Dentomaxillofacial Radiology (2013) 42, 20130060

ª 2013 The Authors

http://dmfr.birjournals.org

RESEARCH
Cervical vertebral column morphology in patients with obstructive
sleep apnoea assessed using lateral cephalograms and cone beam
CT. A comparative study
L Sonnesen*,1, KE Jensen2, AR Petersson3, N Petri4, S Berg5 and P Svanholt1
1
Department of Orthodontics, Institute of Odontology, Faculty of Health Sciences, University of Copenhagen, Copenhagen N,
Denmark; 2Department of Radiology, Musculoskeletal Section, Rigshospitalet, Copenhagen, Denmark; 3Department of
Radiology, Institute of Odontology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark; 4Department
of Ear-Nose-Throat, Nykoebing F. Hospital, Region Zealand, Denmark; 5ScanSleep Clinical Trials Aps, Copenhagen, Denmark

Objectives: Few studies have described morphological deviations in obstructive sleep apnoea
(OSA) patients on two-dimensional (2D) lateral cephalograms, and the reliability of 2D
radiographs has been discussed. The objective is to describe the morphology of the cervical
vertebral column on cone beam CT (CBCT) in adult patients with OSA and to compare 2D
lateral cephalograms with three-dimensional (3D) CBCT images.
Methods: For all 57 OSA patients, the cervical vertebral column morphology was evaluated
on lateral cephalograms and CBCT images and compared according to fusion anomalies and
posterior arch deficiency.
Results: The CBCT assessment showed that 21.1% had fusion anomalies of the cervical
column, i.e. fusion between two cervical vertebrae (10.5%), block fusions (8.8%) or
occipitalization (1.8%). Posterior arch deficiency occurred in 14% as partial cleft of C1 and
in 3.5% in combination with block fusions. The agreement between the occurrence of
morphological deviations in the cervical vertebral column between lateral cephalograms and
CBCT images showed good agreement (k 5 0.64).
Conclusions: Prevalence and pattern in the cervical column morphology have now been
confirmed on CBCT. The occurrence of morphological deviations in the cervical vertebral
column showed good agreement between lateral cephalograms and CBCT images. This
indicates that 2D lateral cephalograms (already available after indication in connection with,
e.g. treatment planning) are sufficient for identifying morphological deviations in the cervical
vertebral column. For a more accurate diagnosis and location of the deviations, CBCT is
required. New 3D methods will suggest a need for new detailed characterization and division
of deviations in cervical vertebral column morphology.
Dentomaxillofacial Radiology (2013) 42, 20130060. doi: 10.1259/dmfr.20130060

Cite this article as: Sonnesen L, Jensen KE, Petersson AR, Petri N, Berg S, Svanholt P. Cervical
vertebral column morphology in patients with obstructive sleep apnoea assessed using lateral
cephalograms and cone beam CT. A comparative study. Dentomaxillofac Radiol 2013; 42:
20130060.

Keywords: vertebral column morphology; sleep apnoea; X-ray; cone beam computed tomography

