See

discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/7358099

Dysgnathia, orthognathic surgery and spinal

posture

Article in International Journal of Oral and Maxillofacial Surgery May 2006

DOI: 10.1016/j.ijom.2005.09.009 Source: PubMed

CITATIONS READS

13 67

7 authors, including:

Klaus Sinko Josef G Grohs

Medical University of Vienna Medical University of Vienna
27 PUBLICATIONS 461 CITATIONS 55 PUBLICATIONS 642 CITATIONS

SEE PROFILE SEE PROFILE

Gabriele Millesi Dritan Turhani

Medical University of Vienna Medical University of Vienna
23 PUBLICATIONS 512 CITATIONS 61 PUBLICATIONS 1,368 CITATIONS

SEE PROFILE SEE PROFILE

Some of the authors of this publication are also working on these related projects:

dissemination of tumor cells View project

vertebral compression fractures View project

All content following this page was uploaded by Josef G Grohs on 31 March 2016.

The user has requested enhancement of the downloaded file.

Int. J. Oral Maxillofac. Surg. 2006; 35: 312317
doi:10.1016/j.ijom.2005.09.009, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Dysgnathia, orthognathic K. Sinko1, J.-G. Grohs2,

G. Millesi-Schobel1, F. Watzinger1,
D. Turhani1, G. Undt1, A. Baumann1

surgery and spinal posture

1
University Hospital of Cranio-Maxillofacial
and Oral Surgery, Medical University, Vienna,
Austria; 2University Hospital of Orthopaedics,
Medical University, Vienna, Austria

K. Sinko, J.-G. Grohs, G. Millesi-Schobel, F. Watzinger, D. Turhani, G. Undt,

A. Baumann: Dysgnathia, orthognathic surgery and spinal posture. Int. J. Oral
Maxillofac. Surg. 2006; 35: 312317. # 2005 International Association of Oral and
Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Abstract. The aim of this study was to evaluate the spine by video rasterstereography
before and after orthognathic surgery. Twenty-nine patients (17 patients with a
skeletal class III, 7 patients with a skeletal class II, and 5 patients with mandibular
asymmetry) were evaluated preoperatively and 1 year postoperatively. Video
rasterstereography is a method of back surface measurement and shape analysis
Key words: orthognathic surgery; video raster-
using the moire topography. Orthognathic surgery in cases of class III and stereography; spinal posture.
asymmetry did not lead to significant changes in body posture. In class II patients it
led to some changes in body posture, but without orthopaedic consequences. It is Accepted for publication 15 September 2005
concluded that orthognathic surgery causes minimal or no change in body posture. Available online 18 January 2006

In the 1990s, a possible association
between occlusal and postural distur-
bances was widely propagated by the mass
media. As a result, an increasing number
of patients confronted medical practi-
tioners with the issue. An association
between dental occlusion and the vertebral
column or body posture has been dis-
cussed in the published literature for a
long time20. In 1933 DALISE4 stated that
orthopaedics of the trunk and extremities
and orthodontics are indivisible parts of
general orthopaedics. Some authors found
strong evidence for an association
between malocclusion and posture, espe-
cially with regard to the head and neck9,10.
In 1955 DUYZINGS7 observed an alteration
in the position of the hyoid and an altera-
tion of cervical lordosis in class II patients.
As the cervical spine is a part of the
vertebral column, he presumed that this
influenced the body posture as well.
WACHSMANN26 stated that muscular weak-
ness, which he considered to be related to
a weakness of the mesoderm, might be a
reason for breathing through the mouth,
prognathism and a flabby body posture.
MULLER-WACHENDORF16 also stated that
malocclusion and postural disorders are
manifestations of weak connective tissue.
RICKETS19 and VIG et al.25 found that head
posture is influenced by respiratory func-
tion. Some authors considered it possible,
but not certain, that malocclusion and pos-
tural disorders are interrelated11. In a
review published in 1999 MICHELOTTI
et al.13 found some evidence for a correla-
tion between occlusion and posture, but it
appears to be limited to the cranio-cervical
portion of the vertebral column and tends to
disappear when descending in the cranio-
caudal direction. They concluded that it is
not advisable to treat postural imbalance by
means of occlusal therapy or vice versa,
especially if the therapeutic modalities are
irreversible. In 1996 FERRARIO et al.8 stated
that modifications in body posture second-
ary to stomatognathic alterations were
mainly observed in patients, and diverse
findings were obtained in healthy young
adults5.
Following the introduction of orthog-
nathic surgery as a routine procedure, very
few studies have focused on the effect of
these surgical procedures on pos-
ture1,2,17,27. The method used in all of
these previous studies was cephalometric
analysis; thus, only the upper cervical
spine was assessed. To the authors knowl-
edge no one has yet tried to determine
whether orthognathic surgery affects the
entire vertebral column and body posture.
This prospective study was designed to
identify differences, if any, between class
II and class III patients in respect to the
vertebral column and body posture. In

