Journal of

Oral Rehabilitation

Journal of Oral Rehabilitation 2009 36; 922936

Review Article

Posturography as a diagnostic aid in dentistry: a systematic

review
G. PERINETTI & L. CONTARDO

Department of Biomedicine, School of Dentistry, University of Trieste, Trieste, Italy

SUMMARY The aim of this systematic review of the

literature was to assess the scientific evidence for
detectable correlations between the stomatognathic
system and whole-body posture and to provide
information on the relevance of posturography as a
diagnostic aid in dentistry. A literature survey was
performed using the Medline database, covering the
period from January 1966 to May 2009, and using the
medical subject headings. After selection, 21 articles
qualified for the final analysis. Only one study was
judged to be of medium high quality, with all of the
rest classified as of low quality design. Only two
studies included follow-up of 28 days and 1 year.
Overall, 14 of the studies reported detectable correlations between the stomatognathic system and
body posture in at least one of the parameters used,
although in four of these studies the authors suggested caution in the interpretation of their data.
After a reappraisal of the data provided in 13 of the

Introduction
Recently, growing attention has been focused on
potential correlations between the stomatognathic system, referred to as the mouth, jaws and closely
associated structures and whole-body posture. As this
is a new topic, most of the information available to date
is not conclusive, and several clinical applications that
might arise from potential correlations have not been
addressed either correctly or fully.
To date, only one systematic review has been
published on this topic (1) that, however, suffers from
the following limitations: (i) with to the ample selection
criteria used, it provides an answer relating to the
existence of such correlations, although it does not
2009 Blackwell Publishing Ltd

studies, a weak correlation that reaches biological,

but not clinical, relevance is apparent. With limitations because of the poor methodological quality of
the present published studies, conclusions are that a
correlation between the stomatognathic system and
whole-body posture can be detected, at least under
experimental conditions; although posturography
has little relevance in the monitoring of body
posture responses to changes in the stomatognathic
system (including temporomandibular disorders).
While more investigations with improved levels of
scientific evidence are needed, the current evidence
does not support the usefulness of posturography as
a diagnostic aid in dentistry.
KEYWORDS: body posture, stomatognathic system,
dental occlusion, malocclusion, temporomandibular
disorders, posturography, diagnosis
Accepted for publication 4 October 2009

address the question of whether real clinical applications can be derived from them; (ii) it was focused on
correlations between the stomatognathic system with
the head and neck (cervical) regions, which does not
prove that whole-body posture would be influenced as
well and (iii) a critical reappraisal of the previous data
was not provided; instead, the conclusions reported by
the various study authors were followed.
Therefore, the present review was aimed at evaluating whether the degree of correlation seen in previous
studies has potential for clinical applications. This was
accomplished through analysis of the relevance of
posturography for the detection of body posture
responses to modifications occurring in the stomatognathic system (i.e. treatments or pathological
doi: 10.1111/j.1365-2842.2009.02019.x

POSTUROGRAPHY IN DENTISTRY
conditions), to ultimately determine whether posturography is a useful diagnostic aid in dentistry.

Materials and methods

Search strategy
To identify all of the studies that examined the correlations between the stomatognathic system and body
posture, a literature survey was carried out through the
Medline database (Entrez PubMed, http://www.ncbi.
nim.nih.gov). The survey covered the period from 1
January 1966 to 31 May 2009 and used the medical
subject heading (MeSH) term: body posture, which
was crossed with the MeSH terms stomatognathic
system, dental occlusion, malocclusion, mandibular
occlusion position, jaw occlusion position, temporomandibular craniofacial disorders and orofacial myofascial pain (Table 1). A search in the
Cochrane Controlled Clinical Trials Register was also
performed with the same criteria. Finally, a manual
search, through references within the studies examined,
was also performed.

Selection criteria and study classification

The retrieved studies had to use any of the following
static and dynamic posturographic methods to analyse

the correlations between the stomatognathic system

and body posture: (i) physical examination; (ii) postural
platform; (iii) body photographs; (iv) rasterstereography (i.e three-dimensional photography) and (v)
dynamic tests of gait or stepping. No restrictions were
set for studies on normal occlusion malocclusion or on
asymptomatic temporomandibular disorder (TMD)positive subjects. Both experimental and observational
study designs were included in the review. Publications
such as case reports, case series, reviews and opinion
articles were excluded, and the detailed exclusion
criteria are listed in Table 2. The studies included were
thus classified as follows: (i) randomized clinical trials
(RCTs); (ii) controlled and non-controlled clinical trials
(CCTs and NCCTs, respectively); (iii) cohort case
control studies and (iv) cross-sectional (CS) studies
(see also Table 3).
In more detail, if modification of the mandibular
position was achieved by using cotton rolls, gauzes or
splints positioned between the dental arches, this was
considered as a treatment, and the corresponding study
classified as a clinical trial. On the contrary, when no
device was used to influence the mandibular position,
the study was classified as observational. The studies in
which the groups belonged to different populations, i.e.
asymptomatic versus TMD-positive, have been classified as clinical trials if a treatment was included,

Table 2. Exclusion criteria used in the review

Table 1. The number (no.) of studies retrieved according to the
automatic and manual searches
Automatic search medical subject
heading terms added to body posture

No.

