British Journal of Orthodontics

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Natural Head Position, Posture, and Prognathism:

the Chapman Prize Essay, 1986

S. C. Cole B.D.S., M.S.c., F.D.S., D.Orth.

To cite this article: S. C. Cole B.D.S., M.S.c., F.D.S., D.Orth. (1988) Natural Head Position,
Posture, and Prognathism: the Chapman Prize Essay, 1986, British Journal of Orthodontics, 15:4,
227-239, DOI: 10.1179/bjo.15.4.227

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 British Journal ~f Orthodontics/Vol. 15/1988/227 239

Natural Head Position, Posture, and

Prognathism: the Chapman Prize Essay,
1986
S. C. CoLE, B.D.S., M.S.c., F.D.S., D. 0RTH.
Eastman Dental Hospital, 256 Grays Inn Road, London WCl.

Abstract. Natural head position and natural head posture are terms which have been used synonymously
to describe the spatial relationships of the head with reference to the true vertical, the cervical column, or
both. This is confusing, and it would seem logical to ascribe one term to one reference and consider the
phenomena separately. For the purposes of this prospective cephalometric survey, natural head position will
describe the relationship of the head to the true vertical, while natural head posture will describe the
relationship of the head to the cervical column. In order to investigate these two relationships of the head,
five groups were formed, three representing horizontal discrepancies selected on ANB differences (class I,
II and Ill dental base relationships) and two representing vertical discrepancies selected on Bjork's posterior
angles ('high angle' and 'low angle' groups). Despite the marked differences in 'ske/etar pattern shown
between the .five groups, the values obtained/or the saddle angles (N-S-Ar) showed no significant difference.
However, the natural head positions and natural head postures were sign!ficantly d!fferent (P < 0.01 ).
Natural head position affected cranial base orientation and this alone produced class II or Ill effects.
Natural head position was also associated with maxillary prognathism whilst natural head posture appeared
more closely related to mandibular prognathism. These phenomena may help to explain an apparent class
ll or Ill tendency in cases where the saddle angle is normal.
Index words: Head posture, Prognathism, Saddle angle

Introduction ships. Bjork (1947) showed how the size of the

Prognathism is defined as 'a marked forward pro-
jection of maxilla or mandible beyond the normal
distance from the cranial base' (British Standards
Institution 1983). This latter structure has been the
subject of considerable debate with regard to its
role in prognathism. In the nineteenth century,
Virchow (1857) believed that increased flexure of
the cranial base increased the degree of prognath-
ism, but Welcher (1982) believed that the opposite
was true and that increased flexure reduced pro-
gnathism. However, Bjork (1947) with the benefit
of cephalometric radiographs supported Virchow's
view.
Orthodontists are especially interested in the
causes of discrepancies in sagittal jaw relation-
Present addresses: Orthodontic Department, John Radclilfe
Hospital, Oxford, and Orthodontic Department, Royal Berk-
shire Hospital, Reading.
0301-228X/88/004227+ 13102.00
saddle angle (N-S-Ar) could alter the length of the
cranial base in the horizontal plane between
nasion and articulare and thereby affect the relative
prognathism of maxilla to mandible. In general,
a small saddle angle was associated with a rela-
tive mandibular prognathism, because articulare
and hence the mandible were displaced anteriorly.
A large saddle angle was associated with a
relative maxillary prognathism by the opposite
effect.
In a later paper, Bjork (1969) pointed out that
the cranial base also had a relationship to posture.
This was because, although the more anterior angle
N-S-Ar had a role in determining the positions of
the jaws, the posterior angle N-S-Ba determined
the position of the foramen magnum and hence the
cervical column (Fig. 1). The cranial base, therefore,
has a role in determining the prognathism of the
jaws and also the posture of the head.
C 1988 British Society for the Study of Orthodontics
 228 S. C. Cole BJO Vol. /5 No. 4

The subjects were then allocated to groups using

the A-N-B difference to define the groups in the
horizontal plane and the sum of Bjork's posterior
angles to define the groups in the vertical plane
(Fig. 2). Five groups were formed based on these
parameters (Table I).

Ar

FIG. I. Cranial base angles. These two cranial base angles are
interrelated as part of the cranial base structure. However, N- FIG. 2. Cephalometric parameters. Subjects were allocated to
S-Ar affects jaw relationships, and N·S·Ba affects head posture. each of the five groups using two cepholometric parameters (see
group parameters, Table 1). Horizontal plane: A-N-8. Vertical
Plane: Sum ofBjork's Posterior Angles, N-S-Ar, S-Ar-Go, Ar-
Go-M, total= 396±6°
Associations have since been found between head
posture and the vertical relationships of the jaws
(Ricketts, 1968; Solow and Tallgren, 1976, 1977; Groups I, 11, and III represent classes I, 11, and
Linder-Aronson, 1979). Marcotte (1981) found Ill skeletal patterns, respectively, but have normal
significant correlations between head posture and vertical facial proportions. Groups IV and V rep-
horizontal jaw relationships. However, compara- resent 'high angle' and 'low angle' groups, respec-
tively little work had been carried out in this field tively, but have normal horizontal proportions.
of research and the purpose of this study is to
investigate skeletal abnormalities in the sagittal
plane with specific reference to the cranial base and TABLE I Group parameters
the posture of the head.
ANB Sum of
Skeletal difference Posterior angles
Group pattern (degrees) (degrees)

