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Relationships of sagittal skeletal discrepancy,

natural head position, and craniocervical
posture in young Chinese children
Ying Liu1, Xinhua Sun1, Yuanping Chen1, Min Hu1, Xu Hou1, Chang Liu1,2
Department of Orthodontics, Hospital of Stomatology, JiLin University, Changchun, China, 2 State Key
Laboratory of Oral Diseases, West China College of Stomatology, West China Hospital of Stomatology,
SiChuan University, Chengdu, China

Objective: The aim of this study was to investigate the relationships of sagittal skeletal discrepancy, natural
head position (NHP), and craniocervical posture in young Chinese children with average vertical facial
Methods: Ninety patients with average Frankfort mandibular plane angle (FH/ML) were classified into
skeletal class I, II, and III relationships according to their ANB angle. Cephalometric radiographs in
NHP were taken. Variables representing sagittal and vertical craniofacial morphology, head posture,
and craniocervical posture were measured and compared.
Results: Subjects in the skeletal class II group showed the largest craniovertical angles and craniocervical
angles, while subjects in the skeletal class III group exhibited the smallest craniovertical angles and
craniocervical angles, though not all the measurements showed significant differences. The angle
formed by the nasion-sella line and the tangent to the posterior border of the mandibular ramus (NSL/
RL) was largest in the skeletal class II group and smallest in the skeletal class III group (P 5 0.05).
Discussion: Significant differences exist in NHP and craniocervical posture among skeletal class I, II, and
III relationships in young Chinese children. Subjects with skeletal class II relationship tended to exhibit
more extended head, and children with skeletal class III relationship often exhibited flexed head.
Keywords: Craniocervical posture, Craniofacial morphology, Natural head position

Introduction distant object at eye level.3 The concept of NHP was

Intracranial reference planes, such as the sella-nasion introduced to orthodontics in the 1950s by Downs.1
(SN) and Frankfort (FH) horizontal planes, are Natural head position as a reference system has been
widely used in combination with other planes in con- advocated mainly due to its good intra-individual
temporary cephalometric analysis to assess vertical or reproducibility to a true vertical line in both short
sagittal skeletal relationship.1 However, the reliability and long periods of time.4–6 Previous studies indicated
of these reference planes was questioned due to the that the reproducibility of NHP after 5–10 minutes,
observations that these planes change continuously 5 years, and even 15 years was still as good and reliable
during growth, and vary highly among individuals.1 as that of the initial one.6 Additional features that vali-
Therefore, measurements based on these planes are date the use of NHP in cephalometry as well as clinical
likely to yield misleading information, and the use examinations include its representation of a true life
of true vertical planes as an alternative seems to be appearance.1
reasonable.1,2 Natural head position and craniocervical posture are
Natural head position (NHP) is a standardized head dictated by the neuromuscular balance and response to
position with the subject’s head erect and looking at a physiological and environmental conditions.7 Hence,
numerous functional factors, which may have an influ-
ence on the neuromuscular activity, such as nasal
Correspondence to: Chang Liu, Department of Orthodontics, Hospital of obstruction, temporomandibular disorders (TMD),
Stomatology, JiLin University, 1500 Qinghua Road, Chao Yang District,
Changchun, JiLin 130021, China. Email: and bruxism, are ascribed to the alteration of head

ß W. S. Maney & Son Ltd 2015

DOI 10.1179/2151090315Y.0000000015 CRANIOt: The Journal of Craniomandibular & Sleep Practice 2015 VOL . 00 NO . 0 1
Liu et al. Skeletal discrepancy, NHP, craniocervical posture

