Orthodontics

Relationships of sagittal skeletal discrepancy,

natural head position, and craniocervical
posture in young Chinese children
Ying Liu1, Xinhua Sun1, Yuanping Chen1, Min Hu1, Xu Hou1, Chang Liu1,2
1
Department of Orthodontics, Hospital of Stomatology, JiLin University, Changchun, China, 2 State Key
Laboratory of Oral Diseases, West China College of Stomatology, West China Hospital of Stomatology,
SiChuan University, Chengdu, China

Objective: The aim of this study was to investigate the relationships of sagittal skeletal discrepancy, natural
head position (NHP), and craniocervical posture in young Chinese children with average vertical facial
pattern.
Methods: Ninety patients with average Frankfort mandibular plane angle (FH/ML) were classified into
skeletal class I, II, and III relationships according to their ANB angle. Cephalometric radiographs in
NHP were taken. Variables representing sagittal and vertical craniofacial morphology, head posture,
and craniocervical posture were measured and compared.
Results: Subjects in the skeletal class II group showed the largest craniovertical angles and craniocervical
angles, while subjects in the skeletal class III group exhibited the smallest craniovertical angles and
craniocervical angles, though not all the measurements showed significant differences. The angle
formed by the nasion-sella line and the tangent to the posterior border of the mandibular ramus (NSL/
RL) was largest in the skeletal class II group and smallest in the skeletal class III group (P 5 0.05).
Discussion: Significant differences exist in NHP and craniocervical posture among skeletal class I, II, and
III relationships in young Chinese children. Subjects with skeletal class II relationship tended to exhibit
more extended head, and children with skeletal class III relationship often exhibited flexed head.
Keywords: Craniocervical posture, Craniofacial morphology, Natural head position

Introduction distant object at eye level.3 The concept of NHP was

Intracranial reference planes, such as the sella-nasion
(SN) and Frankfort (FH) horizontal planes, are
widely used in combination with other planes in con-
temporary cephalometric analysis to assess vertical or
sagittal skeletal relationship.1 However, the reliability
of these reference planes was questioned due to the
observations that these planes change continuously
during growth, and vary highly among individuals.1
Therefore, measurements based on these planes are
likely to yield misleading information, and the use
of true vertical planes as an alternative seems to be
reasonable.1,2
Natural head position (NHP) is a standardized head
position with the subject’s head erect and looking at a
Correspondence to: Chang Liu, Department of Orthodontics, Hospital of
Stomatology, JiLin University, 1500 Qinghua Road, Chao Yang District,
Changchun, JiLin 130021, China. Email: 1398639141@qq.com
introduced to orthodontics in the 1950s by Downs.1
Natural head position as a reference system has been
advocated mainly due to its good intra-individual
reproducibility to a true vertical line in both short
and long periods of time.4–6 Previous studies indicated
that the reproducibility of NHP after 5–10 minutes,
5 years, and even 15 years was still as good and reliable
as that of the initial one.6 Additional features that vali-
date the use of NHP in cephalometry as well as clinical
examinations include its representation of a true life
appearance.1
Natural head position and craniocervical posture are
dictated by the neuromuscular balance and response to
physiological and environmental conditions.7 Hence,
numerous functional factors, which may have an influ-
ence on the neuromuscular activity, such as nasal
obstruction, temporomandibular disorders (TMD),
and bruxism, are ascribed to the alteration of head