Stomatognathic system
Dental occlusion
Malocclusion
Mandibular occlusion
Mandibular position
Jaw occlusion
Jaw position
Temporomandibular disorders
Craniofacial disorders
Orofacial pain
Myofascial pain
Total with cumulative entries
Total without cumulative entries
Total included by automatic search
Total included by manual search
Total included

1102
273
222
134
280
130
261
143
31
79
53
2708
1576
20
1
21

2009 Blackwell Publishing Ltd

Case series with no statistical analysis, case reports,

comments, letters to the Editor and reviews.
Studies on animals.
Studies in which the compared groups showed differences in
any parameter at the beginning of the study, or their
matching in age and gender was not declared or derivable
from the published data.
Studies limited to the investigation of the correlations
between the stomatognathic system and headneck region.
Studies that evaluated the mandibular posture in response to
body position changes.
Studies limited to the investigation on the morphological
correlations between the craniofacial complex and the
vertebral spine.
Studies on pathologies not related to the stomatognathic area
(i.e. obstructive sleep apnoea, vestibular disorders).
Clinical trials testing the effects of self-care postural training
on the stomatognathic system muscle pain function, if this
training included also head and neck posture exercises.
Studies with major bias in the statistical analysis, i.e.
dependent data treated as independent.

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G. PERINETTI & L. CONTARDO

Table 3. Study designs of the articles included in the review, with
the corresponding levels of evidence according to their methodological procedures
Level

Study design

1
1A
1B
1C

Experimental studies
Randomized clinical trial
Controlled clinical trial (CCT) with follow-up
CCTwithout follow-up non-controlled
clinical trial (NCCT) with follow-up
NCCT without follow-up
Observational studies
Cohort casecontrol study
Cross-sectional study

1D
2
2A
2B

otherwise they were classified as casecontrol studies if

a repetition of measures (under different conditions)
was performed; otherwise, they were classified as CS
studies.
Finally, studies having a repetition of the measures
performed at the very same time point, i.e. posturography in two consecutive different mandibular
positions, were classified here as longitudinal without
follow-up. The reason behind this classification resides
in the concept that by using this protocol, it is possible
to investigate the direction (descending or ascending) of
any possible correlation between the stomatognathic
system and body posture, which is not possible in a
single-recording CS study.

Data collection
Data were collected on the following items: year of
publication, study design, sample size, gender distribution, age, other features (i.e. asymptomatic, TMDpositive), treatment performed or recording conditions,
follow-up, type of posturographic recordings, main
results according to the authors and indications for
the use of posturography as a diagnostic aid in dentistry
(see Table 4). If a study also included an analysis of the
posture of the cervical region, this portion of the results
was not taken into account. Similarly, results from
recording methods different from posturography, i.e.
electromyography, were not considered in the present
review.

Quality evaluation of the studies

To document the methodological soundness of each
article, a modified quality evaluation method from

Toffol et al., (2) was used with respect to pre-established

characteristics. The following characteristics were used:
(i) study design (according to the level of scientific
evidence, including the use of control groups and
follow-up, see above and Table 2); (ii) adequacy of
sample selection description; (iii) description of method
of error analysis; (iv) adequacy of statistics; (v) previous
estimate of sample size and (vi) blinding for measurements.
The following systematic scores were assigned to
individual retrieved articles:
1 Study design (1A: 6 points; 1B: 5 points; 1C: 4 points;
1D: 3 points; 2A: 2 points; 2B: 1 point)
2 Adequacy of sample selection description according to
the different study designs and based on four criteria
as follows: (i) age and gender; (ii) occlusal status; (iii)
functional disorders of the stomatognathic system and
(iv) any systemic condition that might alter the body
posture (full description: 2 points; partial description:
1 point)
3 Description of method error analysis (2 points)
4 Adequacy of statistics (parametric or non-parametric
tests used where appropriate: 2 points; parametric
tests used when non-parametric tests would be
more appropriate, multiple comparisons with uncorrected P values, statistical analysis only partially
described: 1 point)
5 Previous estimate of sample size (1 point)
6 Blinding for measurements (1 point).
The quality of the studies was considered as follows:
1 Low: with a total score 8 points
2 Medium: with a total score >8 and 10 points
3 Medium high: with a total score >10 and 12 points
4 High: with a total score >12 points.
The two authors of the present review independently
assessed the articles. The data were extracted from each
article without blinding to the authors, and intraexaminer conflicts were resolved by discussion of each
article, to reach a consensus.

Reappraisal of the reported outcomes

To perform a reappraisal of previously reported results
in terms of the differences that were statistically and or
clinically significant, the effects size (ES) coefficient (3)
was calculated. The ES coefficient is the ratio of the
difference between the recordings of two different
groups (within the same recording condition) or two
recording conditions (within the same group) divided
2009 Blackwell Publishing Ltd

Design

CS

CCT

CS

CCT

CS

NCCT

Article

Darlow et al.
(17)

Ferrario et al.
(7)

2009 Blackwell Publishing Ltd

Zonnenberg
et al. (18)

Milani et al.
(6)

Nicolakis
et al. (19)

Fujimoto
et al. (9)

21 (2024)

10 F

12 M

5 M; 20 F
5 M; 20 F

22 M; 8 F

25.8 (2428)

28.3 (1839)
28.2 (1539)

31.5 (1641)

35.5 (1763)
30.4 (1849)

21 (1923)

10 F

8 M; 32 F
7 M; 33 F

21 (1921)

31.0 (NA)
36.3 (NA)

Mean age
(range or s.d.)