and craniocervical posture because of the anatomical students’ sample, the Australian Aboriginals were
and biomechanical relationship between the position reported to have a shorter cervical spine, a less
of the head and cervical spine and dentofacial struc- pronounced cervical lordosis, and a larger craniocervi-
tures.7–10 It has been shown that nasal obstructions cal angle.19 However, how craniofacial morphology in
resulted in elevation of the head, relative to the cervical sagittal or vertical dimension is exactly associated
column and the true vertical.8 Conversely, reduced with the NHP and craniocervical posture, respectively,
nasal resistance from corticosteroid treatment, in the Chinese population, is still not clear. The aim of
adenoidectomy, or rapid maxillary expansion led to a the present study was to investigate the relationships of
flexion of the head and a decrease in the craniocervical sagittal skeletal discrepancy (skeletal class I, II, III),
angulation.8 It has also been documented that subjects NHP, and craniocervical posture in young
with TMD tended to show an increased craniocervical Chinese children with average vertical facial patterns.
angulation and a marked forward inclination of the
upper cervical spine,9 while bruxers displayed a more Methods and Materials
anterior and downward tilting of the head.10 Materials
Meanwhile, according to previous studies, NHP and The subjects involved in the present study were selected
craniocervical posture are associated with various den- from a large pool of patients who sequentially arrived
toskeletal malocclusions, orthopedic treatments, and for orthodontic treatment. Cephalometric radiographs
orthognathic surgeries. The relationships between were taken for diagnosis and treatment purposes. The
NHP and various malocclusions, such as crowding in final sample comprised 90 children aged 11–14 years,
the maxillary and mandibular dental arches, overbite, and was divided into three groups according to ANB
crossbite, and molar relationships have been studied value (Table 1). The primary criteria for inclusion in
before.11,12 Solow13 found that subjects with anterior the study were Chinese ethnic origin, confirmed date
crowding showed more extended head posture, and he of birth, nose breathers with complete dentitions, no
noticed that there were some correlations between bilat- history of orthodontic treatment, no wounds, burns,
eral distal molar occlusion and craniocervical angles. or scar tissue in the face and neck region, no craniofacial
Additionally, it has been reported that the application pathology, i.e. TMD, and average Frankfort mandibu-
of facemasks with rapid maxillary expansion for lar plane angle (FH/ML). In addition, since the sagittal
1 year led to a significant flexion of the head.14Mean- skeletal discrepancy can be ascribed to abnormal
while, mandibular setback surgery for mandibular pro- growth in the maxilla, mandible, or both, only subjects
trusion was found to increase craniocervical angulation, with normal SNA and SNB values were selected in the
while mandibular advancement surgery could result in a skeletal class I relationship (group 1), while subjects
more flexed head posture.15,16 with a normal SNA value and a small SNB value were
It has likewise been demonstrated that growth included in skeletal class II relationship (group 2), and
changes in craniocervical posture were related to corre- subjects with a small SNA value and normal SNB
sponding changes in the growth pattern of the facial value were selected in skeletal class III relationship
skeleton, and that in individuals with a large or a (group 3). Details of the sample are given in Table 1.
small craniocervical angle, the subsequent facial devel- The study was approved by the Ethics Committee
opment could, to some extent, be predicted.17 Solow3 of JiLin University. Informed consent was obtained
noticed that the posture of the head in relation to the from all the children and their parents.
cervical column showed more correlations with facial
morphology than the conventional measures of head Methods
posture. In those studies, subjects with a large Cephalometric radiographs were taken by a single
craniocervical angle showed reduced facial prognath- technician using ProMax (Planmeca, Helsinki,
ism, large mandibular plane inclination, and large Finland). The machine had a standardized focus-film
lower anterior facial height, whereas subjects with a distance of 164 cm, and the distance from the film to
small craniocervical angle, on average, showed a shorter the medial plane was 19 cm. Exposure data were
anterior facial height, larger sagittal jaw dimensions, 60–84 kV and 1–16 mA s.1 The X-ray device had
and a less steep inclination of the mandible.18 a focus of 0.5 mm. No correction was made to the con-
A number of studies have focused on the associ- stant linear enlargement of 13%. An aluminum wire
ations between craniofacial morphology, NHP, and was mounted in front of the cassette to indicate a
craniocervical posture in different populations, true vertical position on the film.
and found that ethnic origin may influence the head The radiographs were exposed with the subjects
and neck position.3,11,18,19 Compared to the Danish standing in self-balance position: the children were

2 CRANIOt: The Journal of Craniomandibular & Sleep Practice 2015 VOL . 00 NO . 0

Liu et al. Skeletal discrepancy, NHP, craniocervical posture

Table 1 Details of the sample.

