GUEST

EDITORIAL

Natural head position-a revival

Coenraad F. A. Moorrees

Boston, Mass.

N a t u r a l head position is a standardized and reproducible position, of the head in an upright posture, the eyes focused on a point in the distance at eye level, which implies that the visual axis is horizontal. In cephalometrics, it is readily registered by instructing the subject standing or sitting in the cephalostat to look at a point on the wall in front, exactly at eye level. A small mirror (diameter no more than 10 cm), the midpoint of which also at eye level, can be used also for head orientation. Mirror orientation has the additional advantage that the patient is able to self-align the midline of the head with the vertical ruler attached in the middle of the cephalostat. Earrods then become superfluous, which is advantageous because the left and right ear openings are generally positioned asymmetrically both vertically and sagittally. As a result, insertion of earrods turns or tilts the head and produces poor quality radiographs. Artists, anatomists, and anthropologists have used natural head position to study man's face throughout the ages. Moreover, NHP has been used routinely for clinical examination in medicine and dentistry by plastic and maxillofacial surgeons, as well as by orthodontists. As early as the 1860s, craniologists realized that skulls had to be oriented in a manner approximating the natural head position of the living for craniometric studies. To determine natural head position, a horizontal or vertical reference line outside the cranium was used, but preference was given generally to the horizontal. Efforts were made to determine the landmarks through which a horizontal plane traverses the living head in its "natural position." The next task was to apply this concept to craniology, and determine which anatomic plane within the skull corresponded closest to the "horizontal". After considerable deliberation at four anthropologic congresses, an agreement was reached fi-

Lecture note for the Craniofacial Biology and Computer Imaging Course, Oral Biology 609, The Harvard School of Dental Medicine

nally at the craniometric conference in Frankfurt am Main in 1884 to accept the plane through left and right porion and left orbitale, proposed at the meeting in 1882, as the best compromise for orientation of crania. This Frankfurt horizontal supposedly yields maximal differences in the configuration of the cranium between racial groups and the smallest variability within each group. Nonetheless, orthodontists dealing with living subjects, rather than inert crania, have used this "Frankfurt Horizontal" faithfully in cephalometrics. They have also completely disregarded the warning of Downs, expressed in the third of his classic papers and published in the Angle Orthodontist (1956), where Downs illustrates that discrepancies between cephalometric facial typing and photographic facial typing disappear when a correction is made for those persons in whom the "Frankfurt plane" is not horizontal, but tilted up or down while the patient is looking at a point in the distance at eye level and thus in natural head position. Likewise, cephalometric findings can be misleading, when using the nasion-sella line in the anterior skull base as a reference line, because landmarks for all intracranial reference lines are not stable points in the cranium and are subject to biologic variation in the vertical relationship of their landmarks, namely, sella (S) to nasion (N) and for the Frankfurt horizontal porion to orbitale. Since the cant or inclination of intracanial reference lines is quite variable, they are unsuitable for cephalometric analysis. Registration of the head in its natural position has the advantage that an extracranial vertical or a horizontal perpendicular to the vertical can be used as a reference line. A plumb line or the side of the radiograph can serve as the vertical. For facial photography, a ligature wire plumb line is advised. When SN is markedly inclined downward, facial angels, such as SNA and SN pogonion (Pg), become small and when SN is inclined upward, facial angles are increased. It is therefore inevitable that prognathous persons with a low cranial base will be grouped in the orthognathous category and orthog-

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American Journal of Orthodontics and Dentofacial Orthopedics Volume 105, No. 5

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nathous persons with a high cranial base in the prognathous category. The anterior skull base, represented as S-N, is presumably stable in growing persons, which is not the case, since nasion is a landmark on an actively growing suture, and it moves forward, upward, or downward in growing children throughout the teenage period. Only the anterior aspect of sella is stable, but not its geometric center since the pituitary gland enlarges during growth. The S-N line may therefore rotate slightly over time and, as a result, a considerable back or forward swing of the chin occurs because it is the farthest away from the S-N line and thereby the actual changes during treatment are misrepresented. Little attention is paid to proper orientation of faces in orthodontic journals. As if by design, patients with Class II malocclusion are portrayed with the head turned down before treatment, and with the head up after treatment, to reinforce the accomplishment of therapy, i.e., correction of a retrognathic mandible. Natural head position can also be estimated, and these estimates are remarkably reproducible for experienced observers who have the necessary judgment. A keen eye can then inspect radiographs taken by assistants and, if necessary, correct head posture for quality control. For analysis of treatment results and facial growth, one radiograph out of the serial radiographs of a patient, with good registration of natural head position, should be used to standardize natural head position on all other serial records of that subject, superposing the tracings on the stable skull-base area. The vertical on each tracing then has an identical orientation to the skull base in an individual series. Skull-base superposition is readily accomplished, because its radiographic image reveals

characteristic and stable patterns of opaque lines in the medial and superior aspects of the orbital roofs, the inner layer of the frontal bones, the lesser wings of the sphenoid, markings in the paper-thin superior outline of the ethmoid, the cortex of the planum sphenoidale, the medial aspect of the outline of sella turcica, and the ventral margin of the sphenoidal sinus. The term natural head posture is also encountered in the literature. Whereas, natural head position is a standardized position, natural head posture is a physiologic position of the head, when taking the first step forward from the standing to a moving or walking posture. This so-called "orthoposition" is characteristic for a person and reproducible, but differs among persons and is seemingly different between those with free and those with obstructed nasal breathing. It was developed by Molhave, a Danish orthopedic surgeon, for studying the biodynamics of the human body. For cephalometric analysis, the standardized natural head position is obviously preferable to natural head posture that is subject to individual variation.
Reprint requests to:

Dr. Coenraad F. Moorrees 4 Peacock Farm Rd. Lexington, MA 02173-0317

APPENDIX

Additional sources for reference:

1. Downs WB. The role of cephalometrics in orthodontic case analysis and diagnosis. AM J ORTHOD 1952;38:162-82. 2. Moorrees CFA, Kean MR. Natural head position, a basic consideration in the interpretation of cephalometric radiographs. Am J Phys Anthrop 1958;16:213-34. 3. Moorrees CFA. Natural head position. In: Jacoson A,

Caulfield PW, eds. Introduction to radiographic cephalometry. Philadelphia:Lea & Febiger, 1985:pp. 84-9.