Materials I I 2-4 396+6

11 11 >4 396+6
The material for this investigation consisted of lii Ill <2 396+6
standardized cephalometric radiographs of 110 IV 'High angle' 2-4 > 402
patients who attended the Eastman Dental Hospi- V 'Low angle' 2-4 < 390
tal, London, for orthodontic diagnosis and treat-
ment. They were subsequently included in the study
if the following criteria were fulfilled: A total of 15 subjects were excluded from the
caucasian study because they failed to fulfil the cephalometric
no pathology criteria.
aged 8-18 years The age and sex distributions are shown in
no previous orthodontic treatment. Table 2.
 IJJO November /988 Head Position, Posture, and Prognathism 229

TABLE 2 Age and sex distribution

Male Female Mean age Total

Group I 10 10 13·5 20
Group 11 10 11 11·8 21
Group Ill 8 10 13·1 18
Group IV 4 15 IH 19
Group V 8 9 IH 17
Totals 40 55 12-6 95

Methods
Head posture is a variable phenomenon and there-
fore the orientation of the head needs to be
standardized and then measured from specified
frames of reference. To avoid confusion of terms,
the two frames of reference adopted were con-
sidered separately and the following definitions
used.
Natural head position: the relationship of the head
to the true vertical.
Natural head posture: the relationship of the head
to the cervical column.
Common to both definitions is the fact that the
subject was sitting unsupported in the rehearsed,
subjectively determined, head balance position.
In order to maximize reproducibility and stan- Fta. 4. The resultant radiograph obtained including reference
dardization of the radiographs, a spirit level device marks.
was used as described by Showfety et al. (1983).
The device was attached to the side of the head •••
using a double-sided sticky-back square and it
provided a horizontal reference on the patient
which could then be compared with a gravity
defined vertical reference (Fig. 3). Vertical reference
was in the form of a chain mounted at the left hand
margin of the X-ray cassette and this also registered
on the film.
PC

VRb
FIG. 3. Patient sitting in cephalostat with horizontal wire and
vertical chain references. FIG. 5. The points digitized in the project.
230 S. C. Cole BJO Vol. /5 No. 4

TABLE 3 Cephalometric landmarks

HRa Horizontal reference a: the anterior point of the horizontal reference wire
HRb Horizontal reference b: the posterior point of the horizontal reference wire
VRa Vertical reference a: the upper most point on the vertical reference line
VRb Vertical reference b: the lower most point on the vertical reference line
CVSIP The most postero-inferior point on the corpus of the 5th cervical vertebra
CV21P The most postero-interior point on the corpus of the 2nd cervical vertebra
CV2TP The posterior tangent point on the odontoid process of the 2nd cervical vertebra
Ba Basion: the most inferior point on the anterior margin of foramen magnum
Op Opisthion: the most posterior point of the foramen magnum
PlC Posterior inferior contour: the most distant point on the calvarial outline from a line joining Op and PC
PC Posterior contour: the most distant point on the calvarial outline from the line joining VRa--VRb
PSC Posterior superior contour: the most distant point on the calvarial outline from a line joining PC and SC
se Superior contour: the most superior point on the calvarial outline from a line drawn perpendicular to the line VRa-
VRb
Br Bregma: the midpoint of the coronal suture on the external cranial contour
ASC Anterior superior contour: the most distant point on the calvarial outline from a line joining AC and Br
AC Anterior contour: the most proximal point on the calvarial outline form VRa-VRb
N the most anterior point on the fronto-nasal suture
0 Orbitale: the most inferior point on the bony orbital margin
ANS Anterior nasal spine: the mid-point of a line across the base of the anterior nasal spine where it is 2 mm thick
A A point: the deepest point in the maxillary profile between the anterior nasal spine and the alveolar crest
UIA Upper incisor apex: the root tip of the maxillary central incisor
PM Pterygo-maxillare: the point of intersection between the nasal floor and the posterior contour of the maxilla
DBC Disto-buccal cusp: the disto-buccal cusp tip of the upper first permanent molar
LIA Lower incisor apex: the root tip of the mandibular central incisor
LIT Lower incisor tip: the incisal tip of the most prominent mandibular central incisor
UIT Upper incisor tip: the incisal tip of the most prominent maxillary central incisor
8 B point: the deepest point on the mandibular profile between pogonion and the alveolar crest
Po Pogonion: the most anterior point on the bony chin
On Gnathion: the most antero-inferior point on the bony chin
M Menton: the most inferior point on the bony chin
Go Gonion: the most postero-inferior point on the contour of the angle of the mandible
Ar Articulare: the point of intersection of the dorsal contours of the articular process of the mandible and the temporal
bone
p Porion: the most superior point of the external auditory meatus
s Sella: the mid-point of the Sella-Turcica determined by inspection
H Hyoid: the most anterior point on the body of the hyoid bone