SNA angle SNB angle

Description Total/boys Age (years) mean + SD ANB angle (uu) (uu) mean + SD (uu) mean + SD

Number of subjects 90/45 12.32 + 2.32 – – –

Skeletal class I relationship (group1) 30/15 12.43 + 1.14 0–5 81.73 + 1.89 78.95 + 2.21
Skeletal class II relationship (group2) 30/15 12.40 + 1.12 w5 81.58 + 3.01 75.72 + 3.04
Skeletal class III relationship (group3) 30/15 12.13 + 1.67 v0 77.72 + 2.57 80.28 + 2.36

told to make themselves comfortable, relax their arms were compared for each registration, and the error
by their sides, and stand with their heels together and variance was calculated using Dahlberg’s formula:
toes apart by 45uu. Participants were asked to tilt their qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
heads forward and backward with decreasing ampli- Me ¼ d 2 =2n
tude until they achieved what they considered to be
where d represents the difference between two
their natural head posture, and then they were
registrations, and n is the number of duplicate regis-
instructed to look straight ahead. After NHP was
trations. Hypothesis testing indicated no significant
determined, ear rods were inserted into external audi-
differences between the two registrations.
tory meatus to make sure no head movements and
horizontal rotation took place during the test. The
radiographs were taken with the lips in light contact Statistical analysis
and the teeth in centric dental occlusion. All statistical analysis was performed using the
All cephalometric radiographs were converted to Statistical Package for Social Sciences (SPSS), version
digital format using a flatbed scanner (ScanMaker 12.0 (SPSS Inc, Chicago, IL, USA). For the purpose
9800XL, Microtek, CA, USA) and measurements of descriptive statistics, the mean values were indicated
carried out by computer. The reference lines are with standard deviations. Students’ t-tests were used to
listed in Table 2 and Fig. 1. Meanwhile, a description examine possible differences between genders; however,
and meaning of the variables are indicated in Table 3 no significant differences were found at the 5% level.
and Fig. 1. For assessment of the reliability of the Therefore, boys and girls were analyzed as a pool in
measurements, 26 randomly selected radiographs
were remeasured by the same investigator 2 weeks
after the initial analysis. Cephalometric variables

Table 2 Illustration of the reference lines.

line Illustration

NSL Nasion-sella line, the line through N and S

FH Frankfort line, the line through O and P
NL Nasal line, the line through ANS and PNS
ML Mandibular line, the tangent to the lower
border of the mandible through Me
HOR True horizontal line, the line perpendicular to VER
RL Ramus line, the tangent to the
posterior border of the mandibular ramus
OPT Odontoid process tangent. The posterior
tangent to the odontoid process through
the most postero-inferior point on the
corpus of the second cervical vertebra
CVT The line through the most postero-inferior
point on the corpus of the
second and fourth cervical vertebra
EVT The line through the most postero-inferior
point on the corpus of the
fourth and sixth cervical vertebra
VER True vertical line, the vertical line
projected on the film Figure 1 Cephalometric tracing illustrating all angular
S-Go Posterior facial height, distance between S and Go
measurements. The definitions of the postural angles are
N-Me Anterior facial height, distance between N and Me

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Liu et al. Skeletal discrepancy, NHP, craniocervical posture

Table 3 Description of variables. three groups for ANOVA, P v 0.05 or v0.01.