Introduction

On lateral cephalograms, deviations in the morphology of
the cervical vertebral column as regards fusion anomalies
*Correspondence to: Dr L Sonnesen, Department of Orthodontics, Institute of
Odontology, Faculty of Health Sciences, University of Copenhagen, 20 Nørre
Alle, DK-2200 Copenhagen N, Denmark. E-mail: alson@sund.ku.dk
Received 8 February 2013; revised 6 March 2013; accepted 8 March 2013
and posterior arch deficiency have been described in re-
lation to craniofacial syndromes and cleft lip and palate.
Deviations such as fusion anomalies have been observed
in craniosynostosis syndromes, such as Pfeiffer’s disease,
Crouzon’s disease and Apert’s syndrome.1–5 Deviations of
the cervical column morphology have also been observed
 Cervical spine morphology in OSA patients
2 of 9 L Sonnesen et al
in Saethre–Chotzen, Klippel–Feil, Turner and Down
syndromes.6–11 Malformations of the upper cervical ver-
tebrae have been closely investigated in patients with cleft
lip and/or palate.11–17
Deviations in the morphology of the cervical ver-
tebral column have been described in healthy subjects
with neutral occlusion18 and in patients with severe
skeletal malocclusion traits, such as deep bite, open bite,
maxillary overjet and mandibular overjet.19,20–22 Further-
more, associations have been found between deviations
of the cervical vertebral column morphology, the cra-
niofacial profile and posture of the head and neck.18–22
To the knowledge of the authors, only two studies
have described the morphology of the cervical vertebral
column in patients with obstructive sleep apnoea (OSA) on
two-dimensional (2D) lateral cephalograms.23,24 The prev-
alence of morphological deviations was 43% and 46%
in the two studies, and deviations occurred significan-
tly more often in patients with OSA than in subjects
with neutral occlusion and normal craniofacial mor-
phology.23 Morphological deviations in the OSA pa-
tients were described as fusions between two cervical
vertebrae, block fusions, occipitalization, partial cleft
of C1 or dehiscence of C3 and C4.23,24 In addition, the
craniofacial profile of OSA patients with block fusions
in the cervical vertebrae and fusion of two vertebrae dif-
fered significantly from the craniofacial profile of other
OSA patients.24
The difficulty of reliably determining morphologi-
cal deviations in the cervical vertebral column on
a single lateral cephalogram has been discussed in the
literature.25–27 Studies have found that some fusions
observed on 2D radiographs were more likely to be
“pseudofusions”, and that a more valid method such
as three-dimensional (3D) radiographs [CT or cone beam
CT (CBCT)] is recommended.
Thus, the aims of the present study were: (1) to de-
scribe the morphology of the cervical vertebral column
observed on CBCT in adult patients with OSA; and (2)
to compare the cervical vertebral column morphology
observed on 2D lateral cephalograms with that observed
on 3D CBCTs.
Materials and methods
The OSA group comprised 20 females, aged 26–72 years
(mean age 54.6 years), and 37 males, aged 33–76 years
(mean age 49.7 years). The patients are the first 57 patients
enrolled as part of a longitudinal sleep apnoea study at
the Orthodontics Section, Department of Odontology,
Copenhagen, Denmark, in the period October 2011–
October 2012. The patients were diagnosed with OSA by
sleep studies, using overnight polysomnography. The
apnoea–hypopnoea index (AHI) ranged between 2 and
57 (mean 16.6). The study has been approved by the
Ethical Committee for Copenhagen, Denmark (ref. no.
H-3-2011-086) and the Danish Data Protection Agency
(J. no. 2012-54-0041).
Dentomaxillofac Radiol, 42, 20130060
Lateral cephalograms and cone beam CTs
The lateral cephalograms and CBCTs were taken with
the teeth in occlusion and in the standardized head
posture in the self-balance position as described by
Siersbaek-Nielsen and Solow.28 The radiographs were
taken at the Radiology Section, Department of Odon-
tology, Copenhagen, Denmark.
The lateral cephalograms were taken with a Philips
MEDIO 30 CP X-ray tube (Philips, Eindhoven, Netherlands)
in a cephalostat with a receptor-to-focus distance of 180 cm
and a receptor-to-median plane distance of 10 cm. An
aluminium wedge was placed at the collimator of the X-
ray tube. The exposure parameters were 70 kV, 4 mAs
and 12 ms. No correction was made for the constant
linear enlargement of 5.6%. The profile radiographs
were taken with a photostimulable phosphor plate sys-
tem, Digora PCT (Soredex, Tuusula, Finland).
The CBCTs were taken in a NewTom VGi unit (QR
srl, Verona, Italy). The settings were as follows: standard
scan mode with an imaging volume of 15 3 15 cm2, ex-
posure time of 18 s and axial thickness of 0.3 mm. The
3D images of the cervical vertebrae were analysed for
morphological deviations in the cervical vertebral col-
umn using the NewTom NNT software (QR srl, Verona,
Italy).
Morphology of the cervical vertebrae
The visual assessment of the cervical column included the
first five cervical vertebral units, normally seen on a stan-
dardized lateral skull radiograph. Characteristics of the
cervical column were described according to Sandham29
and divided into either fusion anomalies or posterior
arch deficiency. Accordingly, no differentiations were
made between congenital and degenerative morpho-
logical changes. If any doubt occurred regarding the
category, the region under consideration was registered
as having normal morphology.
Fusion anomalies are defined as fusion, block fusion
and occipitalization. Fusion is defined as fusion of one
unit with another at the articulation facets, neural arch
or transverse processes. Occipitalization is defined as
assimilation, either partially or completely, of the atlas
(C1) with the occipital bone. The definition of block
fusion was modified according to Sonnesen and Kjaer19
and defined as fusion of more than two units at the
vertebral bodies, articulation facets, neural arch or
transverse processes.
Posterior arch deficiency includes partial cleft and
dehiscence.29 Partial cleft is defined as the failure to fuse
the posterior part of the neural arch. Dehiscence is de-
fined as the failure to develop a part of the vertebral
unit.
One author (LS) described the morphological devia-
tions on the lateral cephalograms and another author
(KEJ) described the CBCT images in a blinded fashion.
Both authors have extensive experience in describing the
morphology of the cervical vertebral column on ceph-
alograms and CBCT images, respectively.
 Cervical spine morphology in OSA patients
L Sonnesen et al 3 of 9

