European Journal of Orthodontics 17 ( 1995) 111-120 © 1995 European Orthodontic Society

Natural head position and natural head orientation: basic

considerations in cephalometric analysis and research
A. Lundstrom", F. Lundstrom**, L. M. L. Lebret***, and C. F. A. Moorrees***
Departments of Orthodontics, *Karolinska Institutet, Faculty of Dentistry, Huddinge, **Public Dental
Health Service, l.inkopinq, Sweden, and ***Harvard School of Dental Medicine, Boston, MA, USA

SUMMARY Natural head position (NHP) provides the key for meaningful cephalometric

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analysis because an extracranial reference line is used instead of intracranial reference lines,
known to be subject to considerable biological variation in their inclination.
Although the principle of natural head position is being recognized in the orthodontic
literature, its registration may contain an element of unavoidable error that requires correc-
tion. A new concept of natural head orientation (NHO) has been introduced to maximize
the contribution of NHP to cephalometrics. It is defined as the head orientation of the subject
perceived by the clinician, based on general experience, as the natural head position in a
standing, relaxed body and head posture, when the subject is looking at a distant point at
eye level.
The present study was designed to determine the accuracy and validity of NHO, using
lateral profile photographs cut in a circular shape, obtained from 27 orthodontic patients,
10-14 years old. Findings among four investigators showed a high correlation (r= 0.82-0.96),
in orientating these profile photographs in estimated natural head position (NHP). Moreover,
investigators showed good correlation (r= 0.57-0.84) in head orientation after a 3-week
interval. Mean differences for the same period varied between 0.1 and 2.9 degrees. The
validity of NHO was supported also by a panel investigation.
Clinicians as well as auxiliary personnel can be trained to make a critical judgement of
the recorded natural head position and correct head orientation, whenever indicated, to
enhance the reliability of cephalometric analysis in clinical practice and research.

