European Journal of Orthodontics 36 (2014) 5566

doi:10.1093/ejo/cjt004
Advance Access publication 23 April 2013

The Author 2013. Published by Oxford University Press on behalf of the European Orthodontic Society.
All rights reserved. For permissions, please email: journals.permissions@oup.com

SystematicReview
Craniocervical posture and craniofacial morphology
Liliane de C.RosasGomes, Karla O.CarpioHorta, Joo RobertoGonalves and
Ary dos Santos-Pinto
Department of Orthodontics, Araraquara School of Dentistry, UNESP Univ Estadual Paulista, Araraquara, So Paulo,
Brazil
Correspondence to: Liliane de C.Rosas Gomes, Department of Orthodontics, Faculdade de Odontologia de
Araraquara, UNESP Univ Estadual Paulista, Rua Humait, 1680, Araraquara, So Paulo, Brazil, CEP 14801-903.
E-mail: lilianerosas@hotmail.com
SUMMARYThe

Introduction
Associations between craniofacial morphology and individual variation in head and cervical posture have been reported
(Solow and Tallgren, 1976; Marcotte, 1981; Solow et al.,
1984; Solow and Siersbaek-Nielsen, 1986, 1992; Hellsing
etal., 1987; Showfety etal., 1987; Ozbek and Koklu, 1993;
Huggare and Cooke, 1994; Solow and Sandham, 2002;
DAttilio et al., 2005), showing that functional principles
of cervical spine are of special interest in orthodontics and
orthopaedics. However, important issues remain unanswered. It is still unclear if the craniofacial development is
influenced by the posture of the head and cervical column.
If so, which sagittal and vertical morphological features
would be directly connected with such different postures?
Soft-tissue stretching hypothesis (Solow and Kreiborg,
1977) linked postural-induced stretching of soft-tissue facial
layer, craniofacial morphology, and airway adequacy into
a cycle of factors related to craniofacial morphogenesis. It
stated that the soft-tissue layer of facial skin and muscles
would be passively stretched when the head is extended in
relation to the cervical column, which would increase the
forces on skeletal structures. Such forces would restrict

forward growth of maxilla and mandible and redirect it

caudally (Solow and Kreiborg, 1977; Solow and Sandham,
2002).
A study on lip pressure changes following extension and
flexion of the head reported such forces in a more accurate
way. Bonded strain gauge transducers on upper and lower
central incisors revealed that mean differences between
pressures obtained during natural head posture and 5, 10,
and 20 degrees of extension showed continuous highly
significant increase, whereas during 5, 10, and 20 degrees
of flexion, upper lip pressure continuously decreased
with highly significant values. However, the results were
achieved under experimental conditions of short duration.
It is still unclear whether the response would be maintained
over time (Hellsing and LEstrange, 1987).
It has been shown an association between head
and cervical posture with functional factors such
as breathing, considering that the maintenance of a
sufficient nasopharyngeal space may require postural
changes (Ricketts, 1968; Solow et al., 1984). Solow
et al. (1984) observed that obstructed nasopharyngeal
airways were connected with extension of the head in

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purpose of this study was to investigate the published evidence regarding the association
between head and cervical posture and craniofacial morphology. An electronic search was conducted in
PubMed, Medline, Embase, Scopus, and Cochrane databases up to 23 March 2012. Abstracts that seemed
to correspond with the goals of this review were selected by a consensus between two independent
reviewers. The original articles were retrieved and evaluated to ensure they match the inclusion criteria.
Only articles that directly compared head and/or cervical posture with craniofacial morphology were
included. Atotal of 84 articles were found of which 12 matched all inclusion criteria. Detailed analysis of
the methodology in selected articles revealed quality scores ranging from weak to moderate. Nine articles were cross-sectional studies, whereas only three were longitudinal studies. The findings of selected
articles were linked together in order to clarify the evidence on sagittal and vertical craniofacial features
as well as growth prediction regarding different postures of the head and neck. On the basis of the data
obtained from the literature, significant associations were found between variables concerning head and
cervical posture and craniofacial morphology. However, the results of this systematic review suggest that
such associations should be carefully interpreted, considering that correlation coefficients found ranged
from low to moderate. Moreover, conflicting results were observed regarding some postural variables.
Further longitudinal studies are required to elucidate the relationship between the development of craniofacial morphology and functional aspects of head and cervical posture.

56
relation to the cervical column. Moreover, such a condition
was linked to a specific craniofacial type characterized by
mandibular retrognathism and high mandibular planeangle.
Proper understanding of postural mechanism contribution on normal or abnormal craniofacial development is of
fundamental importance for diagnosis and treatment planning of morphological and functional disorders of stomatognathic system. Therefore, a comprehensive systematic
review may contribute to the knowledge of the complex
relationship between head/cervical posture and craniofacial
morphology, critically analysing whether available evidence
is sufficient to support the hypothesis that posture influences
growth and development of craniofacial structures.
Materials and methods
The Preferred Reporting Items for Systematic Reviews and
Meta-analysis (PRISMA) statement was used to guide this
study (Moher etal., 2009) (Supplementary Table1).
Inclusion/exclusion criteria