10 F

23 F; 7 M
23 F; 7 M

Sample size
and gender
distribution

Asymptomatic with
intact dentition

Healthy volunteers
CMD-positive

Two groups with

variable occlusal
conditions

Asymptomatic
TMD-positive

Asymptomatic with
normal occlusion
Asymptomatic with
asymmetrical
occlusion
Mild-to-moderate
TMD-positive

Asymptomatic
Myofascial pain in
the head and neck
regions

Group feature

Table 4. Summarized data of the 21 studies included in the review

Different
mandibular
positions by
wearing splints,
eyes open

28 days

Wearing of a splint
preventing
masticatory muscle
hypertonia

Fourteen static and

dynamic trunk
parameters assessed
by physical
examination
Dynamic tests of gait
rhythm assessed by a
telemeter system

Dynamic
FukudaUnterberger
stepping test

Pupil, shoulder and

pelvis lines assessed
by frontal, dorsal
and lateral photographs

Body sway assessed

by static postural
platform

Twenty-eight static
and dynamic
postural parameters
assessed by physical
examination

Posturographic
recordings

Followup

Different
mandibular
positions, eyes
open

Treatment and or
conditions

Change in
mandibular
position could
affect the gait
stability

No significant
differences in the
distribution of any
parameter
between the
groups
TMD or
asymmetrical
occlusion did not
correlate with
altered COP
features in any of
the mandibular
positions
Some postural
parameters
showed differences
between the
groups. Results
interpreted with
caution
Altering dental
occlusion could
induce
fluctuations in
dynamic posture
attitude
Postural
abnormalities were
more common in
the CMD patients

Main results

Not mentioned

Yes

Not mentioned

Yes

No, at least in
mild-to-moderate
to moderate
TMD-patients

No

Proposed use of
posturography

POSTUROGRAPHY IN DENTISTRY
925

CS

CS

NCCT

CS

Lippold et al.
(20)

Pedroni et al.
(21)

Bracco et al.
(10)

Munhoz
et al. (22)

CS

NCCT

Gangloff and
Perrin (4)

Lippold
et al. (23)

Design

Article

Table 4. (Continued)

21 M; 32 F

6 M; 14 F
3 M; 27 F

23 M; 72 F

18 M; 32 F

29 M; 30 F

16 M; 9 F

Sample size
and gender
distribution

24.6 (9.0)

22.9 (1635)
21.7 (1832)

29 (1852)

21.5 (1925)

5.0 (3.56.8)

27 (8)

Mean age
(range or s.d.)

Asymptomatic
TMJ internal
defragmentpositive with or
without muscle
disorders
Asymptomatic with
skeletal class II and
III

Asymptomatic

Volunteers with
or without TMD

Asymptomatic with
skeletal class I (37);
II (19) and III (3)

Asymptomatic

Group feature

Different
mandibular
positions (a), eyes
closed

Followup

Unilateral
trigeminal
anaesthesia, eyes
open closed

Treatment and or
conditions

Fleche lombaire and

trunk inclination
assessed by
rasterstereography

Nine body postural

parameters assessed
by dorsal and lateral
photographs

Body sway assessed

by static postural
platform

Five orthopaedic
parameters assessed
by physical
examination
Shoulder posture
assessed by physical
examination

Body sway assessed

by static postural
platform

Posturographic
recordings
Postural control is
impaired when
trigeminal
proprioception
inputs are blocked
by anaesthesia
Class II was
correlated with
scoliosis and weak
body posture
Subjects with severe
TMDs showed an
association with a
combination of the
protruded and
asymmetric
shoulder height
posture
A more stable jaw
relationship
improved postural
balance
No difference in any
postural
parameters (except
one out of 17) was
seen between the
groups
Craniofacial
morphology was
not correlated with
the postural
parameters.

Main results

Yes, at least for

subjects with
severe
malocclusion

Not mentioned

Yes

Yes, in TMD
patients

Yes, at least in Class

II children

Not mentioned

Proposed use of
posturography

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Design

CCT

NCCT

NCCT

NCCT

NCCT

Article

Michelotti
et al. (8)

Perinetti (11)

Sforza et al.
(12)

Sinko et al.
(5)

Hosoda et al.
(13)

Table 4. (Continued)

Mean age
(range or s.d.)

2009 Blackwell Publishing Ltd

15 M; 15 F

11 M; 18 F

11 M

13 M; 13 F

14 M; 12 F

20.3 (1.6)

24.5 (1741)

41.6 (3154)

26.8 (2138)

13.7 (1.2)

52 subjects matched for

gender and age

Sample size
and gender
distribution

Asymptomatic

Skeletal class
III (17)
Skeletal class
II (7)
Mandibular
asymmetry (5)

Asymptomatic
astronauts

Asymptomatic with
normal occlusion

Asymptomatic with
no posterior
crossbite
Asymptomatic with
unilateral posterior
crossbite

Group feature

External
disturbance
challenging body
equilibrium,
different jaw
clenching (b)

Different
mandibular
positions by a
splint with
posterior contacts
only (a), eyes
open closed
Orthognathic
surgery

Various spinal
posture parameters
assessed by
rasterstereography

Time required for

initiation of recovery
in response to
external
disturbances
assessed by dynamic
postural platform

Body sway assessed

by static postural
platform

1 year

Body sway assessed

by static postural
platform

Body sway assessed

by static postural
platform

Different
mandibular
positions, eyes
open

Different
mandibular
positions, eyes
open closed

Posturographic
recordings

Followup

Treatment and or
conditions

Very minor changes

in body posture
(without
orthopaedic
consequences)
seen only in class II
patients
Jaw clenching
reduced the time
for initiation of
recovery in
response to
medium and large
external
disturbances