Introduction 3. Through estimation (Bass, 1991; Lundstrom

The concept of natural head position (NHP)
was introduced in orthodontics in the 1950s by
Downs (1956), Bjerin (1957), and Moorrees
and Kean (1958). An increasing interest in this
concept has occurred from the 1970s to-date,
when NHP orientation has been used in more
than 40 publications during the last 8 years.
Registration of NHP has been carried out
mainly in four different ways:
1. By lateral head radiographs with subjects
sitting (Moorrees and Kean, 1958), or
standing (Solow and Tallgren, 1971; Cooke,
1986; Cooke and Wei, 1988a).
2. Photographically with subjects standing or
sitting in NHP, (Bjerin, 1957; Lundstrom,
1982b; McWilliam and Rausen, 1982;
Lundstrom and Lundstrom, 1992).
et al., 1991).
4. Through a combination of radiographic
registration and estimation to correct gross
errors (Moorrees and Kean, 1958).
Lundstrom and Lundstrom (1989,1992) recom-
mended the photographic method to keep sub-
jects undisturbed by ear-rods of a cephalostat
and to allow repeated registrations without any
added roentgen dosage to the patient.
Many investigators have used mirror orienta-
tion as a means to attain NHP, with subjects
looking into their own eyes during the registra-
tion (Bjerin, 1957; Moorrees and Kean, 1958).
NHP is not a fixed position, demonstrated
longitudinally by Loreille (1975) and by others
through triple (Bjerin, 1957) or duplicate regis-
trations (Moorrees and Kean, 1958; Lundstrom
1982b; McWilliam and Rausen, 1982; Cooke
112
and Wei, 1988a; Siersbaek-Nie1sen and Solow,
1982).
Random variation of NHP registrations
has been calculated to within a range of
1.5-2 degrees (Bjerin, 1957; Moorrees and
Kean, 1958; Lundstrom, 1982b; Luyk et al.,
1986; Cooke, 1988; Cooke and Wei, 1988a;
Lundstrom and Lundstrom, 1992) owing to
difficulties for subjects to reproduce a mean
natural head position (MNHP, Lundstrom,
1982a).
Many investigators have studied the variabil-
ity of reference lines used in cephalometric
analysis (Downs, 1956; Bjerin, 1957; Moorrees
and Kean, 1958; Foster et al., 1981; Lundstrom,
1981; Cooke, 1986; Cooke and Wei, 1988b;
Lundstrom and Lundstrom, 1989, 1992).
Results obtained confirm each other and dem-
onstrate large variability in the indination of
intracranial reference lines related to the extra-
cranial horizontal (HOR). The small differences
in registering natural head position is actually
a limited problem in comparison with the vari-
ation of intracranial reference lines.
The increasing interest in NHP motivates
further study to elucidate how registration and
estimation thereof can enhance the utilization
of this concept.
Aims
1. To study the reproducibility of photographic
NHP-registration and NHP-estimation.
2. To compare means and standard deviations
for measurements of the soft tissue nasion-
pogonion 1inejhorizontal plane angle
(N'-Pg'jHOR) for registered and estimated
NHP determinations.
3. To correlate assessor differences between
registered and estimated NHP deter-
minations.
4. To compare the validity of registration and
estimation of NHP.
5. To calculate confidence intervals for the
angle sella-nasion to the horizontal plane
(S-NjHOR).
Sample
Subjects selected for the investigation were 27
consecutive patients (14 boys and 13 girls),
A. LUNDSTROM ET AL.
10-14 years, from the orthodontic public dental
health dinic in Linkoping,
Methods
Duplicate photographic NHP registrations,
available as routine material in the orthodontic
dinic, were used. The X-ray assistant per-
forming the registrations was experienced in
instructing patients how to stand relaxed in
front of a vertical mirror on the wall, 1 m ahead
of them. Patients looked into their eyes during
the registration. A fixed plumbline chain
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was photographed together with the patient.
Enlarged copies were produced for all subjects
(18 x 24 em).
Two of the photographs (accepted by
A. Lundstrom and C. F. A. Moorrees as reliable
examples of NHP) were kept for instructive
purposes for the assessors before commencing
NHP estimations (Fig. 1). The remaining 25
photographs were cut in a circular form (CF: 1
to CF:25). The angle (Fig. 2) between the soft
tissue nasion-pogonion line and the plumbline
was calculated after digitizing landmarks,
and one upper and one lower point on the
plumbline.
A white rectangular paper (210 x 297 mm)
was placed on a dark background, its right side
representing the vertical plane. CF: 1 (and so on
to CF:25) was placed on the paper and turned
by each assessor into a position perceived to
correspond with NHP. A ruler was placed on
CF: 1, through the nasion (N') and pogonion
(Pg') landmarks. The elongation of this line
was drawn with a sharp pencil on the rectangu-
lar paper below and above CF: 1. A second
estimation was performed on a new paper after
a 3-week interval.
The angles (VI and V2, Fig. 2) between the
elongated N'-Pg' line and the right side of the
rectangular paper were measured. These angles
thus represented the estimated profile orienta-
tion in NHP on two separate occasions.
All computer measurements as well as statisti-
cal calculations were made by the senior
investigator.
Four assessors participated in this study, all
of whom were experienced in NHP evaluation.
A test was also performed using two under-
graduate dental students, correlating their
assessments with one experienced investigator
(assessor 1).
NATURAL HEAD POSITION AND ORIENTATION 113

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Figure 1 Two patients registered and accepted as good examples of natural head position.

In order to compare the validity of the two
methods, records differing more than 4 degrees
between methods were assessed by a panel
of orthodontists and orthodontic students.
Observers were asked to evaluate random,
coded pairs of photographs to define the head
orientation they perceived as most natural. This
part of the study was performed by 10 ortho-
dontists and 4 orthodontic students.
The angle S-N/HOR was calculated from the
angles N'-Pg'/VERT and the angle S-N/N'-Pg',
as shown in Fig. 3.
Statistical analysis
Means and standard deviations were determined
for VI (= Vreg) and V2 (= Vest). The standard
error of single determinations (s.) were calcu-
lated (based on differences in V-angles between
first and second determinations), according to
the formula:
estimations between s,= 1.0 degrees and s, =
2.7 degrees for different investigators (1, 2, 3,
and 4=AL, FL, LL, and eM, respectively).
The comparatively high value of 2.7 degrees for
assessor 2 was due to a mean difference of
2.9 degrees (P<O.Ol) between first and second
assessments (Table lA).
The correlation between duplicate photo-
graphic (r = 0.9) and estimated registrations
(r=0.6-0.8) indicates relatively high stability
in determining head orientation with both
methods (Table lA).
Table lA Correlation coefficients (r) showing degree
of covariation between Ist and 2nd measurements of
the angle N'-Pg'/VERT and the standard error of
single measurements (s;) of the same angle for photo-
graphic registrations and assessors (in degrees).
N=25. Si= ±..}'Ld2/2N.
Assessors