Table 1 Prevalence of morphological deviations of the cervical vertebral between lateral cephalograms and CBCT images were
column in patients with obstructive sleep apnoea assessed using lateral assessed using the kappa coefficient (k).30 The results
cephalograms (2D) and cone beam CT images (3D)
from the tests were considered to be significant at p ,
2D 3D 0.05. The statistical analyses were performed using SPSS®
Variables n (%) n (%) p v. 20.00 (SPSS Inc., Chicago, IL).
Normal 38 (66.7) 39 (68.4) NS
Fusion anomalies 13 (22.8) 12 (21.1) NS
Fusion 9 (15.8) 6 (10.5) NS
Block fusion 4 (7.0) 5 (8.8) NS Results
Occipitalization 0 (0.0) 1 (1.8) NS
Posterior arch deficiency 7 (12.3) 8 (14.0) NS
Partial cleft 7 (12.3) 8 (14.0) NS Reliability
Dehiscence 0 (0.0) 0 (0.0) NS The reliability of the visual assessment on the CBCT
More than one deviation 1 (1.8) 2 (3.5) NS images was determined by interobserver examination
2D, two-dimensional; 3D, three-dimensional; NS, not significant. between two authors (LS and KEJ) and showed “very
good” agreement (k 5 0.92), as assessed using the kappa
coefficient.30 The interobserver agreement on the lateral
Statistical methods cephalograms has previously been reported (k 5 0.82).19
For the occurrence of morphological deviations of the
cervical column, differences between gender and be- Cone beam CT: Assessment of 3D CBCT showed that
tween lateral cephalograms and CBCT images were 31.6% had morphological deviations of the cervical
assessed using Fisher’s exact test and Mann–Whitney U vertebral column, such as fusion anomalies or posterior
test. The effect of age and AHI was tested by logis- arch deficiency (Table 1). Fusion anomalies occurred in
tic regression analysis. The interobserver agreement 21.1% as fusions either between C2 and C3 or C3 and

Figure 1 Cervical vertebral column morphology in the same patient seen on a lateral cephalogram (a) and on cone beam CT images (b–e) marked
by arrows. (a) Fusion between C2 and C3 at the vertebral bodies and at the articulatory facets, (b) in the right sagittal view, (c) in the coronal view,
(d) in the left sagittal view and (e) in the midsagittal view

