research article craniofacial and cervical morphology related to...

Research ArticleCraniofacial and Cervical Morphology Related to Sagittal SpinalPosture in Children and Adolescents

Emil Segatto1 Angyalka Segatto1 Gaacutebor Braunitzer2 Christian Kirschneck3

Jochen Fanghaumlnel3 Gholamreza Danesh4 and Carsten Lippold5

1 Department of Orthodontics and Pediatric Dentistry Faculty of Dentistry University of SzegedTisza Lajos Korut 64 Szeged 6720 Hungary

2Department of Oral Surgery Faculty of Dentistry University of Szeged Tisza Lajos Korut 64 Szeged 6720 Hungary3 Department of Orthodontics University Medical Center Regensburg Franz-Josef-Strauszlig-Allee 11 93053 Regensburg Germany4Department of Orthodontics Dental Clinic of Witten Herdecke Alfred-Herrhausen-Straszlige 50 58448 Witten Germany5Department of Orthodontics University of Muenster Waldeyerstraszlige 30 48149 Muenster Germany

Correspondence should be addressed to Carsten Lippold lippolduni-muensterde

Received 25 February 2014 Revised 17 July 2014 Accepted 26 July 2014 Published 7 September 2014

Academic Editor Panagiotis Korovessis

Copyright copy 2014 Emil Segatto et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Studies on the relationship between body posture and craniofacial parameters often focus on the cervical spineThus less attentionhas been paid to themorphology of the vertebra C2 that serves as both a structural and functional link between the craniofacial areaand the other part of the spineThe objective of this study was to assess the relation of craniofacial features to certainmorphologicaland positional characteristics of the cervical vertebrae and the spine during growth We determined body posture indices for 69children and adolescents by means of a radiation-free method (rasterstereography) The morphological and positional analysisof the craniofacial area and the cervical vertebrae was based on standardized lateral X-ray cephalograms Medium to strongcorrelations were found between body posture C2 morphology and craniofacial parameters We found significant correlationsbetween the C2 dens axis height and maxillary indices as well as between the C2 dens axis inclination and cephalometrical valuesof the mandibular area Similarly the correlation between the C2 dens axis inclination and the postural index fleche cervicale washighly significant (119875 lt 005 119903 = 0333) These results suggest that morphological features of the odontoid process may serve asvaluable predictive markers in interdisciplinary orthopedic-orthodontic diagnostics

1 Introduction

Abnormal body posture has long been known to be a poten-tial cause of various craniofacial orthopedic and orthodonticconditions [1ndash3] Postural abnormalities in preadolescencecan usually be traced back to pathological curvatures alongthe spine which is vitally important for body balance andstability Pathological curvatures induce the formation ofcompensatory curvatures elsewhere along the spine whichmay result in compensatory head posture [4] Nonphysio-logical curvatures in the frontal axis may cause tilting of thehead to either side whereas curvatures in the sagittal axismayresult in forward or backward tilts This problem has beenwidely discussed in the literature [1 2 5] The introductionof body posture indices came as a result of the development

and widespread use of radiation-free methods A particularlyprecise postural assessment method is photogrammetry-based computer-aided rasterstereography [6]This method ispopular and widely used in studies investigating the etiologyof craniofacial deviations Most of these studies howeverhave concentrated on a limited number of cephalometricindices [7ndash9] Alterations of the cervical spine have longbeen held responsible for compensatory head postures andtheir exact causes have been investigated for many years[10] Early investigations focused on the correlation betweenthe morphological properties of the vertebra C1 (atlas) andcertain measurements obtained in a natural head positionfrom an X-ray cephalogram [11]

As the first cervical vertebra to form a single joint withthe next vertebra (C3) the axis (C2) has a particular static

Hindawi Publishing CorporationBioMed Research InternationalVolume 2014 Article ID 638238 8 pageshttpdxdoiorg1011552014638238

2 BioMed Research International

and functional role in supporting the skull The atlantoaxialjoint is a complex joint that is not found anywhere elsealong the spine Therefore C2 may be regarded as the firstvertebra to link the skull and the atlas to the other part of thespine in a regular manner In spite of this unique positionrelatively little attention has been paid to the morphologicalproperties of C2 and their relation to various cephalometricaland postural parameters [12]

In this study we investigated the relationship betweensagittal postural parameters and the results of a cephalomet-rical examination involving a wide range of cephalometricalindices We were particularly interested in how the morpho-logical and positional properties of the cervical part of thespine are related to the various cephalometrical parametersWe also paid special attention to the morphological andpositional parameters of C2

2 Materials and Methods

21 Study Subjects Participants had been retrospectivelyrecruited from a group of initially 100 patients classified asrequiring orthodontic treatment within a period of 3monthsExclusion criteria were presence of orthopedic illness (egidiopathic scoliosis or Morbus Scheuermann) orthodontictreatment (ongoing or preceding) fewer than two eruptedfirst molars (both maxilla and mandible) fewer than fourerupted incisors lack of tooth germs and permanent eden-tulism Application of these criteria yielded a final studygroup of 69 children and adolescents

