HEAD POSTURE AND CERVICOVERTEBRAL AND CRANIOFACIAL MORPHOLOGY IN PATIENTS

WITH CRANIOMANDIBULAR DYSFUNCTION Jan A. Huggare, Odont.Dr., Aune M. Raustia,

Odont.Dr. ABSTRACT: A relationship between particular characteristics of dental occlusion
and craniomandibular disorders (CMD) has been reported, while less attention has been
focused on the possible effect of dysfunction of the masticatory system on head posture or
cervicovertebral and craniofacial morphology. Natural head position roentgen-
cephalograms of 16 young adults with complete dentition taken before and after
stomatognathic treatment displayed an extended head posture, smaller size of the
uppermost cervical vertebrae, decreased posterior to anterior face height ratio, and a
flattened cranial base as compared with age- and sex-matched healthy controls. The
lordosis of the cervical spine straightened after stomatognathic treatment. The results are
an indication of the close interrelationship between the masticatory muscle system and
the muscles supporting the head, and lead to speculation on the principles of treating
craniomandibular disorders. Dr. Jan A. Huggare received his D.D.S. degree from the
Institute of Dentistry, University of Turku, in 1977. He has been a teacher in the
Depanment of Oral Development and Onhodontics, University of Oulu, where he also
received his Odont.Dr. degree in 1987, and is presently a senior lecturer. He is also an
instructor for postgraduate onhadontic teaching at the Universities of Oulu and Kuopio.
Since 1992, Dr. Huggare has been a visiting postgraduate research fellow at the Dental
School, University of Otago, New Zealand. Dr. Aune M. Raustia received her D.D.S. degree
from the Institute of Dentistry, University of Helsinki, Finland, in 1974. She has been a
teacher in the Institute of Dentistry, University of Oulu, Finland, since 1978. She received
her Odont.Dr. degree from the same university in 1986. Dr. Raustia currently works as a
senior lecturer in the Depanment of Prosthodontics and Stomatognathic Physiology,
Institute of Dentistry, University of Oulu, Finland. 173 The cervical muscles maintaining
head balance and the muscles of the stomatognathic system could be regarded as a
coordinated system in which intervention at any level will bring about a change in the
whole system. Thus, induced alteration of human head posture causes changes in
masticatory muscle activity,'-3 and analogically, manipulation of the jaw muscles by bite
opening procedures will result in a change in the habitual head posture.4 · 5 Because one
of the main symptoms of craniomandibular disorders (CMDs) is muscular tenderness, the
status of the cervicovertebral region and head posture would most probably be affected in
patients suffering from such a condition. If this hypothesis could be proven accurate, the
ever-increasing evidence for an intimate relationship between head posture and
craniofacial and cervicovertebral morphologyC>-8 would give reason to expect that
subjects with particular features of the craniofacial skeleton should be more prone to
CMD. The authors report an attempt to test these hypotheses and to look for systematic
changes in head posture in conjunction with stomatognathic treatment. Subjects and
Methods Natural head position roentgen-cephalograms of 14 females and two males,
aged 14 to 44 years (mean age 28 years) taken before and after stomatognathic treatment,
were analyzed regarding head posture and cervical ~UGGARE AND RAUSTIA CVT/HOR
Figure 1 Variables measured as indicative of head posture. Craniovertical: NSUVER, angle
between the nasion-sella line and the true vertical. FOR/VER, angle between the foramen
magnum line (line through the basion and opisthion) and the true vertical. Craniocervical:
NSUOPT, angle between the nasion-sella line and the dorsal tangent to the odontoid
process of the second cervical vertebra. FOR/OPT, angle between the foramen magnum
line and the tangent to· the odontoid process of the second cervical vertebra. Cervical
inclination: OPTIHOR, angle between the tangent line to the odontoid process of the
second cervical vertebra and the true horizontal. OPT/CVT, angle between the tangent line
to the odontoid process of the second vertebra and the tangent line to the dorsal margins
of the corpus of the third and fourth cervical vertebra. CVTIHOR, angle between the
tangent line to the dorsal margins of the corpus of the third and fourth cervical vertebra
and the true horizontal. spine inclination (Figure 1), morphology of the uppermost part of
the cervical spine (Figure 2), and craniofacial structures (Figure 3). All the roentgenograms
were taken with the same equipment and by the same person (JH) using a technique
introduced by Showfety et al.9 and further tested and described by Huggare. 10 The
pretreatment cephalograms were taken immediately prior to the stomatognathic
treatment and the post-treatment ones were taken approximately six months after
stomatognathic treatment. All the clinical stomatognathic examinations were carried out
by the same dentist specialized in stomatognathic physiology (AMR). The clinical
examination included measurement of the range of movement and function of the
mandible, function of the temporomandibular joints (TMJs), palpation of the TMJs and
masticatory muscles, and recording of pain on movement of the mandible. 11 The degree
of CMD was assessed for all subjects using the anamnestic and clinical dysfunction index of
Helkimo.12 The treatment consisted primarily of counseling, occlusal adjustment,
muscular exercises for the lower jaw, splint therapy, or a combination of these measures.