Dentomaxillofac Radiol, 42, 20130060

 Cervical spine morphology in OSA patients
4 of 9 L Sonnesen et al

C4 (10.5%; Figure 1) or as block fusions (8.8%) between
C2, C3 and C4 or between C3, C4 and C5 (Figure 2).
Occipitalization occurred in 1.8% on one side. The
fusions were located between the vertebral bodies or
between the articulatory facets, either unilaterally or
bilaterally. Posterior arch deficiency occurred in 14%,
always as partial cleft of C1, and in 3.5% in combina-
tion with block fusions (Figure 2).
No statistical effect of age was found in the occurrence
of morphological deviations of the cervical column in
females, but in males the occurrence of morphological
deviations increased significantly with age (p 5 0.024).
No statistical effect of AHI or gender was found in the
occurrence of morphological deviations of the cervical
column (females 35% and males 29.7%).
Lateral cephalograms
The assessment of 2D lateral cephalograms showed
deviations of the cervical vertebral column morphology
in 33.3%, i.e. fusion anomalies or posterior arch de-
ficiency (Table 1). Fusion anomalies occurred in 22.8%
as fusions between C2 and C3 (15.8%; Figure 1) or as
block fusions between C2, C3 and C4 (7.0%; Figure 2).
Posterior arch deficiency occurred in 12.3%, always as
partial cleft of C1, and in 1.8% in combination with
block fusion (Figure 2).
No statistical effect of age, AHI or gender was found
in the occurrence of morphological deviations of the
cervical column (females 35% and males 32.4%).
Comparison of lateral cephalograms and CBCT images
No statistically significant differences in the occurrence
of morphological deviations of the cervical column
were found between lateral cephalograms and CBCT
images. The agreement between the occurrence of cer-
vical vertebral column morphological deviations seen on
lateral cephalograms and CBCT images was good (k 5
0.64). Disagreements were observed in nine patients. In

Figure 2 Cervical vertebral column morphology in the same patient seen on a lateral cephalogram (a) and on cone beam CT images (b–f ) marked
by arrows. (a) Partial cleft of C1 and block fusion between C2, C3 and C4. (b) Block fusion between C2, C3 and C4 in the right sagittal view, (c) on
both sides in the coronal view, (d) in the left sagittal view, (e) partial cleft of C1 in the axial view and (f ) in the coronal view

Dentomaxillofac Radiol, 42, 20130060

 Cervical spine morphology in OSA patients
L Sonnesen et al 5 of 9

five patients, the morphological deviations seen on the
lateral cephalograms were not verified by the CBCT
images, i.e. four patients with fusions between C2 and
C3 (Figure 3) and one patient with partial cleft of C1
(Figure 4). In four patients, the morphological deviations
seen on the CBCT images were not seen on the lateral
cephalograms, i.e. two patients with fusion between the
articulatory facets in only one side (Figure 5), one patient
with partial cleft of C1 and one patient with occipitali-
zation in one side.

Figure 3 Cervical vertebral column morphology in the same patient seen on a lateral cephalogram (a) and on cone beam CT images (b–d) marked
by arrows. (a) Fusion between C2 and C3 at the articulatory facets, (b) no fusion between C2 and C3 in the sagittal right view, (c) in the coronal
view and (d) in the sagittal left view

