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Relationships of vertical facial pattern, natural

head position and craniocervical posture in young
Chinese children

Ying Liu (MD), Shuo Wang (MD), Chunhui Wang (MD) & Chang Liu (PhD)

To cite this article: Ying Liu (MD), Shuo Wang (MD), Chunhui Wang (MD) & Chang Liu (PhD)
(2018) Relationships of vertical facial pattern, natural head position and craniocervical posture
in young Chinese children, CRANIO®, 36:5, 311-317, DOI: 10.1080/08869634.2017.1345461

To link to this article: https://doi.org/10.1080/08869634.2017.1345461

Published online: 02 Jul 2017.

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CRANIO®: The JOuRNAl Of CRANIOmANdIbulAR & Sleep pRACTICe
2018, Vol. 36, No. 5, 307–313
https://doi.org/10.1080/08869634.2017.1345461

ORTHODONTICS

Relationships of vertical facial pattern, natural head position and craniocervical

posture in young Chinese children
Ying Liu MDa, Shuo Wang MDb, Chunhui Wang MDb and Chang Liu PhDb
a
Department of Orthodontics, School of Stomatology, JiLin University, Changchun, China; bKey Laboratory of Oral Medicine, Guangzhou Institute
of Oral Disease, Stomatology Hospital of Guangzhou Medical University, Guangzhou, China

ABSTRACT KEYWORDS
Objective: To investigate relationships of vertical facial patterns, natural head position (NHP), and Craniocervical posture;
craniocervical posture in young Chinese children with skeletal Class I relationship. craniofacial morphology;
Methods: Ninety-four patients with skeletal Class I relationship were classified into low, average, and natural head position;
high angle groups according to their mandibular plane angle (NSL/ML). Cephalometric radiographs vertical facial pattern
in NHP were taken. Variables representing vertical and sagittal craniofacial morphology, head
posture, and craniocervical posture were measured and compared.
Results: Inclinations of the mandible to the true vertical and cervical column were smallest in the
high angle group and largest in the low angle group. Other variables representing head posture
and craniocervical posture were largest in the high angle group, smallest in the low angle group.
Inclinations of ramus to cervical column were largest in the high angle group and smallest in the
low angle group.
Discussion: Subjects with large NSL/ML angles showed extended head and craniocervical posture,
while subjects with small NSL/ML angles exhibited flexed head and craniocervical posture.

Introduction mandibular inclination, and reduced facial prognathism,

Natural head position (NHP) is a standardized position of
the head in the upright posture with the eyes focused on
a distant point at eye level. NHP was first introduced into
orthodontics around the 1950s, and it has been advocated
as a reliable craniofacial reference system, since traditional
cranial reference planes may be misleading. The stability
and reproducibility of NHP have been investigated and
demonstrated in a series of studies [1–3]. Peng and Cooke
[3], along with other authors [1–4], reported NHP to be
stable after 5 minutes, 1 week, 3 to 6 months, 5 years, and
even 15 years from initial recording. Another advantage
of NHP is its accurate reflection of real life appearance
[3,5]. Moreover, NHP may affect a patient’s facial esthet-
ics after orthodontic treatment and orthognathic surgery
[6,7]. Hence, cephalometric radiographs recorded in NHP
allow clinicians to evaluate the dentofacial morphology
more physiologically and objectively and are becoming
more popular in orthodontics [5].
NHP is related to craniofacial morphology, future
growth trends, and various malocclusions [8–11]. Solow
[8] has clarified that, on average, extension of the head
in relation to the cervical column is associated with
large anterior and small posterior facial height, a large
while flexion of the head is related to the opposite cranio-
facial morphological characteristics. Since growth changes
of the facial skeleton are related to corresponding changes
in craniocervical posture, the individual’s subsequent
facial development can, to some extent, be predicted [9].
Furthermore, an association is shown between NHP and
malocclusion traits, such as anterior crowding, overbite,
crossbite, and molar relationship [10,11].
Besides craniofacial morphology, some functional
factors also affect NHP [12–15]. Functional appliance
therapy, e.g. insertion of a splint for one hour, can cause
a significant extension of the head on the cervical spine
and a significant decrease in cervical spine lordosis [12].
The extended head posture shown in children with air-
way obstruction may change to a flexed head posture in
response to relief of the obstruction [13,14]. In a recent
study, subjects with temporomandibular disorders (TMD)
were found to have extended craniocervical posture, and
the angles between the craniofacial reference planes and
the cervical vertebrae increased as TMD progressed
severely [15].
Several studies have reported the craniofacial mor-
phology, NHP, and craniocervical posture in different