ß W. S. Maney & Son Ltd 2015

DOI 10.1179/2151090315Y.0000000015 CRANIOt: The Journal of Craniomandibular & Sleep Practice 2015 VOL . 00 NO . 0 1
Liu et al. Skeletal discrepancy, NHP, craniocervical posture
and craniocervical posture because of the anatomical
and biomechanical relationship between the position
of the head and cervical spine and dentofacial struc-
tures.7–10 It has been shown that nasal obstructions
resulted in elevation of the head, relative to the cervical
column and the true vertical.8 Conversely, reduced
nasal resistance from corticosteroid treatment,
adenoidectomy, or rapid maxillary expansion led to a
flexion of the head and a decrease in the craniocervical
angulation.8 It has also been documented that subjects
with TMD tended to show an increased craniocervical
angulation and a marked forward inclination of the
upper cervical spine,9 while bruxers displayed a more
anterior and downward tilting of the head.10
Meanwhile, according to previous studies, NHP and
craniocervical posture are associated with various den-
toskeletal malocclusions, orthopedic treatments, and
orthognathic surgeries. The relationships between
NHP and various malocclusions, such as crowding in
the maxillary and mandibular dental arches, overbite,
crossbite, and molar relationships have been studied
before.11,12 Solow13 found that subjects with anterior
crowding showed more extended head posture, and he
noticed that there were some correlations between bilat-
eral distal molar occlusion and craniocervical angles.
Additionally, it has been reported that the application
of facemasks with rapid maxillary expansion for
1 year led to a significant flexion of the head.14Mean-
while, mandibular setback surgery for mandibular pro-
trusion was found to increase craniocervical angulation,
while mandibular advancement surgery could result in a
more flexed head posture.15,16
It has likewise been demonstrated that growth
changes in craniocervical posture were related to corre-
sponding changes in the growth pattern of the facial
skeleton, and that in individuals with a large or a
small craniocervical angle, the subsequent facial devel-
opment could, to some extent, be predicted.17 Solow3
noticed that the posture of the head in relation to the
cervical column showed more correlations with facial
morphology than the conventional measures of head
posture. In those studies, subjects with a large
craniocervical angle showed reduced facial prognath-
ism, large mandibular plane inclination, and large
lower anterior facial height, whereas subjects with a
small craniocervical angle, on average, showed a shorter
anterior facial height, larger sagittal jaw dimensions,
and a less steep inclination of the mandible.18
A number of studies have focused on the associ-
ations between craniofacial morphology, NHP, and
craniocervical posture in different populations,
and found that ethnic origin may influence the head
and neck position.3,11,18,19 Compared to the Danish
2 CRANIOt: The Journal of Craniomandibular & Sleep Practice
students’ sample, the Australian Aboriginals were
reported to have a shorter cervical spine, a less
pronounced cervical lordosis, and a larger craniocervi-
cal angle.19 However, how craniofacial morphology in
sagittal or vertical dimension is exactly associated
with the NHP and craniocervical posture, respectively,
in the Chinese population, is still not clear. The aim of
the present study was to investigate the relationships of
sagittal skeletal discrepancy (skeletal class I, II, III),
NHP, and craniocervical posture in young
Chinese children with average vertical facial patterns.
Methods and Materials
Materials
The subjects involved in the present study were selected
from a large pool of patients who sequentially arrived
for orthodontic treatment. Cephalometric radiographs
were taken for diagnosis and treatment purposes. The
final sample comprised 90 children aged 11–14 years,
and was divided into three groups according to ANB
value (Table 1). The primary criteria for inclusion in
the study were Chinese ethnic origin, confirmed date
of birth, nose breathers with complete dentitions, no
history of orthodontic treatment, no wounds, burns,
or scar tissue in the face and neck region, no craniofacial
pathology, i.e. TMD, and average Frankfort mandibu-
lar plane angle (FH/ML). In addition, since the sagittal
skeletal discrepancy can be ascribed to abnormal
growth in the maxilla, mandible, or both, only subjects
with normal SNA and SNB values were selected in the
skeletal class I relationship (group 1), while subjects
with a normal SNA value and a small SNB value were
included in skeletal class II relationship (group 2), and
subjects with a small SNA value and normal SNB
value were selected in skeletal class III relationship
(group 3). Details of the sample are given in Table 1.
The study was approved by the Ethics Committee
of JiLin University. Informed consent was obtained
from all the children and their parents.
Methods
Cephalometric radiographs were taken by a single
technician using ProMax (Planmeca, Helsinki,
Finland). The machine had a standardized focus-film
distance of 164 cm, and the distance from the film to
the medial plane was 19 cm. Exposure data were
60–84 kV and 1–16 mA s.1 The X-ray device had
a focus of 0.5 mm. No correction was made to the con-
stant linear enlargement of 13%. An aluminum wire
was mounted in front of the cassette to indicate a
true vertical position on the film.
The radiographs were exposed with the subjects
standing in self-balance position: the children were
2015 VOL . 00 NO . 0
 Liu et al. Skeletal discrepancy, NHP, craniocervical posture

Table 1 Details of the sample.

