lenses and the fine postural system Influence of the optical configuration of corrective lenses on the functionning of this system. In: K. Taguchi, M. Igarashi & S. Mori (Eds) Vestibular and neural front. Elsevier, Amsterdam, 1994.

(25) ZACH G.A. - Évaluation du profil psychologique de patientes A.T.M. J prosth Dent, 66, 810-2, 1991.