©

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© 2020 EDIZIONI MINERVA MEDICA Minerva Stomatologica 2020 April;69(2):112-8

Online version at http://www.minervamedica.it DOI: 10.23736/S0026-4970.20.04350-2

REVIEW

Dental occlusion and sport performance

Angela MILITI 1, Marco CICCIÙ 1, Sergio SAMBATARO 2, Salvatore BOCCHIERI 2,
Gabriele CERVINO 1, Rosa DE STEFANO 1, Luca FIORILLO 1 *

1Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina,
Messina, Italy; 2Section of Orthodontics, Department of Medicine and Surgery, University of Insubria, Varese, Italy
*Corresponding author: Luca Fiorillo, Department of Biomedical and Dental Sciences and Morphological and Functional Imaging,
University of Messina, Messina, Italy. E-mail: lfiorillo@unime.it

A B S TRACT
INTRODUCTION: In recent years, interest has been given to the relationship between dental occlusion and athletes’
performance. A correct occlusion allows for a correct position of the mandible in space and could be reached by wearing
a splint made by a dentist. Achieving this condition appears to be an advantage for all athletes, and especially for those
who have TMJ dysfunction. The purpose of the study was to investigate the hypothesis and common belief that correcting
the occlusion or the use of a splint could improve an athlete’s performance.
EVIDENCE ACQUISITION: A search on electronic database has been performed and obtained 141 results; then, follow-
ing the application of the inclusion criteria, only 11 articles were selected.
EVIDENCE SYNTHESIS: A good occlusion seems to be an advantage for the athletes.
CONCLUSIONS: The use of an occlusal splint should be evaluated in different sports, because the occlusion and TMJ
conditions of the athletes are different and the efforts in which they are subjected could not be generalized because the
sports have various rules and characteristics that involves the stomatognathic system differently.
(Cite this article as: Militi A, Cicciù M, Sambataro S, Bocchieri S, Cervino G, De Stefano R, et al. Dental occlusion and sport
performance. Minerva Stomatol 2020;69:112-8. DOI: 10.23736/S0026-4970.20.04350-2)
Key words: Dental occlusion; Malocclusion; Sports; Splints; Occlusal splints; Dentistry.

Introduction complete physical, mental, and social well-being

of the patient. Thus, occlusion is more than just

A thletes are always looking for the best

performance on the playing fields. In re-
cent years, attention has been given to the role
the fit of the teeth or “a place where the teeth
meet to eat.” It involves the entire postural appa-
ratus as the support of the skull and jaws relates
of occlusion in improving sports performance to the neck and the complete body. Dental occlu-
and many professionals’ athletes of various dis- sion determines the position of the mandible in
ciplines have been portrayed in photos while space, its stabilization, the control of propriocep-
wearing a “bite” during competitions or at the tive afferents and therefore plays an active role
end of them, increasing the patients’ interest in in protecting the integrity of the TMJ.2-5 Posture
these devices. Patients’ expectations are high and is the relationship between the different skeletal
they often believe that a “splint” placed in the segments understood in the somatic globality,
oral cavity could resolve pain or functional al- suitable for a convenient biomechanical rela-
terations in anatomical districts far from the sto- tionship with the environment. Dental occlusion
matognathic apparatus.1 seems to play an important role in body posture.
The science of occlusion is concerned with the It has therefore been ascertained that a maloc-
study of the contribution of the teeth and jaws to clusion could have a “descending” effect on the