0901-5027/040312 + 06 $30.00/0 # 2005 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Orthognathic surgery and spinal posture 313

addition, the effect, if any, of orthognathic

surgery on the curvature of the vertebral
column and body posture was evaluated.

Materials and methods

Twenty-nine patients (11 men and 18
women) with a mean age of 24.5 years
(range, 1741 years) were examined by
means of video rasterstereography (Jenop-
ticTM, Software DeltamedTM version
2.11)6 24 weeks before orthognathic sur-
gery and 1 year postoperatively. Seven-
teen patients had a skeletal class III, 7
patients had a skeletal class II, and 5
patients had mandibular asymmetry
(Table 1). The surgical procedures per-
formed are listed in Table 2.
All patients received orthodontic ther-
apy with fixed appliances before and after
the surgical procedure. As the aim was to
evaluate the effects of orthognathic sur-
gery on posture only, the first examination
was performed immediately before sur-
gery, when preoperative orthodontic
alignment had been completed and the
patients had been provided with passive
wires (0.01700
0.02500 red-heated stain-
less steel wire in a 0.01800 bracket system).
The second examination was performed
12 months after the surgical procedure.
The fixed orthodontic appliance had been
removed by this time in all patients. It was
presumed that, if posture was altered by Fig. 1. Patient with a horizontal line pattern projected on the naked dorsum.
surgery, a new equilibrium would have
been achieved after 12 months.
The first stage of the examination was the naked dorsum by means of a slide recorded the line pattern produced by the
clinical evaluation by an orthopaedist. (Fig. 1). The lines produced a unique pat- patients back. A rasterstereograph was
After that, the patients were asked to walk tern of light and heavy lines. The curved produced within seconds with the help of
to a marked point and stand barefoot in a surface of the dorsum caused distortion of a video frame grabber and a microprocessor
self-chosen comfortable stance, corre- the lines. It has been shown that postural (Fig. 2); 25,000 primary data points were
sponding to a natural head and body sway during the first 20 s of quiet stance is achieved in a patient of medium stature. A
posture, looking straight ahead at a wall subject to great variation and random char- sophisticated surface shape analysis was
with both arms hanging freely adjacent to acteristics. These transient changes in first- produced by the computer (see Figs 3
the trunk. The illumination was dimmed to and second-order moments usually disap- and 4). The following measurements were
twilight. Eighty-four horizontal lines pear during this time3. After a wait of 20 s, recorded: the apex and angle of thoracic
(about 1 line/cm) were projected on to therefore, a high-resolution video camera kyphosis measured between the 7th cervi-
cal vertebral body, better known as the
vertebra prominens (VP), and the 12th
Table 1. Male-to-female ratios of dysgnathia and control groups thoracic vertebral body (T12); the apex
Class II Class III Mandibular asymmetry Control and angle of lumbar lordosis between
Men 1 9 1 12 T12 and the midpoint (DM) between the
Women 6 8 4 0 right (DR) and left (DL) dimples of the
posterior superior iliac spine; and the point
Total 7 17 5 12
of inflexion between kyphosis and lordosis
(ITL). Vertical deviation of the spine was
measured between the VP and the DM
Table 2. Orthognathic surgical procedures used for different types of dysgnathia between the DR and DL of the posterior
superior iliac spine. The tilt of the iliac crest
Class II Class III Mandibular asymmetry Total was measured between the DL and DR of
Le-Fort I 1 1 0 2 the posterior superior iliac spine.
BSSO 4 1 2 7 The preoperative values for the differ-
Bimax 2 15 3 20 ent malocclusion groups were compared
BSSO: Bilateral sagittal split osteotomy; Bimax: bimaxillary osteotomy. with a group of 12 healthy male baseball
314 Sinko et al.