SNA angle SNB angle

Description Total/boys Age (years) mean + SD ANB angle (uu) (uu) mean + SD (uu) mean + SD

Number of subjects 90/45 12.32 + 2.32 – – –

Skeletal class I relationship (group1) 30/15 12.43 + 1.14 0–5 81.73 + 1.89 78.95 + 2.21
Skeletal class II relationship (group2) 30/15 12.40 + 1.12 w5 81.58 + 3.01 75.72 + 3.04
Skeletal class III relationship (group3) 30/15 12.13 + 1.67 v0 77.72 + 2.57 80.28 + 2.36

told to make themselves comfortable, relax their arms
by their sides, and stand with their heels together and
toes apart by 45uu. Participants were asked to tilt their
heads forward and backward with decreasing ampli-
tude until they achieved what they considered to be
their natural head posture, and then they were
instructed to look straight ahead. After NHP was
determined, ear rods were inserted into external audi-
tory meatus to make sure no head movements and
horizontal rotation took place during the test. The
radiographs were taken with the lips in light contact
and the teeth in centric dental occlusion.
All cephalometric radiographs were converted to
digital format using a flatbed scanner (ScanMaker
9800XL, Microtek, CA, USA) and measurements
carried out by computer. The reference lines are
listed in Table 2 and Fig. 1. Meanwhile, a description
and meaning of the variables are indicated in Table 3
and Fig. 1. For assessment of the reliability of the
measurements, 26 randomly selected radiographs
were remeasured by the same investigator 2 weeks
after the initial analysis. Cephalometric variables
were compared for each registration, and the error
variance was calculated using Dahlberg’s formula:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
X
Me ¼ d 2 =2n
where d represents the difference between two
registrations, and n is the number of duplicate regis-
trations. Hypothesis testing indicated no significant
differences between the two registrations.
Statistical analysis
All statistical analysis was performed using the
Statistical Package for Social Sciences (SPSS), version
12.0 (SPSS Inc, Chicago, IL, USA). For the purpose
of descriptive statistics, the mean values were indicated
with standard deviations. Students’ t-tests were used to
examine possible differences between genders; however,
no significant differences were found at the 5% level.
Therefore, boys and girls were analyzed as a pool in

Table 2 Illustration of the reference lines.

Reference
line Illustration

NSL Nasion-sella line, the line through N and S

FH Frankfort line, the line through O and P
NL Nasal line, the line through ANS and PNS
ML Mandibular line, the tangent to the lower
border of the mandible through Me
HOR True horizontal line, the line perpendicular to VER
RL Ramus line, the tangent to the
posterior border of the mandibular ramus
OPT Odontoid process tangent. The posterior
tangent to the odontoid process through
the most postero-inferior point on the
corpus of the second cervical vertebra
CVT The line through the most postero-inferior
point on the corpus of the
second and fourth cervical vertebra
EVT The line through the most postero-inferior
point on the corpus of the
fourth and sixth cervical vertebra
VER True vertical line, the vertical line
projected on the film Figure 1 Cephalometric tracing illustrating all angular
S-Go Posterior facial height, distance between S and Go
measurements. The definitions of the postural angles are
N-Me Anterior facial height, distance between N and Me
indicated.

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Liu et al. Skeletal discrepancy, NHP, craniocervical posture

Table 3 Description of variables. three groups for ANOVA, P v 0.05 or v0.01.