The mean patient age was 11 years and 10 months (range7 years and 11 months to 16 years and 11 months SD 2 yearsand 2 months) The male to female ratio was 21 48 Parentshad been informed about the exclusion criteria the aims andthe procedures of the study in both oral and written formUnderage children and adolescents participated in the studywith their parentsrsquo informed consent The study conformedin all respects to the tenets of the Declaration of Helsinki andwas approved by the local Ethics Committee

22 Cephalometry Cephalometrical analyses in this studywere carried out on the basis of standardized initialorthodontic treatment records We used lateral skull radio-graphs for planning the orthodontic treatment of individualpatients In this way patients were not exposed to additionalX-rays for study purposes All cephalograms were taken digi-tally by the same operator with a Sironacopy Orthophos XGPluscephalometrical device (Sironacopy Dental Systems GmbHBensheim Germany) and set to the program C3F with animage field of 24 times 27 cm The X-ray source had a focus of05mm and the exposure data were 73 kV and 15mA for149 s We achieved a total enlargement rate of 117 by usinga fixed focal plane length of 1714 cm and a fixed midsagittalplane length of 20 cm and used a reference ruler for exactcalibration Cephalograms were taken in the morning in anatural body position the so-called orthoposition [13 14]

Cephalogramswere analyzedwith the Planmeca RomexisCephalometrical Analysis software 30 according to theRicketts norms [15] Parameters of craniofacial morphology

Po

S

Or

Ba

DCAr

PNS ANS

N

tGo

Xi

Me GnPgPM

Li

Ls

Sto

SbA+1a

+1i

minus1a

minus1i

+6d

PtCF

CC

Pg998400

Pn998400

Figure 1 Cephalometric drawing reference points and measure-ments

measured were cranial deflection facial depth facial axisfacial taper and anterior cranial length To characterizethe maxillomandibular complex we determined lower facialheight Xi-PMOcc +1A-Pg minus1A-Pg the interincisal angleoverjet and overbite For assessing the maxilla we used theLandes angle maxillary height and palatal plane to FH andramus Xi position ramus height and the mandibular arcfor defining the mandible Lip protrusion upper lip lengthand the nasolabial angle were included as indices for facialesthetics (Figure 1)

The morphology of the cervical vertebrae was describedby the following parameters (Figure 2)

(i) C2p C2a the lower P-A width of the body of C2C2m C2m1015840mdashthe lower concavity of the body of C2

(ii) C2s C2i the distance of the apex of C2 from theC2p C2a line that determines the lower edge of thebody of the vertebra

(iii) C2i C2p the posterior distance of the apex of C2 fromC2p

(iv) C2p C2i the anterior distance of the apex of C2 fromC2p

(v) C3p C3a the lower P-A width of the body of C3(vi) C3m C3m1015840 the lower concavity of the body of C3(vii) C4p C4a the lower P-A width of the body of C4(viii) C4m C4m1015840 the lower concavity of the body of C4

The vertical position of the second cervical vertebra relatedto the mandibular angle was described by the followingparameter (Figure 3)

BioMed Research International 3

C2s

C2pC2m

C2aC2i C2m998400

C3pC3m

C3m998400Ca

C4pC4m

C4m998400C4a

(a)

C2s

C2pC2m

C2aC2i C2m998400

C3pC3m

C3m998400Ca

C4pC4m

C4m998400C4a

(b)

Figure 2 Inclination of the dens axis (a) posterior inclination (b)anterior inclination

(i) C2a tGo the vertical distance between the lowermostfrontal point of the body of C2 and a plotted pointrepresenting the mandibular angle (Gonion tGo) asmeasured perpendicularly to the Frankfurt horizon-tal

23 Rasterstereography Rasterstereographical images of thebacks of the patients were obtained in the same examinationsession as the lateral skull radiographs with the Formetric II3D4D device (Diers International GmbHcopy SchlangenbadGermany) which has been designed to generate a three-dimensional photographical image of a personrsquos back instanding position Images are generated with the help of afine line grid projected onto the back of the subject This gridprovides information about the surface of the back at an errorlevel of lt01mm [16] Imaging takes 004 s Six sequentialimages were taken of each patient to reduce the natural swayand breathing effects Reconstruction of sagittal and frontalsections is made possible by the recognition and softwareprocessing of certain significant anatomical structures suchas the iliac spine (SI) and the vertebra prominens (VP) [17](Figure 4)The associated software (Virtual Spine 31 Dierscopy)uses mathematical algorithms to construct a 3D model ofa personrsquos back This way an image of the real deviationof the spine from the vertical axis can be obtained Sagittalcurvatures can be reproduced at a precision of 28∘ [18]