CONTACT Chang Liu changliudentist@gzhmu.edu.cn

© 2018 Informa UK Limited, trading as Taylor & Francis Group
308  Y. LIU. ET AL.
populations, finding that ethnic origin may affect cran-
iofacial morphology, NHP, and craniocervical posture
[8,16,17]. The Australian Aboriginals have a larger ver-
tical jaw relationship, a shorter spinal column, a less pro-
nounced cervical lordosis, and a larger craniocervical
angle, compared with Danish students [17]. However,
Chinese people are rarely investigated. Liu et al. [18]
reported relationships of sagittal skeletal discrepancy,
NHP, and craniocervical posture in young Chinese chil-
dren. Nevertheless, how vertical skeletal discrepancy
exactly associates with NHP and craniocervical posture
in the Chinese population is still not clear. The aim of
this study was to investigate the relationships of vertical
facial pattern, NHP, and craniocervical posture in young
Chinese children with skeletal Class I relationship.
Materials and methods
This study was approved by the Ethics Committee
of Hospital of Stomatology, JiLin University. Written
informed consent was obtained from all the children and
their parents.
The sample size was calculated by PASS 11.0 software
(NCSS, Kaysville, UT, USA), based on an alpha signifi-
cance level of 5% and a beta of 10%, to achieve 90% power.
In order to detect statistical differences among the groups,
the total sample should comprise at least 84 subjects. To
compensate for possible dropouts during the investiga-
tion, more subjects were enrolled, and the final sample
comprised 94 children (10–14 years old). The subjects
involved in the study were selected from a large pool of
patients who were sequentially admitted for orthodon-
tic treatment from September 2015 to September 2016.
Cephalometric radiographs were taken for diagnosis and
treatment purposes. 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 wound, burn, or scar tissue
in the face and neck region, no mandibular or craniofa-
cial pathology, e.g. TMD, and skeletal Class I relation-
ship (determined by both ANB angle and Wits value).
The subjects were divided into three groups, according to
mandibular plane angle (NSL/ML). Details of the sample
are given in Table 1.
Cephalometric radiographs were taken by a single tech-
nician using ProMax (Planmeca, Helsinki, Finland). The
machine had a standardized focus-film distance of 164 cm
and a distance from the film to the medial plane of 19 cm.
Exposure data were 60–84 kV and 1–16 mAs-1. The X-ray
device had a focus of 0.5 mm. No correction was made
for the constant linear enlargement of 13%. An aluminum
wire was mounted in front of the cassette to indicate the
true vertical on the film.
Table 1. Details of the sample.
Age (years)
Description Total/boys Mean ± SD NSL/ML angle
Number of subjects 94/47 12.17 ± 1.42 –
Low angle 30/15 12.20 ± 1.44 <32 °
Average angle 33/17 11.91 ± 1.50 32–40 °
High angle 31/15 12.57 ± 1.12 >40 °
SD = standard deviation; NSL = nasion-sella line; ML = mandibular line.
The radiographs were exposed with the subjects stand-
ing in self-balance position: the children were told to make
themselves comfortable, to relax their arms by their sides,
to stand with their heels together and toes apart by 45°.
Participants were asked to tilt their heads forwards and
backwards with decreasing amplitude until they achieved
what they considered to be their natural head position,
and then they were instructed to look straight ahead. After
NHP was determined, ear rods were slightly inserted into
the external auditory meatus to prevent head movements
and horizontal rotation during the test. The radiographs
were taken with the teeth in centric dental occlusion and
the lips in light contact.
All cephalometric radiographs obtained from the 94
children included were converted to digital format using a
flatbed scanner (ScanMaker 9800XL, Microtek, CA, USA),
and measurements were carried out by computer. The
­reference lines are illustrated in Figure 1, and descriptions
and meanings of the variables are presented in Table 2
and Figure 1. For assessment of the reliability of the
­measurements, 26 randomly selected radiographs were
digitized again and re-measured by the same investiga-
tor two weeks after the initial analysis. Cephalometric
­variables were compared for each registration, and the
error variance was calculated using Dahlberg’s formula:
√∑
Me = d 2∕2n
where d represents the difference between two
­registrations, and n is the number of duplicate registra-
tions. Method errors for the measurements are listed
in Table 3. Hypothesis testing indicated no significant
­difference between the two registrations.
SPSS 12.0 (Lead Tech, Chicago, IL, USA) was used to
statistically analyze the measured values. For the purpose
