Journal of Craniomandibular Practice

ISSN: 0734-5410 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ycra19

Biomechanical Relationship of the Cranial,

Cervical, and Hyoid Regions

Mariano Rocabado R.P.T.

To cite this article: Mariano Rocabado R.P.T. (1983) Biomechanical Relationship of the
Cranial, Cervical, and Hyoid Regions, Journal of Craniomandibular Practice, 1:3, 61-66, DOI:
10.1080/07345410.1983.11677834

To link to this article: http://dx.doi.org/10.1080/07345410.1983.11677834

Published online: 19 Feb 2016.

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Biomechanical Relationship
of the Cranial, Cervical,
and Hyoid Regions
Abstract
The relationship between the cranial, cervical, and hyoid
regions can be modified by removable orthopedic appliances
installed by the dentist and by manual orthopedic techniques
applied to the cervical spine by the physical therapist.
However, each of these disciplines evaluates and treats
according to the patient's symptoms and various objective
criteria that are primarily limited to that field.
The author suggests that these two approaches to normalizing
those relationships must be coordinated. He presents an
objective method of evaluating x-rays to determine the impact
of both disciplines, and suggests that this can help determine
the normal biomechanical relationship of these structures.
He also discusses the importance of the following points as
they relate to this method:
1. The position of the hyoid bone in determining the
appropriate curvature of the cervical spine.
2. The distance between the occiput and the atlas and its
relevance to the headache syndrome.
3. The angular relationship of the cranium and the cervical
spme.

Mariano Rocabado, R.P.T.

Mariano Rocabado, R.P.T.

Mariano Rocabado, who has been in clinical practice for fifteen years, is now
Associate Professor and Coordinator of the Dental School at the University of
Chile. He is also Director of the Rocabado Institute as well as Director of the
Centro de Rehabilitacion Integral.
Soon after receiving his degree from the Physical Therapy School at the
University of Chile at Santiago (1966), Mr. Rocabado studied for six months in
France on a scholarship for specialization on the spine. From 1970 to 1973 he was a
member of the Executive Committee of the World Confederation for Physical
Therapy, and he is now also an Honorary Member of the American Academy of
Craniomandibular Disorders. Mr. Rocabado has lectured in Argentina, Colombia,
Peru, Ecuador, Panama, Honduras, Costa Rica, Canada, Norway, and the U.S. He
resides in Santiago, Chile.

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 61

PHYSICAL THERAPY
Biomechanical Relationship
of the Cranial, Cervical,
A Discussion
he importance of the hyoid bone lies in its unique
T relationship to other structures. It provides
attachment for muscles, ligaments, and fascia of the
pharynx, mandible, cranium, and cervical spine.
When cervical, cranial, and mandibular biome-
chanics are studied, the hyoid bone tends to be over-
looked or given very little attention. However, it is a
unique structure that, unlike all other bones of the
head and neck, has no bony articulations or joint
relationships anteriorly on the cervical spine.
However, it is well-attached to the cervical spine
through the cervical fascia. There are two major
groups of muscles that interact with the hyoid bone:
the suprahyoids and the infrahyoids. These muscles
rely on the hyoid bone for their normal actions, and
they have very important functions in determining
cervical spine curvature. For example, the anterior
belly of the digastric muscle increases the anterior-
posterior dimension of the oral pharynx during swal-
lowing. The posterior belly of the digastric muscle
acts with the stylohyoid muscle to prevent regurgita-
tion of food after swallowing. And the suprahyoid
muscle depresses the mandible by contracting
against the fixed hyoid platform. Thus absence or
abnormality of these structures may seriously impair
mandibular dynamics.
The functioning of the suprahyoid as it induces
tension to the mandible can be observed during nor-
mal orthostatic posture, when the head relies on
equal anterior and posterior muscle tension. The
craniovertebral joints will maintain their normal
position, and the temporomandibular joints will re-
main equally balanced towards the cranium through
tensile forces produced by normal function of the
supra- and infrahyoid muscles.
Many studies have attempted to determine the
actual position of the hyoid bone in relation to the
62 JUNE '83- AUG. '83, VOL. I, NO. 3
and Hyoid Regions
By Mariano Rocabado, R.P.T.
cervical spine, as well as how it fits into the cra-
niomandibular system. However, precise measure-
ment of the hyoid position by cephalometric means
has been difficult. Different investigations suggest
that slight variation in the posture of the cervical
spine, the state of function (su~h as during the pro-
cess of swallowing), the x-ray technique used, or the
tension that the patient may feel when asked to main-
tain the teeth in an occluded position may all affect
the position of the hyoid bone when an x-ray is being
made. However, if these problems are considered
while radiographic studies are being done, conclu-
sions can be made regarding the hyoid position as
related to the cranial, mandibular, or cervical spine
regions. It has been shown that the relationship be-
tween the hyoid bone and the mandible is maintained
from the age of three years, which correlates with the
spurt oflongitudinal growth in the cervical spine that
induces a vertical force to the mandible, through the
light elastic forces of the supra- and infrahyoid mus-
cles. The position of the hyoid bone tends to remain
constant between the inferior half of the body of the
C3 vertebra and the superior half of the C4 vertebra.
During puberty, the hyoid bone usually moves
slightly forward. In the adult, its position is related to
the anterior inferior angle of C3, and the posterior
horns tend to remain constant at the level of the disc
between C2 and C3.
Analysis of the Craniovertebral Relationship, the
Position of the Hyoid Bone, and the Curvatures of
the Cervical Spine
The hyoid bone position is a reflection of the ten-
sions of the muscles, ligaments, and fascia attached
to it (Figure 1). We have studied the relationship of
the hyoid bone to the cervical spine using a technique