In the lateral view sagittal curvatures can be characterizedby the indices fleche cervicale and fleche lombaire Thesevalues give the distance of the apex of the cervical and lumbarlordosis from a virtual vertical plumb line [19] yielding afairly good approximation of the extent of thoracal kyphosis[7] (Figure 5(a)) Body posture also in the lateral view isprimarily characterized by trunk inclination that is defined asthe angle between the real vertical axis and the straight line

connecting the midpoints of the lines between the vertebraprominens (VP) and the left and right crista iliaca superior (SI)(Figure 5(b)) [19]

24 Statistical Analysis The cephalometrical and rasterstere-ographical data of patients were blinded before measure-ments and statistical analysis To determine the methoderror of the cephalometrical measurements we used theDahlbergrsquos formula mean square error 1198782

119864= Σ119889

22119899 (119889 =

difference between repeated measurements 119899 = number ofrecorded radiographs) [20]Themeasurementswere repeatedon randomly chosen radiographs at 2-week intervals by thesame operatorThe acceptable error levels were set at 05∘ and05 mm according to Trpkova et al [21]

All analyses were carried out using the Statistical Packagefor Social Sciences 170 (SPSS Inc Chicago Illinois USA)Descriptive statistics were calculated with regard to meanstandard deviation and range Assumptions for parametricaltests were verified prior to significance testing Correlationsbetween the craniofacial cervical and posture parameterswere assessed by Pearsonrsquos correlation coefficient 119903 with119903 gt 01 denoting a small correlation 119903 gt 03 a mediumcorrelation and 119903 gt 05 a strong correlation The relation ofdens axis inclination and trunk inclination was evaluated bymeans of linear regression analysis Significance adjustmentfor multiple comparisons was done with the Sidak correction(general level of significance was set at 119875 lt 005)

3 Results

The method error calculated by Dahlbergrsquos formula wasbelow the acceptable reference error levels of 05∘ and 05mm[21] in all instances

31 Correlation of Body Posture and Thoracal Kyphosis withCraniofacial Parameters A correlation analysis of the ceph-alometrical craniofacial parameters (Table 1) and the raster-stereographical data (Table 3) yielded the following results

(i) Trunk inclination was significantly correlated with+1A-Pg (119875 lt 005 119903 = minus0284) lip protrusion (119875 lt005 119903 = minus0310) anterior cranial length (119875 lt 005119903 = 0249) and ramus height (119875 lt 005 119903 = 0305)

(ii) Fleche cervicale was not significantly correlated withany of the variables

(iii) Fleche lombaire was significantly correlated with theinterincisal angle (119875 lt 005 119903 = minus0275) and lipprotrusion (119875 lt 005 119903 = 0247)

32 Correlation of Body Posture and Thoracal Kyphosis withCervical Parameters After correlating the cephalometricalcervical parameters (Table 2) with the rasterstereographicaldata (Table 3) the following results were obtained

(i) Trunk inclination was significantly correlated withthe lower concavities of the vertebrae C2 (119875 lt 005119903 = 0453) C3 (119875 lt 005 119903 = 0372) and C4(119875 lt 005 119903 = 0393)


C2aC2

a-tG

o

tgr

tGotgc

Frankfurt horizontal

(a)

C2a

C2a-

tGo

tgr

tGo

tgc


(b)

Figure 3 Vertical position of the second vertebra (C2) (a) above tGo (b) below tGo

(mm)minus200 minus100 0 100 200

(mm)minus200 minus100 0 100 200

Figure 4 Rasterstereographical back surface reconstruction an optical line grid is projected onto the back of the patient while a separatecamera compiles optical measurement data from a different direction

(ii) Fleche cervicale was significantly correlated with thelower concavities of the same vertebrae C2 (119875 lt 005119903 = 0395) C3 (119875 lt 005 119903 = 0318) and C4(119875 lt 005 119903 = 0353) In addition fleche cervicalewas significantly correlated with C2i C2p (119875 lt 005119903 = 0333) (Figure 6)

(iii) Fleche lombaire values were not correlated with anyof the cervical vertebrae indices

An important aim of this study was to determinewhether the projection of the apex dentis on the vertebralbase (C2i C2p or C2p C2i) may be related to any of therasterstereographical back surface indices C2i C2p indicatesa projection falling behind the basis of the vertebra whereasC2p C2i denotes a projection falling upon the vertebral basis(Figure 2)Therefore these projections determine forward orbackward inclinations To find out whether an inclination


Plumb line

Fl eche cervicale

Fl eche lombaire

(a)

Plumb line

Trunk inclination+

minus

ldquoSIrdquo

ldquoVPrdquo

(b)

Figure 5 Rasterstereographical measurements (sagittal plane) (a)fleche cervicale or fleche lombaire sagittal distance between thelowest point of the cervical or lumbar spine and the virtual verticalplumb line (b) trunk inclination angle between the connection lineof the vertebral point (VP) and themidline of the right (DR) and left(DL) dimple points representing the Spina iliaca (SI) of the uprightstanding patient toward the virtual vertical plumb line [1]

determined in such a manner has affected any of the backsurface variables we carried out a linear regression analysisfor the variables dens axis inclination and trunk inclinationWe found that trunk inclination significantly predicted densaxis inclination 120573 = 031 119905(67) = 266 and 119875 lt 005(Figure 7)