of descriptive statistics, the mean values were indicated
with standard deviations. The normality test of Shapiro-
Wilks and the Levene variance homogeneity test were
applied to the data. The data were distributed normally,
and there was homogeneity of variance among the groups.
Student’s t-test was used to examine possible gender dif-
ferences, but there were no significant differences at the
5% level. Therefore, boys and girls were pooled together
in the statistical analysis. One-way analysis of variance
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE  309
Figure 1. Cephalometric tracing illustrating all angular
measurements.
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; RL: ramus
line, the tangent to the posterior border of the mandible; 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; VER: true vertical line, the gravity
determined vertical line projected on the film; HOR: true horizontal line, the
line perpendicular to VER. S-Go: posterior facial height, distance between S
and Go; N-Me: anterior facial height, distance between N and Me. Variables
8-24 are indicated with numbers the same as those in Table 2.
(ANOVA) and the least significant difference (LSD) mul-
tiple comparison test were applied to evaluate the inter-
group differences for measurements; significance level was
p < 0.05.
Results
Values of both ANB angle and Wits were fairly close
among the three groups, as listed in Table 4. Measurements
of NSL/ML, Frankfort mandibular plane angle (FH/ML)
and facial height ratio (FHR) in the three groups exhib-
ited statistical differences respectively (Table 4). NSL/NL
and NL/ML values were smallest in the low angle group
and largest in the high angle group. Statistical differences
among the three groups are shown in Table 4.
Values of variables 8–16 were largest in the high angle
group and smallest in the low angle group (Table 5).
Values of NSL/VER and NSL/CVT in the high angle
group showed significant differences compared with those
in the other two groups, while the NSL/OPT angle was
statistically smaller in the low angle group, as compared
to the other two groups (Table 5). Though no statistical
differences were found among the three groups, values
of FH/VER and FH/CVT in the high angle group were
significantly larger than those in the other two groups
(Table 5).
Values of ML/VER, ML/OPT, and ML/CVT were
smallest in the high angle group and largest in the low
angle group, and there were statistical differences among
the three groups by ANOVA. Significant differences were
found between any two groups for ML/VER and between
the high angle group and the other two groups for ML/
OPT by LSD test. The value of ML/CVT in the low angle
group was significantly different from those in the other
two groups by LSD test (Table 5).
Statistical differences were noticed in the inclinations of
the ramus to the cervical column among the three groups,
which were largest in the high angle group. Differences
between groups are shown in Table 5.
The inclinations of the cervical column did not show
statistical differences among the three groups, while
measurements in the high angle group were smaller than
those in the other two groups (Table 5). There were sig-
nificant differences between the average angle group and
the high angle group for OPT/CVT. The cervical lordosis
was smallest in the average angle group and largest in the
high angle group (Table 5).
Discussion
Peng [3], in a 15-year longitudinal study, affirmed that
NHP was a rather stable and reproducible posture.
Therefore, the slight differences in age among the three
groups should have no effect on the results of the pres-
ent study. Although there is still controversy regarding
the influence of gender on NHP and craniocervical pos-
ture [19–21], the influence was not found in this study.
Therefore, the significant differences observed in this
study could be ascribed to the different vertical facial
patterns rather than to gender.
Both sagittal and vertical skeletal facial morphology are
demonstrated to associate with NHP [8]. Positive non-top-
ographical correlations are found between the sagittal jaw
relationship and the inclination of the nasion-sella line to
the cervical column and the true vertical. Regarding the
vertical facial pattern, the inclination of the mandible to
the cranial base as well as to the nasal line has marked pos-
itive topographical and non-topographical correlations
with the craniocervical posture [8]. Liu et al. [18] dis-
cussed relationships of sagittal skeletal discrepancy, NHP,
and craniocervical posture in young Chinese children,
and found that subjects with skeletal Class II relationship
tended to display more extended heads, while children
with skeletal Class III relationship often exhibited flexed
310 Y. LIU. ET AL.

