European Journal of Orthodontics 11 (1989) 37-42 © 1989 European Orthodontic Society

Changes in head posture and nasopharyngeal airway

following surgical correction of mandibular
prognathism
Ann Wenzel,* Stephen Williams** and Martin Ritzau***
Department of Radiology,* Institute of Orthodontics,** Institute of Oral Surgery,*** Aarhus, Denmark

SUMMARY It was the aim of the present study to cast light on the role of the mandible in
relation to head posture and airway space by evaluating patients before and after surgical
correction of mandibular prognathism. The material comprised standardized profile cephalograms
of 52 patients with mandibular prognathism. All patients had received orthodontic adjustments
prior to mandibular osteotomy. Mean age of the patients was 24.3 years, and 12 males and 40
females participated in the study.
The first profile radiograph of each patient was obtained the day before surgery in the natural
head (mirror) position. All patients underwent mandibular surgery with a bilateral vertical ramus
osteotomy. Approximately one year after surgery, the cephalometric investigation was repeated.
Head posture was evaluated by the craniocervical angulation (NSL/CVT and NSL/OPT) and
airway space as nasopharyngeal airway size (ad, and ad2). Changes in posture and airway
(ex.2-ex.1) were evaluated by paired Mests. The results showed a mean increase in head
posture of 2.7 degrees (p < 0.001) and a mean reduction in airway space of 2.3 mm (p <
0.001).