33 Correlation of C2 Vertebra Morphology with Craniofa-cial Parameters Of the cervical vertebrae indices (Table 2)C2a tGo (the vertical distance of the body of C2 and themandibular angle) was significantly correlated with the fol-lowing craniofacial cephalometrical variables (Table 1) facialaxis (119875 lt 005 119903 = minus0345) facial taper (119875 lt 005 119903 =minus0408) cranial deflection (119875 lt 005 119903 = minus0319) Landesangle (119875 lt 005 119903 = minus0438) ramus height (119875 lt 005119903 = minus0478) and minus1A-Pg (119875 lt 005 119903 = minus0301)

The P-A width of the base of C2 (C2p C2a) was signifi-cantly correlated with upper lip length (119875 lt 005 119903 = 0267)facial depth (119875 lt 005 119903 = 0289) and ramus height (119875 lt005 119903 = 0327)

The lower concavity of C2 (C2m C2m1015840) was significantlycorrelatedwith lip protrusion (119875 lt 005 119903 = minus0296) anteriorcranial length (119875 lt 005 119903 = 0439) and ramus height (119875 lt005 119903 = 0327)

The height of the dens axis of C2 (C2s C2i) was signifi-cantly correlated with the following cephalometrical indicesupper lip length (119875 lt 005 119903 = 0273) maxillary height(119875 lt 005 119903 = 0267) palatal plane to FH (119875 lt 005119903 = 0269) anterior cranial length (119875 lt 005 119903 = 0335)

ramus height (119875 lt 005 119903 = 0506)mandibular arc (119875 lt 005119903 = minus0264) and minus1A-Pg (119875 lt 005 119903 = 0321)

Of the variables characterizing the projection of theapex dentis on the basis of the vertebral body C2i C2p wassignificantly correlatedwith anterior cranial length (119875 lt 005119903 = 0269) whereas C2p C2i was significantly correlatedwiththe interincisal angle (119875 lt 005 119903 = 0800) the nasolabialangle (119875 lt 005 119903 = minus0695) and +1A-Pg (119875 lt 005119903 = minus0701)

34 Correlation of C3 Vertebra Morphology with CraniofacialParameters The P-A width of the base of C3 (C3p C3a)(Table 2) was significantly correlated with upper lip length(119875 lt 005 119903 = 0277) maxillary height (119875 lt 005 119903 = 0238)palatal plane to FH (119875 lt 005 119903 = 0262) anterior craniallength (119875 lt 005 119903 = 0349) and ramus height (119875 lt 005119903 = 0368) (Table 1) whereas its concavity (C3m C3m1015840)showed significant correlation with lip protrusion (119875 lt 005119903 = minus0303) anterior cranial length (119875 lt 005 119903 = 0269)and ramus height (119875 lt 005 119903 = 0321)

35 Correlation of C4 Vertebra Morphology with CraniofacialParameters The P-A width of the body of C4 (C4p C4a)(Table 2) was significantly correlated with maxillary height(119875 lt 005 119903 = 0274) and Xi-PMOcc (119875 lt 005 119903 = 0299)and its lower concavity (C4m C4m1015840) with lip protrusion(119875 lt 005 119903 = minus0289) anterior cranial length (119875 lt 005119903 = 0267) ramus height (119875 lt 005 119903 = 0449) and +1A-Pg(119875 lt 005 119903 = minus0246) (Table 1)

4 Discussion

Unlike earlier publications on the subject we compared theresults of rasterstereographical back surface analysis to thoseof a larger cephalometrical database [19]

The influence of body balance should be discussedregarding the position of the patient positioned meanwhilethe examination of the head position and the body balanceThe examinations in the lateral cephalographs were done innatural head positionNo flexion or extension of the headwasperformed The rasterstereographic images of the patientsback surface were performed in natural standing positionThis results in a normal patient individual body posture andthe results of the lateral head cephalographs and the patientsdata showing kyphosis or lordosis could be analysed

First of all our data support the results of earliercraniofacial analyses by providing associated soft tissue anddental indices [7] For instance lip protrusion was foundto be correlated with trunk inclination and fleche lombairewhereas +1A-Pg showed a strong correlation with trunkinclination and the interincisal angle with fleche lombaire

Although earlier research concentrated primarily on thestructures of the dentofacial area some of the significant butpreviously not described correlations found in this studymayindicate new directions for further research For instance thecorrelation between trunk inclination and anterior craniallength may indicate a link between body posture and theformation of the craniobasal configuration during growth


Table 1 Descriptive statistics of the cephalometrical analysis of the craniofacial parameters SD standard deviation