The reference lines and angular measurements chosen for special investigation were as follows:
VER. the line joining VRa and VRb
HR, the line joining HRa and HRb
CVT, the line joining CV2TP and CVSIP
OPT, the line joining CV2TP and CV21P
FH, the line joining Orbitale and Porion.
NSL, the line joining Nasion to Sella
Natural head position was dete~ined by the angle of the na~ion sella ~ine to the true vertical (NSL-VER).
Natural head posture was determmed by the. angle of the nas10n sella Ime to the cervical column (NSL-CVT).
Sella-Nasion-Frankfort horizontal: the antenor angle between NSL and FH.

To improve reproducibility the subject was asked
to extend and flex the head with decreasing ampli-
tude until it was felt by the subject that the natural
head balance position had been reached. The tube
was then levelled. Extension and flexion were
repeated, and the radiograph taken only '":hen
two consecutive horizontal readings were obtamed
without having to relevel the device.
Standardization was improved by monitoring
the angle formed on the radiograph between the
horizontal and vertical references. Ideally, the angle
between the two should be 90°. If it was not then
this showed that the subject had moved between
the final rehearsal and the X-ray exposure, and the
radiograph was subsequently rejected from the
study. The radiograph (Fig. 4) was then traced and
37 points were digitized (Fig. 5 and Table 3).
Following digitization the records were stored on
disc ready for statistical analysis.
Results
The results are shown in Tables 4-6. In order to
envisage the significance of these findings, the
 BJO November /988 Head Position, Posture, and Prognathism 231

TABLE 4 Means and standard deviations for groups /-V

Group I Group 11 Group Ill Group IV Group V

-----
Mean so Mean so Mean SO Mean so Mean so
Linear morphological variables
N-S 65·8 3-4 64·9 2-4 65·4 3-8 65-4 2·8 66·2 3·5
S-8a 42·7 3·6 42·8 3·1 43·0 2-8 42-4 4-4 43·3 3·3
Ar-Go 40·3 4·3 40·8 3·3 41·4 3·7 38·7 H 43·0 3·6
Go-M 66·3 2-9 64·1 3·2 69·1 5·6 65·7 4·4 66·1 5·0
Ar-Gn 98·4 H 96·1 3·7 102·1 6·5 97·9 5·7 98·5 6·7
ANS-PM 49·5 3-3 50·2 3·0 49·3 2·5 48·5 3·2 49·9 2·5
Lower Ant. Face Ht%
55·0 2-4 54·6 2·0 54·9 1·6 56·6 2·3 53·3 2-4
Angular morphological variables
N-S-8a 130·8 5·4 131·7 5·7 132-3 5·5 132·7 9·1 129·8 4·1
N-S-Ar 124·1 5·1 125·3 5·1 124·3 6·2 124·4 7-6 122·0 4·8
S-N-A 80·7 3·3 82·5 3-4 79·4 3·0 78·5 3-4 84·2 4·1
S-N-8 77·7 3·1 76·6 2-8 79·4 2·7 74·9 3·3 80·7 4·4
A-N-8 3·0 0·5 5·8 1·4 0·0 1·8 3·7 0·9 3·4 1·3
SPAt 395·2 3-4 394-8 2·6 396·3 3·2 404·1 2·7 386·9 2·8
SN-FH 3·5 4·6 3-4 4·5 4·3 4·8 5·9 3·7 2·0 3·7
S-Ar-Go 140·9 5·7 139·9 7·0 141·9 6·6 143-6 7·9 140·5 6·4
Ar-Go-M 130·2 3·6 129·6 5-6 130·1 4·2 136·1 4·9 124-4 4·2
Cranio-facial positional variables
NSL-VER 93-6 7·6 92·0 4·5 98·8 6·2 99·1 8·0 91·5 6·8
FH-VER 90·1 9·1 88·6 5·2 94·5 5·7 9H 7·1 89·5 5·3
HR-VER 89·6 1·3 89·5 1·8 90·0 1·9 89·7 1·4 89·2 1·2
Cranio-facial postural variables
NSL-CVT 100·9 8·1 94·6 7-8 103-3 8·5 109·7 8·9 94·0 8·4
t Sum of posterior angles.

computer was programmed to plot the averaged '""

digitized co-ordinates for each group. The points
were then linked to produce composite diagrams
for each group. These were then superimposed on
Sella in the natural head position and natural head
posture.