112 Minerva Stomatologica April 2020

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DENTAL OCCLUSION AND SPORT PERFORMANCE MILITI

postural attitude. The definition of posture is the formance; this produces stress, fatigue and dis-
union of the positional relationships of the body traction. With this technology (Bite or plate) the
in space, if harmonious the body is in balance, if teeth are clenched and the jaw is allowed to pivot
it is altered it produces dysmetries.6-10 forward to relieve the pressure of the TMJ so the
Sports gnathology is a specialization in gna- release of excess negative hormones ceases, so
thology in order to prevent insults and traumas that the head could free all its potential.14
of the masticatory system following competitive The athlete needs to give maximum perfor-
activity, it also aims, by improving posture, to mance and pay attention to training programs.
promote the recovery of relaxation and the im- During the race, adrenaline and noradrenaline
provement of performance following a muscular are released through the mechanism of stress
effort. When the teeth are at rest, the muscles of (activation of the orthosympathetic). among oth-
the body (neck, head, chest and abdomen) are re- er things, influencing emotions (suffering, fear,
laxed, allowing all other muscles to function at aggression, anger). The main consequences are:
a higher level (increasing performance and de- •  increased cardiac output and blood pressure;
creasing fatigue). When the jaw is relaxed and •  increased blood flow to heart and skeletal
goes slightly forward it widens the respiratory muscles;
tract. The increased oxygen intake allows the •  increased energy metabolism and body tem-
muscles involved in physical exertion to be re- perature;
leased, including those of the back and abdomen •  increased blood sugar, catabolic action.
for recruitment. National and international stud- No athlete or trainer would ever want to give
ies have shown that athletes, once equipped with up this strengthening of muscles and heart as it
Bite or mouth protection plates, show improved does for so-called physiological stress. The ideal
balance, rotation, strength and overall endurance. would be that, once the race was over, suffering,
The relationship between occlusion and posture fear, aggression and anger ended immediately, so
in sport has been talked about for a long time but as to allow the athlete to recover and rest from
in recent years it is becoming aware that maloc- fatigue by fully restoring the energy reserve (re-
clusion may have an effect on the athlete’s pos- freshment phase through vagal and parasympa-
tural attitude, thus compromising performance thetic mechanisms). If you do not have this re-
and increasing the risk of injuries.11-13 covery of resources between one performance
In high level athletes, even a minimal change and another, you will face a phase of chronic
in balance could translate into changes in the stress that could damage the Athlete. Clenching
intensity of strength and coordination skills, as the teeth for 30 seconds increases the pressure
well as causing the onset of a state of muscle ten- of 3.2 mrn of mercury, tightening for 1 minute
sion that adversely affects the whole body, de- the pressure goes to an increase of 5.5 mm of
creasing it global athletic potential. mercury. These data and the experiments carried
Here the Bite becomes the tool able to improve out indicate that the chewing muscles play an im-
athletes’ performance in a natural way because portant role in the harmony of the stress system
postural relationships are optimized, including (muscle contractions of chewing) and relaxation
less energy consumption and a better expression (stretching of the jaw muscles). An integral as-
of physical and mental strength. Man’s motor sessment of the athlete or patient with an accu-
system is organized to counter two forces: grav- rate visit is required which involves an analysis
ity and centrifugal. So, the posture to counter of the dental situation and any destabilizing mal-
these forces requires constant adaptation. When occlusions.11, 12, 14-22
you are focused, tense, nervous, you involuntari- The purpose of this work is to evaluate how
ly clench your teeth and for an athlete it happens dental occlusion (natural good one or “acquired”
when you train and compete, clenching your teeth with a splint) is related to sports performance and
and jaws reduces compression of the jaw joints the possibility that a “splint” could give perfor-
(TMJ) triggering the release of excess amounts mance benefits or not to professional athletes or
of hormones such as cortisol, undermining per- sports subjects.

Vol. 69 - No. 2 Minerva Stomatologica 113

 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

MILITI DENTAL OCCLUSION AND SPORT PERFORMANCE

Evidence acquisition consensus could not be reached. For the stage of

the full-text articles revision, a complete inde-
Application protocol and website recording data pendent analysis was performed.
An investigation methods protocol has been Research classifications
used, this protocol has been submitted in the
PROSPERO website. The manuscript has been The method of classification included all human
then submitted as systematic review, with prospective and retrospective clinical studies,
PROSPERO acknowledgement of receipt num- case-control papers, case series manuscripts and
ber 196473. literature of last year, in order to obtain a recent
The manuscript has been conducted according data review. Included results are published be-
to Preferred Reporting Items for Systematic Re- tween February 2009 and May 2019, on TMJ
view (PRISMA) statement.23-25 dysfunctions related to posture.

Target questions Exclusion and inclusion criteria

The questions processed the following guide- The full texts of all studies related to the main
lines, according to PICO: revision topics were obtained for comparing the
•  Do dental occlusion influence sport perfor- inclusion parameters:
mances in patients who have malocclusion? •  Investigated relations between dental occlu-
sion and sports.
Search strategy The following exclusion criteria:
•  Not enough information regarding the topic
A research in five electronic databases has been
•  Animal or in-vitro studies
conducted, including MEDLINE, PubMed, and
•  Articles published prior to 1 February 2009
EMBASE. In addition, a manual search on Den-
•  No access to the title and abstract
tistry source was conducted, for relevant studies
published. Strategy for collecting data
Digital and searches by hand were then per-
formed in relations between occlusion, TMJ and At the first time, manuscript titles list was high-
sports. Data search has been performed in order lighted to exclude irrelevant publications and
to add significant studies and to increase the sen- search errors, case reports and publication in
sitivity of this study. different language than English. The final selec-
tion was performed reading the full texts of the
Collection data papers in order to approve each study’s eligibil-
ity, based on the inclusion and exclusion crite-
Medical Subject Headings (MeSH) were applied
ria.
for finding the keywords used in the present re-
vision. The selected key words: (“dental occlu- Record of the extracted and collected data ex-
sion” AND “sport”) were recorded for collecting traction
the data. The date of last search with these results
was 31 May 2019. The results and conclusions of the selected full
text papers were used for assembling the data,
Manuscript selections according to the aims and themes of the present
revision.
Data selection and revision has been performed
by independent reviewers of three different affil- Risk of bias assessment
iations (S.B., Messina; R.L.B., Reggio Calabria;
L.F., Naples). They singularly analyzed the ob- The grade of bias risk was independently consid-
tained papers. Results obtained have been com- ered, as reported in literature.26-28
pared and discussed with a fourth independent Potential causes of bias were investigated:
reviewer (G.C.; University of Messina) when a •  selection bias;