Craniofacial parameters Mean SD Minimum MaximumCraniofacial Morphology

Cranial deflection (∘) 2779 253 2077 3622Facial depth (∘) 8586 308 7963 9226Facial axis (∘) 8854 431 7641 9652Facial taper (∘) 6872 416 5858 8061Anterior cranial length (mm) 5428 287 4838 6240

Maxillomandibular ComplexLower facial height (∘) 4646 491 3351 5958Xi-PMOcc (∘) 2527 383 1701 3365Xi-Occ (mm) 075 292 minus586 755+1A-Pg (∘) 2804 754 1399 4620minus1A-Pg (∘) 2159 565 973 3250Interincisal angle (∘) 13037 989 11291 15176Overjet (mm) 468 238 030 1314Overbite (mm) 281 217 minus201 821

MaxillaLandes angle (∘) 6091 320 5224 6725Maxillary height (∘) 5637 336 4832 6621Palatal plane to FH (∘) minus137 385 minus1176 1074

MandibleRamus Xi position (∘) 7011 603 3907 8401Ramus height (mm) 5725 606 4623 7076Mandibular arc (∘) 15219 796 12865 17040

Esthetic relationsLip protrusion (mm) minus071 274 minus910 483Upper lip length (mm) 2021 206 1701 2665Nasolabial angle (∘) 11511 1035 7958 13331

Table 2 Descriptive statistics of the cephalometrical analysis of the cervical parameters SD standard deviation

Cervical parameters Mean SD Minimum MaximumCervical vertebra morphology

C2a tGo (mm) 441 443 minus402 1477C2p C2a (mm) 1242 133 868 1526C2m C2m1015840 (mm) 071 059 000 242C2s C2i (mm) 3020 240 2425 3666C2i C2p (mm) 395 238 000 1234C2p C2i (mm) 207 179 019 586C3p C3a (mm) 1265 126 875 1706C3m C3m1015840 (mm) 062 054 000 221C4p C4a (mm) 1266 124 869 1662C4m C4m1015840 (mm) 043 046 000 199

Table 3 Descriptive statistics of the rasterstereographical analysis SD standard deviation

Rasterstereographical sagittal values Mean SD Minimum MaximumFleche cervicale (mm) 4858 2371 000 10280Fleche lombaire (mm) 2932 1287 531 5480Trunk inclination (∘) 282 337 minus396 1109


Dens axis inclination

120

100

80

60

40

20

0

minus20minus8 minus6 minus4 minus2 0 2 4 6 8 10 12 14

Fl eche

cerv

ical

e

Figure 6 Correlation between dens axis inclination and flechecervicale The dashed curves denote the 95 confidence interval

Trun

k in

clina

tion

12

10

8

6

4

2

0

minus6

minus2

minus4

Dens axis inclinationminus8 minus6 minus4 minus2 0 2 4 6 8 10 12 14

Figure 7 A graphical representation of the results of the regressionanalysis between dens axis inclination and trunk inclination Thedashed curves denote the 95 confidence interval

None of the cephalometrical indices were significantlycorrelated with fleche cervicale and parameters of thecervical vertebrae did not show any significant correlationwith fleche lombaire At the same time a strong positivecorrelation was found between the concavity of the bases ofC2 C3 and C4 trunk inclination and fleche cervicale Thiscorrelation verifies that the sagittal curvatures of the spinebecome accentuated during skeletal maturation

Beyond the concavity indices fleche cervicale was alsosignificantly correlated with the posterior projection of theapex dentis The strong positive correlation suggests that theposterior inclination of the dens axis is directly proportionalto the extent of kyphosis As the apex dentis takes its finalposition as early as the age of 7 years [22] the inclinationshift is possibly related to the caudal displacement of thelower frontal point of the axis (C2a) that falls exactly on the

reference line used for the projection assessment of the apexdentis (Figure 2) Such positional changes of the basis of C2may be traced back to permanent postural irregularities andpermanent changes of the spine caused by such irregularities

The strong correlation between the height of the densaxis with the dentoskeletal parameters of the mandible (eginner gonial angle lower incisor protrusion) deserves specialattention At the same time indicators of the inclinationof the dens axis show a strong correlation with maxillaryparameters such as the nasolabial angle the upper incisorinclination and the interincisal angle

Therefore the examined parameters of the cervical verte-brae are primarily correlatedwith structures of growth duringthis period Dens axis height and inclination however seemto be especially important indices because they show strongcorrelations with both the sagittal parameters of postureand those structures of the dentofacial area with a highlyprognostic value in treatment planningDens axis height andinclination could thus serve as early predictive markers ofdentofacial and posture anomalies

Earlier studies involving all seven cervical vertebraefailed to find a correlation between cervical curvature andcraniofacial morphology in adults [23] However such failuremay be due to differences in head positions because headpositioning has a profound effect on the cervical parametersmeasured The results of the present study corroborate thefindings of earlier studies of the entire cervical area [24]and indicate the necessity of further measurements thatdo not require complicated and almost irreproducible X-ray techniques Although earlier studies have concentratedon the atlas (C1) our results suggest that the dens axismight also be a promising basis of measurement because itsdimensions can be reproducibly determined by means of acephalogram If the resolution of the X-ray image is highenough measurement accuracy may even reach that of CTimages [25]