Error of the method

Repeat radiographs of eight subjects were obtained
after a 6-month interval and the values NSL-VER
and NSL-CVT were calculated using the Dahlberg
( 1940) formula.

(fJ2
...;~
where d = difference between two measurements
and n = sample size. The reproducibility for the
value NSL-VER was 2·18°, while the reproduci-
bility for the value NSL-CVT was 4·20°. These
values are similar to those obtained by Solow and
Tallgren (1971) and Siersbaek-Nielsen and Solow
(1982). FIG. 6. The main reference lines in the project.
 232 S. C. Cole BJO Vol. 15 No. 4

TABLE 5 Significance of difference between groups

Group 2 Group 3 Group 4 Group 5

F ratios t values F ratios t values
----- -------------~---·

Linear morphological variables

N-S 2·58 0·57 1·50 0·79
S-Ba 1·19 0·22 1·82 0·71
Ar-Go 1·26 0·54 1·13 3·70 ***
Go-M 3·13 3-48 .. 1·27 0·27
Ar-Gn 3·08 3·57 .. 1-42 0·26
ANS-PM 1·49 1·00 1·71 1·41
Lower Ant. Face Ht % 1·49 0·51 1·03 4·18 ...
Angular morphological variables
N-S-Ba 1·06 0·31 4·86 Ul24·0
N-S-Ar 1-47 0·53 2-44 1·11
S-N-A 1·35 2·96 * 1-42 4·52 ***
S-N-B 1·07 3·07 •• 1·83 4·55 ***
A-N-B 1·60 11·37 *** 1·92 0·69
SPA 1·50 1·61 1·09 UO·OO ***
SN-FH 1·12 0·60 1·01 3-23
Ar-Go-M 1·76 0·30 1·33 7·67 ***
Cranio-facial positional variables
NSL-VER 1·90 3·97 ••• 1·40 3·04 **
FH-VER 1·21 3·37 •• 1·77 1·72
HR-VER 1·13 0·87 1-45 1·22
Cranio-facial postural variables
CVT-OPT 1·27 1.42 1·02 0·60
NSL-CVT 1·19 3·36 •• 1·14 5·42

• P < 0·05; •• P < 0·01; *** P < 0·001. U, Mann-Whitney U test which was used
where the t test was inappropriate.

Statistical analysis Discussion

Following digitization, the computer calculated
and printed the following analyses:
Mean
Variance
Standard deviation
Coefficient of skewness
Values of skewness: to indicate whether the
coefficient of skewness was significantly different
from zero
The unpaired t test was used for inter-group com-
parisons
The Snedcor F test was used to test the compara-
bility of the variances where:
Greater estimate of variance of population
F=-------------
Lesser estimate of variance of population
The t test was not used in those instances where
the probability of F (i.e. the probability of the
variances being significantly different) was found
to be < 0·01. In these cases a M ann-Whitney U
test was applied. The product moment correlation
analysis (Pearson's r) was calculated between cer-
tain positional and postural variables, and some
linear and angular variables jn each grol,lp.
The mean values for the linear and angular vari-
ables in Group I were similar to those obtained
by. other workers concerning similar age groups
(Rtedel, 1952; Backlund, 1963; Mills, 1973). Group
I was therefore considered to be a good represen-
tation of class I or normal skeletal pattern and the
associated natural head position and natural head
posture of this group were also considered to be
normal.
The cranial base and prognathism
Perhaps the most interesting finding of this study
was that, although different horizontal and vertical
'skeletal' discrepancies had specifically been selec-
ted when compiling the groups, the saddle angle
values showed no significant difference between
any of the groups. This was most unexpected and
it was difficult at first to identify the factors
responsible for the differing skeletal patterns. How-
ever, the natural head positions and natural head
postures as denoted by the angles NSL-VER and
NSL-CVT, respectively, did show significant differ-
ences. The composite diagrams helped to identify
BJO November /988 Head Position, Posture, and Prognathism 233

TABLE 6 Correlation coefficients (Groups 1- V)

N-S-Ar Ar-Go-M SnFH S-N-A S-N-B A-N-B

Group I
NSL-VER 0·147 -0·035 -0·048 0·030 0·027 0·141
NSL-CVT -0·070 -0·187 -0·152 0·008 0·069 0·010
Group 11
NSL-VER 0·413 -0·143 0·347 -0·445 * -0·581 .. 0·125
NSL-CVT -0·096 -0·001 0·138 0·082 -0·020 0·251
Group Ill
NSL-VER 0·144 -0·386 0·489. -0·699 .. -0·727 ... 0·072
NSL-CVT 0·275 -0·236 -0·017 -0·357 -0·549. 0·085
Group IV
NSL-VER 0·463. -0·475 * 0·469. -0·445 -0·515. 0·047
NSL-CVT 0·089 -0·495. 0·265 -0·354 -0·316 -0·205
Group V
NSL-VER 0·358 0·093 0·621 •• -0·432 -0·323 -0·122
NSL-CVT 0·242 0·140 0·179 -0·266 -0·178 -0·018
• p < 0·05; .. p < 0·01; ••• p < 0·001.