Table 2. Description of variables.

No. Variable Description
Sagittal and vertical facial pattern
1 ANB Difference between angles SNA and SNB, the angle formed by point
A, N and B
2 Wits The distance between the points of contact of the perpendiculars of A
and B on occlusal plane
3 NSL/ML Mandibular plane angle, the angle formed by NSL (nasion-sella line,
the line through N and S) and ML (mandibular line, the tangent to
the lower border of the mandible through Me)
4 FH/ML Frankfort mandibular plane angle, the angle formed by FH (Frankfort
line, the line through O and P) and ML
5 FHR Facial height ratio, posterior facial height/anterior facial height,
S-Go/N-Me
6 NSL/NL Angle formed by NSL and NL (nasal line, the line through ANS and
PNS)
7 NL/ML Angle formed by NL and ML
Maxilla and cranium values—head posture
8 NSL/VER Angle formed by NSL and VER (true vertical line, the gravity deter-
mined vertical line projected on the film)
9 FH/VER Angle formed by FH and VER
10 NL/VER Angle formed by NL and VER
Maxilla and cranium values—craniocervical posture
11 NSL/OPT Angle formed by NSL and OPT (odontoid process tangent, the posteri-
or tangent to the odontoid process through the most postero-inferi-
or point on the corpus of the second cervical vertebra)
12 FH/OPT Angle formed by FH and OPT
13 NL/OPT Angle formed by NL and OPT
14 NSL/CVT Angle formed by NSL and CVT (the line through the most postero-infe-
rior point on the corpus of the second and fourth cervical vertebra)
15 FH/CVT Angle formed by FH and CVT
16 NL/CVT Angle formed by NL and CVT
Mandible values—mandibular posture to the true vertical and cervical column
17 ML/VER Angle formed by ML and VER
18 ML/OPT Angle formed by ML and OPT
19 ML/CVT Angle formed by ML and CVT
Mandible values—inclinations of ramus to cervical column
20 RL/OPT Angle formed by RL (ramus line, the tangent to the posterior border of
the mandible) and OPT
21 RL/CVT Angle formed by RL and CVT
Inclination of cervical column
22 OPT/HOR Angle formed by OPT and HOR (true horizontal line, the line perpen-
dicular to VER)
23 CVT/HOR Angle formed by CVT and HOR
Cervical curvature
24 OPT/CVT Angle formed by OPT and CVT

heads. In this study, only subjects with skeletal Class I
relationship were included, so that the current study could
elucidate the relationships of vertical facial pattern, NHP,
and craniocervical posture by eliminating the influence
of sagittal skeletal discrepancy.
In orthodontics, NSL/ML, FH/ML, and FHR are
measurements frequently used to evaluate vertical facial
patterns of subjects in literature along with clinical work
[22,23]. In the present study, the authors evaluated the
vertical facial patterns of subjects according to their NSL/
ML angles. However, NSL/ML angle could not be the sole
criterion in the selection and diagnosis of vertical facial
pattern, since Opdebeeck and Bell [24] reported that a
short face was not necessarily associated with a reduced
NSL/ML angle. In addition, from the long facial pattern
to the short facial pattern, there is a progressive decrease
in the anterior face height and an increase in the poste-
rior face height, and the mandibular diversion becomes
smaller [22]. For the reasons mentioned above, FH/ML
and FHR were measured and analyzed as well. Significant
differences were observed in FH/ML and FHR values
among the three groups, divided according to NSL/ML
angle (Table 4). The consistent tendency of NSL/ML, FH/
ML as well as FHR and remarkable differences among the
three groups indicated that the method used to differenti-
ate the vertical facial types in this study was appropriate.
Values of NSL/ML, NSL/NL and NL/ML were largest in
the high angle group and smallest in the low angle group
(Table 4). Differences for the variables NSL/ML and NL/
ML were much more significant than those of NSL/NL
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 311

Table 3. Method errors for the measurements. were higher in subjects with long faces than those with
Measurements Method error (degree or mm) short faces. In a recent study, extended craniocervical pos-
ANB 0.14 ture of the subjects with TMD was positively related to a
Wits 0.18 hyperdivergent and Class II skeletal pattern [15]. Though
NSL/ML 0.35
FH/ML 0.20 many studies have indicated that the craniocervical char-
FHR 0.01 acteristics are markedly distinctive between different head
NSL/NL 0.24
NL/ML 0.22
types, Akcam [28] held a different opinion, that NHP was
NSL/VER 0.23 not statistically different between the head type groups.
FH/VER 0.07 The debates about previously cited research partially point
NL/VER 0.12
NSL/OPT 0.14 out the complexity of the developmental behavior of the
FH/OPT 0.24 face and the spinal column, meaning further research is
NL/OPT 0.26
NSL/CVT 0.16 required to clarify this controversial topic.
FH/CVT 0.23 Contrary to measurements mentioned above, values of
NL/CVT 0.23
ML/VER 0.18 variables 17 – 19 were largest in the low angle group and
ML/OPT 0.34 smallest in the high angle group. This can be attributed to
ML/CVT 0.32
RL/OPT 0.17
the different rotation patterns of the mandible among the
RL/CVT 0.18 three groups [25,29]. Subjects with short faces exhibit an
OPT/HOR 0.23 anterior direction of facial growth, mandibular anterioro-
CVT/HOR 0.22
OPT/CVT 0.21 tation, while subjects with long faces exhibit a posterior
direction of facial growth and mandibular posterioro-
tation [23]. The results of the current study are well in
among the three groups. It can be interpreted that the line with the previous study, which reported that on the
lower third of the face plays an important role in deter- average, a mandibular line relatively perpendicular to the
mining vertical facial pattern [25]. cervical column and the true vertical was associated with
For variables representing head posture, values of a small NSL/ML angle, and a mandibular line relatively
variables 8–10 were largest in the high angle group and parallel to the cervical column and the true vertical was
smallest in the low angle group. The results of this study related to a large NSL/ML angle [8].
are in line with Solow’s study showing that a small incli- Relationships among craniofacial morphology, mas-
nation of the mandible to the cranial base and the nasal ticatory function, and head posture have been reported
plane is related to flexion of the head [8]. Furthermore, extensively [30,31]. It is widely accepted that bite force
a linear regression analysis showed that extension of the in subjects with rectangular craniofacial morphology and
head in relation to the true vertical line was significantly skeletal deep bite is greater than in subjects with long-face
associated with a large inclination of the jaws and a large morphology and open bite [30]. Subjects with larger crani-
vertical jaw relationship [26]. In Kim’s research, the head ocervical angles often show lower electromyographic activ-
posture was found to be more extended in the skeletal ity of the masseter, meaning lower muscle power, which
open-bite group compared with the dentoalveolar open- is associated with a long face [30]. As muscular activity is
bite group [26]. However, Dubojska et al. [23] held the associated with both vertical craniofacial morphology and
opposite opinion, that the NSL/VER angle in the group craniocervical posture, it may act as a bridge between ver-
with small NSL/ML was higher than that in the group tical craniofacial morphology and craniocervical posture.
with large NSL/ML. Actually, this disagreement can be A large angulation of the ramus line to the cervical
ascribed to the use of the supplementary angle of NSL/ column is found to associate with a large NSL/ML, while
VER in Dubojska’s study. a small angulation of the ramus line to the cervical column
Craniocervical posture and the skeletal pattern of the is related to a small NSL/ML [8]. The results of the current
face are found to be closely related. Values of variables 11 – study are in agreement with previous research; as shown
16 in the three groups followed the tendency that was larg- in Table 5, RL/OPT and RL/CVT were largest in the high
est in the high angle group and smallest in the low angle angle group and smallest in the low angle group.
group. The results of the present study are in agreement In this study, a slight but not significant decrease in
with previous studies that suggested a small NSL/ML, NL/ cervical inclination was observed in the high angle group.
ML angle was related to flexion of the head, while a large A previous study suggested that the NSL/ML and NL/
inclination of the jaws and a large vertical jaw relationship ML angles showed negative associations with the cervical
were associated with extension of the head in relation to inclination [8]. Consistent with other studies, significant
the cervical vertebral column [8,26,27]. Dubojska’s [23] differences of cervical inclination cannot be found among
research also showed that NSL/OPT and NSL/CVT values the three groups in the present study [26,28].
312 Y. LIU. ET AL.

