Craniocervical Posture and Trigeminal Nerve Mechanosensitivity in Subjects with a History of Orthodontic Use: A Cross-Sectional Study

Depósito de investigación de la Universidad de Sevilla https://idus.us.es/ Esta es la versión aceptada del artículo publicado en: This is a accepted manuscript of a paper published in: CRANIO: The Journal fo Craniomandibular & Sleep Practice (2013): 23 July  DOI: 10.1179/crn.2013.31.4.002 Copyright: Informa UK Limited El acceso a la versión publicada del artículo puede requerir la suscripción de la revista. Access to the published version may require subscription.  “This is an Accepted Manuscript of an article published by Taylor & Francis in CRANIO: The Journal fo Craniomandibular & Sleep Practice on 23 July 2013, available at: https://doi.org10.1179/crn.2013.31.4.002.”” 1 Title: CRANIOCERVICAL POSTURE AND TRIGEMINAL NERVE MECHANOSENSITIVITY IN SUBJECTS WITH A HISTORY OF ORTHODONTIA USE: A CROSS-SECTIONAL STUDY Running title: POSTURE AND MECHANOSENSITIVITY IN ORTHODONTICS Authors: Alberto Marcos Heredia-Rizo, Ph.D., M.Sc., P.T.; Ángel Oliva Pascual- Vaca, Ph.D., M.Sc., P.T., D.O.; Cleofás Rodríguez-Blanco, Ph.D., M.Sc., P.T., D.O; Daniel Torres-Lagares, Ph.D., D.D.S.; Manuel Albornoz-Cabello, Ph.D., M.Sc., P.T.; Fernando Piña-Pozo, P.T., D.O.; Antonio Luque-Carrasco, P.T., D.O. Corresponding author: Dr. Alberto Marcos Heredia Rizo. Professor. Department of Physiotherapy. Faculty of Nursing, Physiotherapy and Podiatry. University of Sevilla. Calle Avicena s/n, 41009 Sevilla (Spain) (e-mail: [email protected]) Tlf: (+34) 954486509; Fax: (+34) 954486527 2 BIOGRAPHICAL SKETCHES Dr. Alberto Marcos Heredia Rizo is a professor in physical therapy on the Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, Spain. He received his BSc. in Physiotherapy in 2005 from the Satakunta University of Applied Sciences in Pori, Finland. He received his Ph.D. degree in 2012 from the University of Sevilla. His primary research interest is craniomandibular dysfunction and pain related to postural habits. Dr. Ángel Oliva Pascual-Vaca is a professor and currently chair of the Physiotherapy Department on the Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla, Spain. He received his Ph.D. degree in 2007 from the University of Cádiz (Spain). He is doctor of Osteopathic Medicine (D.O) and works also as an international lecturer in manual therapy and ostheopathy. Dr. Cleofás Rodríguez Blanco is a professor on the Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla. He received his Ph.D. from the University of Sevilla in 2008. He is doctor of Osteopathic Medicine (D.O.) and his primary research interest is related to craniomandibular dysfunctions. He is also an international lecturer in manual therapy. 3 Dr. Daniel Torres Lagares is a professor on the Faculty of Odontology, University of Sevilla. He received his D.D.S in 1999 and his Ph.D. in 2003 from the University of Sevilla. He has published many articles in the field of maxillofacial surgery and his clinical work is mainly focused on this topic. Dr. Manuel Albornoz Cabello is a professor in physical therapy on the Faculty of Nursing, Physiotherapy and Podiatry, University of Sevilla. He received his Ph.D. from the University of Sevilla in 2007. He is currently working in the field of electrotherapy and its possible effects on soft tissues in subjects with temporomandibular dysfunctions. Mr. Fernando Piña Pozo is a physiotherapist specialized in musculoskeletal dysfunctions. He received his BSc. in Physiotherapy in 1999 from the University of Sevilla and his D.O. in 2007. He is currently researching for his MSc. degree in the field of temporomandibular joint dysfunctions. His clinical work focuses on craniocervical pain. Mr. Antonio Luque Carrasco is a physiotherapist specialized in neuromusculoskeletal therapy. He received his BSc. in Physiotherapy in 1997 from the University of Sevilla and his D.O in 2009. He is researching for his MSc. degree in the field of orthodontics and manual therapy. 4 COPYRIGHT STATEMENT The undersigned author transfers all copyright ownership of the manuscript entitled: “Craniocervical posture and trigeminal nerve mechanosensitivity in subjects with a history of orthodontia use: a cross-sectional study” to Cranio, The Journal of Craniomandibular Practice in the event the work is published. The undersigned author warrants that the article is original, is not under consideration for publication by another journal and has not been previously published. I sign for and accept responsibility for releasing this material on behalf of any and all coauthors. Sevilla (Spain), September 7th 2012 Dr. Alberto Marcos Heredia-Rizo Professor. Physiotherapy Department. Faculty of Nursing, Physiotherapy and Podiatry. University of Sevilla. 