0.0191
0.0071

Vert. dev.: vertical deviation; VP: vertebra prominens; DM: midpoint between the right (DR) and the left dimple (DL) of the posterior superior iliac spine; Pelv. dev.: pelvic deviation (deflection of the connection line of DRDL to the true horizontal
t-test

ns
ns

ns
ns
ns
7.50

8.68

8.88
7.45
12.39

10.37

10.92
T12DM (8) SD
Angle of
lordosis

27.45
33.02
36.24
40.58

34.41
44.18
42.28

line); Corr. to V.b.h.: corresponding to vertebral body height; ITL: point of inflexion between kyphosis and lordosis; T112: thoracic vertebral body 112; L15: lumbar vertebral body 15; ns: not significant.
0.0661
t-test

ns
ns
ns

ns
ns
ns
9.73
9.57

8.77

9.78
8.65
9.17
12.91
VPT12 (8) SD
Angle of
kyphosis

43.31
47.01
43.95
52.84

47.59
47.25
54.16
0.0104

0.0605
t-test

ns

ns
ns

ns
ns
Corr. to
V.b.h.

L2/3
L2/3

L3/4
L2/3
L2/3
L2
L3
38.91
39.31
26.21
27.97

38.22
23.41
29.51
SD
Table 3. Pre- and postoperative spinal posture data for different types of dysgnathia measured by video rasterstereography

343.88
382.98
365.77
361.86

393.50
356.78
360.10
Apex of
lordosis
(mm)

T11/12
T11/12

T11/12

T11/12
V.b.h.
Corr.

T 12
T 11
T11
to

46.09
49.74
41.97
21.62

38.22
16.45
16.08
SD

265.53
275.26
246.83
264.58

284.51
248.95
258.68
(mm)
Fig. 2. Rasterstereograph produced by computer. ITL

0.0374
t-test

ns
ns
ns
ns

ns
ns
players. A clinical orthodontic examina- patients than in class II patients and
tion was performed to ensure that all healthy controls. The angle of lumbar
V.b.h.
Corr.

T6/7

T7/8
T5/6
T6/7
individuals in this group had normal lordosis was more pronounced in class
T7
T7

T7
to

occlusion without skeletal dysgnathia. III patients compared to healthy controls.

The mean age of the control group was The apex of lumbar lordosis was more
28.40
29.53
20.42
28.65

29.60
23.43
24.50
SD

16.4 years. In a second evaluation the caudal in class II than in healthy controls;
effect of orthognathic surgery on the dif- the difference was equivalent to the height
kyphosis

149.80
151.11
129.44
140.32

150.93
109.15
132.00
Apex of

(mm)

ferent malocclusion groups was assessed.
The recording of data was not repeated
because, in the recording of biological
of one vertebral body. Before therapy the
tilt of the iliac crest in class II and III
patients differed minimally but signifi-
0.0257
0.0273

0.0005
t-test

ns

ns

ns
ns

parameters, variations within the group cantly from that of healthy controls.
of subjects under investigation are usually After treatment the apex of thoracic
2.00
3.42
4.26
3.51

2.97
4.42
4.03
SD

much larger than the method error of the kyphosis in the group with mandibular
parameter27. asymmetry had moved cranially by about
Pelv. dev.
DLDR

half the height of one vertebral body. In

(8)

1.13
1.42
1.27
0.50

0.60
1.23
2.66

class II patients, the apex of lumbar lor-

Statistical analysis
dosis had moved caudally to an insignif-
All data are mean values. Preoperative icant extent, and the tilt of the iliac crest
11.23
7.69
7.28
7.75

