Journal of Oral Rehabilitation 2008 35; 795800

Inuence of forward head posture on condylar position

H . O H M U R E * , S . M I Y A W A K I * , J . N A G A T A * , K . I K E D A , K . Y A M A S A K I * & A . A L K A L A L Y *Department of Orthodontics, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan,

Private Practice, Takarazuka, Japan and Faculty of Dentistry, The University of Hong Kong, Hong Kong SAR, China

SUMMARY There are several reports suggesting that forward head posture is associated with temporomandibular disorders and restraint of mandibular growth, possibly due to mandibular displacement posteriorly. However, there have been few reports in which the condylar position was examined in forward head posture. The purpose of this study was to test the hypothesis that the condyle moves posteriorly in the forward head posture. The condylar position and electromyography from the masseter, temporal and digastric muscles were recorded on 15 healthy male adults at mandibular rest position in the natural head posture and deliberate

forward head posture. The condylar position in the deliberate forward head posture was signicantly more posterior than that in the natural head posture. The activity of the masseter and digastric muscles in the deliberate forward head posture was slightly increased. These results suggest that the condyle moves posteriorly in subjects with forward head posture. KEYWORDS: forward head posture, condylar position, temporomandibular joint, mandibular rest position, temporomandibular disorders Accepted for publication 6 November 2007

Introduction
Forward head posture is characterized by a dorsal exion of the head together with the upper cervical spine (C1C3), and is accompanied by a exion of the lower cervical spine (C4C7) as well. With this posture, the heads centre of gravity is forward to the spines weight-bearing axis (13). Forward head posture is known to be an undesirable posture in humans (3, 4). Several reports found that forward head posture is more often seen in patients with temporomandibular disorders (TMDs) than in those without TMDs (48). In addition, several other reports demonstrated an association between forward head posture and restraint of mandibular growth, particularly forward growth. Such a growth inhibition is considered to be caused by increased dorsally directed soft tissue pressure in subjects with forward head posture (911). Therefore, it can be speculated that a force may be applied to the temporomandibular joint (TMJ) in humans with forward head posture. Because measurement of the force to the TMJ in humans is very

difcult, the existence of such a force has not yet been proved. Condylar position and or movement have often been examined to estimate the intra-articular pressure of the TMJ (1216). With respect to the inuence of forward head posture on mandibular movement, it was reported that the lower incisor movement path during jaw closing shifted posteriorly in the forward head posture (13). Because there was a low correlation between the incisor and condylar movements (17), the condylar position and or movement in the forward head posture has yet to be elucidated. The purpose of this study was to test the hypothesis that the condylar position is more posterior in the forward head posture than that in the natural head posture.

Materials and methods

Participants Fifteen healthy adult males (Mean s.d. 256 13 yrs) were selected from the students and
doi: 10.1111/j.1365-2842.2007.01834.x

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staffs of Kagoshima University. The inclusion criteria were no clinical signs or symptoms of TMDs, an acceptably good occlusion and no missing teeth. All participants gave informed consent after receiving a full explanation of the goals and structure of the present study, which was approved by the Ethics Committee of Kagoshima University Hospital. The subject sample size was conrmed by a preliminary analysis of the data, with a conventional alpha of 005 and a power level of 080 to avoid incorrect inferences in the interpretation of the results.* preparation gel, Ag AgCl disposable surface electrodes were placed with an interelectrode distance of 20 mm in the direction of the muscle bres. Each electrode-to-skin impedance was lower than 5 kW. The EMG signals were ltered (5 Hz1 kHz) and amplied with a time constant of 30 ms. The sampling frequency of the EMG signal was 256 kHz (21).