s.>
I
+
-
/U-
VlN Photoreg. 2 3 4

0.90 0.77 0.81 0.57 0.84

where 'LJl is the sum of squared differences and s, 1.6 1.0 2.7 2.2 0.6
N the number of duplicate determinations.
Differences between registered and estimated
head orientations (Vreg - Vest) were correlated Table IB Correlation coefficients (r) showing inter-
correlation between assessors for the V-angle (I st
between assessor 1, and assessors 2, 3, and 4, estimation). Mean correlations for each assessor.
respectively, through calculation of correlation
coefficients (Bravais-Pearson). Assessor pair

1/2 1/3 1/4 2/3 2/4 3/4

Results
r 0.64 0.40 0.73 0.55 0.54 0.62
Photographic registration showed a method Mean corr. 1=0.59 2=0.58 3=0.52 4=0.63
error (sJ of 1.6 degrees, while s, varied for
114 A. LUNDSTROM ET AL.

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Figure 2 Three instances showing marked differences in head positioning for registered (left) and estimated (right) natural
head position (diff. 9, 8, and 6 degrees, respectively). Measurement of the N'-Pg'jVERT angle.

In order to compare assessors, inter-
correlation coefficients were calculated between
assessors (lst estimations). Mean correlation
coefficients varied between 0.52 and 0.63, indic-
ating conformity of the assessors for their first
series of NHP estimations (Table 1B). Mean
differences between registered and estimated
V-angle measurements (1st determinations)
were for assessors 1 and 2 small (1.1 and
1.2 degrees, Table 2) and not statistically signi-
NATURAL HEAD POSITION AND ORIENTATION 115

(r=0.82-0.96, P<O.OOI), the strongest (r=

0.96) between assessors 1 and 4 (Table 3,
Fig. 4). The panel investigation showed that the
estimated head position by the majority of
observers (83 per cent) was perceived to be the
HOR 'most natural' (Table 4).
In six of the seven patients (photograph 2
missing for one subject) with large differences
in head orientation (>4 degrees) between regis-
tration and estimation of NHP, duplicate
photographs showed similar head positions in
both registrations in five instances (Table 5).
Five individuals with differences exceeding