The control group, 14 females and two males (mean 174 THE JOURNAL OF
CRANIOMANDIBULAR PRACTICE HEAD POSTURE AND CMD VER Figure 2 Variables
measured as indicative of cervicovertebral anatomy. Dl, height of the atlas dorsal arch. D2,
height of the dorsal arch of the second cervical vertebra. V, height of the anterior tubercle
of the atlas. A-P, distance between the extreme anterior point on the anterior tubercle and
the extreme posterior point on the dorsal arch of the atlas. DENS, height of the dens axis
of the second cervical vertebra. age 26 years, range 21 to 40 years) consisted of voluntary
dental students and employers at the University of Oulu Institute of Dentistry. They had no
subjective symptoms of CMD and their natural head position roentgenocephalograms,
which were made with the same equipment and by the same person (JH) as the
dysfunction group, were used as controls. Mean values and standard deviations of
pretreatment and post-treatment head and cervical spine postures and of pretreatment
cervicovertebral and craniofacial morphology with respect to the control subjects were
calculated. The paired t test was used for statistical calculation of the differences between
the pretreatment and posttreatment values for the disorder group and between the initial
values for the disorder group and the values for the control group. Results As judged by
the Helkimo dysfunction index, most of the patients had anamnestically (Ai) severe
symptoms (A: II; Table 1) in the pretreatment examination. Most of them (nine of 16) had
clinically severe dysfunction (D:III, three of 16 had moderate dysfunction (D:II) and four of
16 experienced mild dysfunction (D:I). The main CMD symptoms before treatment were
tenderness to palpation in the masticatory muscles ( 14 of 16, of which nine of 14 had
tenderness at four or more sites) or in the TMJs (13 of 16), and TMJ sounds (12 of 16).
After stomatognathic treatment only three of 16 had severe dysfunction (D:III), five of 16
had moderate dysJULY 1992, VOL. 1 0, NO. 3 HUGGARE AND RAUSTIA HEAD POSTURE AND
CMD Figure 3 Variables measured as indicative of craniofacial anatomy. Sph/CIIv, angle
between the tangent to the planum sphenoidale and the dorsal tangent to the clivus.
Cliv/For, angle between the dorsal tangent to the clivus and the line through the basion
and opisthion. Pal/ Mand, angle between tbe nasal floor and the mandibular base plane.
Pal/Ram, angle between the nasal floor and the tangent to the dorsal surface of the
ramus, excluding the condyle. Mandl Ram, angle between the man- ~-
~~~b===~~~:_,f{~-:===L_=---For dibular base plane and the tan- P ~ gent to the dorsal
surface of the function (D:II) and seven of 16 experienced mild dysfunction (D:I). One
patient was clinically symptom-free in the post-treatment examination (D:O). Tenderness
to palpation in the masticatory muscles was still observed in 13 of 16 patients (of which
seven of 13 had tenderness at four or more sites). Tenderness in the TMJs was
experienced in seven of 16 and TMJ sounds were found in 11 of 16 cases. All the controls
were anamnestically symptom-free (A:O; Table 1) and three of 16 had no clinical
dysfunction symptoms (D:O). Only one control subject had moderate dysfunction (0:11).