Posterior crossbite,
gender and
occlusal condition
did not correlate
with significant
alteration in the
postural balance
No detectable
correlation was
seen between
dental occlusion
and body posture
No differences in
body sway were
seen between the
mandibular
conditions

Main results

Not mentioned

Not mentioned

Not mentioned

No

Not mentioned

Proposed use of
posturography

POSTUROGRAPHY IN DENTISTRY
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CS

Michelotti
et al. (24)

633 M; 526 F

Sample size
and gender
distribution

NCCT

Tardieu et al.
(15)

6 M, 4 F

24 M; 21 F

21 (2528)

30.7 (2153)

29.2 (10.0)

26.2 (6.8)

12.3
(10.116.1)

Treatment and or
conditions

Different
mandibular
positions with or
without a hell lift
under the right
foot
Different
Asymptomatic,
mandibular
bilateral dental
class I, no crossbite positions, eyes
open closed

Asymptomatic

Asymptomatic with
no posterior
crossbite (1017)
Asymptomatic with
unilateral posterior
crossbite (142)
Asymptomatic with Different
normal occlusion
mandibular
TMD-positive
positions, eyes
open closed

Mean age
(range or s.d.) Group feature

Proposed use of
posturography

Yes
Body sway assessed
by static postural
and occlusal force
assessed by
computerized
methods
Yes
Body sway and signal Dental occlusion
affected postural
power assessed by
control only under
both static and
the dynamic
dynamic postural
conditions
platforms

No

Body sway assessed

by static postural
platform

No detectable
correlation was
seen between
dental occlusion
TMDs and body
posture
Changing of the
mandibular
position affected
body posture and
vice versa

Leg length inequality

assessed by physical
examination

Unilateral posterior No
crossbite was not
associated with leg
length inequality

Main results

Follow- Posturographic
up
recordings

CCT, controlled clinical trial; NCCT, non-controlled clinical trial; CS, cross-sectional; M, males; F, females; Asymptomatic and symptomatic, subjects without or with signs or
symptoms of any temporomandibular myofascial disorders, as classified by the authors; NA, not available; CMD, craniomandibular disorder; TMDs, temporomandibular disorders;
TMJ, temporomandibular joint; MORA, mandibular orthopaedic repositioning appliance; COP, body centre of pressure. Further notes: a, including a stable position held by
wearing an intra-oral device; b, assessed by an electromyography recording of the masseter muscles.

NCCT

Sakaguchi
et al. (14)

Perinetti (16) Case

19 M; 16 F
control
15 M; 20 F

Design

Article

Table 4. (Continued)

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POSTUROGRAPHY IN DENTISTRY
by the within-subject standard deviation (s.d.), and it
was calculated as follows:

ma  mb
ES r
2
2
s.d.a na s.d.b nb
s.d.a s.d.b
where, ma and mb are the means for the generic
group recording conditions A and B; s.d.a and s.d.b are
the corresponding standard deviations; na and nb are the
corresponding sample sizes.
An ES coefficient reported by a given study had to be
>0.2 to be regarded as biologically significant (3) i.e. a
weak correlation existing but with no or poor clinical
meaning. With an ES coefficient equal to or above 1.0
used as the minimum value to consider the posturography as a reliable diagnostic tool, this would mean that
the difference between two groups conditions in any
posturographic recording must be at least equal to the
variability observed within the same groups conditions. This is a theoretical pre-requisite for a diagnostic
tool to be accurate. The ES coefficients were thus
calculated whenever possible, in all of the comparisons
reported in the studies included, and the studies were
then sorted according to the highest ES coefficients
obtained. Finally, the percentage variations in the
posturographic recordings corresponding to the highest
ES coefficients were also calculated.

Results
Study search
The results of the automatic and manual searches are
summarized in Table 1. According to the automatic
search, a total of 1576 articles were retrieved. Among
these, 20 studies (see below) were judged to be relevant
according to the inclusion exclusion criteria. Finally,
by using a manual search, one more relevant study (4)
was retrieved and included in this review. In particular,
even though one study (5) had an unmatched control
group, it was included in the review, because three
other matched experimental groups were compared
and analysed longitudinally. Data from that control
group were thus not considered here, and the study was
classified as non-controlled. Therefore, the present
review includes 21 relevant studies, which are listed
in Table 4.
2009 Blackwell Publishing Ltd

Study designs
The designs of the 21 studies are listed in Table 4. These
studies included 12 experimental and nine observational studies classified as follows: 1 CCT with 28 days
of follow-up (6), 2 CCT without follow-up (7, 8), 1
NCCT with 1 year of follow-up (5), 8 NCCT without
follow-up, (4, 915), 1 casecontrol study (16) and 8 CS
studies (1724). No RCTs or meta-analyses were
retrieved.

Quality analysis
The results of the quality analysis are given in Table 5.
The quality was medium high in only one study (8),
and it was low in all of the other studies.
The selection description was classified as adequate in
six studies and as not adequate in 15 studies (Table 5).
However, in all of the studies, data regarding the age,
gender and functional disorders of the stomatognathic
system were satisfactory, with the exception of one
study in which no age range was reported (17). In 10
studies (4, 10, 1214, 1719, 21, 22), no information
was given about the occlusal status of the subjects
examined. Moreover, regarding the description of any
systemic condition that might alter the body posture
(i.e. neurological vestibular disorders and positive for
previous history of trauma), eight studies (47, 9, 15,
17, 18) did not provide any information. On the
contrary, all of the other studies (8, 1014, 16, 1924)
reported that subjects positive for such conditions, as
assessed either anamnestically or by a physical examination, were not enrolled.
Only five studies (8, 19, 20, 23, 24) included a
method error analysis.
Statistical methods were judged appropriate in 15
studies (4, 811, 13, 1624). On the contrary, in six
studies, the statistical analysis was judged inappropriate
because the use of parametric tests when non-parametric tests would have been more appropriate (57, 12,
15), or because the multiple nature of the comparisons
was not taken into account and corrections of the P
values in pairwise comparisons were not declared (14).
No studies used any previous estimates of sample
size, with the exception of two studies (8, 24), in which,
however, a posteriori power analysis was performed.
Because the estimated power was above 80%, the point
was assigned. Finally, only three studies (8, 17, 19)
used blinding for measurements.