114 Minerva Stomatologica April 2020

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

DENTAL OCCLUSION AND SPORT PERFORMANCE MILITI

•  performance bias and detection bias; Synthesis of results

•  attrition bias;
Julia-Sanchez et al.18 in a recent review found
•  reporting bias;
that there is evidence of correlations between the
•  examiner blinding, examiner calibration,
masticatory and cervical muscles, there is a re-
standardized follow-up description, standardized
ciprocal connection between the trigeminal and
residual graft measurement, standardized radio-
vestibular nuclei with an important influence of
graphic assessment.
the stomatognathic system on body balance; this
group of researchers highlighted that tradition-
Evidence synthesis ally, research involving the relationship between
the stomatognathic system and balance control
The results obtained from a careful analysis of of the body were made only on controlled situ-
the literature, after applying the correct inclusion ations, and these conditions doesn’t consider the
and exclusion criteria, were further evaluated by afferences of dental occlusion for body balance
the authors. control when real conditions are present, which
certainly influence the response of the organism
Study selection
and the postural attitude of the athletes. Baum
At the first research a number of 141 studies have et al.29 in their work study aimed to investigate
been obtained. Applying inclusion and exclusion the influence of a change in dental occlusion by
criteria only articles published in the last 10 years means of a dental splint on the rehabilitation of
have been included. At this point the remaining a glenohumeral internal rotation deficit (GIRD)
66 articles were further skimmed by evaluating among volleyball players. They divided 22 pro-
only the studies on humans (50), and subsequent- fessional female volleyball players in two groups
ly only those available in full text format (35), so and studied range of motion and the isomet-
as to be able to consult all the available results. ric strength of the dominant shoulder, with and
Then articles have been manually selected and at without splints: no differences were detected by
the end of the research 11 articles were obtained them between the two groups in different tests
(Figure 1). they carried out. Leroux et al.30 revealed that the
interposition of an occlusal splint significantly
increased the proportion of athletes presenting
Ovid MedLine, PubMed, Embase Additional records identified
asymmetric muscular contractions from 14.3%
Identification

- Search terms: “dental occlusion” through other Oral Sciences

AND “sport”
- Publication dates: 01/02/2009-
and Biology and Anatomy to 85.7% (P=0.025). Dias et al.31 studied thirteen
source (N.=0)
31/05-2019
- Languages: English
national-level male shooters without any cervical
- Results (N.=141) disease. For each athlete, were made an occlusal
Paper deleted because
Filtered
published before 10 years splint and a placebo splint and they shots in ran-
(N.=91) domized order in all different experimental con-
Screening

50 search results
dition, without any improvement in electromy-
Paper deleted because not
Filtered
full-text and English language ography activity of upper limb muscles, but they
(N.=15) obtain just a reduction of the average oscillation
Full-text articles assessed
for eligibility with adequate area and of shot dispersion while they wear the
Eligibility

information (N.=35) proper occlusal splint. Fisher et al.32 tested the

Filtered Not enough information about cycling sprint performance of twenty-three men
selected topic or RCTs (N.=24)
with the Wingate Anaerobic Test (WAnT) with-
Titles and abstracts were selected out founding any differences in any aspect of that
according to relevancy after
duplicates removal (N.=11) test (time to peak power, peak power, minimum
Included

power, power drop, and average power) with

Articles included (N.=11) or without occlusal splint. Julia-Sanchez in a
different work with another group of research-
Figure 1.—PRISMA (Preferred Reporting Items for Sys-
tematic Reviews and Meta-Analyses) flow diagram. RCT: ers14 evaluated on an unstable platform different
randomized controlled trial. dental occlusion conditions (intercuspal position