No. Variable Description LSD post hoc tests showed that there were statistical
differences between group 2 and group 1 as well as
Sagittal and vertical facial pattern
group 3, P v 0.05 or v0.01, as shown in Table 5.
1 ANB Angle formed by SNA and SNB
2 FH/ML Frankfort mandibular plane angle The values of variables 9–12 (NSL/RL, FH/RL,
3 NSL/ML Mandibular plane angle NL/RL, ML/RL), which represented rotation of
4 S-Go/N-Me Facial height ratio, posterior facial
height/anterior facial height
ramus in relation to cranium in the three groups,
Head posture were largest in group 2 and smallest in group 3, but
5 NSL/VER Angle formed by NSL and VER there were no significant differences among groups.
6 FH/VER Angle formed by FH and VER
7 NL/VER Angle formed by NL and VER However, the measurement of NSL/RL demon-
8 ML/VER Angle formed by ML and VER strated statistically significant differences between
Rotation of ramus in relation to cranium group 2 and group 3 (Table 5).
9 NSL/RL Angle formed by NSL and RL Statistically significant differences were found for the
10 FH/RL Angle formed by FH and RL
11 NL/RL Angle formed by NL and RL variables 13–24 (NSL/OPT, FH/OPT, NL/OPT, ML/
12 ML/RL Angle formed by ML and RL OPT, NSL/CVT, FH/CVT, NL/CVT, ML/CVT,
Craniocervical posture NSL/EVT, FH/EVT, NL/EVT, ML/EVT) representing
13 NSL/OPT Angle formed by NSL and OPT craniocervical posture. It was noticed that values of
14 FH/OPT Angle formed by FH and OPT
15 NL/OPT Angle formed by NL and OPT NSL/CVT, NL/CVT, ML/CVT between group 2 and
16 ML/OPT Angle formed by ML and OPT group 3 appeared significantly different, P v 0.05.
17 NSL/CVT Angle formed by NSL and CVT
18 FH/CVT Angle formed by FH and CVT
Though other variables representing craniocervical
19 NL/CVT Angle formed by NL and CVT posture did not show meaningful differences, they
20 ML/CVT Angle formed by ML and CVT were still highest in group 2 and lowest in group 3, as
21 NSL/EVT Angle formed by NSL and EVT
22 FH/EVT Angle formed by FH and EVT shown in Table 5.
23 NL/EVT Angle formed by NL and EVT Variables 25–30 (OPT/HOR, CVT/HOR, EVT/
24 ML/EVT Angle formed by ML and EVT HOR, OPT/CVT, CVT/EVT, OPT/EVT) represent-
Inclination of cervical column ing cervical column inclination and cervical curva-
25 OPT/HOR Angle formed by OPT and HOR
26 CVT/HOR Angle formed by CVT and HOR ture, respectively, in the three groups, did not
27 EVT/HOR Angle formed by EVT and HOR demonstrate significant differences; however,
Cervical curvature OPT/HOR and CVT/HOR values in group 2 were
28 OPT/CVT Angle formed by OPT and CVT slightly larger than those of group 1 and group 3;
29 CVT/EVT Angle formed by CVT and EVT
30 OPT/EVT Angle formed by OPT and EVT the OPT/CVT angle was largest in group 2 and
lowest in group 3 (Table 5).

the statistical analysis. One-way analysis of variance Discussion

(ANOVA) and post LSD analysis were used to evaluate In longitudinal studies, NHP has been shown to be
the intergroup differences for measurements; remarkably reproducible, even after 15 years.5,6
significance level was P v 0.05. Therefore, the slight difference in age among the
three groups should have no effect on the results in
Results the present study. Although there is still controversy
ANB angles, which represented sagittal facial pattern regarding the influence of gender on NHP and cra-
among three groups, exhibited statistical differences, niocervical posture, this influence was not found in
and values of FH/ML did not show significant differ- this study. Meanwhile, the number of boys and
ence among three groups (Table 4). Both measure- girls in each group was exactly equal to others; there-
ments of mandibular plane angle (NSL/ML) and fore, the significant differences observed in this study
facial height ratio (posterior facial height/anterior could be considered as differences totally associated
facial height, S-Go/N-Me) in the three groups exhib- with the different skeletal relationships rather than
ited almost the same values (Table 4). Variables repre- with gender.20,21
senting vertical facial pattern (FH/ML, NSL/ML, Previous studies showed that both sagittal and verti-
S-Go/N-Me) did not show statistical differences. cal skeletal facial morphology were associated with
For the variables 5–8 (NSL/VER, FH/VER, NHP.3 In orthodontics, FH/ML, NSL/ML, and
NL/VER, ML/VER) representing head posture, S-Go/N-Me are measurements frequently used to
values were smallest in group 3, largest in group 2, evaluate vertical facial patterns of subjects in clinical
and there were significant differences among the work along with literature research.22 Though the

4 CRANIOt: The Journal of Craniomandibular & Sleep Practice 2015 VOL . 00 NO . 0

Liu et al. Skeletal discrepancy, NHP, craniocervical posture

Table 4 Descriptive statistics of sagittal and vertical facial pattern.