Introduction lations have been found between airway resist-

A correlation between craniofacial morphology
and head posture has been demonstrated in
several studies (Solow and Tallgren, 1976, 1977;
Thompson Posnick, 1978; Marcotte, 1981; So-
low et al, 1984; Wenzel et al., 1985; Huggare,
1986; Showfety et al., 1987; Tallgren and Solow,
1987). It is a general conclusion from most
of these investigations that large craniocervical
angles are related to large vertical anterior
dimensions and a small facial prognathism. It
has also been a trend in most of the studies that
higher correlations have been found between
variables representing posture and mandibular
morphology than between posture and maxillary
morphology. Severe obstruction of nasal airway
has also been shown to correlate with large
upper anterior face heights in adenoidal (Linder-
Aronson and Backstrom, 1960; Linder-Aronson,
1970), and allergic children (Hansen et al., 1987),
while asthma of varying severity did not result
in changed morphology (Wenzel et al., 1985;
Hojensgaard et al., 1987). Only weak corre-
ance and head posture (Solow et al., 1984).
The interaction between cranial morphology,
posture, and airway space is thus not fully
comprehended.
In order to investigate whether changes in one
parameter will be accompanied by change in
other variables, longitudinal studies are needed.
Adenoidectomy has been shown to result in
changes in craniofacial morphology in adenoidal
children compared to controls (Linder-Aronson,
1975, 1979), and a decrease in craniocervical
angulation has been shown following intranasal
treatment with corticosteroids in comparison to
placebo in asthmatic children (Wenzel et al.,
1983). In animal studies, switching from nasal
to oral breathing (and vice versa) led to changes
in posture and facial shape (Harvold, 1975;
Vargervik et al., 1984). Correlations between
change in mandibular inclination and head pos-
ture have been observed in full denture wearers
(Tallgren et al., 1983), and it has been demon-
strated that growth changes in head posture were
correlated to craniofacial development (Solow,
38 ANN WENZEL, STEPHEN WILLIAMS AND MARTIN RITZAU
12 •
10-
8.
6.
v/// 77A
'//A
4
'//A
2+ y///,
WA
16 17 18 19 20 21 22 23 24 25 26 29 30
Figure 1 Sex and age distribution of 52 patients with mandibular prognathism.
1986) and to the growth rotation of the mandible
in children (Tallgren and Solow, 1981). It has
been argued that mandibular development is of
great importance in determining head posture
through an effect on airway resistance (Solow et
ai, 1984).
It was the aim of the present study to cast
light on the effect of mandibular position on
head posture and airway size by evaluating the
craniocervical angulation and nasopharyngeal
airway in patients before and after surgical
correction of mandibular prognathism.
Subjects and methods
The subjects comprised fifty-two patients with
mandibular prognathism who had received
orthodontic adjustments prior to mandibular
osteotomy. Sex (12 males and 40 females) and
age (x = 24.3 yrs) distribution of the patients
can be seen in Figure 1. The protocol was
approved by the local Committee of Ethics and
informed consent was given by all patients after
they had received written and verbal information
regarding the study.
Pre-surgical orthodontic treatment
The pre-surgical orthodontic phase involved the
use of fixed orthodontic appliances over an
average period of 12 months. The aim was
twofold:
1. Removal of the dentoalveolar compensation
777/
VAA
34 35 38 39 40 41 42 47 48
YEARS
arising from the basal discrepancy to be
corrected (Solow, 1980). This usually in-
volved proclination of the mandibular inci-
sors and, in some of the cases, retraction of
the maxillary incisors as well as correction in
the transverse dimension.
2. Levelling of the dental arches and elimination
of intraarch discrepancies in tooth alignment.
The result of the pre-surgical orthodontic
therapy was the creation of two dental arches
that permitted maximal benefit from the planned
surgical treatment, in particular with regard to
facial profile. Adequate post-operative func-
tional conditions were established by maximum
intercuspidation in order to avoid relapse.
Surgical treatment
Bilateral vertical ramus osteotomy was per-
formed on all patients. In this procedure, the
bone segments were mobilized, and the proximal
fragments containing the condyles were placed
laterally to the anterior part (Fig. 2). In all cases
the condyles were left passive in the articular
fossae, no attempt being made for active repo-
sitioning. After intermaxillary fixation, the pati-
ents were randomly allocated to one of two
groups, one of which was provided with a lightly
tightened 0.4 mm soft stainless steel wire for
fixation (osteosynthesis) of the mandibular bone
fragments ( + OS, N = 26), and the other with-
out intra-mandibular fixation ( — OS, N = 26).
Finally, the wounds were closed in layers. Inter-
maxillary fixation lasted for six weeks.
HEAD POSTURE, AIRWAY AND MANDIBULAR PROGNATHISM
Figure 2 Bilateral vertical raraus osteotomy performed on
52 patients.
A profile radiograph with the teeth in centric
occlusion was obtained the day before, and
approximately one year after surgery (x = 1.12
yrs), for each patient. Radiographs were taken
in the natural head position (mirror position) as
previously described (Solow and Tallgren, 1971).
All radiographs were taken by dental auxiliaries
after instruction in the recording procedure.
Assessment of head posture, determined as the
craniocervical angulation, was performed on the
profile radiographs by using the cephalometric
landmarks illustrated in Figure 3. Airway space
was~ recorded in millimetres as previously de-
scribed (Linder-Aronson and Henrikson, 1973),
and also illustrated in Figure 3.
Student's /-test was used to evaluate differ-
ences in posture and airway space between the
+ OS and the —OS group before and after
surgery. Changes in posture and airway were
determined as the differences between examin-
ation 2 and examination 1 (ex.2-ex.l). Paired t-
tests were used to evaluate the changes in head
posture and airway space for the whole group
after surgery. This test was also used to evaluate
differences in the interposition of the second and
fourth vertebrae.
Results
Before surgical treatment, craniocervical angu-
lation did not differ significantly in the +OS
39
Figure 3 Cephalometric landmarks on profile radiograph.
and the - O S groups (for NSL/CVT, p = 0.99;
for NSL/OPT, p = 0.75) and neither did airway
space (for adl5 p = 0.97; for ad2, p = 0.95).
Equally, one year after surgery, no significant
differences were found between the two groups
(NSL/CVT, p = 0.68; NSL/OPT, p = 0.62;
ad,, p = 0.61; ad2, p = 0.41). The values for
craniocervical angulation and airway space
in the two groups before and after surgery can
be seen in Table 1. The groups were then
pooled for the evaluation of changes after
surgery.
The mean time elapse between first and second
examination was 1.12 years (range 0.93-2.47
yrs). After surgery 77 percent of the patients
had raised their head. The mean difference in
craniocervical angulation was an increase of
2.7° (p < 0.001) with a standard deviation of
approximately 5° (Table 1). The distribution
of changes in NSL/CVT can be seen in Fig-
ure 4. After surgery, 83 percent of the patients
40 ANN WENZEL, STEPHEN WILLIAMS AND MARTIN RITZAU

Table 1 Craniocervical angulation and airway space before and approximately

one year after surgery in the osteosynthesis (N = 26) and non-osteosynthesis
(N = 26) groups. Changes evaluated for both groups pooled (N = 52).