No. Variable Description LSD post hoc tests showed that there were statistical
differences between group 2 and group 1 as well as
Sagittal and vertical facial pattern
group 3, P v 0.05 or v0.01, as shown in Table 5.
1 ANB Angle formed by SNA and SNB
2 FH/ML Frankfort mandibular plane angle The values of variables 9–12 (NSL/RL, FH/RL,
3 NSL/ML Mandibular plane angle NL/RL, ML/RL), which represented rotation of
4 S-Go/N-Me Facial height ratio, posterior facial
height/anterior facial height
ramus in relation to cranium in the three groups,
Head posture were largest in group 2 and smallest in group 3, but
5 NSL/VER Angle formed by NSL and VER there were no significant differences among groups.
6 FH/VER Angle formed by FH and VER
7 NL/VER Angle formed by NL and VER However, the measurement of NSL/RL demon-
8 ML/VER Angle formed by ML and VER strated statistically significant differences between
Rotation of ramus in relation to cranium group 2 and group 3 (Table 5).
9 NSL/RL Angle formed by NSL and RL Statistically significant differences were found for the
10 FH/RL Angle formed by FH and RL
11 NL/RL Angle formed by NL and RL variables 13–24 (NSL/OPT, FH/OPT, NL/OPT, ML/
12 ML/RL Angle formed by ML and RL OPT, NSL/CVT, FH/CVT, NL/CVT, ML/CVT,
Craniocervical posture NSL/EVT, FH/EVT, NL/EVT, ML/EVT) representing
13 NSL/OPT Angle formed by NSL and OPT craniocervical posture. It was noticed that values of
14 FH/OPT Angle formed by FH and OPT
15 NL/OPT Angle formed by NL and OPT NSL/CVT, NL/CVT, ML/CVT between group 2 and
16 ML/OPT Angle formed by ML and OPT group 3 appeared significantly different, P v 0.05.
17 NSL/CVT Angle formed by NSL and CVT
18 FH/CVT Angle formed by FH and CVT
Though other variables representing craniocervical
19 NL/CVT Angle formed by NL and CVT posture did not show meaningful differences, they
20 ML/CVT Angle formed by ML and CVT were still highest in group 2 and lowest in group 3, as
21 NSL/EVT Angle formed by NSL and EVT
22 FH/EVT Angle formed by FH and EVT shown in Table 5.
23 NL/EVT Angle formed by NL and EVT Variables 25–30 (OPT/HOR, CVT/HOR, EVT/
24 ML/EVT Angle formed by ML and EVT HOR, OPT/CVT, CVT/EVT, OPT/EVT) represent-
Inclination of cervical column ing cervical column inclination and cervical curva-
25 OPT/HOR Angle formed by OPT and HOR
26 CVT/HOR Angle formed by CVT and HOR ture, respectively, in the three groups, did not
27 EVT/HOR Angle formed by EVT and HOR demonstrate significant differences; however,
Cervical curvature OPT/HOR and CVT/HOR values in group 2 were
28 OPT/CVT Angle formed by OPT and CVT slightly larger than those of group 1 and group 3;
29 CVT/EVT Angle formed by CVT and EVT
30 OPT/EVT Angle formed by OPT and EVT the OPT/CVT angle was largest in group 2 and
lowest in group 3 (Table 5).

the statistical analysis. One-way analysis of variance Discussion

(ANOVA) and post LSD analysis were used to evaluate
the intergroup differences for measurements;
significance level was P v 0.05.
Results
ANB angles, which represented sagittal facial pattern
among three groups, exhibited statistical differences,
and values of FH/ML did not show significant differ-
ence among three groups (Table 4). Both measure-
ments of mandibular plane angle (NSL/ML) and
facial height ratio (posterior facial height/anterior
facial height, S-Go/N-Me) in the three groups exhib-
ited almost the same values (Table 4). Variables repre-
senting vertical facial pattern (FH/ML, NSL/ML,
S-Go/N-Me) did not show statistical differences.
For the variables 5–8 (NSL/VER, FH/VER,
NL/VER, ML/VER) representing head posture,
values were smallest in group 3, largest in group 2,
and there were significant differences among the
In longitudinal studies, NHP has been shown to be
remarkably reproducible, even after 15 years.5,6
Therefore, the slight difference in age among the
three groups should have no effect on the results in
the present study. Although there is still controversy
regarding the influence of gender on NHP and cra-
niocervical posture, this influence was not found in
this study. Meanwhile, the number of boys and
girls in each group was exactly equal to others; there-
fore, the significant differences observed in this study
could be considered as differences totally associated
with the different skeletal relationships rather than
with gender.20,21
Previous studies showed that both sagittal and verti-
cal skeletal facial morphology were associated with
NHP.3 In orthodontics, FH/ML, NSL/ML, and
S-Go/N-Me are measurements frequently used to
evaluate vertical facial patterns of subjects in clinical
work along with literature research.22 Though the