Search strategy
This systematic review was performed using the following
electronic databases: PubMed, Medline, Embase, Scopus, and
Cochrane (from 1966 to 2012). For our search query, medical subject headings (MeSH) terms and free text were used in
combination to restrict the search. Some of the keywords used
in the search were growth and development, craniocervical
posture, facial morphology, head position, and craniofacial type. Supplementary Table2 shows detailed information
regarding specific search terms and combinations.
Two independent reviewers screened the publications
found in the databases. After excluding repetitions, a first

selection based on title was performed. Manual search of

the references was conducted to find other relevant articles.
Another selection on the basis of abstracts was conducted to
find potentially useful articles. When divergences occurred
in articles selection, reasons were clearly identified, and a
consensus achieved. Subsequently, full-text articles were
obtained for those references that appeared to match our
inclusion criteria. The search was updated on 23 March 2012.
Critical appraisal
Articles were assessed for the quality of their methodology
by two examiners. Critical appraisal was performed regarding nine criteria (Supplementary Table3). Each study was
graded as weak (0 to <13 points), moderate (13 to 15
points), high moderate (>15 to 18 points), and strong (>18
points). The kappa () coefficient was used to assess agreement between the reviewers.
Results
The initial search yielded 155 PubMed citations, 77 Medline
citations, 345 Embase citations, 112 Scopus citations, and 0
Cochrane citations. After excluding repetitions, completely
off-topic titles were excluded, which returned 73 articles.
Manual search of references revealed 11 additional articles.
After abstract reading, 27 off-topic articles and 9 non-English
publications were excluded, which resulted in 48 references
achieved by a consensus. Subsequently, full-text articles were
obtained for those references that appeared to match our
inclusion criteria. Out of the 48 topic-related articles selected,
36 did not fit the inclusion criteria. The remaining 12 articles
were found relevant for the purpose of the study. The search
was summarized in Figure1. Table1 shows detailed information about each one of the included articles.
Methodological quality of included studies
At the end of the critical appraisal phase, there was an agreement of =0.931 (P<0.001) between reviewers. Among
the studies, six presented moderate quality level and the
other six were considered weak.
The following were the main methodological
shortcomings: only one article presented detailed
information about including representatives of the three
different facial types in selection description; none of the
articles reported sample size calculation; just three articles
were longitudinal studies and none reported measurement
blinding when assessing craniofacial morphology and head/
cervical posture (Table2).
Head and cervical posture versus craniofacial
morphology
Variables used for head and cervical posture cephalometric analysis are shown in Figure 2 and Supplementary
Table 4. Figure 3 illustrates the cephalometric points and

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Longitudinal, cohort, casecontrol, cross-sectional and case

series studies that directly compared craniofacial morphology with head and/or cervical posture were eligible to be
part of this review. Case reports and literature reviews were
not included. Searches were restricted to English publications involving only humans. The study population consisted of healthy child, adolescent or adult subjects of both
genders. Patients with any congenital disorder or syndrome
as well as those with history of previous head or neck surgery were not included. The sample must not have been
constituted by patients with a single skeletal facial type,
given the fact that different skeletal patterns are required to
make it possible the correct analysis of differences related
to posture and morphologic facial features. Measurements
used to analyse both postural and morphological variables
must have been obtained from cephalometric radiographs
performed in natural head position (NHP). Articles that presented any questionable information regarding cephalometric measurement were not included. Articles were excluded
if they did not match the inclusion criteria.

L.C.R. Gomes etal.

57

Craniocervical Posture and Craniofacial Morphology

reference lines used for craniofacial morphology assessment. Considering that a majority of the selected articles
used correlation coefficients for assessing the comparison
between postural and craniofacial morphology variables,
such coefficients were grouped together to make the quantitative analysis of results feasible. Data were summarized
considering the minimum and maximum correlation coefficients found among the selected articles, regarding sagittal
(Table3) and vertical diagnostic features (Table4).
Sagittal assessment
On the basis of significant correlation coefficients between
postural and morphological variables, as well as significant
differences among skeletal classI, classII, and classIII groups,
it was observed that greater craniocervical and craniovertical
angles were related to lower lengths of the maxilla (Solow
and Tallgren, 1976) and mandible (Solow and Tallgren,
1976; Showfety etal., 1987), greater maxillary (Solow and
Tallgren, 1976; Marcotte, 1981; Showfety etal., 1987; Ozbek
and Koklu, 1993) and mandibular retrognathism (Solow and
Tallgren, 1976; Marcotte, 1981; Solow etal., 1984, , Showfety
et al., 1987; Ozbek and Koklu, 1993; Leitao and Nanda,
2000), and a skeletal class II pattern (Solow and Tallgren,
1976; Solow etal., 1984; Ozbek and Koklu, 1993; Leitao and
Nanda, 2000; DAttilio etal., 2005). Lower cervicohorizontal

angles were related to maxillary and mandibular protrusion

regarding measurements that considered extracranial
reference lines (Ozbek and Koklu, 1993) and large sagittal
interjaw discrepancy (Solow etal., 1984; Ozbek and Koklu,
1993). One article reported facial prognathism (Hellsing
et al., 1987) in association with increased cervicovertical
angles. Cervical spine was significantly straighter in skeletal
class III patients (P 0.001) and markedly curved in
skeletal classII patients regarding the angle formed by the
intersection of the cervical vertebra tangent and the lower
segment of the cervical vertebra (CVT/EVT) (P 0.01)
(DAttilio etal., 2005). Subjects with lower maxillary length
(PNS-vpOK) were associated with a more lordotic cervical
curve (Tecco and Festa, 2007). Other authors did not find
significant correlations between cervical lordosis (OPT/CVT,
CVT/EVT) and craniofacial morphology considering sagittal
analysis (Solow and Tallgren, 1976; Hellsing et al., 1987;
Ozbek and Koklu, 1993).
Vertical assessment
Greater craniocervical and craniovertical angles were related
to large anterior face height (Solow and Tallgren, 1976;
Showfety etal., 1987; Leitao and Nanda, 2000), small posterior face height (Solow and Tallgren, 1976; Solow etal.,
1984) and thereby reduced face height ratio (S-Go/N-Me;

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Figure1 Flow chart.