7.32
6.29
7.51
SD

differences between groups were evalu- was altered after therapy. Class III patients
ated with the Students t-test for unpaired revealed no significant changes after ther-
Vert. dev.
VPDM
(mm)

data. Changes within groups, resulting apy. For details, see Table 3.
0.62
0.83
4.28
0.30

2.52
3.33
2.24

from surgery, were evaluated with the

Students t-test for paired data.
Discussion
Healthy controls

asymmetry

asymmetry
Mandibular

Mandibular

This investigation was based on the pre-

Results
Class III

Class III
Class II

Class II
POST-OP

mise that if occlusion and posture are

PRE-OP

Prior to treatment, the apex of thoracic inter-dependent, the greatest difference

kyphosis was more cranial in class III would be seen between extreme class II

Fig. 3. Example of frontal surface shape analysis produced by computer (see footnote to Table 3
for abbreviations).
and extreme class III occlusions. Patients
were examined before and after orthog-
nathic surgery. If the surgical procedure
alters body posture, it was presumed that a
new equilibrium would be achieved after
12 months.
All patients for the study were recruited
from those being treated for dysgnathia at
the oral and maxillofacial surgery clinic.
No patient had general orthopaedic pro-
blems or chronic back pain requiring
orthopaedic therapy. This is not surprising
because, in general, orthopaedic problems
such as chronic back pain are known to
commence after the age of 30; the mean
age of our patients was 24 years.
There appears to be a major difference
between patients undergoing primary
orthognathic surgery and orthopaedic
patients with idiopathic scoliosis or spon-
dylolisthesis. While orthodontic problems
have been very commonly observed in
general orthopaedic patients10,15,18, no or
very slight orthopaedic differences were
found between class I, class II and class III
angle relationships or crossbites. HIRSCH-
11
FELDER & HIRSCHFELDER found no signif-
icant differences between the different
Orthognathic surgery and spinal posture
angle classes with regard to pelvic tilt.
STERZIG et al.24 observed no typical head
posture for the different angle classes.
These two groups conducted their exam-
inations in children and adolescents: the
former in those less than 18 and the latter
in those less than 13 years of age. One
reason for their results may have been that,
in general orthopaedic disease, habitual
scoliosis and a flabby body posture
develop due to general weakness of the
connective tissue, which also leads to
malocclusions16. Class III and severe class
II may be influenced by genetic factors,
with no accompanying disorder of the
vertebral column.
In the present study only a few mea-
surements were found to differ signifi-
cantly between the malocclusion groups.
Variations within the different malocclu-
sion groups were very large (see SD in
Table 3). Some of these significant differ-
ences may have been due to the different
sex ratios in the control group (all males)
and the study group (two thirds female,
Table 1). Significant differences between
males and females were noted in the class
III group. This may have been due to the
315
different average body height of men and
women; the height of the subjects was not
measured. The number of patients was too
small to allow gender-specific statements.
Some of the differences recorded may
have been due to the difference in mean
age of the controls (16.4 years; growing
age) and the study group (24.5 years; not
of growing age). The significant differ-
ences were, in fact, not homogenous.
Hence, it is not confirmed whether a typi-
cal form of vertebral column exists for the
different malocclusions.
Despite the small number of patients,
the present study revealed that factors
other than occlusion play a more impor-
tant role in head and body posture. There
is strong evidence that breathing impedi-
ments, such as large tonsils or allergies,
causing the individual to breathe through
the mouth may alter head posture25. The
exclusive presence of a skeletal class II is
no guarantee for forehead posture. A ske-
letal class III patient with large tonsils or
an allergy causing restricted nose breath-
ing may have a more pronounced forehead
posture than a class II patient with unim-
peded nose breathing. In humans, head
and body posture may be primarily related
to resisting the force of gravity5,23. Two
mechanisms have been proposed for the
control of head and body posture. Proprio-
sensitive nerve inputs from muscles, ten-
dons, joints and the balancing system of
the inner ear serve as crude positioning
systems. Fine adjustment is effected by
inputs from the visual righting system21.
The patients psychological state is also
known to be a relevant factor11. Skeletal
dysgnathia alone is not a major factor in
the alteration of body posture. MILANI
et al.14 stated that much of the ideas about
occlusion are based more on belief than on
evidence. It should not be thought that all
occlusal disorders have repercussions on
posture.
The effects of orthognathic surgery on
the cervical portion of the vertebral col-