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5 degrees were, as compared to estimations,
perceived to have an unnatural, flexed photo-
graphic position of the head (Fig. 2). The cor-
responding mean differences (Table 2) agreed
with this finding.
Calculation of the angle S-N/HOR was lim-
ited to observers 1 and 4, who showed a remark-
able covariation in their perception of NHP.
The correlation coefficient for S-N/HORest
VERT between them was as high as r=0.93 with a
Figure 3 Calculation of the S-NjHOR angle from the
non-significant mean difference of only 1 degree.
N'-Pg'jVERT angle (V) and the S-NjN'-Pg' angles (V3). The 95 per cent confidence interval range was
23.8 degrees for photographic registrations,
versus 13.6 degrees by estimations for assessor
Table 2 Means and standard deviations of the
N'-Pg'jHOR angle (in degrees) for duplicate regis-
1 and 13.0 degrees for assessor 4 (Table 6).
tered and estimated NHP determinations. N = 25. Maximum and minimum differences in the
sample are shown in Fig. 5. The standard devi-
Mean (1) Mean (2) SD (1) SD (2) ation of S-N/HOR(NHO) = 5.3 degrees was
larger (P<O.OOI), than for S-N/HOR(NHO)
Reg. 4.3±0.8 3.4±0.9 4.1 4.5 (3.3 and 3.1 degrees).
Assessors
1 3.2±0.4 2.8 ±0.5 1.9 2.3
2 3.I±0.7 6.0±0.7 3.4 3.6 Discussion
3 1.9±0.7 0.7 ±0.4 3.5 2.0
4 1.9±0.3 1.8±0.2 0.7 1.2 Mean correspondence between assessors is, on
the whole, very good. The slight extension for
assessors 3 and 4 compared to assessors 1 and
ficant. For assessors 3 and 4 these differences 2 (2-3 degrees) may depend on a slightly differ-
were slightly larger (2.4 and 2.4 degrees, ent perception of natural head position between
P<0.05 and P<O.OI). All differences were pos- centres. The fact that assessors 3 and 4 were
itive, indicating a tendency for assessors 3 and used to sitting patients in their NHP evaluations
4 to define NHPest somewhat extended in rela-
tion to NHP r eg (Table 2). Table 3 Correlation coefficients (r) showing covari-
For all assessors the standard deviation for ation between assessor I and the other assessors for
estimated NHP (0.7-3.5 degrees) was smaller differences between registered (V reg ) and estimated
than for registered NHP (4.1 degrees), statistic- (Vest) values of the N'-Pg'jVERT angle (1st obs).
ally significant for assessors 1 and 4 (P<O.OOI;
Table 2). Assessors
Direction and amount of extension/flexion
Assessor 1 to: 2 3 4
between registered and estimated head positions r 0.82 0.84 0.96
showed a strong correlation for all assessors
116 A. LUNDSTROM ET AL.

Degrees
14

r= 0.96

10

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Mean =2.9 degrees
2 so = 4.7 degrees
Cl
Q)
>k.

-2

--6

--6 -3 o 12 degrees
Mean =1.6 degrees
SO =4.6 degrees
Vreg - Vest (assessor 1)

Figure 4 Scattergram showing covariation for differences between photographic registered and estimated natural head
position between assessors I and 4.

Table 4 Numbers and percentages of answers from 14 panel members, asked to state their preference among
random pairs of photographs of photoregistered (NHP reg ) and estimated (NHPest ) natural head positions, in
order to choose the 'most natural' one, in seven subjects differing more than 4 degrees between methods.

Subject preference 15 17 28 37 39 13 49 Total

NHPreg 5 1 4 1 1 o 5 17
NHP est 9 13 10 13 13 14 9 81
NHPest in % of total no. 64 93 71 93 93 100 64 83

may perhaps have had some influence.
According to Bjerin (1957), who compared
photographic registrations for standing and sit-
ting subjects, the difference in NHP was on the
same level (diff. = 1.9 degrees).
The strong correlation (Table 3, r =
0.82-0.96) between assessors for their devi-
ations from NHP in estimating natural head
orientation (NHO) shows that photographic
registrations must be checked to eliminate obvi-
NATURAL HEAD POSITION AND ORIENTATION 117

Table 5 First and second of photoregistered ous errors in head orientation, resulting in clin-
N-PgjVERT angles in six patients with large differ- ically misleading information.
ences (> 4 degrees) between photoregistered (V reg) The panel investigation (Table 4) confirms
and estimated (Vest)NHP-related angles (in degrees). this conclusion. An experienced clinician should
A negative angle indicates that the estimated head be able to adjust the head orientation of the
position is flexed in relation to the registered head
position. photograph to what is perceived to be the
natural head orientation (NHO) (Fig.2) in
Patient instances for which· registration has resulted
in an 'unnatural' head position. The definition
38 17 39 15 13 49 of NHO is, in general, synonymous with NHP.
If the registered head position shows 'unnatural'
Difference 8.3 6.0 5.9 5.3 -4.1 -4.1 flexion or extension of the head, an adjustment
v., 1 11.3 15.1 9.5 11.0 -5.4 -1.9
should be undertaken by a person trained for
v., 2 11.7 15.6 3.3 11.5 -3.8 -0.2

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this task.
A difference between NHP and NHO is not
necessarily the result of gross errors in the

Table 6 Means, standard deviations, and confidence intervals (95 per cent)
for the angle S-NjHOR (in degrees). The horizontal plane was related to the
head for photographic registration (NHP) and for estimation (NHO) of nat-
ural head position.