Some significant correlations are difficult to explainThese include the correlation between trunk inclinationand lip protrusion or the correlation between dens axisheight and upper lip length We propose that these are notreal generalizable correlations but rather result from thecharacteristics of our sample

We also evaluated possible gender differences for theparameters studied but none were found Given that theage ranges included the pubertal growth period this is acounterintuitive result However it must be noted that oursample used was not balanced in terms of gender (more thantwice as many girls as boys) and that this could account forthe gender indifference observed

5 Conclusion

Our measurements of children and adolescents showed newassociations between sagittal back surface parameters anda large number of craniofacial indices Since these mea-surements were made in children and adolescents duringthe growth phase the repetition of such measurements inadults whose skeletal development is completed seems to


be indicated Our results suggest that the morphologicalparameters of the vertebra C2 that is situated at the borderof the craniofacial area in a position distinguished in both astructural and functional respect could be efficiently used ininterdisciplinary orthopedic-orthodontic diagnostics

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper

References

[1] B Solow and A Tallgren ldquoHead posture and craniofacialmorphologyrdquo The American Journal of Physical Anthropologyvol 44 no 3 pp 417ndash435 1976

[2] M R Marcotte ldquoHead posture and dentofacial proportionsrdquoAngle Orthodontist vol 51 no 3 pp 208ndash213 1981

[3] B Solow and S Siersbaek-Nielsen ldquoGrowth changes in headposture related to craniofacial developmentrdquo American Journalof Orthodontics vol 89 no 2 pp 132ndash140 1986

[4] A Bellyei ldquoA gerinc betegsegei mellkasdeformitasokrdquo in Azortope dia tankonyve T Vızkelety Ed pp 112ndash159 SemmelweisKiado Budapest Hungary 1995

[5] B Solow and S Siersbaek-Nielsen ldquoGrowth changes in headposture related to craniofacial developmentrdquo The AmericanJournal of Orthodontics vol 89 no 2 pp 132ndash140 1986

[6] W Frobin and E Hierholzer ldquoRasterstereography a pho-togrammetric method for measurement of body surfacesrdquoPhotogrammetric Engineering and Remote Sensing vol 47 no12 pp 1717ndash1724 1981

[7] C Lippold G Danesh G Hoppe B Drerup and L Hack-enberg ldquoSagittal spinal posture in relation to craniofacialmorphologyrdquo Angle Orthodontist vol 76 no 4 pp 625ndash6312006

[8] C Lippold G Danesh M Schilgen B Drerup and L Hack-enberg ldquoRelationship between thoracic lordotic and pelvicinclination and craniofacial morphology in adultsrdquo AngleOrthodontist vol 76 no 5 pp 779ndash785 2006

[9] C Lippold G Danesh G Hoppe B Drerup and L Hack-enberg ldquoTrunk inclination pelvic tilt and pelvic rotation inrelation to the craniofacial morphology in adultsrdquo The AngleOrthodontist vol 77 no 1 pp 29ndash35 2007

[10] J Huggare P Pirttiniemi and W Serlo ldquoHead posture anddentofacial morphology in subjects treated for scoliosisrdquo Pro-ceedings of the Finnish Dental Society vol 87 no 1 pp 151ndash1581991

[11] M Sandikcioglu S Skov and B Solow ldquoAtlas morphologyin relation to craniofacial morphology and head posturerdquoEuropean Journal ofOrthodontics vol 16 no 2 pp 96ndash103 1994

[12] H Gjoslashrup L Sonnesen S S Beck-Nielsen and D HaubekldquoUpper spine morphology in hypophosphatemic rickets andhealthy controls a radiographic studyrdquo European Journal ofOrthodontics vol 36 no 2 p 217 2014

[13] A M Sahin Saglam and N E Uydas ldquoRelationship betweenhead posture and hyoid position in adult females and malesrdquoJournal of Cranio-Maxillofacial Surgery vol 34 no 2 pp 85ndash92 2006

[14] B Solow and A Sandham ldquoCranio-cervical posture a factorin the development and function of the dentofacial structuresrdquo

European Journal of Orthodontics vol 24 no 5 pp 447ndash4562002

[15] F Notzel Fernrontgenseitenbild-Analyse Deutscher ZahnarzteVerlag Koln Germany 2006

[16] B Drerup and E Hierholzer ldquoBack shape measurement usingvideo rasterstereography and three-dimensional reconstructionof spinal shaperdquo Clinical Biomechanics vol 9 no 1 pp 28ndash361994

[17] BDrerup andEHierholzer ldquoAutomatic localization of anatom-ical landmarks on the back surface and construction of a body-fixed coordinate systemrdquo Journal of Biomechanics vol 20 no10 pp 961ndash970 1987