GROUP 11 GROUP IV
GROUP Ill GROUP V

··~
··...

;··
·.
! ···...
/
························
····························

lf\: I ' i=m

'[··...
~ •••••••
... · · · · · · · · :·~:· · ·
Ill 11
\, ••• •••••••••••• V•H
rv

FIG. 7. Groups 11 and Ill compared. FIG. 8. Groups IV and V compared.

the factors responsible for the different skeletal 7-10). Figure 7 compares classes 11 and Ill. The
patterns that were not attributable to the size of saddle angles and facial heights are similar. How-
the saddle -angle (no significant difference between ever, the cranial base orientations and degrees of
any of the groups). A different natural head position prognathism are different. Figure 8 compares the
(NSL-VER) was exhibited by each group (Figs 'High angle' and 'Low angle' groups. The saddle
 234 S. C. Cote
GROJJP ll
GROUP V
FIG. 9. Groups 11 and V compared.
angles are similar, but the cranial base orientations,
facial heights, and degrees of prognathism are
different. The class II and 'low angle' Group V had
a similar lowered natural head position (Fig. 9),
while the class III and 'high angle' Group IV had
a similar raised natural head position (Fig. I 0).
After some consideration, it became evident that
altered cranial base orientation relative to the true
vertical (NSL-VER) could produce class 11 or III
effects (Fig. I la).
Where natural head position was raised, the
distance from N to Ar in the horizontal plane was
effectively reduced. The length of the cranial base
was shortened horizontally by the altered natural
head position and not by the size of the saddle
angle (N-S-Ar identical in all three instances in Fig.
I la). Therefore, an increased NSL-VER could have
a class III effect by effectively shortening the cranial
base in the horizontal plane and a reduced NSL-
VER could have a class 11 effect by effectively
lengthening the cranial base in the horizontal plane.
This altered orientation of the cranial base pro-
duced effects similar to those described by Bjork
(1947; Fig. lib).
In an attempt to demonstrate this point further,
two patients were selected both of which has very
BJO Vol. 15 No. 4
GROUP Ill
.k-
(··•,,,•. .... ················:::.-H.IV
FIG. 10. Groups Ill and IV compared.
similar linear and angular cranial base dimensions
(Fig. 12). However, one was a class 11 with an ANB
of 5o while the other was a class Ill with an ANB
of - 1·1 ". The differences in natural head position
were striking as were the consequent effects on
Nasion and Articulare which were relatively dis-
placed by the different cranial base orientations
and not in these cases by the size of the saddle
angle (or the linear cranial base dimensions).
Natural head position, posture, and maxillary pro-
gnathism
Maxillary prognathism was not associated with
maxillary length (ANS-PM), these values being
similar in all groups. However, maxillary prognath-
ism, denoted by SNA (i.e. the antero-posterior
relationship of the maxilla to the skull base) was
increased in those groups showing lowered natural
head position (class 11 and 'low angle' groups, Fig.
9) and was reduced in those groups showing raised
natural head position (class lJl and 'high angle'
group, Fig. 10). These differences were significant.
The vertical relationship of the maxilla was
assessed by the angle SN-FH (Fig. 6). This value
BJO Nrnwnher /988
Head Position, Posture, and Prognathism 235

j··········
I •••••••••••
N I ••••••••••• ••••
s ~
I!.---------------
: I -------------
~\
rl
I . \ '\
~
~ ·····················
I ~ \
I • '
~ '\
I ~ I
I ~ i
I I ··=·:·············
...
tt-\---- ___
I I ' :
················
~L~~S.J ______
~·.~~......
...
_1 :
1 .. f
I I I
Ll _______C_,L.A._S~ JI_Ef[E~I. __ -1- __ I
I I f.......
·. . ················
I _______ _c~~S_!!!~'=f~~T- __ I ~
a