developed by Dr. Bibby 1 from South Mrica and
adapted to these cephalometric examinations by the
author. It uses the hyoid triangle, which allows the
assessment of hyoid bone posture. This may be used
as one of the components necessary to determine:
1. The craniovertebral relationship.
2. The relationship of the hyoid bone to the
curvatures of tile cervical spine.
3. Normal physiological positions and func-
tions.
The study of these biomechanical relationships is
important to the dental field. For this reason, we
have presented here a detailed procedure for com-
pleting cephalometric studies of the craniovertebral
relationships, the relation to the hyoid triangle, and
the determination of normal or abnormal curvatures
of the cervical spine.
Cephalometric Points and Defmitions
C3: The most inferior anterior angle of the body of
the third cervical vertebra.
RGN (Retrognathion): The most inferior posterior
point of the mandibular symphysis.
H (Hyoidale): The most superior anterior point of the
body of the hyoid bone.
Hyoid Plane: The plane from H along the long axis of
the greater horns of the hyoid bone.
Hyoid Plane Angle: The most superior posterior
angle made by the intersection of the hyoid plane
G? l;j~::·. .
c::::J
e7 ;9:~:~·~:·······
.
~-·
N..
.... "' ,'~
...
.-I5-C-AP..:..U-LA'I
Fig. I
Tensile forces of the head, neck, mandible, and hyoid regions.
BIOMECHANICAL RELATIONSHIP
with the plane of C3-RGN.
AA: The most anterior point of the body of the atlas
(Cl vertebra) seen in the lateral cephalometric
radiograph.
PNS (Posterior Nasal Spine): The tip of the posterior
nasal spine seen in the lateral cephalometric radio-
graph.
MGP (McGregor's Plane): A line that connects the
basi-occiput with the posterior nasal spine.
OP (Odontoid Plane): A line that crosses from the
anterior inferior angle of the odontoid to the apex
of the odontoid.
OA: The distance from the basi-occiput to the pos-
terior arch of the atlas (Cl vertebra).
General Considerations for Cephalometric Tracings
of the Head, Neck, and Hyoid Regions
1. The hyoid tracing employs planes between the
cervical spine and the mandibular symphysis.
2. A triangle is formed by joining the cephalometric
points of the retrognathion (RGN), the hyoidale
(H), and C3.
3. The anterior posterior position of the hyoid bone
is determined by measurements from the plane of
H-RGN and H-C3 in anterior and posterior direc-
tions.
4. The vertical position of the hyoid bone is deter-
mined by dropping a perpendicular from the plane
ofC3-RGN to a point labeled H-1 on the hyoidale
(H).
5. The angular position of the hyoid bone is consi-
dered.
6. The analysis of the hyoid triangle gives the posi-
tion of the hyoid bone fixed in space in three
directions without the use of cranial reference
planes. Slight variations of cranial position will
induce in those planes large discrepancies which
can cause errors in the measurement of the hyoid
position; this is avoided by using the triangle
method.
7. Craniovertebral positions are evaluated by using
the posterior angle produced by the intersection
of the MGP plane and the OP plane. This angle is
an average of 101 degrees and can vary 5 degrees
\.
... into either extension or tlexion.
...---''--, 8. The normal OA averages between 4 and 9 mm .
--
I STERNUM I
When it is less than 4 mm, mechanical suboccipit-
al compression may be induced; this is a source of
posterior headaches.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 63
ROCABADO

Method for Tracing the Cranial, Cervical, and

Hyoid Regions for Nonnal Head and Neck Posture

Cephalometric studies do not normally incorpo-

rate the curvatures of the cervical spine and the
craniocervical position. These are important factors
to consider when studying the function and stability
of the craniomandibular system. This procedure will
allow the practitioner to analyze the normal or start-
ing point for treatment procedures and prognosis.