Type of study

Cross sectional

Cross sectional

Cross sectional

Longitudinal

Cross sectional

Cross sectional

Longitudinal

Cross sectional

Longitudinal

Cross sectional

1. Solow and
Tallgren (1976)

2.Marcotte (1981)

3. Solow etal.
(1984)

4. Solow and
Siersbaek-Nielsen
(1986)

5. Hellsing etal.
(1987)

6. Showfety etal.
(1987)

7. Solow and
Siersbaek-Nielsen
(1992)

8. Ozbek and Koklu

(1993)

9. Huggare and
Cooke (1994)

10. Leitao and

Nanda (2000)

Mean age
range (years)*

284

36

106

34

43

125

43

24

136

120

284 male

20 boys,
16 girls

57 female,
49 male

16 girls,
18 boys

43 females

63 boys,
62 girls

20 girls,
23 boys

12 boys,
12 girls

120 male

21 classI,
12 classII
Div 1, 03 classIII

12 classI,
18 classII
Div 1, 04 classII
Div 2

Calculations
based on EVT
line were limited
to 112 subjects

12 classI, 25
classII Div 1, 06
classII Div 2

22.6 (1825)

12

1929

9.9 (SD 1.4)

1546

815

9.5 (7.712.9)

8.6 (7.69.4)

Not reported

2230

Not applicable

Not applicable
Not applicable

2.7 (14)

Not applicable

Not applicable
2.8 (23.6)

Not applicable

25
Not applicable

Mirror position
Mirror position

Mirror position

Mirror position

Look into the far distance

(fluid-level device)****
Mirror position

No external references
(fluid-level device)****
Self-balance and mirror
position
Self-balance and mirror
position

Mean period of
observation**,
range (years)

Results

Self-balance and mirror

position

Cephalometric radiographs
obtained in NHP (specific
method)

Other relevant
features

Sample size (n)

Gender
distribution

Method used to perform

measurements

Sample characteristics

Methods

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Study/year

Table1 Characteristics of studies on head posture and facial morphology.

(Continued)

Craniocervical, craniovertical, cervicohorizontal, and cervical lordosis

angles related to facial morphology;
r=0.180.57; significance at 5 and
1%
Craniovertical angle (TVH) related
to facial morphology; r=0.270.45;
significance at 0.1%
Craniocervical, craniovertical, and
cervicohorizontal angles related to
facial morphology; r=0.410.67;
significance at 5, 1, and 0.1%
Craniocervical and cervicohorizontal
angles related to true growth rotation
of the mandible; r=0.410.55; significance at 5, 1, and 0.1%
Cervicovertical and cervical lordosis
angles (CVT/EVT) related to facial
morphology; r=0.180.34; significance at 5, 1, and 0.1%
Craniovertical angle (SN/V) related
to facial morphology; r=0.290.62;
significance at 5 and 0.1%
Craniocervical, craniovertical, and
cervicohorizontal angles related to
facial growth; r=0.350.59; significance at 5, 1, and 0.1%
Craniocervical, craniovertical, and
cervicohorizontal angles related to
facial morphology; r=0.190.62;
significance at 5, 1, and 0.1%
Craniovertical angles related to
mandibular growth direction in boys;
r=0.59; significance at 1%
Craniovertical angles related to
facial morphology; r=0.160.57;
significance at 5, 1, and 0.1%

Associations found; correlation

coefficients range***/other statistical
method; significance

58
L.C.R. Gomes etal.

59

Head posture and growth prediction

*Mean age at the first observation in case of longitudinal studies.
**Just for longitudinal studies.
***It was only shown the magnitude of correlations found regarding variables of interest for the purpose of this review.
****A fluid-level device was used to transfer the NHP to the cephalostat.

Not applicable
Mirror position
Cross sectional
12. Tecco and Festa
(2007)

98

56 males,
42 females

31.5 (1851)

Not applicable
40 Skelatal classI, 9.5 (SD 0.5)
40 Skeletal classII,
40 Skelatal classIII
60 girls,
60 boys
Cross sectional
11. DAttilio etal.
(2005)

120

Cephalometric radiographs
obtained in NHP (specific
method)
Gender
distribution

Other relevant
features

Mean age
range (years)*
Sample size (n)

Mirror position

Craniocervical, cervicovertical, and

cervical lordosis angles related to
facial morphology; KruskalWallis
one-way analysis of variance;
significance at 5, 1, and 0.1%
Cervical curvature related to facial
morphology; r2=0.24; significance
at 5%

Associations found; correlation

coefficients range***/other statistical
method; significance
Method used to perform
measurements

Methods
Type of study
Study/year

Table1Continued

0.38 r 0.51; P 0.001) and S-Go/ANS-Me proportion (0.38 r 0.41; P 0.001; Ozbek and Koklu, 1993).
It was also associated with high mandibular plane angle
(Solow and Tallgren, 1976; Marcotte, 1981; Solow et al.,
1984; Showfety et al., 1987; Ozbek and Koklu, 1993;
Leitao and Nanda, 2000), large inclination of the maxilla
to anterior cranial base (Solow and Tallgren, 1976; Solow
et al., 1984; Ozbek and Koklu, 1993), and high occlusal
plane angle (r=0.32; P 0.05) (Marcotte, 1981). Lower
cervicohorizontal angles were linked to large anterior face
height (Solow and Tallgren, 1976), small posterior face
height (Solow etal., 1984) as well as high mandibular plane
angle (Solow and Tallgren, 1976; Ozbek and Koklu, 1993).
Articles reported decreased lower and total face height and
also small inclination of the mandible to anterior cranial
base (Hellsing et al., 1987) in association with increased
cervicovertical angles. Straightened cervical lordosis
assessed by CVT/EVT or OPT/CVT angles was related to
high mandibular plane angle and large anterior face height
(Solow and Tallgren, 1976; Hellsing etal., 1987).