Skeletal class Skeletal class Skeletal class

I relationship II relationship III relationship
No. Variable (group 1) (group 2) (group 3) P P (1–2) P (1–3) P (2–3)
Mean + SD Mean + SD Mean + SD

1 ANB 2.76 + 1.36 5.86 + 1.03 (2.55 + 1.21 0.000 *** *** ***
2 FH/ML 28.93 + 2.52 28.11 + 2.56 29.00 + 1.96 0.299
3 NSL/ML 36.48 + 3.82 36.16 + 3.64 36.33 + 3.51 0.929
4 S-Go/N-Me .6450 + .018 0.6451 + .016 0.6455 + .017 0.876
***P v 0.001.

Table 5 Descriptive statistics of variables.

Skeletal class Skeletal class Skeletal class

I relationship II relationship III relationship
No. Variable (group 1) (group 2) (group 3) P P (1–2) P (1–3) P (2–3)
Mean + SD Mean + SD Mean + SD

5 NSL/VER 96.98 + 5.83 100.50 + 6.57 95.98 + 6.01 0.019 * **

6 FH/VER 89.43 + 4.04 92.44 + 5.32 88.66 + 6.04 0.019 * **
7 NL/VER 88.00 + 5.63 90.82 + 4.96 86.60 + 6.69 0.027 **
8 ML/VER 60.50 + 4.88 64.33 + 5.82 59.66 + 5.80 0.005 ** **
9 NSL/RL 91.13 + 5.06 93.06 + 4.11 90.43 + 3.79 0.074 *
10 FH/RL 84.92 + 4.81 85.20 + 4.65 83.10 + 3.95 0.152
11 NL/RL 82.15 + 4.87 83.38 + 5.10 81.05 + 4.10 0.187
12 ML/RL 54.65 + 6.01 56.89 + 5.66 54.10 + 4.30 0.130
13 NSL/OPT 95.42 + 6.38 98.22 + 6.80 95.55 + 5.66 0.178
14 FH/OPT 87.87 + 5.56 90.17 + 6.82 88.22 + 5.92 0.323
15 NL/OPT 86.44 + 5.21 88.54 + 7.12 86.17 + 5.77 0.283
16 ML/OPT 58.94 + 5.63 62.06 + 6.82 59.22 + 5.73 0.111
17 NSL/CVT 103.03 + 7.77 106.00 + 8.10 101.52 + 7.18 0.093 *
18 FH/CVT 95.48 + 6.23 97.94 + 8.34 94.19 + 7.53 0.162
19 NL/CVT 94.05 + 6.96 96.32 + 7.89 92.14 + 7.22 0.110 *
20 ML/CVT 66.55 + 6.43 69.83 + 8.50 65.19 + 7.29 0.062 *
21 NSL/EVT 107.19 + 9.04 109.48 + 9.16 105.93 + 10.83 0.320
22 FH/EVT 99.67 + 7.76 101.76 + 8.99 98.60 + 9.42 0.450
23 NL/EVT 98.20 + 8.78 100.14 + 8.29 96.55 + 11.18 0.375
24 ML/EVT 70.70 + 8.13 73.65 + 9.07 69.60 + 10.78 0.258
25 OPT/HOR 91.56 + 6.52 92.28 + 6.61 90.43 + 5.02 0.520
26 CVT/HOR 83.95 + 6.38 84.50 + 6.94 84.47 + 5.93 0.935
27 EVT/HOR 100.20 + 6.54 99.31 + 6.52 99.95 + 7.39 0.882
28 OPT/CVT 7.61 + 4.81 7.78 + 5.79 5.97 + 4.06 0.309
29 CVT/EVT 4.15 + 7.61 3.81 + 5.15 4.41 + 8.34 0.953
30 OPT/EVT 11.77 + 9.05 11.59 + 7.93 10.38 + 8.60 0.803

*P v 0.05, **P v 0.01.