umn have been studied by several authors.
ACHILLEOS et al.1 observed cervical hyper-
flexion after mandibular setback osteot-
omy and a more upright cervical spine
after mandibular advancement2. WENZEL
et al.27 explained the increase in cranio-
cervical angulation after mandibular set-
back as being due to psycho-social factors
which stimulate the patients to lift their
head after surgery. PHILLIPS et al.17 studied
201 patients who had undergone 5 differ-
ent surgical procedures; the authors
observed no significant short- or long-term
changes in neck posture in any of the
surgical groups. As cephalometric X-rays
were used for evaluation in all of these
316 Sinko et al.
Fig. 4. Example of lateral surface shape analysis produced by computer (see footnote to Table 3
for abbreviations).
studies, only the upper, or at best the
entire, cervical spine was examined. This
method only allows two-dimensional
assessment of the cervical spine in the
sagittal plane; lateral bending or rotation
may escape detection. Video rasterstereo-
graphy, as used in the present study, is a
method of back surface measurement
based on automatic back surface recon-
struction and shape analysis, depending on
the moire topography. It is a non-invasive
and non-injurious way of evaluating body
posture and allows the investigator to
measure alterations in the curvature of
the vertebral column without the use of
X-rays12. Video rasterstereography com-
pares well with plain films in terms of
accuracy and is an adequate method for
use in the clinical setting6.
The vertebral column was assessed in
all three dimensions. The differences
between the preoperative and postopera-
tive examinations were minimal. No sig-
nificant differences were found in class III
patients. One limitation of video raster-
stereography is that the vertebral column
can only be examined from the vertebra
prominens to the sacrum. It should be
noted that the entire cervical spine has
been extensively investigated by standard
X-rays in previous studies.
The small number of patients may have
been a limitation of the present study.
Given the minimal differences between
the malocclusion groups, the results are
likely to have been similar for a larger
sample. It was difficult to convince
patients without pain of the necessity of
two additional visits to evaluate their ver-
tebral column. This was especially true for
the second assessment after the comple-
tion of the whole treatment.
The accuracy of the recording of natural
posture is a major issue. A large number of
published studies have used the so-called
mirror position; however, the position of
the head and body determined by an exter-
nal reference (mirror) may not be identical
to the habitual position. In the mirror
position the head is kept higher than in
the self-balance position. The so-called
orthoposition (self-balance position) was
found to be reproducible in posture stu-
dies22 and was used in the present study as
being more natural than the mirror posi-
tion.
In summary, all measured values of the
spine before and after orthognathic sur-
gery were within the physiological range.
No patient required any orthopaedic
intervention before or after orthognathic
surgery. Head and body posture seems to
be primarily related to resisting gravity
and not to malocclusion. In individual
cases, when dysgnathia is associated with
orthopaedic problems or cervical muscle
dysfunction, additional orthopaedic treat-
ment or physiotherapy might be benefi-
cial.
References
1. Achilleos S, Krogstad O, Lyberg T.
Surgical mandibular setback and changes
in uvuloglossopharyngeal morphology
and head posture: a short- and long-term
cephalometric study in males. Eur J
Orthod 2000: 22: 383394.
2. Achilleos S, Krogstad O, Lyberg T.
Surgical mandibular advancement and
changes in uvuloglossopharyngeal mor-
phology and head posture: a short- and
long-term cephalometric study in males.
Eur J Orthod 2000: 22: 367381.
3. Carroll JP, Freedman W. Nonstation-
ary properties of postural sway. J Bio-
mech 1993: 26: 409416.
4. DAlise C, Orthopedics and
Orthodontics. Adv Orthod 1933: 3:
121129 (in German).
5. Daly P, Preston CB, Evans WG. Pos-
tural response of the head to bite opening
in adult males. Am J Orthod 1982: 82:
157160.
6. Drerup B, Hierholzer E. Back shape
measurement using video rasterstereogra-
phy and three-dimensional reconstruction
of spinal shape. Clin Biomech 1994: 9:
2836.
7. Duyzings JA. Orthodontics and body
posture. Dtsch Zahnarztl Z 1955: 10:
1921.
8. Ferrario VF, Sforza C, Schmitz JH,
Taroni A. Occlusion and center of foot
pressure variation: is there a relationship?
J Prosthet Dent 1996: 76: 302308.
9. Fromm B, Lundberg M. Postural beha-
viour of the hyoid bone in normal occlu-
sion and before and after surgical
correction of mandibular protrusion. Sven
Tandlak Tidskr 1970: 63: 425433.
10. Gresham H, Smithells P. Cervical and
mandibular posture. Dent Rec 1954: 74:
261264.
11. Hirschfelder U, Hirschfelder H.
Sagittal jaw relations and spinal posture:
studies on the problem of correlation.
Fortschr Kieferorthop 1987: 48: 436448.