Three longitudinal studies found a clear pattern

of associations between head and cervical posture
with craniofacial growth determined by structural
superimposition method (Solow and Siersbaek-Nielsen,
1986, 1992; Huggare and Cooke, 1994; Table5). Subjects
with greater cervicohorizontal and small craniocervical
angles were associated with a horizontal facial growth
pattern characterized by reduced backward displacement
of the temporomandibular joint (TMJ), increased growth
in length of the maxilla (Solow and Siersbaek-Nielsen,
1992), increase in maxillary and mandibular prognathism
(Solow and Siersbaek-Nielsen, 1992), and larger than
average forward true rotation of the mandible (Solow
and Siersbaek-Nielsen, 1986, 1992). Subjects with lower
cervicohorizontal and large craniocervical angles were
associated with a vertical facial development and are likely
to exhibit large backward displacement of the TMJ, reduced
growth in length of the maxilla (Solow and SiersbaekNielsen, 1992), reduction of maxillary and mandibular
prognathism (Solow and Siersbaek-Nielsen, 1992), and less
than average forward true rotation of the mandible (Solow
and Siersbaek-Nielsen, 1986, 1992). Craniovertical angle
significantly correlated with mandibular growth direction.
The larger the angulation, the more vertical the facial
growth pattern in boys (Huggare and Cooke, 1994).
One article developed a prediction model from which
it was suggested that children with the angle between the
nasion-sella reference line and the odontoid process tangent
(NSL/OPT) larger than 113 degrees may exhibit a vertical growth pattern of the lower face, whereas children with
NSL/OPT smaller than 79 degrees may exhibit a horizontal
growth pattern (Solow and Siersbaek-Nielsen, 1992).

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Sample characteristics

Mean period of
observation**,
range (years)

Results

Craniocervical Posture and Craniofacial Morphology

60

L.C.R. Gomes etal.

Table2 Critical appraisal scores of included studies.

Study/year

1. Solow and Tallgren (1976)

2. Marcotte (1981)
3. Solow etal. (1984)
4. Solow and Siersbaek-Nielsen (1986)
5. Hellsing etal. (1987)
6. Showfety etal. (1987)
7. Solow and Siersbaek-Nielsen (1992)
8. Ozbek and Koklu (1993)
9. Huggare and Cooke (1994)
10. Leitao and Nanda (2000)
11. DAttilio etal. (2005)
12. Tecco and Festa (2007)

Critical appraisal scores

1

4.1

4.2

2
2
2
2
2
2
2
2
2
2
2
2

0
0
0
1
0
0
2
0
1
0
0
0

1
1
0
1
1
1
1
1
0
1
1
1

1
1
1
0
1
1
1
0
0
1
2
1

2
0
2
2
1
1
2
2
2
2
2
0

2
2
2
2
2
2
2
1
1
2
2
2

2
2
2
2
2
2
2
2
2
2
2
2

2
0
1
2
2
1
1
2
2
2
2
2

2
2
2
2
2
2
2
2
2
2
1
2

0
0
0
0
0
0
0
0
0
0
0
0

Total score

Rating

14
10
12
14
13
12
15
12
12
14
14
12

Moderate
Weak
Weak
Moderate
Moderate
Weak
Moderate
Weak
Weak
Moderate
Moderate
Weak

1, Proposition; 2, study design; 3, sample size; 4, selection description (4.1, different facial types; 4.2, gender/age features); 5, method for obtaining
NHP; 6, cephalometric analysis; 7, method error analysis; 8, statistical analysis; 9, blind measurement.

Discussion

Figure2 Cephalometric postural variables. The convention employed for angles related to the true vertical was that downward opening angles formed
behind the true vertical (VER) were taken as negative, whereas angles formed in front were positive.

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The term extension of the head has been used to denote

a raised position of the head in relation to the cervical column or the true vertical (Solow and Tallgren, 1976; Hellsing
etal., 1987; Showfety etal., 1987; Leitao and Nanda, 2000;
Solow and Sandham, 2002). Thus, it was associated with
increased craniocervical angles (Solow and Tallgren, 1976;
Solow et al., 1984; Solow and Siersbaek-Nielsen, 1986,
1992; DAttilio et al., 2005) and increased craniovertical ones (when considering the downward opening angles

formed in front of the true vertical) (Solow and Tallgren,

1976; Solow etal., 1984; Showfety etal., 1987; Solow and
Siersbaek-Nielsen, 1992; Leitao and Nanda, 2000).
An extended head position was also related to cervical
spine sloping forward (Solow and Tallgren, 1976; Ozbek
and Koklu, 1993; Solow and Sandham, 2002). Therefore,
it was linked to decreased cervicohorizontal angles
(Solow and Tallgren, 1976; Solow etal., 1984; Solow and
Siersbaek-Nielsen, 1986, 1992; Ozbek and Koklu, 1993)
and increased cervicovertical ones (when considering the
magnitude of downward opening angles formed behind the

61

Craniocervical Posture and Craniofacial Morphology

true vertical; Hellsing etal., 1987; DAttilio etal., 2005).

On the other hand, the term flexion of the head denotes
a forward bent position of the head (Solow and Tallgren,
1976; Showfety et al., 1987) and is generally associated
with backward slope of the cervical column (Solow and
Tallgren, 1976; Solow and Sandham, 2002), i.e. a vertical
cervical posture (Ozbek and Koklu, 1993).
It was observed that, in general, correlations obtained for
cervicohorizontal angles showed opposite signs when compared with those obtained for craniocervical and craniovertical angles, which means that an extended head position
is actually related to forward cervical posture (Solow and
Tallgren, 1976; Solow and Sandham, 2002). However, care
must be taken when interpreting the results of correlations regarding cervicovertical angles. Conventionally, the
downward opening angles formed behind the true vertical
were taken as negative, whereas those formed in front were
considered positive. Thus, increased cervicovertical angles
mean backward inclination of the cervical column.
Authors believe that the craniofacial morphology is often
visually masked by the posture of the head and cervical column (Bjork, 1951; Brodie, 1971). Investigators stated that the
convex facial profile is masked somewhat by the extension
of the head relative to the true vertical, which tends to reduce
the facial convexity by increasing the prominence of the chin.
Conversely, in those individuals with prognathic facial profiles,