5 ABSTRACT The purpose of the study was to evaluate whether, in asymptomatic subjects, there are differences in: (i) head posture while sitting and standing still and (ii) trigeminal nerve mechanosensitivity, between those who have a history of using orthodontics and those who have not. The sample consisted of 72 subjects (21 ± 2.14 years), one group who had used orthodontia in the past (n=37) and another group who had not had previous orthodontic treatment (n=35). We measured the CranioVertebral Angle (CVA) when the subject was sitting and standing still by means of lateral photographs, and the pressure pain threshold (PPT) of the trigeminal nerve. The orthodontics group showed a more upright position of the head when sitting compared to the non-orthodontics group, with the difference being statistically significant (ANOVA test; p < 0.001; F1,70=16.705; R2=0.19), but not for the standing position (p= 0.538). The values of the PPT in the trigeminal nerve (supraorbital-V1, infraorbital-V2 and mandibular-V3) were lower in both sides (dominant and non-dominant) in the non-orthodontics group. The between group comparison (ANOVA test) showed statistically significant differences for the trigeminal nerve PPT in its different branches (V1 p=0.001; F1,70=13.012; R2=0.15) (V2 p=0.004; F1,70=9.103; R2=0.11) (V3 p=0.005; F1,70=8.228; R2=0.10). Based on these observations, we conclude that subjects with a history of orthodontia use show a better sitting craniocervical posture and mechanosensitivity of the trigeminal nerve branches relative to the group which have not used orthodontics in the past. Keywords: head, neck, orthodontics, posture, pain threshold, trigeminal nerve 6 Introduction Rocabado 1 defined the term Cranio-Cervico-Mandibular Unit, CCMU, to take into consideration the morphofunctional and dynamic interaction that exists between head, neck and jaw. The biomechanics of the relationship within the CCMU has been the subject of considerable debate and controversy among different authors. For Perinetti et al. 2,3 there is no clinically significant association between the posture of the craniocervical segment and the type of dental occlusion. But Sakaguchi et al., 4 Gadotti et al., 5 Rocabado 6 and Visscher et al., 7 among others, claim that different postural attitudes result in different occlusion characteristics and viceversa, so that a change in craniocervical posture generally affects mandibular biomechanics. In general, it is thought that a neutral head posture is linked to a neutral relationship of the molars, 6 while a forward head posture increases the incidence of Class II malocclusion. 8-10 However, Armijo et al. 11 consider that even though there is an increased tendency to link the stomatognathic system with orthopaedic findings in clinical practice, the real evidence for this relationship needs to be built upon better quality studies. In this sense, several studies have been done on the influence on the CCMU of changes to dental occlusion, whether therapeutic (orthodontics and surgery, for example) or not. 12-19 Nevertheless, no solid conclusions have been reached in this matter. In addition, the use of orthodontic devices has been correlated to the occurrence of dental and craniofacial pain, mostly headaches, 20-22 and changes in head posture 23. Besides, hyperexcitability of the trigeminal nerve to mechanical pressure stimulation has been described in studies of 7 patients suffering from temporomandibular joint (TMJ) disorders 24 and chronic cervicogenic or tension type headaches. 25 However, to the best of our knowledge, there have been no studies directly correlating trigeminal mechanosensitivity with head posture or the use of orthodontics. Thus, the objective of the present work was to determine whether, in asymptomatic subjects, there are differences between those who have and those who have not had a previous history of using orthodontics, in their: (i) head posture while sitting or standing still, and (ii) sensitivity of the branches of the trigeminal nerve to stimulation by mechanical pressure. Material and Methods Sample and examiners The sample consisted of undergraduate students of the Faculty of Nursing, Physiotherapy, and Podiatry of the University where the study was designed and the subjects were selected according to a non-random procedure of convenience. The inclusion criteria were: (i) age between 18-27 years old; (ii) a