The head was more elevated in the dysfunction group, expressed as significantly more
increased craniovertical (NSUVER; FORNER) and craniocervical angulations (FOR/OPT) than
in the controls (Table 2). The bending of the cervical spine (OPT/CVT), which was slightly
but not significantly greater in the dysfunction patients than in the controls, showed a
significant straightening after the stomatognathic treatment (Table 3). All the measures of
cervicovertebral anatomy were smaller in the dysfunction group than in the controls,
significantly so for the dorsal arch height of the atlas (DI; Table 4). Of the craniofacial
variables, the cranial base angulations (Sph/Cliv; Sph/For) were more obtuse than in the
healthy controls and the ratio between the posterior and anterior face heights (P/A) was
smaller. No statistically significant differences were found between the groups JULY 1992,
VOL. 10, NO.3 ramus, excluding tbe condyle. Ram/Cond, angle between the tangent to the
dorsal surface of the ramus and the inclination of the dorsal surface of the condylar neck.
U/Pal, angle between length axis of the most labially inclined upper incisor and the nasal
floor. L/Mand, angle between the length axis of the most labially inclined lower incisor and
the mandibular base plane. UIL, angle between the length axes of the most labially
inclined upper and lower incisors. PIA, ratio between the sella-gonion (posterior face
height) and nasion-menton distances (anterior face height). OJ, horizontal overbite
( oveljet), measured parallel to the occlusal plane. Ob, vertical overbite, measured
perpendicular to the occlusal plane. in any of the variables representing the dentoalveolar
structures (Table 5). Discussion Although longitudinal studies and clinical experience
suggest that a small proportion of CMD patients do not improve with conventional
stomatognathic treatment methods, 13· 14 all the present patients except one who had
mild dysfunction received some benefit from the treatment (Table 1). It must be pointed
out that the etiology of CMD is multifactorial. The major points of view are that etiologic
factors appear to include occlusal interferences, emotional disturbances, general
musculoskeletal disorders, and an impaired state of health. 14· 15 The multidisciplinary
approach and methods of physical medicine would often be the most useful in treating
these patients.16·17 It has been pointed out on several previous occasions that instability
of the dental occlusion is a significant risk factor for developing craniomandibular
dysfunction syndrome.1 8-20 Although the design of this study did not take into
consideration the morphological aspects of the dental occlusion, some of the
cephalometric variables illustrate, at least to some extent, the dental morphologiTHE
JOURNAL OF CRANIOMANDIBULAR PRACTICE 175 HUGGARE AND RAUSTIA HEAD
POSTURE AND CMD Table 1 Individual Anamnestic (Ai) and Clinical (Di) Dysfunction Index
(Helkimo 1974) in the Patients and Controls* Pretreatment Post-treatment Controls
Subject Ai Di Dysfunction Score Di Dysfunction Score Ai Di Dysfunction Score 1 II II 6 I I 0 I I
2 II III II II 6 0 II 6 3 I I 2 0 0 0 I I 4 II III 12 II 8 0 I 4 5 II II 7 I 2 0 0 0 6 II I 3 I 2 0 I 2 7 I II 8 I 2 0 0
0 8 0 I 2 I I 0 0 0 9 II III 17 III II 0 I I 10 II III 17 III II 0 I 2 II II III 17 III II 0 I 2 12 II I 3 I 3 0 I 2 13
II III 16 II 7 0 I I 14 II III II II 6 0 I I 15 II III 16 II 8 0 I I 16 II III 16 I 3 0 I I * Ai 0, Anamnestically
symptom free; Ai I, anamnestically mild symptoms; Ai II, anamnestically severe symptoms.