the mandible protrusion tends to be masked by the forward posturing of the forehead. The results of correlation coefficients
analysis regarding craniovertical angles seem to support this
hypothesis (Solow and Tallgren, 1976; Marcotte, 1981; Solow
etal., 1984; Showfety etal., 1987; Leitao and Nanda, 2000).
In general, the results of selected articles statistical
analysis in this systematic review corroborate the softtissue stretching hypothesis (Solow and Kreiborg, 1977).
Therefore, an extended head posture and/or forward inclination of the cervical column were related to individuals with
high mandibular plane angle and long-face morphology
as well as retrognathic profile (Solow and Tallgren, 1976;
Marcotte, 1981; Solow etal., 1984; Solow and SiersbaekNielsen, 1986; Hellsing etal., 1987; Showfety etal., 1987;
Solow and Siersbaek-Nielsen, 1992; Ozbek and Koklu,
1993; Huggare and Cooke, 1994; Leitao and Nanda, 2000;
Solow and Sandham, 2002; DAttilio etal., 2005). On the
other hand, subjects with short-face morphology and lower
mandibular plane angle, as well as those with mandibular
prognathism often carry their heads somewhat lowered and/
or presented a backward inclination of the cervical column
(Solow and Tallgren, 1976; Marcotte, 1981; Solow et al.,
1984; Solow and Siersbaek-Nielsen, 1986; Hellsing etal.,
1987; Showfety etal., 1987; Solow and Siersbaek-Nielsen,
1992; Ozbek and Koklu, 1993; Huggare and Cooke, 1994;
Leitao and Nanda, 2000; Solow and Sandham, 2002).

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Figure3 Cephalometric points and reference lines used for craniofacial morphology assessment.

Solow and
Tallgren
(1976)

-0.33**** -0.33**** Showfety

etal., 1987

-0.20**** -0.20**** Solow and

Tallgren,
1976

Minimum Maximum References

Minimun Maximum References

0.25*** 0.25***

Pg-Go, Co-Gn

A-PNS

0.38***

0.37***

0.49***

Maximum

Solow and
Tallgren
(1976)

References

0.18****

0.31***

Ozbek and
Koklu
(1993)
Hellsing
etal.
(1987)

0.57***** 0.57***** Leitao and

Nanda
(2000)

0.43***** 0.46***** Ozbek and

Koklu
(1993)
0.54*** 0.54***
Solow and
Tallgren
(1976)
0.62***** 0.62***** Showfety
etal.
(1987)
0.62*****, 0.62*****, Ozbek and
0.50***** 0.50***** Koklu
(1993)
0.45***** 0.45***** Marcotte
(1981)

0.45***

Minimum

SNB, N-B(H)*, B-VER/N-VER**

Mandibular position

0.23**** 0.24**** Ozbek and

0.29***
Koklu
(1993)
0.19**** 0.19**** Hellsing
0.18****
etal. (1987)

0.37***** 0.40***** Ozbek and

Koklu
(1993)
0.48*** 0.48*** Solow and
Tallgren
(1976)
0.29**** 0.29**** Showfety
etal.
(1987)
0.54*****, 0.54*****, Ozbek and
0.58***** 0.58***** Koklu
(1993)
0.27***** 0.27***** Marcotte
(1981)

Solow and
Tallgren
(1976)

Maximum References

Minimum

SNA, A-Nperp, N-A(H)*,

A-VER/N-VER**

Maxillary position

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0.62***** 0.62***** Showfety

etal.
(1987)
0.60*****, 0.60*****, Ozbek and
0.46***** 0.46***** Koklu
(1993)
0.32***** 0.32***
Marcotte
(1981)
0.56***** 0.56***** Leitao and
Nanda
(2000)
0.35***** 0.35***** Ozbek and
Koklu
(1993)

Solow and
Tallgren
(1976)
0.49**** 0.59**** Solow etal.
(1984)
0.47***** 0.51***** Ozbek and
Koklu
(1993)
0.54***
0.54***** Solow and
Tallgren
(1976)
0.42**** 0.67***** Solow etal.
(1984)
Solow
etal.
(1984)
Solow and
Tallgren
(1976)

0.44**** 0.44****

-0.43**** -0.43**** Solow

etal.
(1984)

0.18**** 0.18****

Solow and
Tallgren
(1976)

0.52***

0.49***
0.21**** 0.23****

Minimum Maximum References

Maximum

Minimum

References

AN.Pog

SNPog, SN.Sym, Pog-VER/N-VER**

Sagittal interjaw relationship

-0.23**** -0.24****

0.22****

Ozbek and
Koklu
(1993)

Ozbek and
Koklu
(1993)
0.19***** 0.19***** Leitao and
Nanda
(2000)

0.22****

Minimum Maximum References

ANB, B-VER/A-VER**

Topographic correlations are in bold; only correlation coefficients significant at the 5% level are shown.
*Measurements parallel to the horizontal (H) constructed at a fixed angle of 7 below SN line. Only performed by Marcotte (1981).
**Measurements that considered extracranial reference lines. Significant correlations were only found for craniovertical and cervicohorizontal angles in Ozbek and Koklu (1993) article. Articles that considered the downward opening angles formed behind the true vertical for craniovertical angle
assessment had the sign of correlation coefficients corrected (Marcotte, 1981; Showfety etal., 1987; Leitao and Nanda, 2000).
***P<0.01, ****P<0.05, *****P<0.001.