Before surgery 1 y after surgery Change:s (ex.2-ex.l)

X s.d. X s.d. X s.d.
+ OS 96.8 6.7 99.4 5.4 1
NSL/CVT 2.73* 4.6
-OS 97.0 6.7 100.1 5.5 J
+ OS 89.9 7.2 92.6 5.6 1
NSL/OPT 2.67* 5.2
-OS 90.4 8.1 93.5 6.1 I

ad, + OS 23.4 4.3 21.5 3.9)

-2.2* 2.4
-OS 23.3 4.3 20.9 4.5 1
+ OS 23.4 4.6 21.6 3.7 1
ad 2 —2.3* 2.4
-OS 23.5 3.7 20.8 3.5 j

* p< 0.001.

ANSL/CVT 0
J

6
4

-11-10-6-5-4-3-2-1 0 1 2 3 4 5 6 7 8 9 10 11 12
Figure 4 Distribution of changes in head posture (NSL/CVT) in 52 patients.

A ad 2 r Discussion
i
The patients in the present study were allocated
10 to an osteosynthesis and a non-osteosynthesis
8
group, during surgery, but as no differences
between the groups were found for the para-
meters evaluated in this study, the groups were
pooled. The two groups will be evaluated separ-
ately regarding position and morphology of the
temporomandibular joint in a future study.
I Natural head position was recorded in the
-9 -8 -7 -6 -5 -4 -2 -1 present study by the mirror method described
Figure 5 Distribution of changes in nasopharyngeal airway previously by Solow and Tallgren (1971), for
(ad 2 ) in 52 patients. which varying reproducibility has been reported
(Siersbaek-Nielsen and Solow, 1982; Lundstrom,
showed a reduction in airway space. The mean 1982; Luyk et al., 1986). Others have suggested
difference was a decrease of 2.3 mm (p < 0.001) the fluid-level method, with a method error
with a standard deviation of 2.4 mm (Table 1). documented to be less than for the mirror
The distribution of the changes in ad2 can be method (Vig et al., 1981; Showfety et al., 1983;
seen in Figure 5. No significant changes were Huggare, 1985). In the present study double
observed in the relationship of the second and registration of head posture was not performed
fourth vertebrae (p = 0.57). due to ethical considerations. In the recording
HEAD POSTURE, AIRWAY AND MANDIBULAR PROGNATHISM
of a biological parameter, however, the varia-
tion within the group of subjects under investi-
gation is usually much larger than the method
error of this parameter. This is also true for the
mirror method. The method is very easy for
clinical use and was therefore chosen for the
present study. Dental auxiliaries performed the
lateral cephalograms in the natural head pos-
ition. They had been instructed in the positioning
of the patients before the study started and were
not reinstructed during the two years the study
lasted. The auxiliaries were totally unbiased as
they were not aware of any expected changes in
posture.
The results in this study revealed an increase
in craniocervical angulation following surgical
treatment of mandibular prognathism. An ear-
lier investigation evaluated the position of the
hyoid bone and the head in patients with man-
dibular protrusion (Fromm and Lundberg,
1970). Although reference points and lines were
not the standard as used in more recent studies
(a vertebral line was fitted by eye to the midpoints
of the third to sixth vertebral bodies and the
angle to the perpendicular line measured), the
results showed that the patients had raised their
head on average two degrees after surgical
correction of the protrusion. No assessment of
airway space was performed.
Nasopharyngeal airway size was recorded in
the present study on lateral radiographs, and no
measures for airway resistance were obtained.
Two studies have observed statistically signifi-
cant correlations between nasopharyngeal air-
way size on radiographs and respiratory
resistance by rhinomanometry (Holmberg and
Linder-Aronson, 1979; Serensen et al., 1980),
but correlations found have only been able to
explain approximately 25 percent of the vari-
ation in resistance within the groups. The results
in this investigation revealed a decrease in naso-
pharyngeal airway size following surgery. A
decrease in airway size on radiographs, though,
is not necessarily followed by an increase in