FH/ML angle was used in this study to estimate the downward posture than subjects with normal occlu-
vertical facial pattern of the samples, NSL/ML and sion.15 This phenomenon may be attributed to individ-
S-Go/N-Me were measured, in addition. High uals’ efforts to compensate for the skeletal
homogeneity in values of FH/ML, NSL/ML, and discrepancy, as past studies indicated that anterior
S-Go/N-Me among the three groups (Table 4) and downward head posture has a maxillary protru-
indicated that all the subjects participating in this sive and mandibular retrusive effect.17 And after surgi-
study had average vertical facial pattern, so that the cal treatment of the mandibular protrusion, the head
connection of the sagittal skeletal relationship, NHP, posture was found to be raised.15 In addition, statisti-
and craniocervical posture could be explained by cally significant differences were observed between
excluding the influence of vertical craniofacial skeletal variables in group 1 and group 2 as well as variables
patterns. in group 2 and group 3, but not between variables in
Values representing head posture were highest in group 1 and group 3. Meanwhile, group 2 showed a
group 2 and lowest in group 3. The findings in the pre- small SNB value, while group 3 showed a small SNA
sent study were in accordance with previous studies, value, indicating that the mandible might play a
which showed that individuals with a marked mandib- more significant role in determining head posture
ular protrusion carried their heads in a more than maxillary.23

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Liu et al. Skeletal discrepancy, NHP, craniocervical posture

However, the correlation between head posture complexity of the developmental behavior of the face
and craniofacial morphology has been a more con- and the spinal column, meaning that further research
troversial subject. In one researcher’s study, there is required to clarify this controversial topic.
were potentially contrasting results when referring In the present study, the inclination of the cervical
to different variables.3 Regarding the sagittal jaw column among three groups tended to be almost the
relationship, positive non-topographical correlations same value. Hedayati et al.24 also failed to document
were found with the inclination of the nasion-sella significant differences in the inclination of the spinal
line to the cervical column and the true vertical, column in his study. However, OPT/HOR and CVT/
while ML/VER showed negative non-topographical HOR values in group 2 were slightly larger than
correlations with the sagittal jaw relationship.3 those of group 1 and group 3, suggesting extension
D’Attilio et al.21 reported no significant differences of the head in skeletal class II subjects.
in cranial posture among the three skeletal malocclu- Though there was no significant difference in OPT/
sion groups, while according to Hedayati et al.’s24 CVT among the three groups, the OPT/CVT angle
measurement, PNS-ANS/Ver and SN/Ver differed was largest in group 2 and smallest in group 3.
significantly among the three malocclusions. This result was supported by previous studies, which
It has been demonstrated that changes in head pos- indicated the weak association between craniofacial
ture were correlated to craniofacial development and morphology and cervical curvature.20 Tahereh
rotational growth patterns of the mandible in children. et al.28 found that the cervical spine was significantly
Angles between horizontal craniofacial reference lines straighter in skeletal class III subjects. Meanwhile,
and the ramus represented the rotation of the ramus in there were also some studies that rejected any particu-
relation to the cranium, the lower the value, the more lar correlation in subjects with different sagittal jaw
forward the rotation of the mandible.25 In the present postures and cervical column curvatures.20
study, values of variables 9–12 (representing rotation The different and sometimes conflicting findings
of ramus in relation to cranium) were smallest in reported above may, to some extent, have been due
group 3 and largest in group 2 (Table 5). These results to differences in the samples, designs, and method-
were well in line with studies that indicated the ologies used in the various studies.
forward rotation of the ramus had a mandibular pro- The cervical column in a functional and morpho-
trusive effect.25 The growth and rotation patterns in logical aspect has a close relation with craniofacial
different skeletal relationships were clarified again in structures.7 It has been hypothesized that there is a
the present study. different developmental origin for the upper and
It was found that the craniocervical posture is lower segments of the cervical column, while upper
related to the craniofacial morphology.3 Values of cra- segment development was considered to be closely
niocervical angulation in the three groups followed the linked to facial development, the lower segment was
same tendency as discussed above (Table 5), and were classically considered as the final upper part of the
consistent with other reports. Previous studies have column.21 The difference in developmental origin
confirmed that children in skeletal class II showed may lead to the inconsistent tendency in variables
a significantly higher extension of the head upon the of EVT/HOR, CVT/EVT, and OPT/EVT, which
spinal column compared to children in skeletal class involved the lower part of the cervical column.
I and III malocclusion.21 Rocabado et al.26 described Studies about the relationships between head pos-
an association between class II malocclusion and a for- ture and craniofacial morphology suggested that the
ward cervical inclination, combined with an extended craniocervical posture might influence the craniofacial
craniocervical angle.26 Moreover, subjects of skeletal development.17,22 According to the soft-tissue
class II malocclusion tended to suffer from TMD com- stretching hypothesis, an extension of the craniocervi-
pared with the other two types of malocclusions, and cal posture leads to a passive stretching of the soft-
on average, children with TMD often showed a signifi- tissue layer and creates a dorsally directed force,
cant sagittal jaw relationship and increased craniocer- which impedes the forward-directed component of
vical angles, which might be an additional evidence the normal growth of the face.7 Wenzel et al.29
supporting the current study’s findings.9 However, confirmed this hypothesis and provided evidence
a study on head posture in 13 class II and 17 class I chil- involving neuromuscular feedback and passive stretch-
dren indicated that distal occlusion and increased ing of the soft-tissue layer covering the face and neck.
overjet were associated with a flexed head posture According to this study, subjects who had mandibular
and a backward bend of the spine.27 This disagreement setback surgery for mandibular prognathism were
with previously cited research partially pointed out the found to have angulation of the cranial base to the