0 points = dysfunction group No. 0 = clinically symptom free = Di 0 I to 4 points =
dysfunction group No. I = mild dysfunction = Di I 5 to 9 points = dysfunction group No. 2 =
moderate dysfunction = Di II I 0 to 25 points = dysfunction group No. 3 = severe
dysfunction = Di III cal characteristics of these subjects. In terms of these variables (incisor
inclination, overjet, and overbite), there were no significant differences between the
dysfunction group and the healthy controls. The basal structures of the craniofacial
skeleton on the other hand, showed some distinct dissimilarities between the groups. The
features seen in the dysfunction group, an obtuse cranial base and a reduced posterior to
anterior face height ratio, are those seen in conjunction with skeletal open bites, which, in
fact, has been advocated as the most harmful condition for the normal functioning of the
stomatognathic system.21 • 22 It has also been shown that an Table 2 Means and
Standard Deviations of Head Posture and Cervical Spine Variables for 16 Patients with
Craniomandibular Disorders and Their Age- and Sex-Matched Controls Dysfunction
Controls Patients X so X so Difference NSUVER 97.0 3.37 101.9 4.73 4.9** FORIVER 92.4
4.47 98.6 8.45 6.2* NSUOPT 92.3 6.78 97.1 6.73 4.8 FOR/OPT 87.3 7.07 94.8 9.56 7.5*
OPTIHOR 94.3 6.96 94.7 5.89 0.4 OPT/CVT 10.4 5.45 13.5 5.92 3.1 CVTIHOR 81.6 5.35 79.1
7.24 -2.5 *p < 0.05. **p < O.QI. Paired t test. 176 THE JOURNAL OF CRANIOMANDIBULAR
PRACTICE extended head posture and a low dorsal arch of the first cervical vertebra, which
were important findings here, are often seen in women with open bitesY The early
findings of Schwarz, 24 stating that the position of the jaws at rest depends on the position
of the head, and the "sliding cranium theory" introduced recently by Makofsky,25 fosters
speculations about extended head posture as a causative factor in the development of
CMD. As the cranium bends backward through a change in the craniovertical and
craniocervical angulations (NSLNER; NSLIOPT), the occiput is translated anteriorly, causing
a simultaneous forward shift of the whole maxillary dentition in relation to the mandible.
In order to obtain occlusal support, the mandible must be forced anteriorly, which will
probably affect the muscular Table 3 Means and Standard Deviations of Pretreatment and
Post-Treatment Head Posture and Cervical Spine Inclination for 16 Patients with
Craniomandibular Disorders Pretreatment Post-Treatment X so X so Difference NSUVER
101.9 4.73 101.3 4.76 -0.6 NSUOPT 97.1 6.73 96.8 6.53 -0.3 OPTIHOR 94.7 5.89 94.7 7.36
0.0 OPT/CVT 13.5 5.92 12.3 6.30 -1.2* CVTIHOR 79.1 7.24 80.3 7.00 1.2 *p < 0.05. Paired t
test. JULY 1992, VOL. 10, NO.3 HUGGARE AND RAUSTIA Table 4 Means and Standard
Deviations of Cervicovertebral Anatomy in 16 Subjects with Stomatognathic Disorders and
Their Ageand Sex-Matched Controls Dysfunction Controls Patients X SD X SD Difference D1
9.6 2.07 7.9 1.12 -1.7** D2 12.6 2.00 11.4 2.03 -1.2 v 10.9 1.50 10.3 1.29 -0.6 A-P 48.1 2.73
46.9 3.46 -1.2 DENS 35.0 2.07 34.8 2.11 -0.2 **p < O.Ql. Paired t test. Table 5 Means and
Standard Deviations of Craniofacial Variables in 16 Patients with Craniomandibular
Disorders and Their Age- and Sex-Matched Controls Dysfunction Controls Patients X SD X
SD Difference Sph/Cliv 107.8 5.83 112.9 4.36 5.1 ** Clic/For 119.3 3.96 125.3 7.68 6.0**
Pai/Mand 21.5 4.35 23.2 7.77 1.7 Pal/Ram 86.7 8.33 84.8 7.19 -1.9 Ram/Cond 16.9 6.30
16.7 6.18 -0.2 Mand/Ram 116.4 6.95 117.9 12.0 1.5 U/Pal 109.3 9.60 108.2 9.91 -1.1
UMand 97.3 7.54 95.1 8.24 -2.2 UIL 130.6 13.30 132.4 10.09 1.8 PIA (in%) 67.2 3.37 62.1
4.95 -5.1** Oj 2.1 1.34 2.6 1.26 0.5 Ob 2.6 1.93 2.6 1.37 0.0 **p < O.Ql. Paired t test.