4 CRANIOt: The Journal of Craniomandibular & Sleep Practice 2015 VOL . 00 NO . 0

 Liu et al. Skeletal discrepancy, NHP, craniocervical posture

Table 4 Descriptive statistics of sagittal and vertical facial pattern.

Skeletal class Skeletal class Skeletal class

I relationship II relationship III relationship
No. Variable (group 1) (group 2) (group 3) P P (1–2) P (1–3) P (2–3)
Mean + SD Mean + SD Mean + SD

1 ANB 2.76 + 1.36 5.86 + 1.03 (2.55 + 1.21 0.000 *** *** ***
2 FH/ML 28.93 + 2.52 28.11 + 2.56 29.00 + 1.96 0.299
3 NSL/ML 36.48 + 3.82 36.16 + 3.64 36.33 + 3.51 0.929
4 S-Go/N-Me .6450 + .018 0.6451 + .016 0.6455 + .017 0.876
***P v 0.001.

Table 5 Descriptive statistics of variables.

Skeletal class Skeletal class Skeletal class

I relationship II relationship III relationship
No. Variable (group 1) (group 2) (group 3) P P (1–2) P (1–3) P (2–3)
Mean + SD Mean + SD Mean + SD

5 NSL/VER 96.98 + 5.83 100.50 + 6.57 95.98 + 6.01 0.019 * **

6 FH/VER 89.43 + 4.04 92.44 + 5.32 88.66 + 6.04 0.019 * **
7 NL/VER 88.00 + 5.63 90.82 + 4.96 86.60 + 6.69 0.027 **
8 ML/VER 60.50 + 4.88 64.33 + 5.82 59.66 + 5.80 0.005 ** **
9 NSL/RL 91.13 + 5.06 93.06 + 4.11 90.43 + 3.79 0.074 *
10 FH/RL 84.92 + 4.81 85.20 + 4.65 83.10 + 3.95 0.152
11 NL/RL 82.15 + 4.87 83.38 + 5.10 81.05 + 4.10 0.187
12 ML/RL 54.65 + 6.01 56.89 + 5.66 54.10 + 4.30 0.130
13 NSL/OPT 95.42 + 6.38 98.22 + 6.80 95.55 + 5.66 0.178
14 FH/OPT 87.87 + 5.56 90.17 + 6.82 88.22 + 5.92 0.323
15 NL/OPT 86.44 + 5.21 88.54 + 7.12 86.17 + 5.77 0.283
16 ML/OPT 58.94 + 5.63 62.06 + 6.82 59.22 + 5.73 0.111
17 NSL/CVT 103.03 + 7.77 106.00 + 8.10 101.52 + 7.18 0.093 *
18 FH/CVT 95.48 + 6.23 97.94 + 8.34 94.19 + 7.53 0.162
19 NL/CVT 94.05 + 6.96 96.32 + 7.89 92.14 + 7.22 0.110 *
20 ML/CVT 66.55 + 6.43 69.83 + 8.50 65.19 + 7.29 0.062 *
21 NSL/EVT 107.19 + 9.04 109.48 + 9.16 105.93 + 10.83 0.320
22 FH/EVT 99.67 + 7.76 101.76 + 8.99 98.60 + 9.42 0.450
23 NL/EVT 98.20 + 8.78 100.14 + 8.29 96.55 + 11.18 0.375
24 ML/EVT 70.70 + 8.13 73.65 + 9.07 69.60 + 10.78 0.258
25 OPT/HOR 91.56 + 6.52 92.28 + 6.61 90.43 + 5.02 0.520
26 CVT/HOR 83.95 + 6.38 84.50 + 6.94 84.47 + 5.93 0.935
27 EVT/HOR 100.20 + 6.54 99.31 + 6.52 99.95 + 7.39 0.882
28 OPT/CVT 7.61 + 4.81 7.78 + 5.79 5.97 + 4.06 0.309
29 CVT/EVT 4.15 + 7.61 3.81 + 5.15 4.41 + 8.34 0.953
30 OPT/EVT 11.77 + 9.05 11.59 + 7.93 10.38 + 8.60 0.803