Experimental procedure
During the recordings, each participant was seated in an upright but relaxed position with a back support up to the scapula while keeping the eyes closed. Natural head posture was attained by adjusting the Frankfort plane of the participant parallel to the oor (Fig. 1). Deliberate forward head posture was attained by instructing the participant to move his head 10 cm anterior to the natural head posture while keeping the Frankfort plane horizontally (Fig. 1). The chair, on which the participant was sitting, was then moved 10 cm posteriorly to preserve the anteroposterior distance between the head and camera in the two head postures. In each head posture, maximum intercuspation (centric occlusion: CO) position and mandibular rest position were recorded for 3 s each (17). To nd the hinge axis point, minor jaw opening and closing movements were recorded for 10 s in the natural head posture (14, 18, 19). To normalize the EMG data, the activity of masseter and temporal muscles during the maximum voluntary clenching and the activity of the digastric muscle during the maximum voluntary mouth opening were recorded for 3 s in the natural head posture (21, 22).

Recording system For the recording of mandibular movement and muscle activity, an optoelectric jaw tracking system with six degrees of freedom was used. The system consisted of a head frame, a face bow, a pointer, light-emitting diodes (LEDs), CCD cameras, an amplier and a personal computer. The head frame and the face bow, each with three LEDs, were attached securely to the head and to a dental clutch which was bonded to the labial surface of the lower incisors respectively. The dental clutch was bent to ensure minimal inhibition of the movement of the mandible and lips (14, 16, 18, 19). A stand with two vertically installed CCD cameras with an intercamera distance of 1 m was placed in front of the participant. The horizontal distance between the cameras and the head of each participant was kept at approximately 12 m during recording. Using a pointer with two LEDs, the lower central incisor point and the bilateral condylar points on the skin were recorded. To locate the condylar point on the skin; rst, a line connecting the tragus and the lateral ocular angle was constructed; second, a point was located 13 mm anterior to the tragus along this line; third, a 5-mm-long perpendicular line was constructed inferior to this point. The sampling frequency of the mandibular movement was 893 Hz. The mean measurement error of the mandibular movement was 150 lm (SD 10) (20). To ensure the relaxation of the muscles, electromyography (EMG) from the supercial masseter, anterior temporal and anterior digastric muscles was recorded. After the skin was lightly abraded by rubbing with skin*Sample Power for Windows; SPSS Japan Inc., Tokyo, Japan. Gnathohexagraph system Ver. 1.31; OnoSocki Ltd, Kanagawa, Japan.

Data analysis of the mandibular movement The measurement and analysis system used in this study was almost the same as in previous studies (14, 16, 18, 19). Regarding the inuence of head posture on the measurement accuracy of each measurement point, the difference in coordinates between the natural head posture and deliberate forward head posture was calculated at the CO position. As a result, inuence of head posture on the measurement accuracy was less than 015 mm.

SkinPure; Nihon Kohden, Tokyo, Japan. Blue Sensor N-00-S; METS Co, Tokyo, Japan. Polygraph system 360; NEC, Tokyo, Japan.

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Fig. 1. Schematic diagram of the natural head posture and deliberate forward head posture.

The hinge axis point on the sagittal plane was mathematically calculated by solving the minimal point of the moving distance around the condylar point on the skin during 10 s of minor jaw opening and closing tapping movements on each side (23). The hinge axis point 20 mm medial to the skin was used as a condylar point for analysis (14, 18, 19, 24). The mean 3D coordinates of the incisor point and bilateral condylar points for 1 s at the centre of the recording time were used in this study. The relative position of the mandibular rest position to the CO position was calculated in each head posture.

paired t-test for normally distributed variables and with Wilcoxons signed rank test when the distribution of data was not normal. The observed signicance level of each test, i.e. probability (P), was calculated for each comparison. A value of P < 005 was considered statistically signicant. These tests were performed using conventional statistical analysis software.**

Results
In the natural head posture, the relative position of the mandibular rest position to the CO position was inferior at the incisor point and antero-inferior at the bilateral condylar points, while the relative position was postero-inferior at the incisor point and posterior at the bilateral condylar points in the deliberate forward head posture (Table 1, Fig. 2). The incisor point and bilateral condylar points at the mandibular rest position in the deliberate forward head posture were signicantly more posterior (approximately 11 mm at the condylar points on average) in the anteroposterior direction than those in the natural head posture. However, in the lateral and vertical directions, there were no signicant differences between the two head postures (Table 1). The normalized EMG activity of the masseter and digastric muscles at the mandibular rest position in the deliberate forward head posture increased signicantly more (03 and 18% s respectively) than those in the natural head posture. However, there was no signicant difference at the normalized EMG activity of the temporal muscle in the two head postures (Table 2).
**SPSS for Windows; SPSS Japan Inc., Tokyo, Japan.

