CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Forward Head Posture: Its Structural and

Functional Influence on the Stomatognathic
System, a Conceptual Study

Humberto E. Gonzalez D.D.S. & Arturo Manns D.D.S., Odont. Dr.

To cite this article: Humberto E. Gonzalez D.D.S. & Arturo Manns D.D.S., Odont. Dr. (1996)
Forward Head Posture: Its Structural and Functional Influence on the Stomatognathic System, a
Conceptual Study, CRANIO®, 14:1, 71-80, DOI: 10.1080/08869634.1996.11745952

To link to this article: http://dx.doi.org/10.1080/08869634.1996.11745952

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 • REHABILITATIVE MEDICINE

Forward Head Posture: Its Structural and

Functional Influence on the Stomatognathic System,
a Conceptual Study
Humberto E. Gonzalez, D.D.S.; Arturo Manns, D.D.S., Odont. Dr.

ABSTRACT: An extensive conceptual analysis to establish the primary role a forward head posture
plays in the appearance of sorne craniomandibular dysfunctions and internai derangements of the tem-
0886-9634/1401- poromandibular joints, associated to craniocervical postural disturbances. The analysis is based on find-
071$03.00/0, THE
JOURNAL OF ings contributed by scientific investigations in the field of dentofacial orthopedies and dysfunction.
CRANIOMANDIBULAR Special emphasis has been put on the influence of forward head posture on the craniofacial growth as it
PRACTICE,
Copyright© 1996 can determine a morphoskeletal and neuromuscular pattern leading to a dysfunctional condition. A cor-
by CHROMA, lnc. relation is established between Class Il Occlusion, forward head posture, and craniomandibular dys-
Manuscript received function. The concept of craniocervical postural position is defined, as weil as its close relation to the
June 29, 1995; revised
manuscript received mandibular postural position.
November 9, 1995; accepted
November 9, 1995
Dr. Humberto E. Gonzalez
Av. Salvador 149, Of. 904
Santiago, Chile

n human organisms require a stable and balanced

Dr. Humberto Gonzalez received his

DD.S. degree at the School of
Odonto/ogy at the Universidad de Chile in
1986./n 1992 he attended a postgraduate
course in "improvement of Occlusion" at
the University. During his professional
career he has participated in a number of
courses on the same subject. He special-
izes in oral rehabilitation.
Dr. Arturo Manns is a full professor on
the Faculty of Medicine and Ondonto/ogy,
Universidad de Chile and head of the
Oral Physiology Laboratory. He also
holds thefol/owing positions: Fe/lowship
at the Humboldt Foundation in Germany
and Visiting Professor, Faculty of
Odontology, Universidad de Concepcion,
Chile. He is the author of a book entitled,
"Stomatognathic Physiology" (published
in Spanish). He has also published numer-
ous book chapters and articles in severa/
journals in the field of Oral Physiology,
Occlusion and Dysfunction. Dr. Manns
has given lectures and taught postgradu-
ate courses in Chile and other countries.
A body posture as the support on which voluntary
and coordinated movements may be initiated as
part of the ir natural functions. The neuromuscular system
is ultimately responsible for always maintaining this pos-
ture so that, in order for a certain muscular group to exer-
cise its protagonistic action, there necessarily must exist
another group of muscles providing the stabilizing and
positioning effect for the bone structures to execute a vol-
untary action. The locomotive system receptors, espe-
cially those of muscles and joints, inform the central
nervous system of changes in position and movement so
these nervous centers may process said sensory input and
generate a response expressed as a muscular activity that
modifies a certain posture.
The stomatognathic system is not alien to these events
and requires a stable muscular-skeletal posture to per-
form its multiple daily functions. Form and function are
closely linked, and any alteration in form or position may
also alter the system's healthy functioning.
Recent publications have brought to light the fact that
the head posture is affected in subjects with cran-
iomandibular dysfunction (CMD). Huggare and Raustia 1
demonstrated that patients suffering CMD held their
heads raised significantly higher, and in ali cases a
greater cervical curvature (hyperlordosis) could be
observed, even if not in a statistically significant mea-
sure. Moya, et al.,2 when treating patients with spasms of

71
FORWARD HEAD POSTURE: A CONCEPTUAL STUDY GONZALEZ AND MANNS

the stemocleidomastoid and trapezius muscles by means development of the face are shown in the following out-
of an occlusal splint of 4.0-5.5 mm thickness, demon- lines(Figures 1 and 2).
strated that the increase of the vertical occlusal dimension A. Ventroflexion of head on cervical spine is expressed
generates a significant craniocervical extension and as follows:
decrease of the lordosis in the cervical spine. This true - Small craniocervical angle
interrelation established between the head and neck ( ' NSL/OPT - NSL/CVT)
posture on the one band and the vertical occlusal dimen-
sion on the other becomes strongly altered when indi-
viduals permanently adopt a forward head position. This
postural bad habit affects the craniocervical posture, as
well as the mandibular postural position3-6 in such a way
that a craniomandibular dysfunctional condition may
become manifest.
The purpose of the present study is to analyze the
consequences of adopting a forward head position in
form as as well as in fonction of the stomatognathic
system, and its possible primary role in the development
of a craniomandibular dysfonction.

Rationale

The forward head position is characterized by a dorso-

extension of the head together with the upper cervical
spine (Cl-C3), accompanied by a flexion of the lower
cervical spine (C4-C7), whereby the cervical curvature
is increased, a condition called hyperlordosis. This ab-
normal postural position is most frequently adopted
and maintained by patients as a response to a psycho-
affective or pathological condition,7 exercising a deep
Figure 1
structural as well as functional influence on the stom-
atognathic system.

Structural Influences

From a structural viewpoint, the significant correlation

existing between head posture and craniofacial and den-
toaveolar morphology bas been proven. 8- 10 Solow, and
Tallgrenlo could determine through a cross study using
cephalometry, that the extension of the head on the cervi-
cal spine is associated to a significant mandibular retro-
sion. Later they confirmed this finding by longitudinal B
studiesll· 12 and found that the craniocervical extension
correlates in a significant way with a facial growth pat-
tern of vertical type. It becomes evident that the head pos-
ture deeply influences the facial growth direction, which
refers to the craniocervical angulation and cervical incli-
nation and the subsequent sagittal or vertical develop- RE Fmi
ment of the face. The craniocervical angulation determines ML
an an teri or or posterior rotational growth of the jaw,
Figure2
which depends on the head showing a ventroflexion or a In Figures 1 and 2, referenc:e points and lines on the cephalometric
dorsoextension respectively. All of the foregoing and the radiographs. Sorne postural angles are indicated. For definitions see
consequences of the craniocervical angulation on the Solow and Tallgren 10 and Solow and Siersbaek-Nielsen."

72 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JANUARY 1996, VOL. 14, NO. 1

GONZALEZ AND MANNS
- Retroinclination of cervical spine
( AOPT/HOR - CVT/HOR)
Associated to:
1. Horizontal and sagittal facial development
(brachifacial).
2. lncrease of the upward and forward mandibular
rotation.
( ' ref crb/ML-NSL/ref ml-ref crb/ref ml)
3. lncrease of facial prognathism.
( As-n-ss 1s-n-sm 1sn-pg)
4. Lesser anterior facial height, greater posterial
facial height.
( ' n-ss 1sp-gn 1n-gn s-pm 1cd-tgo 1
ar-tgo 1s-tgo)
5. Scarce mandibular inclination with respect to
the nasal plane and NSL.
(' NL/ML- NSL/ML)
6. Major lengthwise growth of the upper jaw.
( Ass-pn 1sp-pm 1n-sp)
7. Scarce backward displacement TMJ.
( 'n-ar 1s-ar 1n-s-ar)
8. Larger nasopharyngeal space.
( An-s-pm 1pm-s-ba 1cv 2•P - cv 4iP)
9. Lesser skull base angulation.
( 'n-s-ba 1NSL-FMP 1s-b-o)
B. Dorsoextension of head on cervical spine (as present
in forward head position), is expressed as follows:
- Large craniocervical angle
( A NSL 1OPT - NSL 1CVT)
- Proinclination of cervical spine
( ' OPT 1HOR - CVT 1HOR)
Associated to:
1. Vertical type development of face (dolicho-
facial).
2. lncrease of backward and downward mandibu-
lar rotation.
( A ref crb 1 ML-NSL 1ref ml - ref crb 1ref ml)
3. Reduction of facial prognathism.
( ' s-n-ss 1s-n-sm 1sm-pg)
4. Greater anterior face height, lesser posterior
face height.
( A n-ss 1sp-gn 1n-gn ' s-pm 1cd-tgo 1
ar-tgo 1s-tgo)
5. Greater mandibular inclination with respect to
the nasal plane and NSL.
( ANL/ML- NSL/ML)
6. Scarce lengthwise growth of the upper jaw.
(' ss-pm 1sp-pm 1n-sp)
7. Great backward displacement TMJ.
( A n-ar 1s-ar 1n-s-ar)
8. Smaller nasopharyngeal space.
( ' t n-s-pm 1pm-s-ba 1
JANUARY 1996, VOL. 14, NO. 1
FORWARD HEAD POSTURE: A CONCEPTUAL STUDV
CV 2sp- CV 4ip)
9. Greater skull base angle.
(An-s-ba/ NSL-FMP 1s-b-o)
10. Retroinclination of upper incisors.
( ' over jet 1pr-n-ss)
11. Associated to Class II skeletal type.
Ali of the foregoing suggest the presence of a growth
mechanism coordinated between facial development and
head posture.
This mechanism was presented by Solow and
Kreiborg, 13 who developed a hypothetical model, where
the obstruction of the upper airway would lead to an
increase of the craniocervical angulation in order to ease
breathing. This would stretch the soft facial tissue layer
covering the face and neck, especially the suprahyoid
muscles, 14 whereby the downward and backward strength
component produced by the tension of the soft tissues
on the mandible, would restrict or redirect the facial
development into a more caudal direction. This combin-
ation would explain the vertical type growth of the face
that may be observed in patients with craniocervical
dorsoextension. Ali of the foregoing should explain
how the head posture affects the development of the
face, but: "What is the cause leading to increased cranio-
facial angulation?"
It bas been widely demonstrated that there exists a
relationship between airway adequacy and head pos-
ture.1S-1SThis airway adequacy may be interpreted as the
maintenance of a sufficient nasopharyngeal space to
develop sorne physiological functions of the stoma-
tognathic system, such as breathing, swallowing and
phonoarticulation. 19 Of these, breathing is the most essen-
tial function and bas a vital importance for the sustenance
of life. Therefore, to properly breathe, the organism bas
to be able to adapt to conditions hindering it. This adapt-
ing implies a certain.muscular function capable of con-
trolling the position of mandible, lips, tongue, and skull
with respect to the cervical spine to ease breathing. 20 This
was experimentally proven by Vig, 21 who compared the
craniocervical angulation before and after total ob-
struction of nasal breathing in normal individuals. He put
a clip on their noses and blindfolded them. The ex-
periment led him to conclude that total nasal obstruction
leads to a progressive extension of the head, that is, to
an increase of the craniocervical angulation that is mani-
fest during the first fifteen minutes and peaks after one
and a half hours. Blindfolding did not produce any alter-
ation. When considering that breathing may be restricted
by anatomie or allergie factors, it is evident that there is a
sequence of biologie events beginning with a nose
obstruction maintained in the course of time, that leads to
physiological changes. These changes produce a cranio-
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 73
FORWARD HEAD POSTURE: A CONCEPTUAL STUDY
cervical postural adaptation to facilitate breathing, which,
in turn, leads to a postural mandibular adaptation, and
finally brings about a change in the skeletal growth
with dentoalveolar compensation or adaptation. The
aforementioned craniocervical postural adaptive change
to facilitate breathing corresponds in the great majority
of cases, to forward head position, but how do we get to
this conclusion?
When departing from the basic fact that normal breath-
ing in human beings is nasal, any restriction hindering
their airway shall necessarily lead us to oral breathing,
which is phylogenetically more primitive. An example of
nasal obstruction is the presence of adenoids. 22-25 Therefore,
to breathe through the mouth, the mandible bas to be low-
ered. This produces a decrease of the tension of the
suprahyoid muscles. The hyoid bone is freed of the sus-
pensory muscular action and is allowed to faU down-
wards and backwards, reducing the pharyngeal air
passage. Consequently, the head bas to assume a farther
forward and more extended position in order to passively
move the hyoid bone forward and upward by tensioning
the suprahyoid musculature, and the dimension of the air
passage is restored. We can visualize the forward head
position accompanied by a craniocervical dorsoextension
as an adaptive response to alterations of the airflow. If
this pathological condition is maintained over a long
time, it leads to an altered muscular activity that may
influence the bone growth and generate morphological
facial changes. These changes are characterized by indi-
viduals with dolichofacial features, a Class II skeletal
frame and great divergence in their maxillary bases,26 as
described by Ricketts. 27
Functional Influences
Before describing the disturbances of the stomatog-
nathic system's fonctions produced by forward head
position, we have to briefly describe the ideal state, the
mechanisms of craniocervical postural control, and the
causes of forward head position.
Under normal conditions the head is dynamically bal-
anced on the cervical spine when our eyes look towards
the horizon. In this position, proper to all biped beings,
the head fonctions by itself as a first class lever. Kapandji2 8
describes the position as follows: "When placing the
point of support at the leve) ofthe occipital bone condyles,
the major mass of the head is located in the front of the
fulcrum and tums into the lever resistance, whose center
of gravity is located close to the sella turcica. The strength
is represented by the neck muscles which have to com-
pensate the head's weight at all times." In this position,
the cervical spine presents a slight curvature that is con-
74 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
GONZALEZ AND MANNS
cave in back, also known as physiologicallordosis. 1t fol-
lows that the posterior cervical muscles must have a con-
stant muscular tonus to prevent the head from falling
forward. This biomechanical craniocervical balance
should be maintained at ali times, because neck muscles
only need a slight, although sustained, muscular con-
traction without exerting a major energetic effort to
balance the system within its physiological area.
The head is able to maintain this position through cer-
tain neuromuscular mechanisms that regulate posture.
These may be subdivided in peripheral or sensorial and
central, or cerebral ones. Both mechanisms definitely
modulate the activity of the alphamotoneurons. 29
Kraus7 describes three peripheral control mechanisms.
The first of these corresponds to the vestibular system
pertaining to the internai part of the hearing organ, whose
sensorial receptors, located in the semi-circular channels,
detect the position of the head and its change in space,
acting as a balancing organ. The second control mecha-
nism corresponds to the ocular system which, in addition
to giving the spatial perception by locating the visual
field, also bas a proprioceptive ocular fonction that gen-
erates a synergie activity between neck muscles and eye
muscles. Both systems play an important role in main-
taining the head position, as well as in coordinating the
movements ofeyes, head and neck through the labyrinthian
and the ocular straightening reflexes, 30 which both have
the ability to influence the neck muscles' activity. The
third mechanism, corresponds to the proprioceptive
system of the neck formed by the neuromuscular spindles
and the articular mechanoreceptors. The most important
of these is the latter, because they produce the tonie neck
reflex (TNR),3 1 which is activated by stimulation of the
tendinous Golgi organs when the ligaments of the cervi-
cal spine are stretched. This, in turn, produces a reflex
contraction of the neck muscles, allowing one to keep the
head always raised. This latter mechanism is thought to
provide the basic control of the craniocervical posture,
since although the first two pass on the information ofthe
head position in space and are unable to determine the
angle formed between head and cervical spine. This ori-
entation can only be achieved by the neck's propriocep-
tive system. In our opinion, a fourth peripheral mechanism
should be described, which would correspond to
interceptors informing the adequate airflow. This mecha-
nism would be able to influence the cervical muscular
activity in such away asto generate a postural change in
order to ease breathing in case it bas been hampered.
Autonomous reflexes of bulbar integration such as swal-
lowing, coughing, sneezing, or vomiting, in order to be
performed, need an adequate adjustment of breathing and
of the craniocervical posture.32 A more extensive investi-
JANUARY 1996, VOL 14, NO. 1
GONZALEZ AND MANNS
gation shaH be needed to prove the neurophysiological
basis of this hypothesis.
The central neuromuscular mechanisms controlling the
craniocervical posture are the same ones that determine
the body posture. Possibly, the head orientation could be
achieved by an interaction ofthe peripheral system (tonie
neck reflex) and the cerebral control system. Influences
on the head posture coming from the latter system seem
to be expressed through the tonie neck reflex.
When both neuromuscular mechanisms, previously
described (peripheral and central), have failed to achieve
and maintain the straight postural position of the indi-
vidual, the craniocervical posture most commonly adopted
by patients is the forward head position. Reasons why
this happens are outlined in Table 1.
Actually, the causes described above would act as
predisposing or triggering factors for forward head
posture. It must be pointed out especially that this mal-
position is adopted gradually as a consequence of adap-
tive or compensatory cervical phenomena in response to
the presence of the causes mentioned earlier. In this adap-
tive state, patients lack the cognitive ability to become
aware of their malposition which, consequently, can not
be self-corrected. This happens because the afferent input
coming from the peripheral system that has gradually
become disturbed, is interpreted by the central control
system as being correct. As a consequence, a self perpetu-
ating condition arises. This condition does not in itself
constitute a pathology. In fact, it is a balancing reaction of
the organism, but if kept up for a prolonged period of
time, it alters the whole system's normal functioning and
consequently leads to the potential development of an
associated pathology.
After establishing the causes of forward head position
and its craniocervical postural control mechanism, we
shall analyze the physiological/functional consequences
that such a condition may bring about for the stomtog-
nathie system.
Table 1
Possible Causes Of Developing FHP
1. Altered neurimuscular feedback:
- Peripheral: Visual, proprioceptive, reticular, semi-circular,
neural disturbances.
- Central: Emotional psychic conditions, stress.
2. Obstructed airway:
-Nasal obstruction -Nasal allergy
-Adenoids - Septum deviations
3. Posture:
-Cervical macrotrauma (whiplash) -Bad habit
- Cervical microtrauma - Labor activity
-Cervical spine abnormalities - lnheritance
4. Soft tissues:
- Tissue scar
JANUARY 1996, VOL. 14, NO. 1
FORWARD HEAD POSTURE: A CONCEPTUAL STUDY
Basieally, a change of head posture can produce a
change of mandibular position. Severa} investigations
have proven such a statement. Daily33 demonstrated
that a bite opening experimentally produced by a mechan-
ical deviee was accompanied by a significant cranio-
cervical extension. In patients who received immed
iate complete dentures, Tallgren, et al.34· 35 determined
that changes in the mandibular inclination due to reab-
sorption of the bone ridges were accompanied by changes
in the craniocervical posture. Salonen, et al. 36 who also
worked with patients wearing complete dentures, found a
significant relationship between head posture and physio-
logical freeway space.
Smith, 37 discussing the investigation mentioned above,
emphasizes that the head posture has to be considered in
relation to the mandibular posture. Urbanowicz 38 claims
there exists a real interrelation between craniocervical
and mandibular postures. Goldstein and Kraus, et al. 39 by
using kinesiograph, determined that the forward head
position was accompanied by a change in the mandibular
postural position (MPP) that showed as a significant
decrease of the physiologieal freeway space as a result of
an upward and backward displacement of the mandible.
This elevated and retruded mandibular postural position
caused by forward head position is due to influence
exercised by the muscular activity as well as the tissue
elasticity of the mandible. Severa} reports point to
the presence of a change in the EMG activity of the
masticatory muscles caused by changes in the head
position. 40·42 Funakoshi and Fujita43 determined that
the craniocervical dorsoextension produced a greater
muscular activity in the temporal muscle and a moderate
increase in the masseter. The digastric muscle in tum, did
not show any variations in its muscular activity. Boyd44
later obtained the same results. Funakoshi and Amano,45
experimenting with decerebrated rats, found that the
tonie neck reflex has a facilitatory influence on the masti-
catory muscles and increases their muscular tonus. They
also found that the extension of the head produces an
increase of the muscular activity in the temporal and mas-
seter muscles. The muscular activity resulting from the
craniocervieal extension produces an elevation and retro-
sion force that acts on the mandible, which results in a
decrease of the physiological freeway space. 46 On the
other hand, the tissue elasticity, mainly represented by
the visco-elastie properties of the muscular and tendinous
connective tissues, can also influence the mandibular
postural position, when they are stretched as a result of
forward head position. During the craniocervical exten-
sion, the tension of the mastieatory and suprahyoid mus-
cles increases, which leads to a mandibular elevation and
retrusion; 47 -49 Based on the foregoing we conclude that
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 75
FORWARD HEAD POSTURE: A CONCEPTUAL STUDV
forward head position can exercise an influence on the
position as well as on the movement of the mandible.
The position, represented by the mandibular postural
position is now more elevated and retruded and, there-
fore, a reduction of the physiological freeway space may
be observed. The movement represented by the path of
mandibular closure now occurs farther backwards than
usual which makes the initial occlusal contacts locate
farther back than the maximal intercuspal position. Being
aware that ali movements start from a certain rest
position, which in this case would be the mandibular
postural position, we may deduce that, if this position is
altered, the movement shall also undergo an alteration.
Based on this principle, McLeanso studied variations in
occlusal contacts induced by changes of the body posture
in straight as weil as, in supine position. His results
proved that the occlusal contacts were more retruded in
the supine position than in the straight position. Recently,
Makofsky,s 1using a computerized instrument known as a
T -scan, recorded dental contacts of patients who bad
undergone a surgical fusion of the craniovertebral region
which prevented them from making normal movements
of head dorsoextension and ventroflexion. The record-
ings of dental contacts he obtained from these patients
were different from those of the control group. therefore,
he suggests that a craniovertebral fusion alters the effect
of the head posture on occlusion. Other studies confirmed
the same findings.s2-5 4 Mohl5 5 proved that the habituai
path of closure depends on posture. The craniocervical
tension alters the mandibular closure path, moving it far-
ther backward. Thus, functional influences that a forward
head position may exercise on the stomatognathic system
may be seen in the following diagram.
Muscular activity
0 /t
(ALTERED)
'\..r_L
Discussion
Based on proven scientific findings, alteration of the
craniocervical posture (FHP) is capable of generating a
very definite pattern of changes, in craniofacial morph-
ology. These changes are linked to an alteration of the
system's normofunction in such a way that it may be
76 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
GONZALEZ AND MANNS
stated that forward head position can exercise an influ-
ence on the shape as weil as on the function of the whole
stomatognathic system, which means:
Biological
condition GENERATES Shape LEADJ!O Function
FHP Specifie Altered Nor-
Morphological mofunction.
Craniofacial Pattern
This postural condition creates a biological state that is
likely to lead to a dysfunctional condition:
1. Alterations of the sensorial peripheral input as,
i.e., an obstructed airway 21 , psychic conditions57
or others (Table 1) generate a specifie muscular
function.
2. This new muscular activity in response to the dif-
ferent stimuli present, leads to a structural adapta-
tion,ss in this case forward head position.
3. If forward head position is maintained over an
individual's whole period of growth and develop-
ment, it is likely to produce a change in direction
of the craniofacial and dentoalveolar growth as a
result of the new muscular activity:9· 11 facial
development of a vertical type (dolichofacial),
backward displacement of the TMJ, facial retrog-
nathia, a wider gonian angle, 12 in other words, a
Class II skeletal type may be observed associated
to craniocervical extension.
4. In this close relationship between forward head
position and a Class II skeletal type, it may be
observed that the muscular activity42· 43 and tissue
elasticity 47, 48 exerted on the mandible, are other
than normal function.
5. Forward head position is able to influence the
stomatognathic system's function and to alter the
mandibular position and movement.7
6. A reduction of the physiological freeway space 39
produced by a change of the mandibular postural
position and a mandibular closure path located
farther back than the usual path, which in turn
makes that occlusal contact occur farther back
than the maximal intercuspal position, are conse-
quences brought about by forward head position.
7. This occlusal discrepancy produced by forward
head position, added to the already altered
muscular activity, creates susceptibility to
craniomandibular dysfunction.
Experimental evidences prove that forward head posi-
tion is present in craniomandibular dysfunction or may be
the cause. Huggare and Raustia1found that patients (mean
age 28 years) who suffered from craniomandibular
JANUARY 1996, VOL. 14, NO. 1
GONZALEZ AND MANNS
dysfunction bad an altered head posture, consisting of
significant dorsoextension, expressed as an increase of
the craniocervical angulation. In addition, the cervical
spine bending was more pronounced, although this was
not statistically significant. However, after treating the
dysfunction the straightening of the cervical spine was in
fact notorious. In the present study, it can be observed
that forward head position was present in patients with
craniomandibular dysfunction, although this was not
specifically stated. Later, Salonen, et al. 36 measured the
craniocervical posture in edentulous individuals, who
received new dentures to replace their abraded ones.
Their findings point to a significant association between
the Joss of vertical occlusal dimension and cran-
iomandibular dysfunction. Patients who showed a great
reduction of the ir physiological freeway space held their
heads raised higher than the average, and a positive cor-
relation between the dysfunction index and the need to
increase the vertical occlusal dimension could be observed.
Also, in those patients where an extension of the cervical
spine occurred after inserting the new dentures, their dys-
function index improved noticeably. Smith 37 mentioned
that the straightening or stretching of the cervical spine
partly improved the symptomatology present in cran-
iomandibular dysfunction. He stresses that the vertical
occlusal dimension and the mandibular position have to
be taken into account re garding the cervical spine. Darling
and Krauss 59 found that the resting vertical dimension
(RVD) in individuals with forward head position increased
after correcting the head posture with kinesiotherapy.
Tallgren et al. 34• 35 was the first to demonstrate how the
cervical spine was capable of adapting by modifying both
its bending and its inclination when faced with changes in
head posture or in mandibular inclination. Later, Huggare
and Raustia1, Salonen et al. 36 in the same line ofresearch
as the above authors, discovered that it was possible to
observe craniomandibu1ar dysfunction associated with
these postural changes. However, none of them perceived
the evident existence of forward head position as an indi-
vidual pathological entity present in ali cases published
on the subject. Therefore, in order to determine how for-
ward head position became apparent in a profile teleradi-
ograph, we will analyze cephalometric tracing of the
cervical spine, in normal and abnormal conditions
(Figures 3 and 4).
Forward head position is capable of producing alter-
ations in the TMJ. In a recently published article,
Schellhas60 analyzes relations existing between internai
derangements of TMJ and facial growth disturbances
(dysmorphosis) in 14-year old or even younger children.
Out of 128 patients with facial dysmorphosis, 112 pre-
sented at least one type of alteration in their TMJ.
JANUARY 1996, VOL. 14, NO. 1
FORWARD HEAD POSTURE: A CONCEPTUAL STUDY
However, the most remarkable fact is that, out of 60
patients who presented retrognathia, 56 showed internai
derangements ofboth TMJ, frequently even in an advanced
state, meaning disk displacement without reduction,
perforations of the articular disk, and degenerative
osteoarthritis, an aseptic necrosis. This very marked
association between retrognathia and articular pathology
(TMJ) (93.31 %) might induce us to conclude rather
lightly that there is a cause/effect relationship between
them. However, after careful evaluation, we should ask
ourselves whether retrognathia is the actual cause of the
internai derangements of TMJ in this case. Certainly not,
if we turn our attention to the excellent papers published
by Solow and Tallgren 10 and Solow and Siersbaeck-
Nielsen11. 12 to understand this situation, we find that
mandibular retrognathia is significantly associated with
an extension ofthe head over the cervical spine (dorsoex-
tension), which is always present in forward head posi-
tion. Certainly mandibular retrognathia is not the cause of
pathology of the joint (TMJ), but only an expression of
the postural condition (FHP) described.
However, we must still clarify how forward head posi-
tion is capable of indirectly generating alterations of the
TMJ. In this connection, we must mention the intimate
relationship existing between FHP and nasorespiratory
obstruction. Ricketts 61 stated that this obstruction may
definitely plays a role in the abnormal condylar develop-
ment, due to adopting the habit of oral breathing to dimin-
ish resistance and to increase the volume of the inhaled
air, the mandible bas to be moved forward. This facili-
tates mouth breathing, and results in retraction of the
chin. This means that the lateral pterygoid muscle must
keep the condyle attached against the articular eminence
which may be considered a repetitive microtrauma for the
TMJ. Ricketts states that a microtrauma affects the chon-
drogenic area of the condyle and may lead to degenera-
tive arthritis. More recently, Dibbets62 observed that TMJ
dysfunctions develop during the active growth period of
children. He demonstrated that patients with cran-
iomandibular dysfunction are characterized by a more
marked retrognathia than the average patient, present a
small mandibular body, lesser posterior facial height, a
shorter ramus, and a wide gonian angle. In a study on
apes, McNamara58 established that alterations in quantity
and/or direction of condylar growth were only evident in
young apes in their active growth period.
Presumably the adoption of FHP during the growth
and development period of individuals cannot only gen-
erate occlusal discrepancies and an altered neuromuscu-
lar activity, but may also cause heavy structural and
functional disorders of the TMJ, ali of which predisposes
to develop craniomandibular dysfunction.
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 77
FORWARD HEAD POSTURE: A CONCEPTUAL STUDY GONZALEZ AND MANNS

BOR
BOR
VER OPI' cvr VER OPI' cvr
Figure 3 Figure4
Normal tracing for postural variables Abnormal tracing (FHP) for postural
of cervical spine and head posture variables of cervical spine and head posture
Characterists Expressed like Characterists Expressed like
Craniocervical ventroflexion Decrease of NSL/OPT angle Craniocervical dorsoextension Increase of NSL/OPT angle
Extension,straightening Increase of CVT/HOR angle Flexion or pro inclination Decrease of CVTlHOR angle of
or stretching of the cervical spine lower cervical spine
Tendency to keep the OPT/CVT angle in normal Higher bending of the Increase of OPT/CVT angle
physiologicallordosis range cervical spine (hyperlordosis)
due to the upper cervical raquis
(Cl C2 C3)

Reference points NSL: Nasion-sella line: The line through n and s.

n: Nasion. The most anterior point of the frontonasal suture.
s: Sella. The centre of the sella turcica.
cv2tg: The tangent point of OPT on the odontoid process of second
cervical vertebra
cv2ip : The most postero-inferior point on the corpus of second cervi-
cal vertebrae.
cv4ip: The most postero-inferior point on the corpus of fourth cervical
vertebrae.
Conclusions
According to published data56 in 70% of cases, a corre-
lation exists between Class II occlusion and FHP. Many
of these patients show a symptoms of disturbances in
their temporomandibular joint (TMJ).This makes up the
relation existing between head posture, craniofacial mor-
phology and craniomandibular dysfunction. Not infre-
quently, dentists who treat patients with CMD are
confronted with clinical cases that are refractory to ther-
apy with occlusal splints. Possibly the craniocervical pos-
ture of these patients was not thoroughly evaluated. In
these cases the origin of the dysfunction is not found in
the TMJ or in occlusal discrepancies, but is a conse-
quence of craniocervical malposition. We shall therefore
OPT: Odontoid process tangent. The posterior tangent to the odon-
toid process through cv2ip.
CVT: Cervical vertebrae tangent. The posterior tangent to the odon-
toid process through cv4ip.
HOR: True horizontalline. The line perpendicular to VER.
VER: True verticalline. The verticalline projected on the film.
state that such internai derangements associated to FHP
which are a consequence of this malposition, are a sec-
ondary TMJ pathology.
Mintz63 stated that "TMJ syndromes can develop based
on an orthopedie postural problem that affects the muscu-
lature, which is necessary to maintain a good craniocervi-
cal posture and good health." Based on this, we believe
that the craniocervical complex must have a specifie pos-
tural position to assure the whole system's normal func-
tion. This natural head posture, balanced by a normal and
harmonious muscular function, allows the mandible to
adopt its adequate mandibular postural position, and to
correct the physiological centric relation (PCR). The
craniocervical posture becomes even more important
when taking into account that the PCR is determined by
the muscular system and not by the ligamentary position,

78 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE JANUARY 1996, VOL. 14, NO. 1

GONZALEZ AND MANNS FORWARD HEAD POSTURE: A CONCEPTUAL STUDY

as was formerly believed.
If the mandible has its own mandibular postural posi-
tion (MPP) out of which ali of its functional movements
are started and completed, the craniocervical spine also
has a postural position. We will cali this point within the
whole functional area craniospinal movement, the cranio-
cervical postural position (CCPP). Its alteration (i.e., by
FHP) will have a direct repercussion on the mandibular
postural position (MPP). This can be represented in the
following ways.
MIP
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~MPP~
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FHP----------------~---------------NHP
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