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G. PERINETTI & L. CONTARDO

Table 5. Quality evaluation of the 21 studies included in the review
Method
error
analysis

Article

Grade

Sample
description

Darlow et al. (17)

Ferrario et al. (7)
Zonnenberg et al. (18)
Milani et al. (6)
Nicolakis et al. (19)
Fujimoto et al. (9)
Gangloff and Perrin (4)

2B
1C
2B
1B
2B
1D
1D

Partial
Partial
Partial
Partial
Partial
Partial
Partial

No
No
No
No
Yes
No
No

Lippold et al. (20)

Pedroni et al. (21)
Bracco et al. (10)
Munhoz et al. (22)

2B
2B
1D
2B

Full
Partial
Partial
Partial

Yes
No
No
No

Lippold et al. (23)

Michelotti et al. (8)

2B
1C

Full
Full

Yes
Yes

Perinetti (11)
Sforza et al. (12)
Sinko et al. (5)
Hosoda et al. (13)
Michelotti et al. (24)

1D
1D
1C
1D
2B

Full
Partial
Partial
Partial
Full

No
No
No
No
Yes

Perinetti (16)
Sakaguchi et al. (14)
Tardieu et al. (15)

2A
1D
1D

Full
Partial
Partial

No
No
No

Adequacy of statistics
(type of tests used)
Yes (non-parametric)
No (parametric)
Yes (parametric)
No (parametric)
Yes (non-parametric)
Yes (parametric)
Yes (parametric and
non-parametric)
Yes (non-parametric)
Yes (non-parametric)
Yes (parametric)
Yes (parametric and
non-parametric)
Yes (parametric)
Yes (parametric)
Yes (parametric)
No (parametric)
No (parametric)
Yes (parametric)
Yes (parametric and
non-parametric)
Yes (non-parametric)
No (non-parametric)
No (parametric)

Previous
estimate of
sample size

Blinding in
measurements

Quality
score

Judged
quality
standard

No
No
No
No
No
No
No

Yes
No
No
No
Yes
No
No

5
6
4
7
7
6
6

Low
Low
Low
Low
Low
Low
Low

No
No
No
No

No
No
No
No

6
4
6
4

Low
Low
Low
Low

No
Yes (a)

No
Yes

6
12

No
No
No
No
Yes (a)

No
No
No
No
No

7
5
6
6
8

Low
Medium
high
Low
Low
Low
Low
Low

No
No
No

No
No
No

6
5
5

Low
Low
Low

a, a posteriori power analysis.

Study populations

Condition recordings and study treatments

A few studies included specifically male (9, 12) or

female (7) subjects. In one study (6), regular members
of a multisport club were chosen, and in another (12),
male astronauts were enrolled.
The ages of the subjects were also variable, with some
studies including children (20, 24) and others including
very large age ranges of subjects (18), with most of the
studies including subjects between 20 and 30 years of
age (Table 4).
Fourteen studies included only asymptomatic subjects with variable occlusal conditions (5, 6, 20, 23),
normal occlusion (9, 11, 15), unilateral crossbite (8, 24)
or non-specified occlusal status (4, 10, 1214). Six
studies compared asymptomatic subjects with patients
positive for functional disorders of the stomatognathic
system (1619, 21, 22). One study (7) included three
groups of asymptomatic subjects with and without
normal occlusion, and a group of TMD-positive
patients.

Among the observational studies, recordings were

taken under no particular conditions, such as for all of
the CS studies (1724), or under different mandibular
positions, as in the case of the casecontrol study (16).
Among the studies classified as clinical trials, the
treatments were as follows: (i) change of mandibular
positions through the use of intra-oral devices (including clench with cotton rolls between the dental arches)
(79, 11, 14, 15); (ii) wearing of a splint to modify the
masticatory muscle hypertonia, as recorded through
electromyography analysis (6, 10, 12); (iii) unilateral
trigeminal anaesthesia (4); (iv) orthognathic surgery (5)
and (v) external disturbance for challenging body
equilibrium, using an oscillating platform recorded in
combination with different jaw clenching (13).
Finally, only one study (14) made use of an intra-oral
device that did not interfere with the occlusion mandibular position, thus simulating a placebo treatment.
The same study also made use of a hell lift under the
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POSTUROGRAPHY IN DENTISTRY
right foot to determine any influence of body posture
on the mandibular position assessed by a computerized
occlusal system.

Posturographic recordings
Sixteen studies recorded body posture exclusively
under static conditions, subdivided as follows: three
studies used qualitative posturographic parameters
assessed by physical examination (1921), 13 studies
used quantitative posturographic parameters assessed
by physical examination (24), postural platform (4, 7, 8,
1012, 14, 16), body photographs (18, 22) and rasterstereography (5, 23).
Three studies recorded body posture exclusively
under dynamic conditions and using quantitative
parameters, such as through the FukudaUnterberger
stepping test (6), or the analysis of gait rhythm (9) and
timing of posture recovery in response to external
disturbances (13).
The last two studies (17, 19) recorded body posture
under both static and dynamic conditions by using
qualitative parameters assessed by physical examination. One of these studies (19) reported the number of
abnormalities along the frontal and sagittal trunk
planes as a final postural outcome.