history of having used orthodontics for at least one year (for those to be included in the orthodontics group); (iii) absence of symptoms in the cervical spine, upper limbs and craniofacial area within the past four weeks previous to data collection and (iv) willingness to participate in the study. The preestablished exclusion criteria were: (i) a history of cranial-vault, craniofacial, TMJ, or mandibular fractures and/or surgery; (ii) a history of whiplash injury; (iii) degenerative disorders of the central and/or peripheral nervous system; (iv) spinal fractures and/or surgery at any level; (v) suffering or having suffered 8 osteitis, or cranial-vault, craniofacial, or TMJ rheumatic or tumoural diseases; and (vi) consumption of analgesics or anti-inflammatory drugs within 48 hours prior to data collection. For a two-tail study, considering a large effect size (d=0.8), an α value of .05 and a statistical power of 90%, a sample size of 34 subjects per group was necessary (software: Gpower 3.1.2 ®). The total sample group finally comprised 72 subjects (N=72), 23 men and 49 women, aged between 18 and 27 years, mean age 21 ± 2.14 years. The sample was split into two groups according to whether or not the subject had used orthodontics in the past: an orthodontics groups (n=37) and a nonorthodontics group (n=35). Prior to the measurements, the participants signed an informed consent form prepared in accordance with the bioethics principles of the Declaration of Helsinki (version 2008). Subsequently, they responded to a custom designed instrumental questionnaire consisting of items relating to: (i) socio-demographic data; (ii) physical data (height, weight); (iii) general information (years of use of orthodontics, type of orthodontics, presence or absence of retention material, one-year prevalence of headache, neck and/or TMJ pain). The process of selection and data collection was conducted by two therapists with over 10 years of healthcare experience from October 2010 to June 2011, maintaining similar ambient conditions on the successive days. The practitioner carrying out the measurements remained unaware of the subject's group membership. The study received approval and its design conformed to the guidelines of the Ethical Committee of Experimentation of the University. 15 have been considered as a confounder term, but no correlation has been found between pain, head posture and/or PPT of the trigeminal nerve in the studied sample (p>.05). This aspect is consistent with the findings of Visscher et al. (2002) 35 who, in a study of 250 subjects, concluded that there was no correlation between head posture and pain in the craniomandibular region, whether or not associated with neck pain. Besides, the mean one - year prevalence of neck pain in the adult population (18–80 years) is estimated at 37.2%, 36 a very close figure to the value of our sample, 38.9% (28/72), for the one-year prevalence of neck and/or temporomandibular pain. Likewise, the oneyear prevalence of headache, 43.1% (31/72), is also within the average range described by previous studies that estimated around 40% of prevalence for tension-type headache 25. Moreover, there were no differences in the betweengroups comparison for these variables (table 1). Therefore, we assume that the one-year prevalence of craniomandibular pain has had no effect on the differences observed in the aspects under study, even when it should be taken into consideration, since it is usually linked to signs and symptoms of temporomandibular disorders. With respect to the trigeminal nerve's sensitivity to stimulation by mechanical pressure, the greater excitability measured in the non-orthodontics group is evidence for the interaction between the posture of the craniocervical axis and the processing of nociceptive information by the cervical trigeminal complex. 37 La Touche et al. 37 used algometry on the masseter and temporal muscles, and compared subjects with a normal head posture (as in our nonorthodontics subjects) with those with a corrected posture (as in our orthodontics group). They found that the former group presented greater 16 excitability of the trigeminal muscle nociceptors, which coincides with our observations. They concluded, however, that the cause of this phenomenon can not be distinguished with certainty. In this sense, there is a lingering belief in the clinical context that the use of orthodontics is correlated with the prevalence of signs and symptoms associated with TMJ disorders, 38 even though there is no sound scientific foundation for any causal link between these variables. 