Mean±SE SD Range CI

HOR (NHP) 4.8 ± 1.1 5.3 -1.2... 15.6 -6.7... 17.1

HOR (NHO) (ass 1) 6.6±0.7 3.3 -0.7... 12.5 -0.2... 13.4
HOR (NHO) (ass 4) 7.9±0.6 3.1 0.2... 12.7 1.4... 14.4

Figure 5 Minimum (1.7 degrees) and maximum (11.2 degrees) inclination of the S-N line related to the mean horizontal
(HOR) estimated by assessors 1 and 2 (first registration).
118
registration of NHP. The strong correlation
between the two photographic registrations of
the V-angle (r=0.9) shows that the difference
between NHP and NHO essentially results from
habitual deviations of NHP from NHO.
Individuals, who habitually keep their heads
flexed or extended in a way perceived as unnat-
ural (Fig. 2), should not be cephalometrically
analysed from the horizontal related to their
registered head position. The NHO related hori-
zontal is then the preferred reference line.
This procedure may be questioned because
of its subjective character, but for the time
being, no better alternative seems to be
available.
The systematic difference of 2.9 degrees for
one assessor after a 3-week interval indicates
that individual deviations from mean standards
must be judged with caution. A 3-degree differ-
ence is, however, small and should be of little
significance. This problem should be less liable
to give clinically misleading information if
the extracranial S-HOR line is chosen instead
of a more variable intracranial reference line.
According to Lundstrom and Lundstrom
(1992), the S-NjHOR showed a standard devi-
ation of 5.3 degrees which can be compared to
1.6 degrees head position instability in photo-
graphic registration ofNHP in the present study
(Table 1).
Differences must be expected between indi-
viduals in their ability to estimate NHP. Two
undergraduate dental students were tested in
this respect on the present material. One student
correlated relatively well with assessor 1 (r =
0.67, P < 0.001), while for the other a weaker
correlation was found (r=0.44, P<0.05). To
what extent training can compensate for initial
difficulty in this respect, remains an interesting
question.
The panel study confirms the difference
between individuals in estimating NHP. Ten of
14 panel members were very close in their
evaluations (complete concordance for four of
them and difference in only one case for six),
while the other four differed in two instances
(one member) or three cases from the majority.
It seems probable that the first ten have a better
grasp for natural head orientation than the
last four.
The finding (Table 6) that variation in the
S-NjHOR angle is larger for photographic
registrations than for estimations of NHP
A. LUNDSTROM ET AL.
should not be overlooked (SD = 5.3 degrees,
versus 3.1-3.3 degrees, P<O.OOI). This differ-
ence in variability is interesting and the follow-
ing three explanations may be considered:
1. The error component of the photographic
registrations is larger than that for
estimations.
2. Registrations and estimations do not express
the same concept.
3. Assessments are biased through a tendency
for assessors to evaluate the inclination of
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the N'-Pg' line closer to the mean value than
appropriate.
The strong correlation (r=0.90) between
duplicate photographic registrations, confirmed
by V-angles given in Table 5, do not favour
hypothesis no. 1. The difference in standard
error for assessor 1 and 4 between registrations
and estimations (1.6 degrees, versus 1.0 and
0.6 degrees, P<0.05 and <0.001), may be
interpreted as a confirmation of this hypothesis,
as at least part of the explanation. Moorrees
and Kean (1958) recommend that a small
mirror (10 em diameter), vertically adjustable
to the pupillary level, should be used at NHP
registrations rather than a long mirror, the
purpose being to ensure that the visual axis of
the subject is in the horizontal plane. Since this
method was not used in the present study it is
not possible to know whether the error compon-
ent might have been reduced, had that method
been followed.
The validity comparison (Tables 4 and 5)
of large differences between registered and
estimated NHP determinations, showed that
estimated NHP gives a 'more natural' head
orientation than the registered orientation,
indicating that the second hypothesis should