Cervicovertical
angles

Cervicohorizontal
angles

Craniovertical
angles

Craniocervical
angles

Lengths of the mandible

Lengths of the maxilla

Table3 Correlation coefficients between postural variables and craniofacial morphology: Sagittal assessment.

62
L.C.R. Gomes etal.

Co-Go, Ar-Go

S-Go

SN.GoMe, NSL.ML, MP.H*,

NSL.NL, ANS-PNS.NS
NSL.GoGn, NSL.MBL, FH.ML

Inclination of jaw bases

Solow and
Tallgren
(1976)

0.30**

Solow and
Tallgren,
1976
0.25**

0.32**

Solow and
Tallgren,
1976

0.23**** Leitao and 0.33**

Nanda
(2000)

0.12***

0.25**

Solow and 0.20*** 0.28**

Tallgren
(1976)

Solow and
Tallgren
(1976)

Solow and 0.24**

Tallgren
(1976)

0.34**

Solow and
Tallgren
(1976)

0.42***

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Solow etal.
(1984)

0.34**

0.34**

Solow and
Tallgren
(1976)

0.21*** 0.21*** Solow and

Tallgren
(1976)

0.57**

Solow and 0.32** 0.33**

Tallgren
(1976)
Solow etal. 0.42*** 0.44***
(1984)

Solow and
Tallgren
(1976)
0.42*** 0.42***
Solow
etal.
(1984)
0.46**** 0.50**** Ozbek
0.23*** 0.26*** Ozbek
and Koklu
and Koklu
(1993)
(1993)
0.30**
0.41**
Solow and 0.36** 0.36**
Solow and
Tallgren
Tallgren
(1976)
(1976)
0.31**** 0.31**** Marcotte 0.51*** 0.51*** Solow
(1981)
etal.
(1984)
0.43*** 0.43*** Solow etal. 0.33**** 0.33**** Ozbek
(1984)
and Koklu
(1993)
0.33*** 0.33*** Showfety
etal. (1987)
0.39**** 0.52**** Ozbek
and Koklu
(1993)
0.16**
0.45**** Leitao and
Nanda
(2000)
0.24** 0.25** Solow and
Tallgren
(1976)
0.32****0.33**** Ozbek
and Koklu
(1993)
0.32** 0.34**** Hellsing
etal. (1987)
0.23** 0.29** Solow and
Tallgren
(1976)
0.25** 0.25** Hellsing
etal. (1987)

0.37**

Only correlation coefficients significant at the 5% level are shown. Topographic correlations are in bold.
*Angle between mandibular plane (MP) and the horizontal (H) constructed at a fixed angle of 7 below SN line. Only performed by Marcotte (1981). Articles that considered the downward opening angles formed behind the true vertical for craniovertical angle assessment had the sign of
correlation coefficients corrected (Marcotte, 1981; Showfety etal., 1987; Leitao and Nanda, 2000).
**P<0.01, ***P<0.05, ****P<0.001.

0.42***

0.46*** 0.47*** Solow etal. 0.41*** 0.41*** Solow etal.

(1984)
(1984)

0.33**

0.43*** 0.48*** Solow etal. 0.42*** 0.47*** Solow etal.

(1984)
(1984)

Solow and 0.23**

Tallgren
(1976)

0.37**

0.29**

0.27** Hellsing
0.27** 0.29**** Hellsing
etal., 1987
etal., 1987
0.21*** 0.21*** Solow and 0.22*** 0.22*** Solow and
Tallgren,
Tallgren,
1976
1976
0.19*** 0.19*** Hellsing
etal., 1987

0.25**

Cervicovertical
angles
Cervical lordosis 0.19*** 0.19*** Solow and
angles
Tallgren
(1976)

0.29**

Cervicohorizontal 0.24**
angles

Showfety
etal. (1987)

0.32**

0.20**** 0.263**** Leitao and

Nanda
(2000)

0.24**

0.24**

0.34***

0.34***

Solow and
Tallgren
(1976)

Solow and
Tallgren
(1976)

Solow and
Tallgren
(1976)

0.23**

0.23**

Craniovertical
angles

0.48**

0.42**

Craniocervical
angles

Minimum Maximum References Minimum Maximum References Minimum Maximum References Minimum Maximum References Minimum Maximum References Minimum Maximum References Minimum Maximum References Minimum Maximum References

S-PNS

N-Gn, N-Me

N-A, N-ANS

ANS-Gn, ANS-Me

Posterior face height

Anterior face height

Table4 Correlation coefficients between postural variables and craniofacial morphology: vertical assessment.

Craniocervical Posture and Craniofacial Morphology

63

64

0.35*
0.35*

0.42**

Only correlation coefficients significant at the 5% level are shown. Topographic correlations are in bold.
*True rotation of the mandible is determined as growth change in angles REFcrb/REFmI and NSL/REFml. REFcrb is the reference line through the fiducial points in the cranial base. On film 1, REFcrb coincides with NSL; REFml is
the reference line through the fiducial points in the mandible. (Fiducial points are transferred from film 1 to film 2 after superimposition of films on stable structures in anterior cranial base and/or in the mandible).
**P<0.01, ***P<0.001, ****P<0.05.

0.59**
0.59**
0.59***
0.52**
0.49**

0.48**

0.51**

0.52**** 0.52****

0.59***

0.35**** 0.35****

0.36**** 0.37****
0.40**** 0.40****
0.55***
0.52**
0.43**** 0.46**
0.48**** 0.48**
0.55*** 0.58***

0.45***
0.54***
0.44**
0.41**

Craniocervical
0.47**
0.51***
angles
0.55***
Cervicohorizontal 0.50*** 0.52***
angles
Craniovertical
angles

Minimum Maximum Minimum Maximum Minimum Maximum Minimum Maximum Minimum Maximum Minimum Maximum
Minimum Maximum
Minimum Maximum Minimum Maximum

SN-Pgn
SNA (degrees/year)
A-Pm (mm/year)
REFcrb/REFml*

NSL/REFml*

Solow and Siersbaek-Nielsen (1992)

Solow and Siersbaek-Nielsen (1986)

Table5 Correlation coefficients regarding postural and craniofacial growth variables.