airway resistance. None of the individuals in-
cluded in this study had enlarged adenoids or
other causes for airway obstruction. On the con-
trary, individuals with a Class III morphology
are expected to have adequate airway flow which
is not necessarily altered due to a few millimetres
reduction in size. A model has previously been
developed (Solow and Kreiborg, 1977) suggest-
ing that changes in craniofacial morphology will
41
lead to changes in head posture through changes
in respiratory resistance. A detailed description
of the intercorrelation of the changes in these
three parameters in the Class III patients will be
given in a separate paper.
In the present study, a number of other
factors could, however, have influenced the head
position after surgery. In a recent questionnaire,
the patients included in the present study were
asked of their motivation for and satisfaction
with treatment. The majority of the patients
reported a significant increase in self-confidence
subsequent to the surgical treatment and were
prepared to recommend such treatment for
others in the same situation (Ritzau et al., 1987).
Other studies have similarly shown that even
fairly small discrepancies in jaw morphology
have a high influence on patients' self-estimation
(Hillerstrom et al., 1971; Lefebre and Barclay,
1982). There might therefore, in this group of
patients, be psycho-social factors which stimu-
late the patients to lift their head, thereby
reinforcing the changes in head posture arising
from the biological changes.
Acknowledgements
The authors thank Mrs Asta Rodding, Mrs
Ruth Jensen, and Mrs Merete Schou for their
help in obtaining the lateral cephalograms.
Address for correspondence
Dr Ann Wenzel
Department of Radiology
Royal Dental College
Vennelyst Boulevard
DK-8000 Aarhus C
Denmark
References
Fromm B, Lundberg M 1970 Postural behaviour of the
hyoid bone in normal occlusion and before and after
surgical correction of mandibular protrusion. Swedish
Dental Journal 63: 525-533
Hansen J B, Minsson A, Solow B 1987 Nasal respiratory
resistance and facial morphology. Nordisk Odontologisk
Forening, 70th Annual Meeting, Copenhagen, Denmark.
Abstract: 88
Harvold E P 1975 Experiments on mandibular morphogen-
esis. In: Determinants of mandibular form and growth.
Mandibular morphogenesis, J A McNamara (ed), Michi-
gan, Ann Arbor
42 ANN WENZEL, STEPHEN WILLIAMS AND MARTIN RITZAU
Hillerstrom K, Serensen S, Wictorin L 1971 Biological and
psycho-social factors in patients with malformation of the
jaws. Scandinavian Journal of Plastic Reconstruction and
Surgery 5: 34-40
Hojensgaard E, Wenzel A 1987 Dentoalveolar morphology
in children with asthma and perennial rhinitis. European
Journal of Orthodontics 9: 265-270
Holmberg H, Linder-Aronson S 1979 Cephalometric radio-
graphs as a means of evaluating the capacity of the
nasal and nasopharyngeal airway. American Journal of
Orthodontics 76: 479-490
Huggare J 1985 Thefluid-levelmethod for recording natural
head posture. Proceedings of the Finnish Dental Society
81: 199-203
Huggare J 1986 Head posture and craniofacial morphology
in adults from northern Finland. Proceedings of the
Finnish Dental Society 82: 199-208
Lefebre A, Barclay S 1982 Psychosocial impact of cranio-
facial deformities before and after reconstructive surgery.
Canadian Journal of Psychiatry 27: 579-584
Linder-Aronson S 1970 Adenoids: Their effect on mode of
breathing and nasal airflow and their relationship to
characteristics of the facial skeleton and the dentition.
Acta Otolaryngologica, Supplement 265: 1-132
Linder-Aronson S 1975 Effects of adenoidectomy on the
dentition and facial skeleton over a period of five years.
In: Transactions of the Third International Orthodontic
Congress, J T Cook (ed), pp 85-100
Linder-Aronson S 1979 Naso-respiratory function and
craniofacial growth. McNamara (ed), Michigan, Ann
Arbor: 121-147
Linder-Aronson S, Backstrom A 1960 A comparison be-
