CRANIO®

The Journal of Craniomandibular & Sleep Practice

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

The Association Between Posture of the Head and

Malocclusion in Saudi Subjects

Eman A. AlKofide & Eman AlNamankani

To cite this article: Eman A. AlKofide & Eman AlNamankani (2007) The Association Between
Posture of the Head and Malocclusion in Saudi Subjects, CRANIO®, 25:2, 98-105, DOI: 10.1179/
crn.2007.016

To link to this article: http://dx.doi.org/10.1179/crn.2007.016

Published online: 31 Jan 2014.

Submit your article to this journal

Article views: 16

View related articles

Full Terms & Conditions of access and use can be found at

http://www.tandfonline.com/action/journalInformation?journalCode=ycra20

Download by: [University of California, San Diego] Date: 01 April 2016, At: 03:18
 OCCLUSION

The Association Between Posture of the Head and

Malocclusion in Saudi Subjects
Eman A. AlKofide, B.D.S., M.S., D.Sc.; Eman AlNamankani, B.D.S., M.S.

ABSTRACT: The purpose of the present study was to examine whether a relationship exists between
posture of the head and neck, and the presence of certain malocclusal problems. Dental models, in addi-
tion to lateral cephalometric radiographs, taken in the “natural head position” of 180 male and female
subjects were obtained. The postural angles between the head and the cervical column, termed cran-
iovertical, craniocervical, cervicohorizontal, and cervical curvature, were measured. The malocclusal
0886-9634/2502-
Downloaded by [University of California, San Diego] at 03:18 01 April 2016

098$05.00/0, THE
traits studied were: molar relation, crowding, spaces, overbite, overjet, crossbites, and midline displace-
JOURNAL OF ments. Results show that a relationship between crowding and head posture could only be found in sub-
CRANIOMANDIBULAR
PRACTICE,
jects with upper arch crowding and cervical curvature (p<0.01). A significant difference in craniocervical
Copyright © 2007 and cervicohorizontal angles was observed in subjects with overbite, compared to subjects without over-
by CHROMA, Inc.
bite (p<0.01, p<0.001). The influence of gender on overbite and head posture was also found to be
strongly correlated (p<0.05). With regard to molar relation, Class II malocclusion showed a stronger rela-
Manuscript received
May 24, 2005; revised tion with craniovertical and cervicohorizontal angles than both other classes (p<0.05, p<0.01). A signifi-
manuscript received cant correlation was found between craniovertical angles NSL/VER and overjet, irrespective of gender
December 12, 2006;
accepted or age (p<0.05). Crossbite was strongly correlated with all craniocervical angles (p<0.05). It can be con-
January 11, 2007 cluded that certain malocclusal problems are more strongly associated with head posture than others,
Address for correspon- and that crowding does not seem to play a major role in this association in the present study.
dence:
Dr. Eman A. AlKofide
Orthodontic Division
College of Dentistry
King Saud University
P.O. Box 60169
Riyadh, 11545

Saudi Arabia
E-mail:
ealkofide@hotmail.com
Dr. Eman A. AlKofide received a B.D.S.
from King Saud University, College of
Dentistry, Riyadh, