International Journal of Pediatric Otorhinolaryngology 73 (2009) 1732–1736

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

The measurement of craniocervical posture: A simple method to evaluate

head position
Antonino Marco Cuccia *, Caradonna Carola
Department of Oral Sciences, Section of Orthodontics, Via del Vespro 129 – 90127 Palermo, Italy

A R T I C L E I N F O A B S T R A C T

Article history: Objective: Some studies have correlated craniocervical posture (CCP) with pharyngeal airway space
Received 8 June 2009 diameter, breathing conditions, neck pain, headache, dentofacial structures and temporomandibular
Received in revised form 4 September 2009 disorders. Several methods have been suggested in an attempt to establish the best way of evaluating
Accepted 6 September 2009
head position using teleradiographs and cephalometric analysis. The objectives of this study therefore
Available online 27 September 2009
were to describe a method of measuring the natural head position (NHP) without exposure to radiation
or fixture of the cephalostat, and then to test whether there might be a simple method of reproducing
Keywords:
this position in the cephalostat to make lateral cephalograms in the study of CCP.
Head posture
Cephalostat
Methods: The sample consisted of 50 healthy children (28 females and 22 males with a mean age of
Temporomandibular disorders 10.9  4.9 years). Each subject was asked to place their feet in a standardized positions (a 308 angle between
Respiratory disease the medial border of the feet with heels together using a V-podalic stabilizer), to tilt the head backwards and
forwards to a decreasing extent until a natural head balance was reached, to adopt a natural posture of the
shoulders, and to allow both arms to hang free. A self-adhesive circular reflecting cutaneous marker was
applied to three points to enable a better view of the landmarks: the most anterior point of the frontonasal
suture (N), the auricular tragus (Tr) and the most prominent spinous process of the seventh cervical vertebra
(C7). An operator marked the specific anatomical points of the children’s profiles with a felt-tip pen on a
mirror placed to one side of the patient and fixed on the wall: the N point, the Tr point, the most inferior point
of the chin in the lateral view (Me) and the deepest point on the posterior contour of the cervical lordosis. A
digital body posture measuring system captured a first image of each subject in NHP (T0). Five minutes later,
with the same position and orientation of the feet, the operator placed the head of the subject in the
cephalostat so that the new head position coincided with the head position previously registered in the
mirror and a second picture was taken (T1). After a further 5 min, the subject was asked to place himself in
NHP again, similarly repositioning their own feet to check the precision of the method of positioning, and a
third picture was taken (T2). Three craniocervical angular measurements were taken for head posture
measurement: N-Tr-Vert, determined by the extended line from the N point to the Tr point and the vertical
line projected onto the image by a line (Vert); C7-Tr-Vert, determined by the extended line from C7 to Tr and
Vert; and C7-Tr-N, the angle between C7-Tr line and Tr-N line. In order to determine the stability of all the
measurements of head position at T1, T2 and T3, a paired-sample t-test was used using an a of 0.05 and a
power of 0.90.
Results: It was found that there were no statistically significant differences in head position between the
pictures at T0, T1 and T2 (N-Tr-Vert, C7-Tr-Vert and C7-Tr-N, P > 0.05).
Conclusion: This method was a good procedure for evaluating head posture without exposure to
radiation. The results also suggest that a simple and rapid method can be used to apply a craniostat to the
patient when a radiograph is required without modifying the NHP.
ß 2009 Elsevier Ireland Ltd. All rights reserved.

1. Introduction position, dental occlusion and neuromuscular activity. Head and

cervical posture evaluation has been a concern for many years, not
Head posture is influenced and controlled by numerous factors: only because of the relationship that exists between head and
visual and vestibular apparatus, proprioceptors of the neck, hyoid cervical posture with temporomandibular disorders, neck pain and
headache, but also because of the biomechanical relationship
between the position of the head, cervical spine, dentofacial
* Corresponding author. Tel.: +39 091 6552232; fax: +39 091 6552232. structures, diameter of the pharyngeal airway space and breathing
E-mail address: [email protected] (A.M. Cuccia). conditions [1–3].