Data analysis of the muscle activity The EMG data for 1 s at the centre of the recording time was full-wave rectied, and normalized by the muscle activity during maximum voluntary clenching or maximum voluntary mouth opening (21, 22). The normalized EMG activities were then time integrated for 1 s. The normalized EMG activity on the right and left muscles was averaged and the mean value was used as a representative value in the analysis.

Statistical analysis The differences between condylar position in the natural head posture and deliberate forward head posture were analysed in each direction. The normalized muscle activity at the mandibular rest position was also statistically analysed between the natural head posture and deliberate forward head posture. According to the type of data, signicance was determined with a

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Table 1. The relative position (mm) of the mandibular rest position to the CO position in the natural head posture and deliberate forward head posture Measurement point Central incisor Natural head posture (mean s.d.) )019 )002 )135 020 )004 )042 022 )008 )043 036 019 099 018 017 032 025 021 030 Deliberate forward head posture (mean s.d.) )158 )014 )169 )090 )013 007 )091 )019 )003 083 060 113 061 027 107 064 032 139

Direction Anteroposterior* Lateral Vertical Anteroposterior* Lateral Vertical Anteroposterior* Lateral Vertical

P-value <0001*** 0393 0257 <0001*** 0126 0234 <0001*** 0182 0067

Right condyle

Left condyle

*Distance in the anteroposterior direction (parallel to FH plane): (+) anterior; ()) posterior. Distance in the lateral direction: (+) left; ()) right. Distance in the vertical direction (vertical to FH plane): (+) superior; ()) inferior. ***P < 001 (paired t-test or Wilcoxons signed rank test).

Fig. 2. Superimposition of mean condylar position (n = 15) at the CO position (dotted line) and mandibular rest position (black line) in the natural head posture and deliberate forward head posture. B = bilaminar zone, D = disc. Table 2. Normalized EMG activity (%s) of each muscle at the mandibular rest position in the natural head posture and deliberate forward head posture Natural head posture (mean s.d.) Masseter muscle Temporal muscle Digastric muscle

Deliberate forward head posture (mean s.d.) 29 19 42 37 63 31

P-value 0023* 0448 0015*

26 19 38 31 45 23

Normalized using the muscle activity during the maximum voluntary clenching. Normalized using the muscle activity during the maximum voluntary mouth opening. *P < 005 (paired t-test or Wilcoxons signed rank test).

Discussion
This study revealed for the rst time that the condylar position at the mandibular rest position in the deliberate forward head posture was signicantly more posterior (approximately 11 mm on average) than that in

the natural head posture. Mandibular rest position is dened as the position that the mandible passively assumes when the mandibular musculature is relaxed (25). The mandible takes the rest position during most of the daytime (26, 27). The results of this study suggested that the condyle moves posteriorly in subjects with forward head posture. The results of this study, concerning the inuence of head posture on the mandibular position and mandibular movement, were almost coincident with the ndings of past studies (13, 28), which found the lower incisor point at the mandibular rest position to be displaced postero-inferiorly in the dorsal exion of the neck (28), and the lower incisor movement path during jaw closing to be shifted posteriorly in the forward head posture (13). To ensure the relaxation of the masticatory muscles, EMG was recorded in the current study. However, the activity of the masseter and digastric muscles at the mandibular rest position was slightly but signicantly increased (03 and 18% s respectively) in the deliberate