However, it is important to consider that the vast majority

of correlations found were low. Moderate correlations were
found regarding variables related to mandibular position
(sagittal assessment) and mandibular base inclination (vertical assessment). Moreover, associations between variables
that are topographically related, i.e. having a reference line in
common, should be distinguished from those between variables that have nothing in common. Topographically related
variables may be correlated even if all reference points
vary independently. On the other hand, non-topographical
correlations are assumed to reflect biological coordinating
mechanism (Solow and Tallgren, 1976). The present review
showed that although topographic associations were widely
found, non-topographic correlations were also observed for
almost all morphologic variables studied. Considering only
non-topographical associations, the correlation coefficients
ranged from r=0.35 (P 0.05) to r=0.59 (P 0.001) in
longitudinal studies and from r=0.18 (P 0.05) to r=0.58
(P 0.001) in cross-sectionalones.
Craniovertical and craniocervical posture are often
determined by nasion-sella reference line (NSL). However,
the inclination of such a line seems to show wide individual variations (Bjork, 1951; Moorrees and Kean, 1958;
Lundstrom, 1982; Ozbek and Koklu, 1993). Ozbek and
Koklu (1993) stated in NHP, the inclination of NSL was
found to be associated with the vertical localization of Sella
turcica point, rather than the extension or flexion of the
entire head. Thus, they concluded that associations between
posture and structure of the head would be merely caused by
the functional factors related to forward cervical posture
and vertical cervical posture.
Corroborating these findings, DAttilio etal. (2005) found
significant differences among three different skeletal types
regarding the values of the inclination of the lower segment
of the spinal column (EVT) to a true vertical (VER). EVT/
VER angle was smaller (as absolute value) in classIII than
in skeletal classIand classII subjects (P<0.001). Moreover,
no significant differences in craniovertical angles were
observed among the three groups. Regarding craniocervical angles formed by the upper section of the spinal column
(NSL/OPT), no significant differences were also observed
among the three groups. However, the angle created between
the head and the midsection of the spinal column (NSL/
CVT) showed significant differences among the three groups.
Subjects in skeletal class II showed a significantly more
extended head upon the spinal column than subjects in skeletal Classes Iand III (P<0.001 and P<0.01, respectively).
The evaluation of craniofacial structure by means of
intracranial reference lines has been criticized considering
that the individual variations in the slope of intracranial reference lines may result in different interpretation of the craniofacial structure of subjects with similar profiles (Bjork,
1951; Moorrees and Kean, 1958; Ozbek and Koklu, 1993).
However, only one article assessed craniofacial morphology
also considering measurements that involved extracranial

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SNB (degrees/year)

SNPog
(degrees/yearr)

REFcrb/REFml*
(degrees/year)

NSL/REFml*
(degrees/year)

Huggare and Cooke

(1994)

L.C.R. Gomes etal.

Craniocervical Posture and Craniofacial Morphology

second cervical vertebra. Moreover, positive correlations

were found regarding craniovertical angles, which means
that extension of the head to a true vertical was related to
increased cervical lordosis.
This observation seems to show evidence of different
behaviours of the upper/middle and lower segments of the
cervical column, which corroborates the natural physiology of cervical column regarding protrusion and retraction
movements, i.e. the lower cervical flexion moves the head
forward and extension moves it backward, whereas the
upper and middle cervical segments respond in a compensatory mechanism to maintain the face-forward position
and keep the visual axis unaltered (Ordway etal., 1999).
Craniocervical angles of the upper and middle segments
(NSL/OPT, NSL/CVT) seem to diminish with lordosis
increase (Solow and Tallgren, 1976; Hellsing etal., 1987),
whereas craniocervical angle of the lower segment (NSL/
EVT) seems to increase (Hellsing etal., 1987). Thus, when
evaluating only the upper/middle segment it is not possible
to establish conclusions about the overall cervical posture.
DAttilio et al. (2005) evaluating differences among
skeletal class I, class II, and class III subjects reported
that cervical spine was significantly straighter in skeletal
classIII subjects (P 0.001). This study also revealed that
a more lordotic curve of the spine was related to greater
extension of the head and, additionally, to a skeletal classII
(P 0.01).
Smaller CVT/EVT angle observed in subjects in skeletal
classIII was probably associated with the significant backward slope of the lower part of the spinal column (EVT/
VER), and not to any difference in the inclination of the
upper (OPT) or middle (CVT) part of the cervical spine.
No significant differences among the three groups were
observed in the inclination of the middle (CVT/VER) or
upper segment (OPT/VER) of the spinal column.
On the other hand, straighter cervical lordosis assessed
by CVT/EVT or OPT/CVT angles was related to high mandibular plane angle, and large anterior face height (Solow
and Tallgren, 1976; Hellsing et al., 1987), features usually found in head extenders. However, very low correlation coefficients explained such associations. Thus, it is still
unclear the relationship between cervical lordosis and craniofacial morphology.
Tecco and Festa (2007) stated that the cervical column
curvature was highly variable between individuals, and only
showed weak influence on craniofacial morphological variables. Subjects with lower maxillary length were associated
with a more lordotic cervical curve in the sagittal plane.
Through regression analysis, they found that this cephalometric variable explained only 24% of the total variance of
cervical curvature.
Cross-sectional studies have indicated the presence of
some biologic mechanisms coordinating changes in posture
and lower facial development. However, considerable caution must be exerted when interpreting findings obtained

