CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Cervical posture analysis in dental students and

its correlation with temporomandibular disorder

Mariana Barbosa Câmara-Souza , Olívia Maria Costa

Figueredo , Paulo Raphael Leite Maia , Isabelle de Sousa
Dantas & Gustavo Augusto Seabra Barbosa

To cite this article: Mariana Barbosa Câmara-Souza , Olívia Maria Costa Figueredo , Paulo
Raphael Leite Maia , Isabelle de Sousa Dantas & Gustavo Augusto Seabra Barbosa (2017):
Cervical posture analysis in dental students and its correlation with temporomandibular disorder,
CRANIO®, DOI: 10.1080/08869634.2017.1298226
To link to this article: http://dx.doi.org/10.1080/08869634.2017.1298226

View supplementary material

Published online: 08 Mar 2017.

Submit your article to this journal

View related articles

View Crossmark data

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ycra20

Download by: [The UC San Diego Library] Date: 10 March 2017, At: 05:49
CRANIO®: The Journal of Craniomandibular & Sleep Practice, 2017
http://dx.doi.org/10.1080/08869634.2017.1298226

TMJ

Cervical posture analysis in dental students and its

correlation with temporomandibular disorder
Mariana Barbosa Câmara-Souza DDS, MSca, Olívia Maria Costa Figueredo DDS, MSca, Paulo Raphael Leite Maia
DDS, MScb, Isabelle de Sousa Dantas DDS, MScb and Gustavo Augusto Seabra Barbosa DDS, MSc, PhDb
a
Department of Prosthesis and Periodontology, Piracicaba Dental School, University of Campinas, Piracicaba, Brazil;
b
Department of Dentistry, Federal University of Rio Grande do Norte, Natal, Brazil

ABSTRACT KEYWORDS
Objective: To evaluate the relationship between temporomandibular disorders (TMD) and Temporomandibular joint
craniocervical posture in the sagittal plane measured from lateral radiographs of the head. disorders; posture;
Methods: The sample was comprised of 80 randomly selected students of dentistry at the cephalometry radiography
Federal University of Rio Grande do Norte. Research Diagnostic Criteria for TMD
(RDC/TMD) was used to evaluate the signs and symptoms of TMD. Lateral radiographs of
each individual were used to measure the position of the hyoid bone, the craniocervical
angle, and the occiput–atlas distance. A chi-square test was used to evaluate the
relationships between craniocervical posture measures and TMD.
Results: No relationship was found between TMD and the craniocervical posture measured
by the positioning of the hyoid bone, head rotation, and the extension/flexion of the head (p
> 0.05). Conclusion: It can be concluded, therefore, that no relationship exists between
cervical posture in the sagittal plane and TMD.

Introduction
Temporomandibular disorder (TMD) is a condition that
affects the temporomandibular joint (TMJ) and/or the
masticatory muscles and associated structures. It can be
classified according to its origin in joint disorders, muscle
disorders, or both [1,2]. TMD has a multifactorial etiol-
ogy usually involving local, emotional, and psychologi-cal
factors. Factors commonly associated with TMD are
malocclusions, improper oral habits such as bruxism and
clenching [3], emotional tension, missing teeth, stress,
joint pathology or trauma, poor posture, and others [4,5].
Poor posture affects the muscles and tendons and influ-
ences the position of the jaw, resulting in changes in the TMJ
region that may be associated with dysfunction of the joint.
Some studies [6,7] have demonstrated that postural changes
of the head and cervical spine function overload the TMJ and
act as a common causal factor for and/or perpetuator of
TMD, while others showed no relationship [8–10], thus
emphasising the need for further studies on this subject.
Since the hyoid bone provides attachment for muscles,
ligaments and fascia of the pharynx, jaw, skull and cervical
spine, it is strongly related to craniocervical posture [7]. It is
a fundamental structure in the proper biomechani-cal
relationship of the stomatognathic system. Changes
in hyoid bone position may affect the TMJ and act as a
factor for TMD.
Therefore, the relationship between TMD and
postural changes in the cervical spine is a topic of
growing interest, in order to provide a multidisciplinary
treatment for the recovery of a patient’s health. Thus,
the aim of this study was to evaluate the relationship
between TMD and crani-ocervical posture measured by
lateral radiographs of the head. The null hypothesis is
that TMD is not correlated with postural changes.
Materials and methods
The Ethics Committee of the Federal University of Rio
Grande do Norte approved this research under protocol
#392.438, and written informed consent was obtained
from all participants. The study was a controlled cross-
sec-tional one in which students of dentistry at the Federal
University of Rio Grande do Norte had postural assess-
ments and were examined for the presence of TMD.
A random sampling process, using a general outline
of systematic sampling, selected the volunteers. Of the
322 students enrolled in the dental school, 101 were
selected for the study through a random drawing, using

CONTACT  Mariana Barbosa Câmara-Souza  mariana_mbcs@hotmail.com

  Supplemental data for this article can be accessed http://dx.doi.10.1080/08869634.2017.1298226.