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forward head posture. The inuence of head posture on the masticatory muscle activity at the mandibular rest position was previously described in the literature: it was reported that the suprahyoid muscle activity was significantly increased in the forward head posture (29), and that the activity of masseter, temporal and digastric muscles was increased in the dorsal exion of the neck (30). The results of the EMG in the current study were almost coincident with the ndings of these past studies (29, 30). The changes in the muscle activity have been explained by the changes in the proprioception, the reexes to activate motor neurons responsible for airway maintenance and the tonic neck reexes (29, 30). The changes in the muscle activity may be one of the causes by which the mandible is posteriorly displaced. Dorsally directed soft tissue pressure from the stretched soft tissue was hypothesized to be one of the factors that modied the mandibular growth (911). In the light of the results of the current study, when viewing the relationship between the forward head posture and the mandibular growth, a hypothesis that force in the posterior direction to the TMJ may inhibit the mandibular growth in the forward head posture could be supported. The results of this study suggested that the condyle moves posteriorly in subjects with forward head posture. When the condyle was positioned posteriorly, an additional force might be added to a posterior region of the TMJ during mastication and or parafunction. The posterior structure of the TMJ, called the bilaminar zone, is weak to load, while the anterosuperior structure of the TMJ is a strong load-bearing site (27, 31, 32). In addition, posterior displacement of the condyle was reported to possibly cause TMDs including TMJ disc displacement (27, 3335). Longterm inuence of the forward head posture on the condylar position and its relationship with TMD needs to be investigated. Japan Society for the Promotion of Science. The authors are grateful to Professor Shuitsu Harada, Professor Youichi Yamasaki and Professor Emeritus Gakuji Ito for their suggestions and advice.

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References
1. Goldstein DF, Kraus SL, Williams WB, Glasheen-Wray M. Inuence of cervical posture on mandibular movement. J Prosthet Dent. 1984;52:421426. 2. Griegel-Morris P, Larson K, Mueller-Kraus K, Oatis CA. Incidence of common postural abnormalities in the cervical, shoulder and thoracic regions and their association with pain in two age groups of healthy subjects. Phys Ther. 1992;72:425431. 3. Gonzalez HE, Manns A. Forward head posture: its structural and functional inuence on the stomatognathic system, a conceptual study. Cranio. 1996;14:7180. 4. Lee WY, Okeson JP, Lindroth J. The relationship between forward head posture and temporomandibular disorders. J Orofac Pain. 1995;9:161167. 5. Fricton JR, Kroening R, Haley D, Siegert R. Myofacial pain syndrome of head and neck: a review of clinical characteristics of 164 patients. Oral Surg Oral Med Oral Pathol. 1985;60:615 623. 6. Braun BL. Postural differences between asymptomatic men and women and craniofacial pain patients. Arch Phys Med Rehabil. 1991;72:653656. 7. Kritsineli M, Shim YS. Malocclusion, body posture, and temporomandibular disorders in children with primary and mixed dentition. J Clin Pediatr Dent. 1992;16:8693. 8. Sonnesen L, Bakke M, Solow B. Temporomandibular disorders in relation to craniofacial dimensions, head posture and bite force in children selected for orthodontic treatment. Eur J Orthod. 2001;23:179192. 9. Solow B, Siersbaeck-Nielsen S. Growth changes in head posture related to craniofacial development. Am J Orthod. 1986;89:132140. 10. Solow B, Siersbaeck-Nielsen S. Cervical and craniofacial posture as predictors of craniofacial growth. Am J Orthod. 1992;101:449458. 11. Solow B, Sandham A. Cranio-cervical posture: a factor in the development and function of the dentofacial structures. Eur J Orthod. 2002;24:447456. 12. Huddleston Slater JJR, Visscher CM, Lobbezoo F, Naeije M. The intra-articular distance within the TMJ during free and loaded closing movements. J Dent Res. 1999;78:18151820. 13. Visscher CM, Huddleston Slater JJR, Lobbezoo F, Naeije M. Kinematics of the human mandible for different head postures. J Oral Rehabil. 2000;27:299305. 14. Miyawaki S, Tanimoto Y, Kawakami T, Sugimura M, TakanoYamamoto T. Motion of the human mandibular condyle during mastication. J Dent Res. 2001;80:437442. 15. Naeije M, Hofman N. Biomechanics of the human temporomandibular joint during chewing. J Dent Res. 2003;82:528 531.

Conclusions
The condylar position at the mandibular rest position in the deliberate forward head posture was more posterior than that in the natural head posture.