Vol. 69 - No. 2 Minerva Stomatologica 115

 ©
or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

MILITI DENTAL OCCLUSION AND SPORT PERFORMANCE

and with cotton rolls between arches, that works splint does not significantly influence the reha-
as a splint) at random order. When the platform bilitation or sport performaces. Leroux et al.30
was set in unstable mode, balance control was concluded that malocclusions had a negative im-
significantly improved with cotton rolls, for rest pact in athletic performance of young elite row-
(P=0.03) and fatigue (P<0.001) parameters. With ers and a good occlusion would be an advantage
the platform set in stable mode, the influence of for these athletes. Dias et al.31 found that splints
dental occlusion only reached statistically val- didn’t affect body posture, upper limb electro-
ue in fatigue condition (P=0.04). Gould et al.33 myography muscle activity, or shot performance
highlighted risks and costs of an injuries in oral in healthy male pistol shooters. Fisher et al.32
cavity, and found that these conditions could ex- found that dental splints have no effects on any
ceed $15000 in treatment in adult life. Maurer aspect of WAnT performance. Julia-Sanchez
et al.11 studied the influence of the mandible on et al., in 2016,14 concluded that proprioceptive
the running pattern of twenty runners with four afferences that came from dental occlusion for
different occlusal condition for each person, per- the balance control becomes effective when are
forming five different running trials while they present difficult conditions for the balance con-
wearing randomly the four splints. They revealed trol are present. Gould et al.33 recommend to use
that runners while have splint had a symmetri- occlusal splint or mouth guard in order to pre-
cal running pattern than without it. Gage et al.34 vent sport-related dental injury. Maurer et al.11
tested two different commercial mouthguard and confirmed the influence of an occlusal splint on
a custom splint in a cohort of 24 weightlifters, running pattern, it allows to have a symmetrical
and their results were a different interocclusal pattern that could reduce the risk of injuries and
distance (affected by splints type (P=0.01)) and help in having a better performance. Gage et al.34
a different expression of activity of the anterior conclusions were that exists a difference in mus-
temporalis and masseter muscles and mean ac- cle activity and their athletes perceived that they
tivity of the sternocleidomastoid muscle differed were stronger and were less encumbered when
among mouthguards (P<0.05). Baldini et al.35 using a custom mouthguard during submaximum
studied 20 air force and 20 civilian pilots; first power clean lifts. Baldini et al.35 result’s con-
of all, they performed and oral examination and firmed that occlusion influence body posture of
a force platform test, to determine the subjects’ pilots. From another work of Baldini et al.36 in a
postural condition. Then, different tests and the cohort of professional basketball player, is clear
result related to occlusion was that the sway area that the gnathological postural treatment of ath-
parameter was significantly influenced by the letes has greater influence on performance when
mandibular position: the lower jaw position with the individual suffers of Temporomandibular
eyes open changed the sway area by about 51% Joint Disorders and they suggest that every ath-
and with eyes closed by about 40%. Baldini in a letes should be analyzed individually in order to
different paper, wrote with another group of re- improve his postural conditions and their sports
searchers36 treated professional basketball play- performance.4, 9, 16, 37-45
ers with occlusal splint and physiotherapy ses-
sions, and obtained a considerably improvement
of symptoms related to stomatognathic system Conclusions
and with an improvement of force of quadriceps To date, in literature there is still no evidence of
muscle. how work the pathophysiological mechanisms
Discussion that relate dental occlusion to sport performance.
In cases of TMJ dysfunctional athletes the re-
Julia-Sanchez et al.18 concluded that afferent searches seem to demonstrate the benefits of
proprioceptive signals from dental occlusion ef- wearing a splint during the sport activity. The
fectively contribute to the body balance control use of an occlusal splint should be evaluated in
when external inputs and perturbations are pres- different sports with targeted studies.
ent. Baum et al.29 found that the use of a dental Every sportsman, if showed a malocclusion,

116 Minerva Stomatologica April 2020

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or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other means which may allow access COPYRIGHT 2020 EDIZIONI MINERVA MEDICA
cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo, or other proprietary information of the Publisher.
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies (either sporadically

to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is not permitted. It is not permitted to remove,

DENTAL OCCLUSION AND SPORT PERFORMANCE MILITI

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Conflicts of interest.—The authors certify that there is no conflict of interest with any financial organization regarding the material
discussed in the manuscript.
Authors’ contributions.—Conceptualization, Salvatore Bocchieri and Gabriele Cervino; methodology, Gabriele Cervino; validation,
Luca Fiorillo, Sergio Sambataro and Rosa De Stefano; formal analysis; data curation, Sergio Sambataro; writing-original draft prepa-
ration, Rosa De Stefano and Sergio Sambataro; writing-review and editing, Salvatore Bocchieri and Luca Fiorillo; visualization, and
Salvatore Bocchieri; supervision, Luca Fiorillo.
History.—Article first published online: March 16, 2020. - Manuscript accepted: February 18, 2020. - Manuscript received: February
6, 2020.

118 Minerva Stomatologica April 2020