0165-5876/$ – see front matter ß 2009 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2009.09.011
 A.M. Cuccia, C. Carola / International Journal of Pediatric Otorhinolaryngology 73 (2009) 1732–1736 1733

Studies found that nasal obstruction induces a head extension torticollis, scoliosis, kyphosis, stomatognathic, vestibular and
which represents a functional response to facilitate oral breathing visual disorders, previous respiratory illness (asthma and bron-
and to compensate for nasal obstruction [4–6]. chitis), recurrent acute infection of the upper airways or inability to
It has been noted that there are changes in the association perform the procedures proposed in the study.
between the nasopharyngeal resistance and the variations of the Fifty children between 8 and 14 years of age participated in the
craniocervical parameters (with reduction in craniocervical study (28 females and 22 males, mean age 10.9  4.9). All subjects
angulation through head flexion), following a tonsillectomy or were then examined by the same clinicians. Each subject was asked to
adenoidectomy [7–9], rapid maxillary expansion [10], and after place their feet in a V-podalic stabilizer so that each child could be
cortisone therapy (budesonide) in children with asthma and similarly repositioned when checking the precision of the method,
chronic rhinitis [11]. with their lower limbs relaxed, and determining the natural position
The existing correlations among breathing, craniocervical of the head by tilting the head backwards and forwards to a
posture and craniofacial development find further confirmation decreasing extent (to find the most neutral position) [27].
in research on the morphogenetic consequences of bronchial Photographs were taken in lateral views with a digital body
asthma and of chronic allergic rhinitis [12,13]. posture measuring system (Body Analysis Capture, Milletrix,
The concept of natural head position (NHP) was introduced to Diasu, Roma). The telecamera was positioned on a tripod at a
orthodontics in the 1950s by Downs, Bjerin, Moorrees [14–16]. distance of 60 cm from the right side of the patient’s face; the first
Although it has been under discussion for so long, a single picture (T0) taken was horizontal to the floor with the help of a
definition of NHP still does not exist, other than it being a position guiding system (Fig. 1).
naturally assumed by a relaxed subject in orthoposition with his/ A mirror (40 cm  50 cm) was fixed on the wall and could be
her eyes fixed towards the horizon and without any external moved vertically depending on the patient’s height. A self-
interference [16–19]. adhesive circular reflecting cutaneous marker (0.5 cm radius)
Various methods have been used to reproduce NHP in the was applied to these points to assist identification of the picture:
cephalostat.
Usumez and Orhan [20] developed a lighter inclinometer  Nasion (N, the junction of the frontonasal suture at the most
connected with a pair of glasses. It has two sensors for measuring anterior point on the curve at the bridge of the nose),
the pitch and roll of the head.  auricular tragus (Tr) and
Murphy et al. [21] constructed such a device by using a  C7 (the most prominent spinous process of seventh cervical
contactless, precision potentiometer capable of measuring single- vertebra).
axis angles. They found that this device could make continuous and
accurate recordings of cranial posture. The operator was guided by a co-worker looking at the live NHP
Ferrario et al. [22] have used the photographic superimposition directly on the monitor. The operator marked the following specific
method: the NHP is captured on a photograph with a plumbline anatomical points on the mirror with a felt-tip pen:
hanging in front of the face and then superimposed onto a
conventional cephalogram for teleradiographic measurements.  N,
Various methods have been proposed to identify the true  Menton (Me, the most inferior point of the chin in the lateral
vertical on the face of the subject in NHP, using a light, placed at the view),
height of the patient’s head or a laser level beam which showed  Tr and
respectively a shadow of the suspended plumbline or a red cross-  the deepest point on the posterior contour of the cervical
light on the left side of the patient’s face. In both cases, two metal lordosis.
beads were fixed along the vertical reference on the face and the
cephalometric radiographs were taken in the standard manner. Five minutes later, the subject was asked to place himself in
The metal beads gave radiopaque shadows, which were connected NHP once more, positioning their own feet on the V-podalic
as a natural vertical axis on the lateral cephalogram [23,24]. stabilizer again.
Showfety et al. introduced a bubble air device that reduced the
error positioning to 28 [25].
Even though natural head position is appropriate and valid, it
has been abandoned for reasons of time-consumption and the
additional complex equipment needed. The objectives of this study
were to describe a method of measuring NHP without exposure to
radiation or fixture of the cephalostat, and to assess whether there
might be a simple method of reproducing this position in the
cephalostat to make lateral cephalograms in the study of CCP.

2. Materials and methods

The study was approved by the Ethics Committee of the

University of Dentistry, Palermo, Italy, and informed consent was
obtained from all the children’s parents.
Sample size calculation was obtained using a paired t-test with
a power of 0.90 a = 0.05 using the minimum value of 2.21 of
difference between variables. Based on these criteria, approxi-
mately 50 patients were needed [26]. The sample was recruited
from the Department of Oral Sciences, University of Palermo, Italy.
The children were selected on the basis of the following
inclusion criteria: absence of lower extremity neuromuscular and/ Fig. 1. A gauding system allows to position the telecamera in perfect horizontal
or musculoskeletal problems, facial or spinal abnormalities such as position.
1734 A.M. Cuccia, C. Carola / International Journal of Pediatric Otorhinolaryngology 73 (2009) 1732–1736

Fig. 2. The operator placed the head of the subject in the cephalostat.
Fig. 3. Cutaneous lines and angles used in the study. The angles were automatically
calculated by the software.

The operator placed the subject’s head in the cephalostat to  N-Tr-Vert angle allows the evaluation of the inclination
coincide with the head position previously registered and a second compared to the vertical plane;
picture was taken (T1, Fig. 2).  C7-Tr-Vert angle represents the cervical inclination compared to
After another 5 min, the subject was asked to place himself in the vertical plane;
NHP again, placing their feet in the same position to check the  C7-Tr-N angle represents the craniocervical angle (Fig. 3).
precision of the method and a third picture was taken (T2).
Software photographs were taken which allowed us to trace 3. Statistical analysis
lines and calculated the values of the angles formed. The true
vertical was marked in each film automatically with a green line. The data are presented as means, standard deviation (SD). To
The angles selected are considered the most representative of determine the stability of all the measurements of head position
CCP in the studies made with photographs [4,28]: without (T0 and T2) and with the cephalostat (T1) a paired-sample

Table 1
Values of angular measurements in the sample (n = 50) at the first picture (T0), after 5 min (T1) and after 10 min with cephalostat (T2).

Angular measurements NHP T0 NHP T1 95% confidence interval Paired t-test

Mean S.D. Mean S.D Upper Lower

N-Tr-Vert (8) 108.3 6.071 109 3.597 2.68 1.28 P = 0.485

C7-Tr-Vert (8) 31.12 5.789 30.33 5.361 1.424 3.004 P = 0.481
C7-Tr-Na (8) 137.9 5.651 139.4 4.528 3.532 0.5322 P = 0.146

NHP T0 NHP T2

N-Tr-Vert (8) 108.3 6.071 110.1 4.706 3.956 0.3558 P = 0.101

C7-Tr-Vert (8) 31.12 5.789 28.82 6.079 0.05587 4.656 P = 0.056
C7-Tr-Na (8) 137.9 5.651 138.8 6.606 3.34 1.54 P = 0.466

NHP T1 NHP T2

N-Tr-Vert (8) 109 3.597 110.1 4.706 2.958 0.7585 P = 0.234

C7-Tr-Vert (8) 30.33 5.361 28.82 6.079 0.1922 3.217 P = 0.080
C7-Tr-Na (8) 139.4 4.528 138.8 6.606 1.975 3.175 P = 0.635

Table 2
Angular measurements of 10 patients without cephalostat (Wo) and with cephalostat (Wi) at the first picture (T0) and 2 days after the first picture (T1).

Angles T0 Wo T1 Wo T0 Wi T1 Wi

Mean SD Min Max Mean SD Min Max Mean SD Min Max Mean SD Min Max

N-Tr-Vert 108.9 3..9 91 119 108.2 3.7 92 117 107.9 5.1 92.3 123 110.9 4 91.4 124.1
C7-Tr-Vert 32 6.1 21.3 40.1 29.2 5 21 39.8 27 5.7 20.4 38.6 27.7 4.9 19.8 37.5
C7-Tr-Na 137.4 4.1 111.4 151 139.9 4.2 110.9 150 136.9 6.1 113 141 140.1 7.1 111.9 138.9

ANOVA one-way

T0 Wo vs T0 Wo vs T0 T0 Wo vs T1 T1 Wo vsT0 T1 Wo vs T1 T0 Wi vs T1
T1 Wo (P value) Wi (P value) Wi (P value) Wi (P value) Wi (P value) Wi (P value)

N-Tr-Vert NS NS NS NS NS NS
C7-Tr-Vert NS NS NS NS NS NS
C7-Tr-Na NS NS NS NS NS NS

Wi (with cephalostat), Wo (without cephalostat), SD (standard deviation), NS (not significant), Min (minimum), Max (maximum).
 A.M. Cuccia, C. Carola / International Journal of Pediatric Otorhinolaryngology 73 (2009) 1732–1736 1735

t-test was used (Table 1). To see if individuals repeated their general, a unique static position but a prime position in a small
positions with and without the cephalostat, duplicate pictures range of body positions.
were made of 10 patients after 2 days. The differences between the In the present study a photographic technique was used
angular variables were evaluated with a one-way repeated to avoid exposing the subjects to radiations, photographic
measures analysis of variance (Table 2). Data were analyzed using techniques being a valid and effective tool in the study of CCP
Primer of Biostatistics for Windows (version 4.02, McGraw-Hill [22,38].
Companies, New York) [29]. Significance for all statistical tests was Some techniques may offer more precise data on CCP, but they
set at P < 0.05. expose subjects to irradiation for relatively long periods of time
[39,21].
4. Results The method proposed permits the carrying out of cephalograms
in NHP very simply. Two operators are required, the first helping
Table 1 shows the results of the tracings made of lateral view the subject achieve a balanced position on the monitor, and the
photographs of the head and neck. The values are expressed in second marking the reference points on the mirror, and in this way
degrees. No statistically significant differences in head posture placing the subject in NHP in the cephalostat. This method also
were observed between the angular measurements at T0, T1 and takes into account the whole body posture rather than the
T2. craniocervical area only; the V-Podalic stabilizer ensures a
No statistical differences were found for any of the angular standard position of the feet so that the craniocervical posture
parameters in the 10 patients between measurements with and will not be influenced by varying foot position.
without the cephalostat at the first visit and 2 days after the first This method is valid not only for the study of craniocervical
visit (Table 2). posture, but also in making cephalometric tracings in the daily
practice, since the NHP constitutes the most valid alternative for
5. Discussion cephalometric analysis.
The great variability that characterizes the intracranial
NHP is the normal balanced position of the head adopted for reference lines (Sella-Nasion, Basion-Nasion, Porion-Orbital)
viewing the horizon or an object at eye level. Determination of NHP when compared to the true horizontal, shows that the inclination
is useful in the orthodontic diagnosis, in the treatment planning for of such reference lines does not represent head posture in a
the surgical management of craniofacial dysmorphic conditions reliable way, and nor is it reliable in cephalometric analysis and in
and in the evaluation of the position of cervical spine and head treatment planning. Leitao and Nanda [40] advise against using
posture among patients with temporomandibular disorders, the S-N reference line, since it has very varying results. For
breathing problems, neck pain, headache and malocclusion example, an SNB angle of 728 (normal value 80  28) does not
[22,30–34]. necessarily mean a retrognatic position of the jaw, since it can also be
A number of valid techniques exist in the literature for due to extreme inclination of the SN line owing to a low position of
transferring the NHP to the cephalostat. However, some of them the sella turcica.
call for sophisticated electronic equipment or procedures that
takes a long time to record and process the photograph, enlarge it 6. Conclusion
accurately to the same size as the radiograph, and then transfer the
natural vertical to the radiograph. Our results demonstrate that it is possible to study the
The objective of this study was to determine if there were any craniocervical posture in children without their exposure to
differences in some craniocervical variables when pictures are radiation or any necessary fixation, and the absence of significantly
taken in the sagittal plane using a normal balanced position with difference in head posture pattern between children with and
and without the cephalostat. without cephalostat. Our results also demonstrate the importance
Various authors recommend the use of the cephalostat and ear- of using reliable measurements in the assessment of children’s
rods in the external acoustic meatus to study the CCP in order to head posture, helping the physical therapists to study the effects of
allow good quality reproduction of the teleradiographs [34,35]. stomatognathic and respiratory systems diseases on head and neck
However, rigid head fixation with the cephalostat prevents the posture in children.
head from achieving a relaxed natural position.
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