balance in its supporting mechanism, particularly the lateral pterygoid muscle. The
straightening of the cervical spine (OPT/CVT) observed after stomatognathic treatment is
then logically associated with the relief of the symptoms related to the muscular
imbalance in the stomatognathic system. This straightening could not be observed in the
form of a significant decrease in either the craniovertical (NSU VER) or the craniocervica1
(NSUOPT) angulation, however, because the spine was straightened almost completely by
a change in its inclination (CVT/HOR). The fact that CMD is often the cause of a variety of
symptoms throughout the head and neck is widely recognized.26• 27 Knowledge of the
functional anatomy and pathokinesiology of the head and neck regions is a necessary
requirement for the understanding of these effects. 16• 17 The present results support the
hypothesis of an association between craniomandibular disorders, head JULY 1992, VOL 1
0, NO. 3 HEAD POSTURE AND CMD posture and craniofacial morphology, and should
consequently raise questions about both the etiology and the treatment of CMD. Would it
be more relevant, for instance, to cure these problems by concentrating the treatment on
craniovertebral joint function rather than on the dental occlusion? Not only the
observations with regard to head posture, but especially those concerned with the
anatomical deviations in the upper part of the cervicovertebral region and its adjoining
cranial structures render this question one of major importance. References I. Lund P,
Nishiyama T, Moller E: Postural activity in the muscles of mastication with the subjects
upright, inclined, and supine. Scand J Dent Res 1970; 78:419-424 2. Forsberg CM, Hellsing
E, Linder-Aronson S, Sheikholeslam A: EMG activity in neck and masticatory muscles in
relation to extension and flexion of the head. Eur J Onhod 1985; 7:177-184 3. Boyd CH,
Slagle WF. Macboyd C, et a!.: The effect of head position on electromyographic evaluations
of representative mandibular positioning muscle groups. J Craniomnndib Pract 1987; 5:51-
53 4. Daly P, Preston CB, Evans WG: Postural response of the head to bite opening in adult
males. Am J Onhod 1982; 82:157-160 5. Urbanowicz M: Alteration of vertical dimension
and its effect on head and neck posture. J Craniomandib Pract 1991; 174-179 6. Solow B,
Tallgren A: Head posture and craniofacial morphology. Am J Phys Anthropol 1976: 44:417-
436 7. Solow B, Siersbaek-Nielsen S, Greve E: Airway adequacy. head posture, and
craniofacial morphology. Am J Onhod 1984; 86:214-223 8. Kyliimarkula S, Huggare J: Head
posture and the morphology of the first cervical vertebra. Eur J Onhod 1985; 7:151-156 9.
Showfety KJ. Vig PS. Matteson SR: A simple method for taking natural head position
cephalograms. Am J Onhod 1983; 83:495-500 10. Huggare J: The "fluid-level method" for
recording natural head posture. Proc Finn Dent Soc 1985; 81: 199-203 II. Carlsson GE.
Helkimo M: Funktionell undersokning av tuggapparaten. In Holst JJ (ed). Nordisk Klinisk
Odontologi, Vol. 8-11. Copenhagen: Forlaget for Faglineratur. 1972; 1-21 12. Helkimo M:
Studies on function and dysfunction of the masticatory system. II Index for anamnestic and
clinical dysfunction and occlusal state. Swed Dent J 1974; 67:101-121 13. Mejersjo C,
Carlsson GE: Long-term results of treatment for temporomandibular joint pain-
dysfunction. J Prosthet Dent 1983; 49:809-815 14. Raustia AM, Pohjola RT, Virtanen KK:
Acupuncture compared with stomatognathic treatment for TMJ dysfunction. Part II.
Components of the dysfunction index. J Prosthet Dent 1986; 55:372-376 15. Kopp S: Pain
and functional disturbances of the masticatory system: A review of etiology and principle
of treatment. Swed Dent J 1982; 6:49-60 16. McNeill C: Craniomandibular (TMJ) disorders-
The state of the art. Part II. Accepted diagnostic and treatment modalities. J Prosthet Dent
1983; 49:393-397 17. Friedman MH, Weisberg J: Application of orthopedic principles in
evaluation of the temporomandibular joint. Phys Ther 1982; 62:597-603 18. Mohlin B.