Dentomaxillofac Radiol, 42, 20130060

 Cervical spine morphology in OSA patients
6 of 9 L Sonnesen et al
Figure 4 Cervical vertebral column morphology in the same patient seen on a lateral cephalogram (a) and on cone beam CT images (b–d) marked
by arrows. (a) Partial cleft of C1, (b) no partial cleft of C1 in the axial view, (c) in the coronal view and (d) in the right sagittal view
Discussion
This is the first time that morphological deviations in
the cervical vertebral column regarding fusion anoma-
lies and/or posterior deficiencies in patients with OSA
have been described on CBCT. The cervical column
morphology in adult patients with OSA has previously
been examined on 2D lateral cephalograms.23 It was
found that fusion between two cervical vertebrae oc-
curred in 26%, block fusions in 12%, occipitalization in
14%, partial cleft of C1 in 2.2% and dehiscence in 3.3%.
In the present study, on 2D cephalograms and CBCT
images, the prevalence was lower except from the oc-
currence of partial cleft, which was six times higher.
Nevertheless, the pattern of morphological deviations in
the cervical column was confirmed on CBCT, except
that no dehiscence was found in the present study. The
Dentomaxillofac Radiol, 42, 20130060
differences in prevalence between the two studies could
be owing to the differences in AHI between the two OSA
groups or to the false-positive findings on the lateral
cephalograms in the previous study. In that study,23 the
AHI ranged between 5.1 and 111.7 (mean 36), and in the
present study the AHI ranged between 2 and 57 (mean
16.6). In both studies, the AHI was higher in OSA
patients with morphological deviations of the spine
compared with OSA patients without morphological
deviations, but the differences were not statistically sig-
nificant. With regard to the reliability in the previous
study, the interobserver evaluation showed very good
agreement (k 5 0.82).23
The reliability of C2 and C3 facet joint fusion has
been discussed previously in the literature. Studies have
found that some fusions observed on 2D radiographs
were more likely to be pseudofusions.25–27 Oblique
 Cervical spine morphology in OSA patients
L Sonnesen et al 7 of 9

Figure 5 Cervical vertebral column morphology in the same patient seen on a lateral cephalogram (a) and on cone beam CT images (b–d) marked
by arrows. (a) No morphological deviations, (b) fusion between C3 and C4 at the articulatory facets in the right sagittal view, (c) in the coronal
view and (d) no fusion between C3 and C4 in the left sagittal view

orientation of the cervical facet joints relative to the
X-ray beam, flexion or extension of the spine and other
morphological variations could result in superposition of
structures and an analogous appearance of fusion. These
studies have recommended a more valid method such as
3D radiographs (CT or CBCT) for assessing fusions. In
the present study, no statistically significant differences in
the occurrence of morphological deviations of the cervi-
cal column were found between lateral cephalograms
and CBCT images, and the agreement was k 5 0.64. This
indicates that there is good agreement between the
findings on the lateral cephalograms and the CBCT

Dentomaxillofac Radiol, 42, 20130060

 Cervical spine morphology in OSA patients
8 of 9 L Sonnesen et al
images. The few disagreements between lateral cephalo-
grams and CBCT images included diagnosis of fusion
between two cervical vertebrae, occipitalization and
partial cleft. Furthermore, if fusion only occurred be-
tween the articulatory facets on one side, the fusion was
not visible on the lateral cephalograms. The results in-
dicate that 2D lateral cephalograms are sufficient for
identifying morphological deviations of the cervical ver-
tebral column. Meanwhile, diagnosis of morphological
deviations of the cervical vertebral column cannot be the
only indication for obtaining lateral cephalograms. For
a more accurate diagnosis and location of morphological
deviations in the cervical vertebral column, a CBCT is
required. The current characterization and division of
deviations in cervical vertebral column morphology is
based on 2D studies from the 1980s. The new 3D
methods will suggest a need for new detailed character-
ization and division of deviations in cervical vertebral
column morphology.
The interesting deviations in prevalence and pattern
in the cervical column morphology now confirmed on
CBCT may prove to be a factor in the pathogenetic
background for sleep apnoea and thereby contribute to
the diagnosis, subdivision and treatment of patients
with OSA.
So far, the complex aetiology of OSA is still not fully
understood, but a number of studies have contributed
to phenotypic differentiations between types of sleep
apnoea. It is well known that older males with an en-
larged body mass index are at risk of developing
OSA.31–33 In studies performed on 2D lateral cepha-
lograms, specific types of craniofacial morphology and
head posture, such as reduced posterior airway space,
abnormally long soft palate, a low position of the hyoid
bone and an extended head posture,34–43 are also con-
sidered predisposing factors. In a previous study, an
association was found between the posture of the head
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