39 Indeed, several authors 38, 40, 41 concur that subjects receiving orthodontic treatment show no increased risk of experiencing signs or symptoms of a TMJ dysfuncion. Besides, orthodontic treatment seems to improve functionally potential signs and symptoms of cranio-mandibular disorders, 23, 42 as in our studied sample. Nevertheless, it is crucial to build up more scientific evidence in this field. Again, although our results show a statistically significant difference between both groups in head posture and trigeminal nerve PPT, the clinical relevance of the phenomenon is difficult to determine, since the effect size of the inter-group differences was small in all cases. We believe that the present study might be a starting point and it would be of great interest in subsequent investigations to enlarge and to heterogenize the sample and to develop followup studies as an alternative to the present cross-sectional approach. Moreover, it would be important to focus on a certain type of orthodontic treatment so that the results might allow inferring conclusions of greater clinical and statistical significance. 17 Conclusion The subjects with a history of orthodontic treatment show a better craniocervical posture (while sitting) and mechanosensitivity of the trigeminal nerve branches relative to the group without having had orthodontic treatment in the past. Conflict of Interests and Funding Sources The authors declare no conflict of interests or funding sources for this study. 18 References 1. Rocabado M: Biomechanical relationship of the cranial, cervical and hyoid regions. J Craniomandibular Pract 1983; 1:61-66 2. Perinetti G: Dental occlusion and body posture: No detectable correlation. Gait Posture 2006; 24:165-168 3. Perinetti G, Contardo L, Biasati AS, Perdoni L, Castaldo A: Dental malocclusion and body posture in young subjects: a multiple regression study. Clinics 2010; 65: 689-695 4. Sakaguchi K, Mehta NR, Abdallah EF, Forgione AG, Hirayama H, Kawasaki T et al: Examination of the relationship between mandibular position and body posture. Cranio 2007; 25: 237-249 5. Gadotti IC, Berzin F, Biasotto González D: Preliminary rapport on head posture and muscle activity in subjects with class I and II. J Oral Rehabil 2005; 32: 794–799 6. Rocabado, Johnston BE, Blakney MG: Physical therapy and dentistry; an overview. J Craniomandibular Pract 1982; 1: 46-49 7. Visscher CM, Huddleston Slater JJ, Lobbezoo F, Naeije M: Kinematics of the human mandible for different head postures. J Oral Rehabil 2000; 27:299-305 8. D’Attilio M, Caputi S, Epifania E, Festa F, Tecco S: Evaluation of cervical posture of children in skeletal Class I, II, and III. Cranio 2005; 23: 219–228 9. Capurso U, Garino GB, Rotolo L, Verna CA: Parametri posturali cefalometrici e malocclusioni dentarie. Mondo Ortod. 1989; 14:345-349 19 10. Nobili A, Adversi R: Relationship between posture and occlusion: a clinical and experimental investigation. J Craniomandibular Pract 1996; 14:274-285 11. Armijo Olivo S, Magee DJ, Parfitt M, Major P, Thie NM: The association between the cervical spine, the stomatognathic system, and craniofacial pain: a critical review J Orofac Pain. 2006; 20:271-287. 12. Castroflorio T, Titolo C, Deregibus A, Debernardi C, Bracco P: The orthodontic treatment of TMD patients: EMG effects of a functional appliance. Cranio 2007; 25: 206-212 13. Botelho AL, Melchior M de O, da Silva AM, da Silva MA: Electromyographic evaluation of neuromuscular coordination of subject after orthodontic intervention. Cranio 2009; 27:152-158 14. Dart RA: The postural aspect of malocclusion. SADJ 1946;1:1- 21. 15. Mertensmeier I, Diedrich P: The relationship between cervical spinal posture and bite anomalies. Fortschr Kieferorthop. 1992; 53: 26-32 16. Huggare JA, Raustia AM: Head posture and cervicovertebral and craniofacial morphology in patients with craniomandibular dysfunction. Cranio 1992; 10:173-177 17. Kondo E, Aoba TJ: Case report of malocclusion with abnormal head posture and TMJ symptoms. Am J Orthod Dentofacial Orthop 1999; 116: 481-493 18. Strini PJ, Machado NA, Gorreri MC, Ferreira Ade F, Sousa Gda C, Fernandes Neto AJ: Postural evaluation of patients with temporomandibular disorders under use occlusal splints. J Appl Oral Sci. 2009; 17:539-543 20 19. Tecco S, Farronato G, Salini V, Di Meo S, Filippi MR, Festa F et al: Evaluation of cervical spine posture after functional therapy with FR-2: a logitudinal study. Cranio 2005; 23: 53-66 20. Michelotti A, Farella M, Martina R: Sensory and motor changes of the human jaw muscles during induced orthodontic pain. Eur J Orthod. 