[18] B Drerup E Hierholzer and B Ellger ldquoShape analysis ofthe lateral and frontal projection of spine curves assessedfrom rasterstereographsrdquo in Research into Spinal DeformitiesJ A Sevastik and K M Diab Eds pp 271ndash275 IOS PressAmsterdam The Netherlands 1997

[19] C Lippold E Segatto A Vegh B Drerup TMoiseenko andGDanesh ldquoSagittal back contour and craniofacial morphology inpreadolescentsrdquo European Spine Journal vol 19 no 3 pp 427ndash434 2010

[20] B Dahlberg Statistical Methods for Medical and BiologicalStudents Interscience Publications New York NY USA 1940

[21] B Trpkova P Major N Prasad and B Nebbe ldquoCephalometriclandmarks identification and reproducibility a meta analysisrdquoTheAmerican Journal of Orthodontics and Dentofacial Orthope-dics vol 112 no 2 pp 165ndash170 1997

[22] H ArponenM Evalahti and JWaltimo-Siren ldquoDimensions ofthe craniocervical junction in longitudinal analysis of normalgrowthrdquo Childs Nervous System vol 26 no 6 pp 763ndash7692010

[23] S Tecco and F Festa ldquoCervical spine curvature and craniofacialmorphology in an adult Caucasian group a multiple regressionanalysisrdquo European Journal of Orthodontics vol 29 no 2 pp204ndash209 2007

[24] A Chatzigianni andD J Halazonetis ldquoGeometric morphomet-ric evaluation of cervical vertebrae shape and its relationship toskeletal maturationrdquoThe American Journal of Orthodontics andDentofacial Orthopedics vol 136 no 4 pp 481e1ndash481e9 2009

[25] A G Kulkarni S M Shah R A Marwah P B Hanagandi andI R Talwar ldquoCT based evaluation of odontoid morphology inthe Indian populationrdquo Indian Journal of Orthopaedics vol 47no 3 pp 250ndash254 2013

Submit your manuscripts athttpwwwhindawicom

Stem CellsInternational

Hindawi Publishing Corporationhttpwwwhindawicom Volume 2014


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and functional role in supporting the skull The atlantoaxialjoint is a complex joint that is not found anywhere elsealong the spine Therefore C2 may be regarded as the firstvertebra to link the skull and the atlas to the other part of thespine in a regular manner In spite of this unique positionrelatively little attention has been paid to the morphologicalproperties of C2 and their relation to various cephalometricaland postural parameters [12]

In this study we investigated the relationship betweensagittal postural parameters and the results of a cephalomet-rical examination involving a wide range of cephalometricalindices We were particularly interested in how the morpho-logical and positional properties of the cervical part of thespine are related to the various cephalometrical parametersWe also paid special attention to the morphological andpositional parameters of C2

2 Materials and Methods

21 Study Subjects Participants had been retrospectivelyrecruited from a group of initially 100 patients classified asrequiring orthodontic treatment within a period of 3monthsExclusion criteria were presence of orthopedic illness (egidiopathic scoliosis or Morbus Scheuermann) orthodontictreatment (ongoing or preceding) fewer than two eruptedfirst molars (both maxilla and mandible) fewer than fourerupted incisors lack of tooth germs and permanent eden-tulism Application of these criteria yielded a final studygroup of 69 children and adolescents

The mean patient age was 11 years and 10 months (range7 years and 11 months to 16 years and 11 months SD 2 yearsand 2 months) The male to female ratio was 21 48 Parentshad been informed about the exclusion criteria the aims andthe procedures of the study in both oral and written formUnderage children and adolescents participated in the studywith their parentsrsquo informed consent The study conformedin all respects to the tenets of the Declaration of Helsinki andwas approved by the local Ethics Committee

22 Cephalometry Cephalometrical analyses in this studywere carried out on the basis of standardized initialorthodontic treatment records We used lateral skull radio-graphs for planning the orthodontic treatment of individualpatients In this way patients were not exposed to additionalX-rays for study purposes All cephalograms were taken digi-tally by the same operator with a Sironacopy Orthophos XGPluscephalometrical device (Sironacopy Dental Systems GmbHBensheim Germany) and set to the program C3F with animage field of 24 times 27 cm The X-ray source had a focus of05mm and the exposure data were 73 kV and 15mA for149 s We achieved a total enlargement rate of 117 by usinga fixed focal plane length of 1714 cm and a fixed midsagittalplane length of 20 cm and used a reference ruler for exactcalibration Cephalograms were taken in the morning in anatural body position the so-called orthoposition [13 14]

Cephalogramswere analyzedwith the Planmeca RomexisCephalometrical Analysis software 30 according to theRicketts norms [15] Parameters of craniofacial morphology