© 2017 Informa UK Limited, trading as Taylor & Francis Group

2    M. B. CÂMARA-SOUZA ET AL.
a systematic random sampling process. Initially, a num-
ber was drawn between 1 and 3, representing the
random start. The remaining students were selected
from the sum of the random start plus 3.
Inclusion criteria
Students enrolled in the dental school of the Federal
University of Rio Grande do Norte, between 18 and 30
years old, up to 1.85 m tall (maximum size of the ceph-
alometric extraoral imaging system), with at least 28 teeth,
and in general good health were included in the study.
Exclusion criteria
Individuals who were undertaking any physical therapy
intervention to alter posture, or who had congenital or
acquired bone abnormalities, neurological disorders,
fibromyalgia, headache or earache, mental illness, or
recent surgical procedures in the orofacial region that
could interfere in the evaluation process, were excluded
from the research.
Analysis of TMD
Axis I of the Research Diagnostic Criteria for TMD (RDC/
TMD) was used for clinical diagnosis of TMD and their type
and subtypes [11]. RDC Axis I consists of the phys-ical
assessment of the patient using 10 items of clinical
examination, with muscle and joint palpation, testing of
mandibular movements, and three subjective ques-tions. A
diagnosis was given after evaluating the summa-ries of
findings, according to a predetermined scheme. Individuals
were grouped according to the presence or absence of TMD
and the type of TMD: muscle TMD, joint TMD (groups II
and III), or mixed TMD.
The examinations were performed by a single spe-
cially trained examiner who performed palpation proce-
dures and verified mandibular movements following the
pressures used in both intraoral palpation (0.5 kg) and
extraoral palpation (1.0 kg), according to Dworkin and
LeResche [11] and Visscher et al. [12]. The examiner
used personal protective equipment and followed the
standards of biosecurity.
Radiographic analysis
A lateral radiograph of the head and neck was used to
measure the occiput–atlas distance (O–A distance), the
craniocervical relationship (craniocervical angle), and
the position of the hyoid bone (H–H′ distance),
according to Rocabado [7].
All examinations were performed at the Department of
Dental Imaging at UFRN by the same trained pro-
fessional using a Kodak 8000C Digital Panoramic and
Cephalometric Extraoral Imaging System (Carestream
Health, Inc., Rochester NY, USA) with exposure of 0.5 s
to 80 kV and 10 mA. For radiographs, the individual was
positioned upright, sideways to the X-ray machine, with
relaxed body, and feet 10 cm apart on a marked point on
the floor, corresponding to the center of the cephalostat.
The arms were held alongside the body, holding a weight
of 1.0 kg in each hand to pull the shoulders down and
allow better visualization of the cervical spine [9].
Each volunteer was asked to look toward the
horizon; do stretches for flexion, extension, and
rotation of the cer-vical spine; and end the movements
in a resting position. After three cycles of inspiration
and expiration, the head was gently stabilized in its
natural position with a frame clamped over the ears, to
avoid movements during radi-ography [9].
Cephalometric tracings were done on the scanned
images using CorelDraw X6 software (Corel
Corporation, Ottawa, ON, Canada). Anatomical points
of interest were the occipital bone, the posterior nasal
spine, the hyoid bone, and the odontoid process of the
second cervical ver-tebra. Cephalometric analysis was
performed by marking the anatomical landmarks.
The O–A distance is a linear measurement from the
base of the occiput (O) to the posterior arch of the atlas
(A) (Figure 1). The standard distance is 4–9 mm [7]. A
posterior rotation of the neck, relative to the occiput,
will occur when the distance is lower than 4 mm, and a
dis-tance greater than 9 mm results in an anterior
rotation of the neck, relative to the occiput.
The hyoid triangle is formed by the union of the most
anterior and inferior point of C3, the most anterior and
Figure 1. Occiput and atlas points and O–A distance,
which measures rotation of the head.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Figure 2. The hyoid triangle: Union of C3, RGn and H
points and H′ line. The H–H′ distance is a measure of
the position of the hyoid bone.
Figure 3. McGregor plane (A–A′), odontoid plane (B–B
′) and craniocervical angle (blue), which measures the
flexion of the head.
superior point of the hyoid bone (H), and the most pos-
terior and inferior point of the mentonian symphysis
(RGn). The union of the points C3 and RGn form the
line H′ (Figure 2). The standard distance of H–H′ is 5
mm, with the apex downwards [7]. When the value is
higher than 5 mm with the apex down, the hyoid bone
is low. If the apex is up, the hyoid is high, and H–H′ is
negative (Figure 2).
Finally, the craniocervical angle is the intersection of
the McGregor plane (A–A′) with the odontoid plane
(B– B1). The normal angle is between 96° and 106° [7].
A value greater than 106° suggests head flexion, and
values below 96° suggest extension (Figure 3).
Inter-examiner reliability
All radiographic examinations were randomized and
analyzed blind for TMD by an independent examiner.
Further, 10 radiographs were randomly selected and
referred to the radiologist of the imaging service of the
Federal University of Rio Grande do Norte to do the
same analysis to measure inter-examiner variability.
Statistical analysis
SPSS version 17.0 was used to analyze differences in
the presence/absence of TMD by O–A distance, hyoid
bone position, and craniocervical angle. Relationships
between measures of craniocervical posture and TMD
were ana-lyzed using chi-squared tests. The inter-
examiner reliabil-ity was assessed using Pearson’s
correlation. Significance levels were set at p ≤ 0.05.
Results
The sample consisted of 101 subjects, although 21 subjects
were excluded from the study: 14 were doing an extracur-
ricular activity in another city, four refused to participate in
the study, and three volunteers were taller than 1.85 m.
Eighty subjects agreed to participate in the research and met
the inclusion criteria: 54 females and 26 males, all aged
between 18 and 26 years (Figure 4). According to the diag-
nosis given by Axis I RDC/TMD, 28 patients had TMD, and
the rest did not. Of the volunteers who had TMD, all fit into
the joint TMD (II and III) and mixed TMD groups. There
was no statistical difference between males and females in
TMD diagnosis (p = 0.583; Table 1).
Sixty-two percent of the total sample experienced
some modification on hyoid bone position (too high or
too low) (Table 2), while 47.5% showed extension or
flexion of the head, as measured by the craniocervical
angle (Table 3). The heads of 42.5% of the subjects
showed anterior rota-tion, as measured by the O–A
distance (Table 4). None of these measures showed any
association with TMD (O–A distance, position of the
hyoid bone, craniocervical angle, p > 0.05 in all cases).
Mean values for each measure of cervical posture were
not statistically different for groups with or without
TMD and presented averages within the normal range:
O–A distance (4 to 9 mm), H–H′ dis-tance (up to 5
mm), and craniocervical angle (96–106°) (Table 5).
The inter-examiner reliability showed that the values
for the craniocervical angle, O–A distance and H–H′ dis-
tance showed good to excellent reliability (Table 6).
Discussion
There was no statistically significant relationship between
TMD and craniocervical posture in this study, thereby
leading to an acceptance of the null hypothesis. A variety
of results have been reported using different methodol-
ogies. Andrade et al. [8] found no relationship between
cervical posture and TMD and also observed that the
4    M. B. CÂMARA-SOUZA ET AL.