1999; 21:397-404 21. Erdinç AM, Dinçer B: Perception of pain during orthodontic treatment with fixed appliances. Eur J Orthod. 2004;26:79-85 22. Abu Alhaija ES, Aldaikki A, Al-Omairi MK, Al-Khateeb SN: The relationship between personality traits, pain perception and attitude toward orthodontic treatment. Angle Orthod. 2010; 80:1141-1149 23. Heredia-Rizo AM, Oliva Pascual-Vaca A, Albornoz Cabello M, Rodríguez Blanco C, Piña Pozo F, Luque Carrasco A: Immediate effects of the suboccipital muscle inhibition technique in craniocervical posture and greater occipital nerve mechanosensitivity in subjects with a history of orthodontia use: a randomized Trial. J Manipulative Physiol Ther 2012 (in press) doi: 10.1016/j.jmpt.2012.06.006 24. Fernández de las Peñas C, Galán del Rıo F, Fernández Carnero J, Pesquera J, Arendt-Nielsen L, Svensson P: Bilateral Widespread Mechanical Pain Sensitivity in Women With Myofascial Temporomandibular Disorder: Evidence of Impairment in Central Nociceptive Processing. J Pain 2009; 10:1170-1178 25. Fernández de las Peñas C, Coppieters MW, Cuadrado ML, Pareja JA: Patients With Chronic Tension-Type Headache Demonstrate Increased 21 Mechano-Sensitivity of the Supra-Orbital Nerve. Headache 2008; 48: 570- 577 26. Raine S, Twomey LT: Head and shoulder posture variations in 160 asymptomatic women and men. Arch Phys Med and Rehabili 1997; 78: 1215-1223 27. Fernández de las Peñas C, Alonso Blanco C, Cuadrado ML, Gerwin RD, Pareja JA: Trigger Points in the Suboccipital Muscles and Forward Head Posture in Tension-Type Headache. Headache 2006; 46: 454-460 28. Horton SJ, Johnson GM, Skinner M: Changes in head and neck posture using an office chair with and without lumbar roll support. Spine (Phila Pa 1976) 2010;35: 542-548 29. Sonnesen L, Bakke M, Solow B: Temporomandibular disorders in relation to craniofacial dimensions, head posture and bite force in children selected for orthodontic treatment. Eur J Orthod 2001; 23:179-192 30. De la Llave Rincón AI, Fernández de las Peñas C, Palacios Ceña D, Cleland JA: Increased forward head posture and restricted cervical range of motion in patients with carpal tunnel syndrome. J Orthop Sports Phys Therapy 2009; 39:658-664 31. Fernández de las Peñas C, Cuadrado ML, Pareja JA: Myofascial trigger points, neck mobility and forward head posture in unilateral migraine. Cephalalgia 2006; 26: 1061–1070 32. Fischer AA: Pressure algometry over normal muscles. Standard values, validity and reproducibility of pressure threshold. Pain 1987; 30: 115-126 22 33. Song WC, Kim SH, Paik DJ, Han SH, Hu KS, Kim HJ, Koh KS: Location of the Infraorbital and Mental Foramen with Reference to the Soft-Tissue Landmarks. Plast Reconstr Surg 2007; 120:1343-1347 34. Lee WY, Okeson JP, Lindroth J: The relationship between forward head posture and temporomandibular disorders. J Orofac Pain. 1995; 9: 161-167 35. Visscher CM, De Boer W, Lobbezoo F, Habets LL, Naeije M: Is there a relationship between head posture and craniomandibular pain? J Oral Rehabil 2002; 29: 1030-1036 36. Fejer R, Kyvik KO, Hartvigsen J: The prevalence of neck pain in the world population: a systematic critical review of the literature. Eur Spine J 2006; 15:834-848 37. La Touche R, París-Alemany A, von Piekartz H, Mannheimer JS, Fernández-Carnero J, Rocabado M: The influence of cranio-cervical posture on maximal mouth opening and pressure pain threshold in patients with myofascial temporomandibular pain disorders. Clin J Pain 2011; 1:48- 55 38. Hannan K: Orthodontic braces and migraine headache: Prevalence of migraine headache in females aged 12-18 years with and without orthodontic braces. Int J Osteopath Med 2005; 8: 146-151 39. Michelotti A, Iodice G: The role of orthodontics in temporomandibular disorders. The role of orthodontics in temporomandibular disorders. J Oral Rehabil 2010; 37: 411–429 40. Egermark I, Magnusson T, Carlsson GE: A 20-year follow-up of signs and symptoms of temporomandibular disorders and malocclusion in subjects 23 with and without orthodontic treatment in childhood. Angle Orthod 2003; 73:109–115 41. Henrikson T, Nilner M: Temporomandibular disorders and the need for stomatognathic treatment in orthodontically treated and untreated girls. Eur J Orthod 2000; 22:283–292 42. Henrikson T, Nilner M, Kurol J: Signs of temporomandibular disorders in girls receiving orthodontic treatment. A prospective and longitudinal comparison with untreated Class II malocclusions and normal occlusion subjects. Eur J Orthod. 2000; 22:271–281 24 FIGURES AND TABLES Figure 1. Measurement of the Craniovertebral Angle (CVA)