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Liu et al. Skeletal discrepancy, NHP, craniocervical posture

cervical column increased by an average of 2.7uu, 7 Solow B, Kreiborg S. Soft-tissue stretching: a possible control
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10 Restrepo CC, Álvarez CP, Jaimes J, Gómez AF. Cervical
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and non-apnoeic snorers, and associated effects of long-term
ture were largest in skeletal class II relationship, fol- mandibular advancement on condylar and natural head pos-
lowed by skeletal class I relationship, and were ition. Eur J Orthod. 2002;24:353–61.
17 Solow B, Siersbaek-Nielsen S. Growth changes in head posture
smallest in skeletal class III relationship. Subjects with related to craniofacial development. Am J Orthod Dentofacial
skeletal class II relationship tended to display more Orthop. 1986;89:132–40.
18 Solow B, Tallgren A. Dentoalveolar morphology in relation to
extended heads, and children with skeletal class III craniocervical posture. Angle Orthod. 1977;47:157–64.
relationship often exhibited flexed heads. 19 Solow B, Barrett MJ, Brown T. Craniocervical morphology
and posture in Australian aboriginals. Am J Phys Anthropol.
Disclaimer Statements 20 Tecco S, Festa F. Cervical spine curvature and craniofacial
morphology in an adult Caucasian group: a multiple regression
Contributors There is no contributors or guarantors. analysis. Eur J Orthod. 2007;29:204–9.
21 D’Attilio M, Caputi S, Epifania E, Festa F, Tecco S. Evalu-
Funding ation of cervical posture of children in skeletal class I, II, and
III. Cranio. 2005;23:219–28.
Conflicts of interest No conflict of interest exits in the 22 Dubojska AM, Smiech-Slomkowska G. Natural head position
and growth of the facial part of the skull. Cranio. 2013;31:
submission of this manuscript. 109–17.
23 Wenzel A, Williams S, Ritzau M. Relationships of changes in
Ethics approval The study was approved by the craniofacial morphology, head posture, and nasopharyngeal
Ethics Committee of JiLin University. airway size following mandibular osteotomy. Am J Orthod
Dentofacial Orthop. 1989;96:138–43.
24 Hedayati Z, Paknahad M, Zorriasatine F. Comparison of natu-
ral head position in different anteroposterior malocclusions.
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