N~-------------------
I S
I ~\
I ~ \
I ~ \
~ \
I ~
I ~
I ~
I •
I ~
I A:r I
I CLASS I I : I
1----------------- ----~-- I
I I
I CLAS~!! . !_FFECT __ _l __ _j
~---------- I
I CLASS Ill EFFECT I
·------- --------------
b relate directly to the position of S, were similar in
FIO. 11. A change in cranial base orientation (natural head
position) shown in (a) can have the same effect as a change in
saddle angle as described by Bjork (1947), shown in (b).
was increased where natural head position was
raised and reduced where it was lowered, although
only significantly between the 'high angle' and 'low
angle' groups (Fig. 8).
Taking SN-FH and SNA to represent the relative
vertical and antero-posterior relationships of the
maxilla to the skull base, respectively, a raised
natural head position was associated with a relative
postero-inferior position of the maxilla (Fig. l4b),
FIG. 12. Two patients with similar linear and angular cranial
base dimensions, but with different degrees of prognathism and
different natural head positions:
HF- DM-
N-S = 68 mm
S-Ba = 45 mm
N-S = 69 mm
S-Ba = 44 mm
N-S-Ar= 121° N-S-Ar= 121°
ANB = 5" ANB = -1·1°
'\
\
' whilst lowered natural head position was associated
)
f with an antero-superior position of the maxilla
(Fig. 13b).
It would appear that, when considering SNA,
I
the angle at N is as dependent on the prognathism
of the maxilla as it is on the position of S, which
is sometimes described as being raised or lowered.
However, the posterior cranial base lengths, which
all groups. Therefore, it would perhaps be more
appropriate to talk, not of high or low positions
of S, but rather of the inclination of the Nasion-
Sella line to the true vertical, i.e. natural head
position.
The correlation coefficients largely supported the
above observations. Relative maxillary prognath-
ism (SNA) was significantly correlated with natural
head position in the class 11 and JJJ groups, but in
the 'high angle' and 'low angle' groups just failed
to reach the level of significance. The negative
correlations indicate that raised natural head
position is associated with maxillary retrognathism
and lowered natural head position is associated
236 S. C. Cole /1./() Vol. 15 No. 4