Ingervall B, Thilander B: Relation between malocclusion and mandibular dysfunction in
Swedish men. Eur J On hod 1980; 2:229-238 19. Mohlin B: Need for orthodontic treatment
with special reference to mandibular dysfunction [Thesis]. Goteborg, 1982 20. Lieberman
MA. Gazit E, Fuchs C, Lilos P: Mandibular dysfunction in I 0--18 year old school children as
related to morphological malocclusion. J Oral Rehabil 1985; 12:209-214 21. Ricketts RM:
Clinical implications of the temporomandibular joint. Am J Onhod 1966; 52:416-439 22.
Jamsa T, Kirveskari P. Alanen P: Malocclusion and its association with clinical signs of
craniomandibular disorder in 5-, I 0- and 15-year old children in Finland. Proc Finn Dent
Soc 1988; 4:235-240 23. Huggare J: Association between morphology of the first cervical
vertebra, head posture and craniofacial structures. Eur J Onhod 1991; 13:435-440 24.
Schwarz AM: Positions of the head and malrelations of the jaws. lnt J Onhod 1928; 14:56-
68 25. Makofsky HW: The effect of head posture on muscle contact position: The sliding
cranium theory. J Craniomandib Pract 1989; 7:286--292 26. Danzig WN. vanDyke AR:
Physical therapy as an adjunct to temporomandibular joint therapy. J Prosthet Dent 1983;
48:96--99 27. Rieder CE, Martinoff SA. Wilcox SA: The prevalence of mandibular
dysfunction Part I. Sex and age distribution of related signs and symptoms. J Prosthet Dent
1983; 50:81-88 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE HUGGARE AND RAUSTIA
HEAD POSTURE AND CMD Discussion HEAD POSTURE AND CERVICOVERTEBRAL AND
CRANIOFACIAL MORPHOLOGY IN PATIENTS WITH CRANIOMANDIBULAR DYSFUNCTION
Howard W. Makofsky, P.T. The relationship between head posture and the stomatognathic
system is of immense importance in the fields of dentistry and physical therapy. Many
authors andresearchers have discussed these interrelationships, but those who have
actually performed the research upon which the rest of us base clinical decisions are few
in number. As a physical therapist I am grateful for the work of Steven L. Kraus, P.T., and
Mariano Rocabado, P.T., whose research, publications, and lectures have inspired many of
us who are especially attracted to this aspect of clinical practice. The authors of this paper,
Drs. Huggare and Raustia, are to be commended for their insight and scholarly approach to
their subject area. Using a pre-test/post-test control group design, they have adeptly
studied the effect of dysfunction of the masticatory system on head posture and
craniofacial morphology. A statistical comparison was made between the experimental
group, i.e., 16 subjects with craniomandibular disorders (CMD) and the control (16
matched subjects without CMD). Natural head position roentgen-cephalograms were
taken on all subjects in the study and precise measurements of all relevant craniofacial and
craniovertebral landmarks, angles, etc., were carefully made and described. It was found
that the experimental group demonstrated significantly increased craniovertical (NSUVER;
FORNER) and craniocervical angulations (FOR/OPT); significantly smaller dorsal arch height
of the atlas (D 1 ); obtuse cranial base angulations (Sph/Cliv;Sph/For) and smaller posterior
to anterior face heights (P/ A) versus the control. The experimental group also
demonstrated a slightly greater cervical spine lordosis (OPT/CVT) compared with the non-
CMD control group, which was not statistically significant. A second statistical test was
performed within the experimental group (subjects with signs and symptoms of CMD) to
determine whether treatment of the dysfunctional stomatognathic system had an effect
on cervical spine alignment. The outcome, though not statistically significant, was that
treatment, i.e., counseling, occlusal adjustment, muscular exercises for the lower jaw, and
splint therapy, caused a slight straightening of the cervical lordosis. 178 THE JOURNAL OF
CRANIOMANDIBULAR PRACTICE In their discussion the authors disclose that no significant
differences were noted between the experimental or dysfunction group and the healthy
controls relative to such dental morphological characteristics as incisor inclination, overjet
and overbite. Consequently, they intimate that the management of CMD should
concentrate more on treatment of the craniovertebral region and less on the dental
occlusion. These authors have not only done a masterful job of presenting their data, but
have also raised some very important issues relative to CMD diagnosis and treatment. The
upper cervical spine differences between the dysfunctional and healthy group, i.e., the
smaller dorsal arch height of atlas in the CMD group, suggest that skeletal changes occur