12. Liljenqvist U, Halm H, Hierholzer E,
Drerup B, Weiland M. 3-Dimensional
surface measurement of spinal deformi-
ties with video rasterstereography. Z
Orthop Ihre Grenzgeb 1998: 136: 5764.
13. Michelotti A, Manzo P, Farella M,
Martina R. Occlusion and posture: is
there evidence of correlation? Minerva
Stomatol 1999: 48: 525534.
14. Milani RS, De Periere DD, Lapeyre L,
Pourreyron L. Relationship between
dental occlusion and posture. Cranio
2000: 18: 127134.
15. Muhlbach R, Rink B. Incidence of mal-
occlusion in patients with adolescent sco-
lioses and Scheuermanns disease. Beitr
Orthop Traumatol 1977: 24: 2025.
16. Muller-Wachendorf R. Neue Unter-
suchungen uber Dysgnathien bei Hal-
tungsfehlern (in German). Fortschr
Kieferorthop 1966: 27: 487495.
17. Phillips C, Snow MD, Turvey TA,
Proffit WR. The effect of orthognathic
surgery on head posture. Eur J Orthod
1991: 13: 397403.
18. Prager A. Comparative studies about the
frequency of abnormal dental position
View publication stats
Orthognathic surgery and spinal posture
and jaws in patients with deformities of
the vertebral column. Adv Dent Orthop
1980: 41: 163168 (in German).
19. Ricketts RM. Respiratory obstruction
syndrome. Am J Orthod 1968: 54: 495
507.
20. Robin P. Practical demonstration on the
construction and placement of a new oral
apparatus for correcting dysmorphia.
Revue Stomatol 1902: 9: 561590 (in
French).
21. Solow B, Sandham A. Cranio-cervical
posture: a factor in the development and
function of the dentofacial structures. Eur
J Orthod 2002: 24: 447456.
22. Solow B, Tallgren A. Natural head
position in standing subjects. Acta Odont
Scand 1971: 29: 591607.
23. Solow B, Tallgren A. Head posture
and craniofacial morphology. Am J Phys
Anthropol 1976: 44: 417435.
24. Sterzig G, Grahoff H, Lenschow B.
The morphological relations of eugnathia
and class-II/1 and class-III malocclusions
to the changes in the topography of the
cervical spine in the lateral teleroentgen-
317
ogram. Fortschr Kieferorthop 1992: 53:
6976.
25. Vig PS, Showfety KJ, Phillips C.
Experimental manipulation of head pos-
ture. Am J Orthod 1980: 77: 258268.
26. Wachsmann K. About the connection
between abnormal dentition with flexion
of the vertebral column and loose body
posture. Adv Dent Orthop 1960: 21: 449
453 (in German).
27. Wenzel A, Williams S, Ritzau M.
Changes in head posture and nasophar-
yngeal airway following surgical correc-
tion of mandibular prognathism. Eur J
Orthod 1989: 11: 3742.
Address:
Klaus Sinko
University Hospital of Cranio-Maxillofacial
and Oral Surgery
Medical University, Waehringer Guertel
18-20, A-1090 Vienna
Austria
Tel: +43 1 40400 4259
Fax: +43 1 40400 4253
E-mail: klaus.sinko@meduniwien.ac.at