Figure 4. Flowchart of patient recruitment.

Table 1. Distribution of female and male subjects and Table 4. Relationship between the craniocervical angle
TMD diagnosis. and the presence or absence of TMD.

Without TMD With TMD Total Without TMD With TMD Total

Gender n % n % n % p* Craniocervical
Male 17 21.25 9 11.25 26 32.5 angle n % n % n % p*
0.583 Normal 27 33.75 15 18.75 42 52.5
Female 35 43.75 19 23.75 54 67.6 Head extension 17 21.25 10 12.5 27 33.75 0.841
Head flexion 8 10 3 3.75 11 13.75
*
Chi-square test. *
Chi-square test.

Table 2. Relationship between O–A distance (normal or anterior

rotation of the head) and the presence or absence of TMD. position of the hyoid bone was stable and not related to
Without TMD With TMD Total TMD. Valenzuela et al. [13] and Visscher et al. [10] also
reported that such association does not exist. In contrast,
O–A distance n % n % n % p* some studies disagree with the present findings [14–16].
Normal 31 38.75 15 18.75 46 57.5
0.537
Anterior 21 26.25 13 16.25 34 42.5
rotation
*
Chi-square test.

Table 3. Relationship between the position of the hyoid bone

(H–H′ distance) and the presence or absence of TMD.

Without TMD With TMD Total

H–H′ distance n % n % n % p*
Normal 19 23.75 11 13.75 30 37.5
Negative 19 23.75 11 13.75 30 37.5 0.922
Greater than 14 17.5 6 7.5 20 25.0
5 mm

*
Chi-square test.
Table 5. Mean and standard deviation of the different measures
of cervical posture in students with and without TMD.