Authors main results and conclusions

Seven studies (7, 8, 11, 12, 17, 23, 24) failed to reveal
any significant difference correlation in all of the
comparisons. In four studies (5, 16, 18, 22), although
some significant differences correlations were seen,
the authors suggested caution in the interpretation of
the data. In all of the other studies (Table 4),
independent of the protocols used, the authors suggested that the correlations between the stomatognathic system and body posture have clinical relevance.
In particular, three studies (14, 15, 20) recommended
the use of posturography as a diagnostic aid in
dentistry. The same was seen for a further study
(23), in which posturography showed significant
correlations only between some craniofacial morphology features and the fleche cervical (part of the results
not considered in the present review). Finally, four
other studies (10, 18, 19, 21) specifically proposed the
use of posturography in the management of patients
affected by functional disorders of the stomatognathic
system.
2009 Blackwell Publishing Ltd

Furthermore, among the studies showing at least a

postural parameter that correlated with the stomatognathic system under any condition, and when longitudinal protocols were used, eight studies (46, 9, 10,
13, 15, 16) reported on a correlation in a descending
way, and the only study that investigated both
descending and ascending correlations reported both
as significant (14).

ES coefficients of the posturographic recordings

For 13 studies (412, 16, 18, 19, 22), calculation of the
ES coefficients was possible for all of the comparisons
reported (Table 6). In all of the other studies, these
calculations were not possible, because the data were
shown in a graphical form (1315), or collected as
nominal (20, 21, 24), or presented as correlation
coefficients (23).
A total of 204 ES coefficients were calculated. Among
these, 98 (48.0%) were below 0.2, 104 (51%) were
between 0.2 and 1.0, and only 2 (1.0%) were above
1.0. The results of the highest ES coefficient calculations
for each of these 13 studies, along with all of the
relative information about the recording conditions and
posturographic methods, are listed in Table 6. Eleven
studies included in this reappraisal revealed a highest
ES coefficient of at least 0.2 (46, 812, 16, 18, 22), and
two studies reported highest ES coefficients of 1.29 (7)
and 1.11 (19). The coefficients of variation were
notably different among the studies, ranging from
13% to 1400%, with no significant correlation with
the entity of the corresponding ES coefficients (not
shown). Moreover, at least for the studies that could be
reappraised here, no notable differences in terms of ES
coefficients were seem among the different types of
comparisons and posturographic recording methods
(Table 6), even though generally the highest ES coefficients were seen for comparisons between asymptomatic versus symptomatic subjects.

Discussion
This review was undertaken to answer the question
whether the posturography is a useful diagnostic aid in
dentistry. To address this question, a further issue has to
be taken into account: the degree of possible correlation
between the stomatognathic system and body posture.
This review also made an initial attempt to describe
what would be best referred to as body posture, by

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G. PERINETTI & L. CONTARDO

Table 6. Reappraisal of thirteen articles through calculation of highest ES coefficient and its corresponding percentage variation in the
comparison and other related information
Variation
(%)

Study

ES

ES coefficient 1.0
Ferrario et al. (7)

1.29

141

1.11*

62

Nicolakis et al. (19)

0.20 ES coefficient <1.00

Sinko et al. (5)
0.92

84

Fujimoto et al. (9)

0.80*

20

Sforza et al. (12)

0.69

60

Perinetti (16)

0.64*

1400

Munhoz et al. (22)

0.49*

42

Zonnenberg
et al. (18)
Perinetti (11)

0.44*

165

0.31

22

Gangloff and
Perrin (4)

0.30

13

Bracco et al. (10)

0.28*

25

Michelotti
et al. (8)

0.27

25

Milani et al. (6)

0.23

625

Comparison (conditions,
no. of subjects)

Parameter

Data source

Asymptomatic vs. symptomatic

subjects (clench, eyes open,
n = 10 per group)
Asymptomatic vs. symptomatic
subjects (n = 25 per group)

Body sway area (as

asymmetry index of
right and left sides)
Number of abnormal
postural parameters on
the trunk sagittal plane

Static postural platform

Class II subjects before and

after orthognathic surgery
(eyes open, n = 7)
Mandibular rest position vs.
5-mm right mandibular
position (eyes open, fast gait
speed, n = 12)
Mandibular rest position vs.
more stable occlusion with
a split (eyes open, n = 11)
Asymptomatic vs. symptomatic
subjects (ICP with cotton
rolls, eyes closed, n = 35
per group)
Asymptomatic vs. symptomatic
subjects (n = 30 and 20,
respectively)
Asymptomatic vs. symptomatic
subjects (n = 40 per group)
Mandibular rest position vs.
ICP (eyes open, n = 26)
Before and after unilateral
trigeminal anaesthesia (eyes
open and closed, n = 27)
Myocentric mandibular
position vs. ICP (eyes closed,
n = 95)
Absence vs. presence of
crossbite (ICP with cotton
rolls, eyes open, n = 52 and
26, respectively)
Wearing of a splint preventing
masticatory muscle
contraction, 21 days vs.
baseline (eyes closed, n = 15)