during growth and development relative to postural and soft tissue influences. These
structural changes were measured not only in the upper cervical spine, but also in the
craniofacial region. This leads to the importance of intercepting these cases in childhood
where the initial signs of an impending musculoskeletal dysfunction may be related to
mouth breathing, swallowing dysfunction, poor posture, etc. I appreciated the authors'
reference to the sliding cranium theory in their discussion. Too often the inframandibular
muscles are credited for mediating the effect of head-neck dorsiflexion on mandibular
position when there is insufficient experimental evidence in the literature to support this
concept. Based on the initial findings of current research into the mechanism by which
head position influences occlusion and upper to lower jaw relations, it appears that during
head-neck dorsiflexion the inframandibular muscles provide a force of stabilization on the
mandible as the sliding cranium causes a forward shift in the maxilla and the upper dental
arch relative to a fixed lower jaw. The authors propose that this backward bent head
position, which is an essential component of forward head posture (FHP), may in tum
impose a strain on the lateral pterygoid muscles as they pull the mandible forward to
obtain occlusal support. This may explain some of the CMD symptomatology that is
observed so often with FHP. In addition to reminding us of the important influences of
head-neck posture on the stomatognathic system, Drs. JULY 1992, VOL. 1 0, NO. 3
HUGGARE AND RAUSTIA Huggare and Raustia call our attention to the reciprocal influence
of the stomatognathic structures on head-neck posture. They found that six months
following treatment the CMD group demonstrated a significant straightening of the
cervical lordosis (OPT/CVT). However, they noted that this change was not associated with
a significant decrease in either the craniovertical (NSLNER) or craniocervical (NSUOPT)
angulations. Other researchers 1 - 4 have studied the effect of bite opening on head-neck
posture. Daly et al. 1 and Solow and Tallgren2 • 3 found significant changes in head
position in response to bite opening, whereas Root et al.4 found a tendency toward raising
of the head with bite opening using an intraoral splint, but not significantly. Daly et al.
suggest that bite opening may restrict the pharyngeal airway by causing the hyoid bone to
drop back. To restore airway dimensions they suggest that the head will consequently
assume a more extended posture. Other researchers5·6 attribute the influence of the
stomatognathic system on head-neck position to the trigeminoneck reflex (TNR) whereby
the neurons conveying proprioceptive input from the periodontal ligament system evoke
neuromuscular responses in the cervical musculature via the spinal nucleus of .the
trigeminal nerve. Urbanowicz7 recently suggested that dentists strongly consider the
effect of changing vertical dimension of occlusion (VDO) on the JULY 1992, VOL. 10, NO.3
HEAD POSTURE AND CMD cervical spine. He points out that a healthy cervical spine may
adjust without difficulty to this reflexive change, but problems arise when the cervical
musculoskeletal system cannot take the added stress placed on it by increasing VDO. The
research presented by the authors of this important paper raise interesting questions
about the way CMD patients are managed. It is another reminder to us that the
interrelationships between the cervical spine, temporomandibular joints and craniofacial
structures must be recognized and respected. I look forward with excitement to further
research into these mechanisms. References I. Daly P. Preston CB, Evans WG: Postural
response of the head to bite opening in adult males. Am J Onhod 1982; 82:157-160 2.
Solow B, Tallgren A: Head posture and craniofacial morphology. Am J Phys Anthropol 1976;
44:417 3. Solow B, Tallgren A: Natural head position in standing subjects. Acta Odontal
Scand 1971; 29:591...«)7 4. Root GR, Kraus SL, Razook SJ, Samson GS: Effect of an intraoral
splint on head and neck posture. J Prosthet Dent 1987; 58:9(}...95 5. Abrahams VC,
Richmond FJR: Motor role of the spinal projections of the trigeminal system. In Anderson,
Matthews (eds), Pain in the Trigeminal Region. Elsevier/North Holland: Biomedical Press,
1977 6. Sumino R, Nozaki S: Trigeminoneck reflex: Its peripheral and central organization.
In Anderson, Matthews (eds), Pain in the Trigeminal Region. Elsevier/North Holland:
Biomedical Press, 1977 7. Urbanowicz M: Alteration of vertical dimension and its effect on
head and neck posture. J Craniomandib Pract 1991; 9:174-179