Without TMD
Postural measure (n = 52) With TMD (n = 28) p*
O–A distance 8.47 ± 2.78 8.53 ± 1.96 0.918
H–H′ distance 1.77 ± 6.36 1.35 ± 4.40 0.754
Craniocervical angle 98.71 ± 10.67 96.4 ± 11.12 0.366

*
Student’s t-test.

Table 6. Inter-examiner reliability values.

r*
Craniocervical angle 0.899
O–A distance 0.925
H–H′ distance 0.964
*
Pearson’s correlation.

This difference can be attributed to factors related to

methodology, such as sample size and the method of
postural evaluation (by means of photograph or radio-
graph). In contrast to the present study, a previous liter-
ature review found a relationship between posture and
TMD [17]; however, much of the assessment was done by
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
photographs, and may thus have larger distortions than
radiographic analysis. Postural visual assessments [18],
photographs [19], or posturograms [11] may present dis-
tortions and variations in the standard anatomical points
marked; therefore, the results may be biased and unrelia-
ble. Thus, this study presents an accurate way to evaluate
the images, since it makes use of radiographs to measure
craniocervical morphology. In addition, the proposed
methodology [7] is a simple, low-cost, and efficient way to
obtain the relation between the craniofacial structures.
The systematic review of Olivo et al. [20] included
clinical trials, cohort studies, case-control studies, and
cross-sectional studies that correlated the posture of the
head and neck with a sample of patients diagnosed with
TMD. From the 12 articles evaluated in this review,
nine papers used clinical signs to determine the TMD
diagnosis, which could generate excessive false
positive diagnoses, leading to a correlation with posture
[21,22]. Also, different methods of postural analysis
were used, demonstrating that a standardization of
techniques and the use of radiographs to evaluate
craniocervical posture are essential.
Farias-Neto et al. [23] conducted a study of postural
analysis using radiographs in 12 patients with TMD,
evaluating five points. Only two measures (the O–A
distance and the craniocervical angle) were statistically
different between the groups with and without TMD, and
they stated that it was not possible to conclude whether
poor posture influences TMD or vice versa. Although the
present study did not find a statistically significant
difference between groups, it was remarkable that most of
the volunteers had some posture alteration. It is a common
condition for dentists and dental students, who spend
hours a day working in uncomfortable positions, and
which compromises their health and quality of life [24].
Faulin et al. [25] evaluated the possible correlation
between TMD and different head postures in the frontal
and sagittal planes using photographs (and the Software
for the Assessment of Posture – SAPO) of undergraduate
students. Saddu et al. [26] evaluated the head and crani-
ocervical posture between individuals with and without
TMD and its subtypes by photographic and radiographic
method. They concluded that no association could be
found between head posture and TMD. These studies used
RDC/TMD for a TMD diagnostic, while for the postural
diagnostic, the first study used photographs, and the sec-
ond used radiographs. Although different methodologies
were used to perform postural analyses, no association was
found between postural changes and TMD. These results
are similar to the present study.
Although this study did not show statistical signif-
icance, it must be considered that a larger sample size
and the evaluation of patients formally diagnosed with
6    M. B. CÂMARA-SOUZA ET AL.
TMD may lead to different results. Thus, there is a need
for standardization in the methodology of studies in this
area to allow robust comparisons among studies. Further
research comparing different methods of posture assess-
ment, and using higher samples to allow extrapolation of
results is required to better explain this relevant topic.
Conclusion
Within the limitations of the study, it may be concluded
that no relationship can be found between craniocervical
posture in the sagittal plane and the presence of tempo-
romandibular disorder in dental students.
Disclosure statement
No potential conflict of interest was reported by the authors.
Funding
This work was supported by the Federal University of Rio
Grande do Norte (UFRN), Brazil.
References
 [1]  Cooper BC, Kleinberg I. Examination of a large patient population