*P v 0.05, **P v 0.01.

FH/ML angle was used in this study to estimate the
vertical facial pattern of the samples, NSL/ML and
S-Go/N-Me were measured, in addition. High
homogeneity in values of FH/ML, NSL/ML, and
S-Go/N-Me among the three groups (Table 4)
indicated that all the subjects participating in this
study had average vertical facial pattern, so that the
connection of the sagittal skeletal relationship, NHP,
and craniocervical posture could be explained by
excluding the influence of vertical craniofacial skeletal
patterns.
Values representing head posture were highest in
group 2 and lowest in group 3. The findings in the pre-
sent study were in accordance with previous studies,
which showed that individuals with a marked mandib-
ular protrusion carried their heads in a more
downward posture than subjects with normal occlu-
sion.15 This phenomenon may be attributed to individ-
uals’ efforts to compensate for the skeletal
discrepancy, as past studies indicated that anterior
and downward head posture has a maxillary protru-
sive and mandibular retrusive effect.17 And after surgi-
cal treatment of the mandibular protrusion, the head
posture was found to be raised.15 In addition, statisti-
cally significant differences were observed between
variables in group 1 and group 2 as well as variables
in group 2 and group 3, but not between variables in
group 1 and group 3. Meanwhile, group 2 showed a
small SNB value, while group 3 showed a small SNA
value, indicating that the mandible might play a
more significant role in determining head posture
than maxillary.23