Baseline for Cephalometric Tracings (Figure 2)

1. Trace McGregor's plane (MGP).

2. Trace the odontoid plane (OP).
3. Measure the posterior angle of the intersection of
the MGP and OP planes.
4. Measure the distance between the basi-occiput
and the posterior arch of the atlas (Cl vertebra).
5. Trace the hyoid triangle. Draw lines from C3 to
RGN, from C3 to H, and from H to RGN. Fig. 2
The orthostatic position of the head on the neck is Cephalometric trdcing of normal head and neck posture.
clinically evaluated by measuring from a vertical
tangent line that runs through the apex of the tho-
racic spine to the surface of the mid-cervical spine.
This distance averages 6 cm in normal head posture.
(See Figure 3.)

Basic Positions of the Hyoid Bone in Relation to

the Curvatures of the Cervical Spine

1. Normal cervical lordosis with a normal cra-

niovertebral relationship: The vertical position of
the hyoid bone must be below the plane of the
C3-RGN. This will give a positive triangle rela-
tionship as shown in Figure 4.
2. Loss of cervical curvatures:
A. Straight cervical spine: If the physiological
curvature of the cervical spine is lost, and (a) a
normal craniovertebral relationship exists, or
(b) the occiput is extended so that the angle of
Fig. 3
MGP-OP is less than 96 degrees, the hyoid A. Forward head-neck posture (abnormal).
bone will be on the plane of C3-RGN. (See B. Normal head-neck posture.
Figure 5.)
B. Reversed physiological curvature of the cer-
vical spine (kyphosis): If there is a reversed C3-RGN, producing a negative triangle (Fi-
curvature of the cervical spine, and (a) a nor- gures 6 and 7).
mal craniovertebral relationship exists, or (b) It appears that the position of the hyoid is tied
the MGP-OP angle is less than 96 degrees,' the more closely to the curvature of the cervical spine
hyoid bone will appear above the plane of than to the craniocervical relationship.

64 JUNE '83- AUG. '83, VOL. I, NO. 3

 BIOMECHANICAL RELATIONSHIP

liAR I ANO ROCABAIJO

liAR I ANO ROCABADO

Fig. 4 Fig. 5
Normal cervical lordosis with a normal cmniovertebrdl Normal cmniovertebml relationship. Stmight cervical spine.
relationship.

liAR I AIIO ROCABADO

Fig. 6 Fig. 7
Normal cmniovertebral relationship. Inverted cervical curvature. Extension of craniovertebral joints. Reversed cervical curvature.

THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 65

ROCABADO
Conclusion
This method of cephalometric tracing relates the
cranium, the cervical spine, the mandible, and the
hyoid bone in a biomechanical functional unit. It also
demonstrates that these structures are not isolated.
This technique allows the clinician to determine nor-
mal and abnormal curvatures of the cervical spine, as
well as normal and abnormal craniocervical rela-
tionships. These two perspectives are associated
with the position of the hyoid bone through a hyoid
triangle tracing that relates cephalometric points be-
tween the cervical spine and the craniomandibular
system. These relationships can be modified through
manual orthopedic techniques, or through remov-
able orthopedic appliances. Unfortunately, a dentist
may be modifying a patient's point of RGN at the
same time that the therapist is independently mod-
ifying the function and posture of the cervical spine
and the cranium. These two approaches must in-
stead be clinically coordinated in order to re-
establish a normal orthostatic position of the head on
the neck, and to establish the normal cranioman-
dibular relationship exhibited in the cephalometric
tracing in Figure 2. This is the biomechanical posi-
tion that best prepares a patient to accept any techni-
ques designed to re-establish normal physiological
function.
66 JUNE '83- AUG. '83, VOL. I, NO. 3
Reprint requests to:
Mr. Mariano Rocabado
Rocabado Institute
/624 South I Street, Suite 104
Tacoma, Washington 98405
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