for the presence of symptoms and signs of temporomandibular disorders.
Cranio. 2007;25(2):114–126.
 [2]  Ohrbach R, Dworkin SF. The evolution of TMD diagnosis:
past, present, future. J Dent Res. 2016;95(10):1093–1101.
 [3]  Fernandes G, Franco-Micheloni AL, Siqueira JT, et al.
Parafunctional habits are associated cumulatively to painful
temporomandibular disorders in adolescents. Braz Oral Res.
2016;30(1):1–7.
 [4]  Yalçınkaya E, Cingi C, Bayar Muluk N, et al. Are
temporomandibular disorders associated with habitual sleeping body
posture or nasal septal deviation? Eur Arch Otorhinolaryngol.
2016;273(1):177–181.
 [5]  Okeson JP. Etiology of functional disturbances in the
masticatory system. In: Okeson JP, editor. Management of
temporomandibular disorders and occlusion. 7th ed. St. Louis (MO):
Elsevier Mosby; 2013. p. 102–128.
 [6]  Chaves TC, Turci AM, Pinheiro CF, et al. Static body postural
misalignment in individuals with temporomandibular disorders: a
systematic review. Braz J Phys Ther. 2014;18(6):481–501.
 [7]  Rocabado M. Biomechanical relationship of the cranial,
cervical, and hyoid regions. Cranio. 1983;1(3):61–66.
 [8]  Andrade AV, Gomes PF, Teixeira-Salmela LF. Cervical spine
alignment and hyoid bone positioning with
temporomandibulardisorders.JOralRehabil.2007;34(10): 767–772.
 [9]  Iunes DH, Carvalho LCF, Oliveira AS, et al. Craniocervical
posture analysis in patients with temporomandibular disorder. Rev
Bras Fisiot. 2009;13(1):89–95.
[10]  Rocha T, Castro MA, Guarda-Nardini L, et al. Subjects
with temporomandibular joint disk displacement do not
feature any peculiar changes in body posture. J Oral
Rehabil. 2017;44(2):81–88. doi: 10.1111/joor.12470
[11]  Dworkin SF, LeResche L. Research diagnostic criteria
for temporomandibular disorders: review, criteria,
examinations and specifications, critique. J
Craniomandibular Disord. 1992;6(4):301–355.
[12]  Visscher CM, Lobbezoo F, Naeije M. Comparison of
algometry and palpation in the recognition of
temporomandibular disorder pain complaints. J Orofac
Pain. 2004;18(3):214–219.
[13]  Valenzuela S, Miralles R, Ravera MJ, et al. Does head
posture have a significant effect on the hyoid bone
position and sternocleidomastoid electromyographic
activity in young adults? Cranio. 2005;23(3):204–211.
[14]  Biasotto-Gonzalez DA, Andrade DV, Gonzalez TO, et
al. Correlation between temporomandibular
dysfunction, cervical posture and quality of life. Rev
Bras Crescimento Desenvolv Hum. 2008;18(1):79–86.
[15]  Olivo SA, Fuentes J, Major PW, et al. The association
between neck disability and jaw disability. J Oral
Rehabil. 2010;37(9):670–679.
[16]  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(2):179–192.
[17]  Saito ET, Akashi PM, Sacco IC. Global body posture
evaluation in patients with temporomandibular joint
disorder. Clinics (Sao Paulo). 2009;64(1):35–39.
[18]  Munhoz WC, Marques AP, Siqueira JTTD. Evaluation
of body posture in individuals with internal
temporomandibular joint derangement. Cranio. 2005;
23(4):269–277.
[19]  Armijo-Olivo S, Rappoport K, Fuentes J, et al. Head
and cervical posture in patients with temporomandibular
disorders. J Orofac Pain. 2011 Summer; 25(3):199–209.
[20]  Olivo SA, Bravo J, Magee DJ, et al. The association
between head and cervical posture and
temporomandibular disorders: a systematic review. J
Orofac Pain. 2006;20(1):9–23.
[21]  Deltoff MN.Diagnostic imaging of the cranio-cervical
region. In: Vernon H., editor. The cranio-cervical
syndrome. Mechanisms, assessment and treatment.
London:Butterworth Heinemann; 2001. p. 49–87.
[22]  Lee WY, Okeson JP, Lindroth J. The relationship
between forward head posture and temporomandibular
disorders. J Orofac Pain. 1995;9(2):161–167.
[23]  Farias-Neto JP, Santana JM, Santana-Filho VJ, et al.
Radiographic measurement of the cervical spine in
patients with temporomandibular dysfunction. Arch
Oral Biol. 2010;55(9):670–678.
[24]  Shirzaei M, Mirzaei R, Khaje-Alizade A, et al.
Evaluation of ergonomic factors and postures that cause
muscle pains in dentistry students’ bodies. J Clin Exp
Dent. 2015;7(3):e414–e418.
[25]  Faulin EF, Guedes CG, Feltrin PP, et al. Association
between temporomandibular disorders and abnormal
head postures. Braz Oral Res. 2015;29(1):1–6.
[26]  Saddu SC, Dyasanoor S, Valappila NJ, et al. The evaluation of
head and craniocervical posture among patients with and
without temporomandibular joint disorders – a comparative
study. J Clin Diagn Res. 2015;9(8):55–58.