Table 4. Descriptive statistics of sagittal and vertical facial pattern.

No. Variable Low angle mean ± SD Average angle mean ± SD High angle mean ± SD p value p (L-A) p (A-H) p (L-H)
1 ANB 2.50 ± 1.37 2.70 ± 1.32 2.74 ± 1.21 .806
2 Wits −1.69 ± 1.47 −1.90 ± 1.38 −1.90 ± 0.97 .856
3 NSL/ML 29.07 ± 2.70 35.94 ± 2.13 43.79 ± 2.57 .000 *** *** ***
4 FH/ML 22.83 ± 3.73 27.92 ± 3.38 34.52 ± 3.53 .000 *** *** ***
5 FHR 0.69 ± 0.02 0.63 ± 0.02 0.59 ± 0.02 .000 *** *** ***
6 NSL/NL 8.00 ± 3.61 8.85 ± 3.02 11.36 ± 3.07 .002 ** **
7 NL/ML 21.07 ± 3.30 27.09 ± 3.50 32.43 ± 3.89 .000 *** *** ***

SD = standard deviation.
**p < 0.01; ***p < 0.001.

Table 5. Descriptive statistics of variables.

No. Variable Low angle mean ± SD Average angle mean ± SD High angle mean ± SD p value p (L-A) p (A-H) p (L-H)
8 NSL/VER 95.71 ± 6.59 97.57 ± 5.44 101.57 ± 6.53 .006 * **
9 FH/VER 89.48 ± 4.83 89.55 ± 4.77 92.31 ± 5.91 .109 * *
10 NL/VER 87.71 ± 6.83 88.72 ± 5.68 90.21 ± 6.21 .405
11 NSL/OPT 93.14 ± 7.85 97.54 ± 6.35 99.69 ± 8.17 .011 * **
12 FH/OPT 86.90 ± 6.55 89.52 ± 6.41 90.43 ± 7.48 .198
13 NL/OPT 85.14 ± 7.01 88.69 ± 6.04 88.33 ± 7.59 .113 *
14 NSL/CVT 101.71 ± 8.14 104.08 ± 7.11 109.31 ± 7.70 .004 ** **
15 FH/CVT 95.48 ± 7.48 96.06 ± 6.67 100.05 ± 6.58 .051 * *
16 NL/CVT 93.71 ± 7.81 95.23 ± 6.77 97.95 ± 7.45 .152
17 ML/VER 66.64 ± 7.54 61.62 ± 5.53 57.79 ± 5.83 .000 ** * ***
18 ML/OPT 64.07 ± 8.32 61.60 ± 6.26 55.90 ± 7.21 .001 ** ***
19 ML/CVT 72.64 ± 8.68 68.13 ± 7.37 65.52 ± 6.87 .010 * **
20 RL/OPT 1.81 ± 5.38 3.99 ± 6.29 7.29 ± 7.08 .020 * **
21 RL/CVT 10.38 ± 7.06 10.53 ± 6.61 16.90 ± 6.86 .001 *** **
22 OPT/HOR 92.57 ± 6.48 90.03 ± 6.52 91.88 ± 5.77 .236
23 CVT/HOR 84.00 ± 6.20 83.49 ± 6.58 82.26 ± 5.18 .639
24 OPT/CVT 8.57 ± 4.70 6.54 ± 5.05 9.62 ± 4.40 .034 *

SD = standard deviation.
*p < 0.05; **p < 0.01; ***p < 0.001.

Unexpectedly, cervical curvature was largest in the
high angle group and smallest in the average angle group,
though there were only slight differences. At present, most
studies have supported that people with large NSL/ML
angles exhibit reduced cervical lordosis, while people
with small NSL/ML angles show increased cervical lor-
dosis [8,17]. The inconsistency of the results of the present
study with others can be explained by the fact that cervical
curvature only has a weak influence on craniofacial mor-
phology [19]. Furthermore, the different and sometimes
conflicting findings reported above may, to some extent,
be due to differences in the samples, designs, and meth-
odologies used in the various studies. Moreover, the disa-
greement may be attributed to the large standard deviation
relative to the mean value of cervical curvature. In future
studies, the authors will make every effort to include more
subjects to minimize the influence of sample size.
Growth changes in craniocervical posture are related to
corresponding growth changes of the facial skeleton [9].
A decrease in craniocervical posture is associated with
anteriorly and horizontally directed growth throughout
the face, while an increase in craniocervical posture is
related to a downward and vertical direction of jaw growth
[23,32]. Nevertheless, based on this cross-sectional study,
it is impossible to make any specific conclusion that results
in determining etiology or cause and effect relationships
from these data. It is therefore suggested to investigate
these parameters in a longitudinal study.
Recently, the importance of the soft tissue paradigm
has been emphasized, and a normal soft tissue propor-
tion is considered a primary treatment goal in orthodontic
or surgical-orthodontic treatment [33,34]. Since NHP is
directly related to the soft tissue profile of the face, this
study suggests that clinicians should carefully evaluate
relationships between the craniocervical posture and the
facial profile in patients with different vertical facial pat-
terns before orthodontic treatment.
Conclusion
Significant differences exist in NHP and craniocervical
posture among different vertical facial patterns in young
Chinese children with skeletal Class I relationship.
Generally speaking, most variables representing head
position and craniocervical posture were largest in the
high angle group and smallest in the low angle group.
Subjects with large NSL/ML angles showed extended
head and craniocervical posture, while subjects with small
NSL/ML angles exhibited flexed head and craniocervical
posture.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Acknowledgments
The authors are grateful to Arthur Gregory Burns for editing
and reviewing the manuscript.
Disclosure statement
The authors report no conflicts of interest.
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