LOWERED NATURAL HEAD I'OSJTION RAISED NATURAL HEAD I'OSITION

Fig 13 Fig 14

a a

b b

I \ I \

d c

e e
f-J. (

•
lOW ANGlE CLASS Ill HIGH ANGlE
CLASS 11

FIG. 13. Lowered natural head position. Progression a-e represents the apparent spatial configuration of the hones of the head
and neck in the class 11 group. Progression a-f represents the apparent spatial configuration of the bones of the head and neck
in the 'low angle' group.
Fro. 14. Raised natural head position. Progression a -e represents the apparent spatial configuration of the bones of the head
and neck in the class Ill group. Progression a-f represents the apparent spatial configuration of the bones of the head and neck
in the 'high angle' group.
BJO November 1988
with maxillary prognathism. SN-FH was positively
correlated with natural head position in the class
Ill and 'high angle' groups indicating that when
raised, the natural head position was associated
with an inferior position of the maxilla and lowered
natural head position was associated with a more
superior position of the maxilla. This could be
considered an adaptive response designed to main-
tain the horizontal visual axis whilst the orientation
of the cranium altered for some other reason. No
association was found between maxillary prognath-
ism and natural head posture. This is in accordance
with the findings ofWoodside and Linder-Aronson
(1979).
The pattern of maxillary prognathism which
arose in association with lowered natural head
position was:
(I) Anterior and superior maxillary position rela-
tive to the skull base (SNA increased, SN-FH
reduced);
(2) The 'class ll effect' of lowered natural head
position which made the mandible retrognathic
and consequently the maxilla appeared more
prognathic (Fig. 15b).
The pattern of maxillary retrognathism which
arose in association with raised natural head
position was:
(I) Posterior and inferior maxillary position rela-
tive to the skull base (SNA reduced, SN-FH
increased);
(2) The 'class Ill effect' of raised natural head
position, which made the mandible prognathic
and consequently the maxilla appeared more
retrognathic (Fig. 15a).
Natural head position, posture, and mandibular pro-
gnathism
Mandibular prognathism was associated with man-
dibular length in the class ll and Ill groups, where
on average it was 2·3 mm shorter and 3·7 mm
longer, respectively, than in the class I group. The
main differences lay in the lengths of the body,
there being a total of 6 mm difference between the
groups II and 111. The gonial angles were normal
and contrary to Bjork (1947) the joint angles (S-
Ar-Go) were also normal and did not contribute
to the differences in prognathism. There was,
therefore, little difference in the overall shape
of the mandible between the class ll and Ill groups
apart from body length. However, mandibular
shape varied significantly between the 'high angle'
and 'low angle' groups, the difference apparently
related to natural head posture.
In the 'high angle' group natural head position
Head Position, Posture, and Prognathism 237
was raised (NSL-VER increased) and natural head
posture was extended (NSL-CVT increased). The
mandible exhibited an opening rotation at the
gonial angle, which was increased (Fig. 14d).
The hyoid bone and cervical column mirrored the
different mandibular patterns (Figs 13d and 14d).
Conversely, in the 'low angle' group natural head
position was lowered (NSL-VER reduced) and
natural head posture was flexed (NSL-CVT re-
duced) although not significantly. The mandible
exhibited a closing rotation, the gonial angle was
reduced and the cervical column and hyoid bone
mirrored the different mandibular patterns (Fig.
I 3d).
SNB was negatively correlated with natural head
position in groups 11-V. This indicated that raised
natural head position was associated with reduced
SNB. This was in accordance with findings of Solow
and Tallgren (1976) who interpreted this to mean
that raised natural head position was associated
with mandibular retrognathism. Although this was
the case in the 'high angle' group it was apparently
not the case in this class Ill group where raised
natural head position was associated with mandibu-
lar prognathism. How then could the mandible be
prognathic when SNB was reduced? The explana-
tion of this apparent dilemma lies in the fact that
SNB is not an entirely reliable indicator of mandi-
bular prognathism and it is quite possible to have
a comparatively small SNB value associated with
mandibular prognathism (Fig. 15a), and a com-
paratively large SNB value associated with man-
dibular retrognathism (Fig. 15b). It would appear
that SNB is as related to the inclination of the SN
line (natural head position) as to the prognathism
of the mandible. Figure 15a reveals raised natural
head position, reduced SNB and mandibular pro-
gnathism.
a b
FIG. IS. SNB is smaller in a (class Ill) than in b (class 11).
 238 S. C. Cole
Conversely, in group 11 where natural head
position was lowered, SNB would be expected to
increase. However, the mandible was retrognathic.
Again the value ofSNB appears more related to the
inclination of the SN line than to the prognathism of
the mandible. Figure l5b shows lowered natural
head position, increased SNB, in conjunction with
mandibular retrognathism.
The differing spatial relationships of the maxilla
and mandible to the different orientations of the
skull base directly influenced the effective antero-
posterior cranial base lengths and this produced
class 11 or III effects, which where mandibular
shape was normal resulted in class 11 and III
skeletal patterns, respectively.
However, in the 'high angle' group raised natural
head position and extended natural head posture
was seen in association with an opening rotation
of the mandible and the gonia! angle was increased.
This reduced the mandibular prognathism which
would otherwise have occurred and contributed
instead to the vertical height of the lower face (Fig.
l4d).
In the 'low angle' group lowered natural head
position and flexed natural head posture was seen in
association with a closing rotation of the mandible.
This increased the prognathism of the mandible at
the expense of lower facial height-which was
reduced (Fig. 13d).
Natural head position, posture, and prognathism
Class II (reduced NSL- VER, reduced NSL-CVT,
Fig. 13a-e). The maxilla was prognathic in associ-
ation with lowered natural head position (Fig. 13b)
and the mandible was retrognathic (class 11 effect
of cranial base orientation). Mandibular shape and
gonia! angle were normal (Fig. 13c). This resulted
in relative maxillary prognathism and relative man-
dibular retrognathism (Fig. 13e).
Class Ill (increased NSL- VER, normal NSL-
CVT, Fig. 14a-e). The maxilla was retrognathic in