Po

S

Or

Ba

DCAr

PNS ANS

N

tGo

Xi

Me GnPgPM

Li

Ls

Sto

SbA+1a

+1i

minus1a

minus1i

+6d

PtCF

CC

Pg998400

Pn998400

Figure 1 Cephalometric drawing reference points and measure-ments

measured were cranial deflection facial depth facial axisfacial taper and anterior cranial length To characterizethe maxillomandibular complex we determined lower facialheight Xi-PMOcc +1A-Pg minus1A-Pg the interincisal angleoverjet and overbite For assessing the maxilla we used theLandes angle maxillary height and palatal plane to FH andramus Xi position ramus height and the mandibular arcfor defining the mandible Lip protrusion upper lip lengthand the nasolabial angle were included as indices for facialesthetics (Figure 1)

The morphology of the cervical vertebrae was describedby the following parameters (Figure 2)

(i) C2p C2a the lower P-A width of the body of C2C2m C2m1015840mdashthe lower concavity of the body of C2

(ii) C2s C2i the distance of the apex of C2 from theC2p C2a line that determines the lower edge of thebody of the vertebra

(iii) C2i C2p the posterior distance of the apex of C2 fromC2p

(iv) C2p C2i the anterior distance of the apex of C2 fromC2p

(v) C3p C3a the lower P-A width of the body of C3(vi) C3m C3m1015840 the lower concavity of the body of C3(vii) C4p C4a the lower P-A width of the body of C4(viii) C4m C4m1015840 the lower concavity of the body of C4

The vertical position of the second cervical vertebra relatedto the mandibular angle was described by the followingparameter (Figure 3)


C2s

C2pC2m

C2aC2i C2m998400

C3pC3m

C3m998400Ca

C4pC4m

C4m998400C4a

(a)

C2s

C2pC2m

C2aC2i C2m998400

C3pC3m

C3m998400Ca

C4pC4m

C4m998400C4a

(b)







119864= Σ119889

22119899 (119889 =



3 Results









C2aC2

a-tG

o

tgr

tGotgc


(a)

C2a

C2a-

tGo

tgr

tGo

tgc


(b)


(mm)minus200 minus100 0 100 200

(mm)minus200 minus100 0 100 200






Plumb line

Fl eche cervicale

Fl eche lombaire

(a)

Plumb line

Trunk inclination+

minus

ldquoSIrdquo

ldquoVPrdquo

(b)











4 Discussion




















120

100

80

60

40

20

0


Fl eche

cerv

ical

e


Trun

k in

clina

tion

12

10

8

6

4

2

0

minus6

minus2

minus4











5 Conclusion






References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















C2s

C2pC2m

C2aC2i C2m998400

C3pC3m

C3m998400Ca

C4pC4m

C4m998400C4a

(a)

C2s

C2pC2m

C2aC2i C2m998400

C3pC3m

C3m998400Ca

C4pC4m

C4m998400C4a

(b)







119864= Σ119889

22119899 (119889 =



3 Results









C2aC2

a-tG

o

tgr

tGotgc


(a)

C2a

C2a-

tGo

tgr

tGo

tgc


(b)


(mm)minus200 minus100 0 100 200

(mm)minus200 minus100 0 100 200






Plumb line

Fl eche cervicale

Fl eche lombaire

(a)

Plumb line

Trunk inclination+

minus

ldquoSIrdquo

ldquoVPrdquo

(b)











4 Discussion




















120

100

80

60

40

20

0


Fl eche

cerv

ical

e


Trun

k in

clina

tion

12

10

8

6

4

2

0

minus6

minus2

minus4











5 Conclusion






References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















C2aC2

a-tG

o

tgr

tGotgc


(a)

C2a

C2a-

tGo

tgr

tGo

tgc


(b)


(mm)minus200 minus100 0 100 200

(mm)minus200 minus100 0 100 200






Plumb line

Fl eche cervicale

Fl eche lombaire

(a)

Plumb line

Trunk inclination+

minus

ldquoSIrdquo

ldquoVPrdquo

(b)











4 Discussion




















120

100

80

60

40

20

0


Fl eche

cerv

ical

e


Trun

k in

clina

tion

12

10

8

6

4

2

0

minus6

minus2

minus4











5 Conclusion






References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of

















Plumb line

Fl eche cervicale

Fl eche lombaire

(a)

Plumb line

Trunk inclination+

minus

ldquoSIrdquo

ldquoVPrdquo

(b)











4 Discussion




















120

100

80

60

40

20

0


Fl eche

cerv

ical

e


Trun

k in

clina

tion

12

10

8

6

4

2

0

minus6

minus2

minus4











5 Conclusion






References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of































120

100

80

60

40

20

0


Fl eche

cerv

ical

e


Trun

k in

clina

tion

12

10

8

6

4

2

0

minus6

minus2

minus4











5 Conclusion






References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of




















References
































of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of





















of






Disease Markers



OncologyJournal of





PPAR Research



Journal of

ObesityJournal of
















research article craniofacial and cervical morphology related to...

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