Apex of kyphosis

Rasterstereography

Coefficient of variation
for gait speed

Dynamic tests of gait

rhythm

Body sway area

Static postural platform

COP displacement on
the x-axis

Static postural platform

Pupil line

Body photographs

Pelvis line on the

dorsal plane
Body sway area

Body photographs

Rombergs quotients of
the sway area

Static postural platform

COP displacement on
the x-axis

Static postural platform

Body weight (as

asymmetry index of
right and left sides)

Static postural platform

Angle of rotation
during gait

Dynamic
FukudaUnterberger
stepping test

Physical examination

Static postural platform

For each of the studies analysed, the greatest effect size (ES) seen in all of the possible comparisons is given.
Variation, corresponding to the ES shown and calculated on the smaller of the two means which were compared; Asymptomatic and
symptomatic, subjects without or with signs or symptoms of any temporomandibular myofascial disorders, respectively, as classified by
the authors; ICP, intercuspidal position; COP, body centre of pressure.
*Difference between the corresponding mean values that was statistically significant.

2009 Blackwell Publishing Ltd

POSTUROGRAPHY IN DENTISTRY
excluding the cervical region, and to systemically
classify the study populations and designs and the
different posturographic recordings used.
Of the 1576 studies retrieved by the automatic
search, only 20 matched the inclusion exclusion criteria. Most of the excluded studies were focused on the
correlation between the stomatognathic system and the
cervical region, which cannot be considered as representative of the body posture. Therefore, a careful
re-evaluation of the role of these studies in showing
significant correlations needs to be carried out, and
previous reviews (1, 25) that did not distinguish these
aspects should have their conclusions re-evaluated.
Moreover, the present review includes studies with
asymptomatic subjects as well as others including TMDpositive patients, with or without a treatment. Even
though these studies were focused on different situations, the poor capability of posturography in detecting
changes in the whole-body posture seen independently
of the design used, would justify a direct comparisons of
the results, at least regarding the accuracy aspects of
posturography as a diagnostic aid in dentistry.

Study design and quality analysis

No RCTs were retrieved, confirming a general tendency
in orthodontics. Moreover, there was a large diversity
among the studies with regard to the protocols used.
Generally, the studies including asymptomatic subjects
were NCCTs or CCTs without follow-up, and recordings
through quantitative posturographic parameters; in
contrast, the studies comparing body posture between
asymptomatic subjects and patients affected by a disorder of the stomatognathic system were also among
those with the CS designs, with postural recordings
made through qualitative parameters (see Table 4).
Importantly, among the 16 longitudinal studies
(Table 4), only two (5, 6) included follow-up. Therefore, all of the conclusions from the rest of these studies
are based on the immediate effects of the change in the
stomatognathic system on the body posture, or vice
versa. In this regard, longitudinal studies with proper
follow-up are warranted, especially when dealing with
the potential impact of occlusal therapy on body
posture.
Overall, 20 studies were classified as low quality
(Table 5), and only one study (8) attained a medium
high quality rating. Although it had a rigorous design,
one further study (24) was classified as low quality,
2009 Blackwell Publishing Ltd

because of the concept that the experimental and

observational studies were pooled. The main reasons
for these low quality scores were related to the lack of
proper follow-up, partial descriptions of the samples,
previous estimates of sample size, lack of method error
analysis and blinding for measurements. Of note, the
repeatability of the posturographic measures through
the use of a postural platform was reported as not
always fully repeatable, as for instance in the case of the
body sway area, which showed a significant error in
one of the studies included (8). Therefore, future
studies with higher scientific quality and proper
follow-up monitoring are warranted.

Degree of correlations
Two distinct aspects that must not be confused are as
follows: the existence of correlations at the biological
level and their potential clinical relevance. Therefore,
while a correlation may be detected experimentally,
this does not mean that it will have clinical relevance.
Thus, only if the correlations reach a clinically significant grade, would the diagnosis and the consequent
treatment plan have to take such aspects into account.
An analysis of the degree of correlations seen between
the stomatognathic system and body posture is therefore of primary importance in determining possible
clinical implications. However, this concept was missed
in most of the studies included in the present review,
with few exceptions (5, 11, 16).
Of interest, most of the studies in which the authors
conclusions were in favour of significant correlations
between the stomatognathic system and body posture
reported statistically significant correlations only in
some of the analyses performed (4, 6, 9, 1315, 20).
Moreover, significant correlations were seen in several
cases only under the most extreme conditions investigated (9, 13, 15) or in extreme class II malocclusion (5).
Also of interest, the two studies with the highest quality
(8, 24) failed to see any significant correlations between
the unilateral posterior crossbite and body oscillation or
leg-length inequality.
According to the results from the studies reporting
significant correlations between the stomatognathic
system and body posture (Table 4), it appears possible
that the stomatognathic system can induce small
modifications that are limited to the cervical region
(26). Hence, these would have biological rather than
clinical implications when referring to whole-body

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G. PERINETTI & L. CONTARDO

posture, as has been implied previously (27), at least
when posture is recorded through the methods
reported here. Indeed, in all of the studies included in
the present review, posturographic methods were used,
and other types of monitoring, such as electromyography of the postural muscles of the body, have not been
considered. It is thus not possible to exclude that should
different approaches be used, more evident correlations
between the stomatognathic system and body posture
might be detected.