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Liu et al. Skeletal discrepancy, NHP, craniocervical posture
However, the correlation between head posture
and craniofacial morphology has been a more con-
troversial subject. In one researcher’s study, there
were potentially contrasting results when referring
to different variables.3 Regarding the sagittal jaw
relationship, positive non-topographical correlations
were found with the inclination of the nasion-sella
line to the cervical column and the true vertical,
while ML/VER showed negative non-topographical
correlations with the sagittal jaw relationship.3
D’Attilio et al.21 reported no significant differences
in cranial posture among the three skeletal malocclu-
sion groups, while according to Hedayati et al.’s24
measurement, PNS-ANS/Ver and SN/Ver differed
significantly among the three malocclusions.
It has been demonstrated that changes in head pos-
ture were correlated to craniofacial development and
rotational growth patterns of the mandible in children.
Angles between horizontal craniofacial reference lines
and the ramus represented the rotation of the ramus in
relation to the cranium, the lower the value, the more
forward the rotation of the mandible.25 In the present
study, values of variables 9–12 (representing rotation
of ramus in relation to cranium) were smallest in
group 3 and largest in group 2 (Table 5). These results
were well in line with studies that indicated the
forward rotation of the ramus had a mandibular pro-
trusive effect.25 The growth and rotation patterns in
different skeletal relationships were clarified again in
the present study.
It was found that the craniocervical posture is
related to the craniofacial morphology.3 Values of cra-
niocervical angulation in the three groups followed the
same tendency as discussed above (Table 5), and were
consistent with other reports. Previous studies have
confirmed that children in skeletal class II showed
a significantly higher extension of the head upon the
spinal column compared to children in skeletal class
I and III malocclusion.21 Rocabado et al.26 described
an association between class II malocclusion and a for-
ward cervical inclination, combined with an extended
craniocervical angle.26 Moreover, subjects of skeletal
class II malocclusion tended to suffer from TMD com-
pared with the other two types of malocclusions, and
on average, children with TMD often showed a signifi-
cant sagittal jaw relationship and increased craniocer-
vical angles, which might be an additional evidence
supporting the current study’s findings.9 However,
a study on head posture in 13 class II and 17 class I chil-
dren indicated that distal occlusion and increased
overjet were associated with a flexed head posture
and a backward bend of the spine.27 This disagreement
with previously cited research partially pointed out the
6 CRANIOt: The Journal of Craniomandibular & Sleep Practice
complexity of the developmental behavior of the face
and the spinal column, meaning that further research
is required to clarify this controversial topic.
In the present study, the inclination of the cervical
column among three groups tended to be almost the
same value. Hedayati et al.24 also failed to document
significant differences in the inclination of the spinal
column in his study. However, OPT/HOR and CVT/
HOR values in group 2 were slightly larger than
those of group 1 and group 3, suggesting extension
of the head in skeletal class II subjects.
Though there was no significant difference in OPT/
CVT among the three groups, the OPT/CVT angle
was largest in group 2 and smallest in group 3.
This result was supported by previous studies, which
indicated the weak association between craniofacial
morphology and cervical curvature.20 Tahereh
et al.28 found that the cervical spine was significantly
straighter in skeletal class III subjects. Meanwhile,
there were also some studies that rejected any particu-
lar correlation in subjects with different sagittal jaw
postures and cervical column curvatures.20
The different and sometimes conflicting findings
reported above may, to some extent, have been due
to differences in the samples, designs, and method-
ologies used in the various studies.
The cervical column in a functional and morpho-
logical aspect has a close relation with craniofacial
structures.7 It has been hypothesized that there is a
different developmental origin for the upper and
lower segments of the cervical column, while upper
segment development was considered to be closely
linked to facial development, the lower segment was
classically considered as the final upper part of the
column.21 The difference in developmental origin
may lead to the inconsistent tendency in variables
of EVT/HOR, CVT/EVT, and OPT/EVT, which
involved the lower part of the cervical column.
Studies about the relationships between head pos-
ture and craniofacial morphology suggested that the
craniocervical posture might influence the craniofacial
development.17,22 According to the soft-tissue
stretching hypothesis, an extension of the craniocervi-
cal posture leads to a passive stretching of the soft-
tissue layer and creates a dorsally directed force,
which impedes the forward-directed component of
the normal growth of the face.7 Wenzel et al.29
confirmed this hypothesis and provided evidence
involving neuromuscular feedback and passive stretch-
ing of the soft-tissue layer covering the face and neck.
According to this study, subjects who had mandibular
setback surgery for mandibular prognathism were
found to have angulation of the cranial base to the
2015 VOL . 00 NO . 0

cervical column increased by an average of 2.7uu,
indicating an extension of the head.
Studies of Showfety et al.30 suggested that maxillary
and mandibular incisors and mean incisor overjets, as
well as anteroposterior molar discrepancy, showed no
statistically significant differences between different
head postures, indicating that dental–alveolar discre-
pancy had no influence on head posture. In the present
study, the authors investigated the relationships of cra-
niofacial morphology, NHP, and craniocervical posture
among different sagittal skeletal relationships in young
Chinese children. Nevertheless, based on this cross-sec-
tional study, it is impossible to make any specific con-
clusion that results in determining etiology or cause
and effect relationships from this data. Investigating
these parameters in a longitudinal study is suggested.
Conclusion
Significant differences exist in NHP and craniocervical
posture among skeletal class I, II, and III relationships
in young Chinese children. Generally speaking, the
angles presenting head posture and craniocervical pos-
ture were largest in skeletal class II relationship, fol-
lowed by skeletal class I relationship, and were
smallest in skeletal class III relationship. Subjects with
skeletal class II relationship tended to display more
extended heads, and children with skeletal class III
relationship often exhibited flexed heads.
Disclaimer Statements
Contributors There is no contributors or guarantors.
Funding
Conflicts of interest No conflict of interest exits in the
submission of this manuscript.
Ethics approval The study was approved by the
Ethics Committee of JiLin University.
References
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