Acknowledgments
This study was partially supported by grants-in-aid for scientic research for K. I., S. M. and H. O. from the

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H . O H M U R E et al.
16. Miyawaki S, Tanimoto Y, Araki Y, Kawakami T, Kuboki T, Takano-Yamamoto T. Movement of the lateral and medial poles of the working condyle during mastication in patients with unilateral posterior crossbite. Am J Orthod Dentofacial Orthop. 2004;126:549554. 17. Tingey EM, Buschang PH, Throckmorton GS. Mandibular rest position: a reliable position inuenced by head support and body posture. Am J Orthod Dentofacial Orthop. 2001;120:614622. 18. Miyawaki S, Ohkochi N, Kawakami T, Sugimura M. Effect of food size on the movement of the mandibular rst molars and condyles during deliberate unilateral mastication in humans. J Dent Res. 2000;79:15251531. 19. Miyawaki S, Tanimoto Y, Inoue M, Sugawara Y, Fujiki T, Takano-Yamamoto T. Condylar motion in patients with reduced anterior disc displacement. J Dent Res. 2001;80:14301435. 20. Tokiwa H, Miura F, Kuwahara Y, Wakimoto Y, Tsuruta M. Development of a new analyzing for stomatognathic functions. J Jpn Soc Stomatognath Funct. 1996;3:1124. 21. Miyawaki S, Ohkochi N, Kawakami T, Sugimura M. Changes in masticatory muscle activity according to food size in experimental human mastication. J Oral Rehabil. 2001;28:778784. 22. Mckay DC, Christensen LV. Electrognathographic and electromyographic observations on jaw depression during neck extension. J Oral Rehabil. 1999;26:865876. 23. Hayashi T, Iijima T. A method of extracting a kinematic characteristic from the motion of a rigid body: estimation of the reciprocating point of a rigid body moving periodically in a two dimensional space. IEICE Trans. 1987;70(D):11571163. 24. Lundeen HC, Gibbs CH. Advances in occlusion. 1st ed. Boston (MA): John Wright; 1982. 25. Zwemer T, Fehrenbach MJ, Emmons M, Tiedemann MA. Mosbys dental dictionary. Philadelphia (PA): Elsevier; 2004. 26. Bando E, Fukushima S, Kawabata H, Kohno S. Continuous observation of mandibular position by telemetry. J Prosthet Dent. 1972;28:485490. 27. Okeson JP. Management of temporomandibular disorders and occlusion. St Louis (MO): Mosby; 1998. 28. Preiskel HW. Some observations on the posture position of the mandible. J Prosthet Dent. 1965;15:625633. 29. Milidonis MK, Kraus SL, Segal RL, Widmer CG. Genioglossi muscle activity in response to changes in anterior neutral head posture. Am J Orthod Dentofacial Orthop. 1993;103:3944. 30. Funakoshi M, Fujita N, Takehana S. Relations between occlusal interference and jaw muscle activities in response to changes in head position. J Dent Res. 1976;55:684690. 31. Bumann A, Lotzmann U. TMJ Disorders and Orofacial Pain. New York: Thieme, 2002. 32. Radu M, Marandici M, Hottel TL. The effect of clenching on condylar position: a vector analysis model. J Prosthet Dent. 2004;91:171179. 33. Pullinger AG, Solberg WK, Hollender L, Guichet D. Tomographic analysis of mandibular condyle position in diagnostic subgroup of temporomandibular disorders. J Prosthet Dent. 1986;55:723729. 34. Imai H, Sakamoto I, Yoda T, Yamashita Y. A model for internal derangement and osteoarthritis of the temporomandibular joint with experimental traction of the mandibular ramus in rabbit. Oral Dis. 2001;7:185191. 35. Hibi H, Ueda M. Body posture during sleep and disc displacement in the temporomandibular joint: a pilot study. J Oral Rehabil. 2005;32:8589.
Correspondence: Shouichi Miyawaki, Professor and Chairman, Department of Orthodontics, Kagoshima University Graduate School of Medical and Dental sciences, 8-35-1, Sakuragaoka, Kagoshima 8908544, Japan. E-mail: miyawaki@denta.hal.kagoshima-u.ac.jp

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