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reference lines (Ozbek and Koklu, 1993). Authors stated

that when the facial prognathism was assessed by traditional
angles (SNA, SNB, and SNPog), which are topographically
correlated with craniovertical and craniocervical postural
parameters (NSL/VER, NSL/OPT, and NSL/CVT), significant negative correlations were obtained, which may falsely
lead to a conclusion that facial prognathism decreases with
the extension of the head. On the other hand, when the facial
prognathism was assessed in the NHP with parameters that
were based on the extracranial reference lines (A-VER/NVER, B-VER/NVER, and Pog-VER/N-VER), they showed
positive correlations with NSL/VER and negative correlations with cervicohorizontal angles (OPT/HOR and CVT/
HOR) (Ozbek and Koklu, 1993).
However, the positive correlations found with NSL/
VER may probably be related to the fact that the greater the
inclination of the SN line during head extension, the more
anteriorly positioned the points A, B, and Pog, in relation to
nasion (N). Conversely, the negative correlations obtained
for cervicohorizontal angles follows the same line of reasoning, regarding the fact that an extended head position is
generally associated with forward inclination of the cervical
column. Therefore, such postural influence on craniofacial
proportions assessed by those variables may generate misunderstandings. On the other hand, when analysing extreme
skeletal patterns, such postural changes may not produce
significant craniofacial proportions changes. However, the
article did not mention sample morphological features.
Controversial results were found regarding cervical lordosis angles. Authors associated extension of the head with
straighter cervical lordosis when considering OPT/CVT
angle (Solow and Tallgren, 1976), whereas other studies
reported high cervical lordosis angles (CVT/EVT) related
to head extenders (DAttilio etal., 2005). Those divergent
results may probably be associated with different angle
analysis.
Through a correlation study, Solow and Tallgren (1976)
observed a tendency towards reduced cervical lordosis in
head extenders regarding measurements obtained from the
upper and middle segments of the cervical column. Such
tendency was observed considering the opposite sign correlations found when comparing the results obtained for
cervical lordosis (OPT/CVT) with those for craniocervical (NSL/OPT, NSL/CVT) and craniovertical (NSL/VER)
angles. Authors also evaluated mean facial diagrams of the
10 subjects with the largest extension of the head and the
most marked flexion of the head in relation to the cervical
column (NSL/OPT), which characterized the two extreme
types proposed bythem.
Through direct comparisons, Hellsing etal. (1987) found
negative correlations between CVT/EVT and upper segment
craniocervical angles (NSL/OPT, NSL/CVT) and positive
correlations regarding the lower cervical segment (NSL/
EVT; P<0.001), which means that a straight cervical lordosis was related to head extension only when considering the

65

66

Conclusions
On the basis of the data available from literature, significant associations were found between variables concerning head posture and craniofacial morphology. However,
our results suggest that such associations should be carefully interpreted, considering that correlation coefficients
found ranged from low to moderate.
The association between cervical lordosis and the head
extension mechanism regarding craniofacial morphology
is still unclear.
Further longitudinal studies are needed in order to elucidate
the relationship between craniofacial development and functional aspects of head and cervical posture. The evidence
found is not enough to support any definite conclusion about
the future mandibular growth in an individual case.
Supplementary material

References
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Brodie A G 1971 Emerging concepts of facial growth. Angle Orthodontist
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DAttilio M, Caputi S, Epifania E, Festa F, Tecco S 2005 Evaluation of
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Hellsing E, LEstrange 1987 Changes in lip pressure following extension
and flexion of the head and at changed mode of breathing. American
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Hellsing E, McWilliam J, Reigo T, Spangfort E 1987 The relationship
between craniofacial morphology, head posture and spinal curvature in 8,
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Huggare J A, Cooke M S 1994 Head posture and cervicovertebral anatomy as
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Lundstrom A 1982 Head posture in relation to slope of the sella-nasion
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Ordway N R, Seymour R J, Donelson R G, Hojnowski L S, Edwards W
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Showfety K J, Vig P S, Matteson S, Phillips C 1987 Associations between
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Solow B, Siersbaek-Nielsen S. 1992 Cervical and craniocervical posture as
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Supplementary material is available at European Journal of

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Funding

Tecco S, Festa F 2007 Cervical spine curvature and craniofacial morphology in an adult Caucasian group: a multiple regression analysis.
European Journal of Orthodontics 29: 204209

So Paulo Research Foundation (FAPESP) (2012/02933-1).

Solow B, Tallgren A. 1976 Head posture and craniofacial morphology.

American Journal of Physical Anthropology 44: 417435

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from such studies. Only indirect inference can be made

about the presence of growth-coordinating mechanism
(Solow and Siersbaek-Nielsen, 1986). Direct inferences
about form/function relationship and the possibility of predicting growth behaviour of facial dimensions require longitudinal assessment (Solow and Siersbaek-Nielsen, 1986,
1992; Ozbek and Koklu, 1993).
The three longitudinal studies included in this review
found a clear pattern of associations between head posture
and subsequent craniofacial growth (Solow and SiersbaekNielsen, 1986, 1992; Huggare and Cooke, 1994), which also
agreed with soft-tissue stretching hypothesis (Solow and
Kreiborg, 1977). Although such associations were found
for both genders in two articles, one article found significant associations only in boys (Huggare and Cooke, 1994).
However, the authors assumed that the girls included in the
study had already passed their peak height velocity that
must have contributed to observed differences in strength of
associations.
The observation of an extremely large or extremely small
craniocervical angle in a child appears to offer some prognostic value regarding facial developmental trends. However,
the low to moderate correlations mean that although posture
seems to influence facial development, many other factors
must also affect this mechanism. Moreover, the determination of causal factors and of the detailed nature of the
mechanism at work requires further studies (Solow and
Siersbaek-Nielsen, 1992).

L.C.R. Gomes etal.