association with the raised natural head position
(Fig. l4b) and the mandible was prognathic due to
the class III effect (Fig. 14c). Although NSL-VER
was increased, on average the cervical column
showed no extension, the value NSL-CVT being
only 2·4° greater than group I (no significant
difference). The mandible exhibited no opening or
closing rotation at the gonia! angle which was
normal. NSL-CVT was negatively correlated with
SNB which indicated that, with the individuals in
this group, flexion of the cervical column (reduction
of NSL-CVT) was associated with an increase
in mandibular prognathism. (increase in SNB).
Mandibular prognathism was not attributable to
810 V<>l. /5 No. 4
size of the joint angle which was normal in this
group, but was certainly contributed to by greater
mandibular length which was significantly in-
creased. Natural head position (NSL-VER) was
negatively correlated with mandibular prognathism
(SNB) which indicated that, in this group, an
increased NSL-VER would be associated with a
reduced SNB (a retrognathic mandible). At first
sight this might appear to be contradictory because
the class Ill group was generally associated with a
raised head position (increased NSL-VER) and
relative mandibular prognathism, i.e. increased
SNB. However, it would appear that SNB is more
related to the inclination of the SN line (natural
head position) than to the prognathism of the
mandible (as discussed previously). In this group,
therefore, raised natural head position was associ-
ated with maxillary and mandibular retrognathism
and it would appear that Class Ill intermaxillary
relationship arose because the maxilla become more
retrognathic than the mandible (Fig. 14e).
'High angle' group (increased NSL- VER, in-
creased NSL-CVT, Fig. 14a-f). The maxilla was
retrognathic in association with the raised natural
head position. (Fig. 14b). However, in this group
the mandible was also retrognathic despite the class
Ill effect of the cranial base orientation. This was
because the mandibular shape was augmented by
an opening rotation. The gonia! angle was markedly
increased and the hyoid bone and cervical column
were posteriorly positioned in association with the
extended natural head posture (Fig. 14d). This
resulted in bimaxillary retrognathism and increased
vertical facial proportions (Fig. l4f).
'Low angle' group (reduced NSL-VER, reduced
NSL-CVT, Fig. 13a-f). The maxilla was prognathic
in association with the lowered natural head position
(Fig. 13b). However, the mandible was also pro-
gnathic, despite the class II effect. This was because
the mandible exhibited a closing rotation which
was associated with a reduced gonia! angle. The
cervical column and hyoid bone were anteriorly
positioned in association with the flexed natural
head posture (Fig. I 3d). This resulted in bimaxillary
prognathism and reduced lower facial proportions
(Fig. 13f).
Conclusions
I. Natural head position affected cranial base
orientation and thereby produced class n or Ill
effects. This phenomenon may help to explain
apparent class IT or Ill tendencies in cases where
the saddle angle is normal.
2. The degree of maxillary prognathism was
closely related to natural head position. No associ-
BJO November 1988
ation was found between maxillary prognathism
and natural head posture.
3. The degree of mandibular prognathism was,
in the first instance, associated with natural head
position via its effects on cranial base orientation
and articulare. However, ultimate prognathism was
augmented by opening or closing rotation, which
increased or reduced the gonial angle, respectively,
and was in turn associated with natural head
posture.
4. Perhaps an addition to the list of the theoreti-
cal causes of prognathism mentioned by Bjork
(1947) could be cranial base orientation (natural
head position).
Acknowledgements
I would like to thank Dr I. R. Reynolds, my project
supervisor, for his help and advice, and Professor
J. R. E. Mills for his interest and support. I would
also like to thank my friends and colleagues at the
Eastman Dental Hospital, London for their help
in collecting the material for this prospective ceph-
alometric study.
References
Backlund, E. (1963)
Facial growth and the significance of oral habits, mouth
breathing and soft tissue for malocclusion,
Acta Odontologica Scandinavica, 21, Suppl. 36.
Bjork, A. (1947)
The face in profile,
Svensk Tandlak Tidskr, 40, Suppl. 607-1116.
Bjork, A. (1960)
The relationship of the jaws to the cranium. Lundstrom, A.
(ed.), In: Introduction to Orthodontics,
McCraw-Hill, London, pp. 104-140.
British Standards Institution (1983)
British Standard Glossary of Dental Terms, BS 4492,
British Standards Institution, London.
Dahlberg, G. (1940)
Statistical methods for medical and biology students,
Interscience, New York.
Head Position, Posture, and Prognathism 239
Llnder-Aronson, S. (1979)
Naso-respiratory function and craniofacial growth, In:
McNamara, J. A. Centre for Human Growth and Development,
Monograph Number 9, Craniofacial Growth Series.
The University of Michigan, Ann Arbor, Michigan.
Marcotte, M. R. (1981)
Head posture and dentofacial proportions,
Angle Orthodontist, 51, 208-213.
Miiis, J. R. E. (1973)
The problem of overbite in class 11, Div. 11 malocclusions,
British Journal of Orthodontics, 1, 34-37.
Rlcketts, R. M. (1968)
Respiratory Obstruction Syndrome,
American Journal of Orthodontics, 54, 495-507.
Rledel, R. A. (1952)
The relationship of maxillary structures to cranium in malocclu-
sion and in normal occlusion,
Angle Orthodontist, 22, 142-145.
Showfety, K. J., Vlg, P. and Matteson, S. (1983)
A simple method for taking natural head position cephalograms,
American Journal of Orthodontics, 83, 495-500.
Sienbaek-Nlelsen, S. and Solow, B. (1982)
Intra and inter-examiner variability in head posture recorded
by dental auxiliaries,
American Journal of Orthodontics, 82, 50-57.
Solow, B. and TaUgren, A. (1971)
Natural head position in standing subjects,
Acta Odontologica Scandinavica, 29, 591-607.
Solow, B. and TaUgren, A. (1976)
Head posture and craniofacial morphology,
American Journal of Physical Anthropology, 4, 417-435.
Solow, B. and TaUgren, A. (1977)
Dento-alveolar morphology and relation to craniofacial pos-
ture,
Angle Orthodontist 47, 157-163.
Virchow, R. (1857)
Untersuchungen uber die entwicklung des schadelgrundes im
gesunden und krankhaften zustande unde uber den einfluss
derselben auf schadelform, gesichtsbildung und gehirnbau
Berlin. '
Welcher, H. (1862)
Untersuchung uber wachsthum und bau des mensschlichen
Schadels, Leipzig. '
Woodslde, D. G. and Llnder-Aronson, S. (1979)
The channelization of upper and lower anterior face heights
compared to population standards in boys between ages 6-20,
European Journal of Orthodontics, 1, 25-40.