tween mouth and nose breathers with respect to occlusion
and facial dimensions. Odontologisk Revy 11: 343-376
Linder-Aronson S, Henrikson C O 1973 Radiocephalometry
analysis of anteroposterior nasopharyngeal dimensions in
6- to 12-year-old mouth breathers compared with nose
breathers. Journal of Oto-Rhino-Laryngology and its
Related Specialities 35: 19-29
Lundstrom F 1982 Registration of natural head posture in
children. Swedish Dental Journal, Supp 15: 147-152
Luyk N H, Whitfield P H, Ward-Booth R P, Williams E
1986 The reproducibility of the natural head position in
lateral cephalometric radiographs. British Journal of Oral
Maxillofacial Surgery 24: 357-366
Marcotte M R 1981 Head posture and dentofacial pro-
portions. The Angle Orthodontist 51: 208-213
Ritzau M, Williams S, Wenzel A 1987 Combined orthodon-
tic surgical treatment of basal discrepancies in jaw mor-
phology: motivation and satisfaction (in Danish).
Tandlaegebladet 91: 649-653
Showfety K J, Vig P S, Matteson S 1983 A simple method
for taking natural-head-position cephalograms. American
Journal of Orthodontics 83: 495-500
Showfety K J, Vig P S, Matteson S, Phillips C 1987
Associations between the postural orientation of sella-
nasion and skeletodental morphology. The Angle Ortho-
dontist 57: 99-112
Siersbaek-Nielsen S, Solow B 1982 Intra- and interexaminer
variability in head posture recorded by dental auxilliaries.
American Journal of Orthodontics 82: 50-57
Solow B 1980 The dentoalveolar compensatory mechanism:
Background and clinical implications. British Journal of
Orthodontics 7: 147-161
Solow B 1986 Growth changes in head posture related to
craniofacial development. American Journal of Ortho-
dontics 89: 132-140
Solow B, Kreiborg S 1977 Soft-tissue stretching: a pos-
sible control factor in craniofacial morphogenesis. Scan-
dinavian Journal of Dental Research 85: 505-507
Solow B, Siersbsk-Nielsen S, Greve E 1984 Airway ad-
equacy, head posture, and craniofacial morphology.
American Journal of Orthodontics 86: 214-223
Solow B, Tallgren A 1971 Natural head position in standing
subjects. Acta Odontologica Scandinavica 29: 519-607
Solow B, Tallgren A 1976 Head posture and craniofacial
morphology. American Journal of Physical Anthropology
44: 417-436
Solow B, Tallgren A 1977 Dentoalveolar morphology in
relation to craniocervical posture. The Angle Orthodontist
47: 157-164
Serensen H, Solow B, Greve E 1980 Assessment of the
nasopharyngeal airway. Acta Otolaryngologica 98: 227-
232
Tallgren A, Lang B R, Walker G F, Ash M M 1983 Changes
in jaw relations, hyoid position, and head posture in
complete denture wearers. Journal of Prosthetic Dentistry
50: 148-156
Tallgren A, Solow B 1981 Long-term changes in hyoid bone
position and craniocervical posture in complete denture
wearers. Journal of Dental Research, special issue 60: 473
Tallgren A, Solow B 1987 Hyoid bone position, facial
morphology and head posture in adults. European Journal
of Orthodontics 9: 1 -8
Thompson Posnick B 1978 Craniocervical angulation and
morphologic variables in children: A cephalometric study.
MSD Thesis, University of North Carolina, Chapel Hill
Vargervik K, Miller A J, Chierici G, Harvold E, Tomer
B S 1984 Morphologic response to changes in neuro-
muscular patterns experimentally induced by altered
modes of respiration. American Journal of Orthodontics
85: 116-124
Vig P S, Showfety K J, Matteson S R 1981 A new
device to reproduce natural head position in routine
cephalograms. Journal of Dental Research, special issue
A 60: 474
Wenzel A, Henriksen J, Melsen B 1983 Nasal respiratory
resistance and head posture: Effect of intranasal cortico-
steroid (Budesonide) in children with asthma and peren-
nial rhinitis. American Journal of Orthodontics 84: 422-
426
Wenzel A, Hojensgaard E, Henriksen J M 1985 Craniofacial
morphology and head posture in children with asthma
and perennial rhinitis. European Journal of Orthodontics
7: 83-92