Clinical implications
Eight studies (10, 14, 15, 1821, 23) suggested the use
of posturography as a diagnostic aid in dentistry, and
one study clearly indicated that the treatment of TMDs
would have beneficial effects on body posture imbalances (6). The same indication was reported in a study
(10) that, however, did not include TMD-positive
subjects. A further study suggested the adaptation of
the dental treatment planning to the body posture
features of the patients (14).
Of note, the CS design (1821, 23) and the lack of
proper follow-up (10, 14, 15) of these studies render
the clinical indications provided poorly reliable. Indeed,
a CS study does not include any knowledge of the
etiological factors of body postural imbalances, i.e. the
observation that malocclusion or TMDs is correlated
with some of the body posture imbalances that does not
necessarily imply any causal relationship. Therefore, it
would not be advisable to treat postural imbalance by
means of occlusal therapy, or vice versa, especially if
the therapeutic modalities are irreversible.

Diagnostic accuracy of the posturographic methods

A main goal of the present systematic review was a
quantitative appraisal of the accuracy of the posturographic measures as indicators of the stomatognathic
conditions. Indeed, any diagnostic tool has to provide
measurement outcomes where the responses obtained
can be considered accurate (i.e. with high sensitivity
and specificity), in terms of the presence absence of a
given pathological condition. However, data on the
accuracy of the posturographic methods in the diagnosis of any stomatognathic system conditions, such as
TMDs, have not been reported to date. A further
difficulty in re-appraising these data resides in the
variability of the number of subjects patients enrolled

in the studies examined, rendering the corresponding

power of the statistical tests also poorly comparable
(28).
Therefore, a critical approach to assess the relevance
of posturography as a diagnostic aid in dentistry has to
rely on the concept that to have high accuracy, the
measurement outcomes recorded in two groups of
subjects (asymptomatic versus TMD-positive) have to
show notable changes between the two conditions, as
compared to the corresponding variances. Indeed, a
low ratio would be responsible for low sensitivity and
specificity, providing a poor diagnostic performance of
a given tool. A statistical approach to quantify this
ratio (taking into account the sizes of the study
populations) is provided by the calculation of the ES
coefficient (3).
The present reappraisal through the ES coefficients
demonstrates that irrespective of the authors conclusions, the variability in each of the posturographic
recordings is very high, making this test poorly accurate, even if used, for instance, for monitoring possible
body posture effects triggered by TMDs. This arises as
almost all of the studies that used posturographic
recordings based on quantitative parameters reported
large variability in most of the datasets (48, 1012, 14
16, 22).
On the basis that about half of the ES coefficients
calculated were below 0.2, and that the other half were
between 0.2 and 1.0, and considering that an ES
coefficient of 0.2 is associated with a small effect (3), a
correlation between the stomatognathic system and
body posture that at least reaches biological, but not
clinical, significance can be hypothesized.
Interestingly, in terms of the ES coefficients, the use
of computerized approaches (postural platform or
rasterstereography) does not appear to provide better
measurement outcomes, as compared to the other
methods (recordings on body photographs or physical
examinations) (Table 6), although a combination of the
postural platform recording (sway area) in the case of
asymptomatic versus symptomatic subjects does appear
to yield slightly higher ES coefficients. However, considering that only 1% of the ES coefficients were above
1.0, and that as a rule of thumb, a diagnostic measurement outcome is considered reliable if it is associated
with an ES coefficient above 2.0, these previous data
are not in favour of posturography as a diagnostic aid in
dentistry. A further confirmation arises from the
observation that the variation of the measured
2009 Blackwell Publishing Ltd

POSTUROGRAPHY IN DENTISTRY
outcomes (as percentages) corresponding to the highest
ES coefficients was very different among the studies
(Table 6). Also of note, seven out of these 13 studies did
not see any statistically significant differences in the
postural parameters recorded even in the cases of the
highest ES coefficients reported (Table 6). However,
four (57, 12) of these seven studies included <17
subjects, which is the sample size needed to detect an
ES coefficient of 1.0 with a power of 0.80 and an alpha
set at 0.05 (3).
In this regard, a previous systematic review on the
sensitivity and specificity of posturography examination by postural platform in the diagnosis of vestibular
dysfunction that reported low accuracy for this diagnostic tool when used alone (29), even in the case of
vestibular impairment, which would be expected to
cause significant postural imbalance.

Conclusions
On the basis of the analysis of these 21 retrieved
studies, it can be concluded that:
1 The quality of the studies available is relatively low,
and further investigations with higher quality designs are warranted;
2 A correlation between the stomatognathic system
and whole-body posture can be detected at least
under experimental conditions;
3 There is, however, little use for posturography in the
monitoring of body posture responses to changes in
the stomatognathic system (including TMDs), with a
large failure rate because of the large variability of
the recordings;
4 Based on quantitative data, the different posturographic methods appear to be similar in terms of
recording the high variability and the consequent
low diagnostic accuracy.

Acknowledgments
The authors are deeply grateful to Dr Tiziano Baccetti
and Dr Lorenzo Franchi (University of Florence,
Florence, Italy) for useful discussions, to Dr Fabio
Pellegrini (Consorzio Mario Negri Sud, Chieti, Italy)
for statistical advice in the calculation of the ES
coefficients, and to Dr Christopher Paul Berrie (Consorzio Mario Negri Sud, Chieti, Italy) for critical
reading of the manuscript. The authors declare no
competing financial interests.
2009 Blackwell Publishing Ltd

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Correspondence: Giuseppe Perinetti, DDS, PhD, Struttura Complessa

di Clinica Odontoiatrica e Stomatologica, Ospedale Maggiore, Piazza
Ospitale 1, 34129 Trieste, Italy.
E-mail: G.Perinetti@fmc.units.it

2009 Blackwell Publishing Ltd