give part of the explanation. The result of the
panel investigation confirms the corresponding
study on Bjerin's sample by Lundstrom et al.
(1991).
To what extent the third hypothesis may be
valid is difficult to assess, but is not confirmed
by the panel examination of extremes, for which
estimations indicated a 'more normal' head
orientation than for registrations. The variation
of the S-N line to the horizontal is considerable
when NHP is used (SD = 5.3 degrees, Table 6)
and although less if NHO is employed, it is still
substantial:
NATURAL HEAD POSITION AND ORIENTATION
SD (assessor 1) 3.3 degrees, 95 per cent CI
range = 13.6 degrees
SD (assessor 4) 3.1 degrees, 95 per cent CI =
13.0 degrees
These findings confirm the marked variability
of the S-N line and the risk of misleading
information when it is used for clinical cephalo-
metric analysis.
Based on the findings presented a distinction
is made between the following concepts:
1. Natural head position (NHP) , defined as the
registered, mirror orientated head position
in a relaxed body and head posture.
2. Natural head orientation (NHO) , defined as
the head position estimated by a trained
clinician as the natural one.
NHO determinations will correct gross errors
in registrations, as well as habitual tendencies
for some individuals to keep the head in what
is perceived as a flexed or extended posture.
NHO should be of interest mainly in combina-
tion with cephalometric analysis of patients with
malocclusion, especially for cases requiring
orthognathic surgery (Lundstrom et al., 1993).
Norm values based on NHP have been pub-
lished adapted to mesh analysis (Moorrees and
Lebret, 1962; Moorrees et al., 1976; Moorrees,
1985), by Cooke and Wei (1981b, 5-point
cephalometric analysis), Lundstrom and
Lundstrom (1989; maxillary and mandibular
prognathism), Lundstrom et al., (1992, soft
tissue profile), and Viazis ( 1991), cephalometric
analysis). Viazis mean values for the angles
N-A/HOR and N-B/HOR differ considerably
(5.3 and 4.5 degrees) from those published by
Lundstrom and Lundstrom (1989). Since
Viazis' (1991) values are not based on individu-
ally determined NHP-orientated material, but
were derived from the Bolton standards on the
assumption that in all illustrations the heads
were orientated in NHP, Viazis' norm values
must be confirmed by further analysis.
Norm values are needed for standard cepalo-
metric variables based on the NHO concept as
defined above.
Research
In connection with research projects, aiming at
studying changes of natural head orientation
over time, uncorrected NHP must for obvious
reasons be used, for instance after orthognathic
119
surgery (Fromm and Lundberg, 1970), treat-
ment to relieve blocked nasal passages to attain
free nasal breathing (Linder-Aronson, 1979;
Solow and Greve, 1979) or with age (Tallgren
and Solow, 1987). Reference can also be made
to analysis of basic differences in facial config-
uration between various malocclusion types
(Cole, 1988; Lundstrom and Cole, 1990). NHP
registrations are also indicated in certain ethnic
comparisons between population groups (Yen,
1973; Lundstrom and Cooke, 1991).
In growth studies based on NHP, superim-
position of radiographs on the initial, or best,
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record in a series may be used (Moorrees
et al., 1985).
Conclusions
1. Because of the large variation of intracranial
lines, the extracranial reference line S-HOR
should substitute, or at least supplement,
the use of intracranial reference lines for
cephalometric analysis of patients with
malocclusion.
2. Photographic registration of natural head
position is recommended. This registration
should be complemented with an adjustment
when head orientation is perceived to be
'unnatural'.
3. Estimation of natural head orientation
(NHO), performed by experienced clinicans,
gives a valuable addition to the natural head
position (NHP) concept.
4. Clinicians as well as auxiliary personnel can
be trained to make critical judgement of the
recorded head orientation, whenever indi-
cated, to enhance the reliability of cephalo-
metric analysis in clinical practice and
research.
Address for correspondence
Dr Fredrik Lundstrom
Department of Orthodontics
S-58185 Linkoping
Sweden
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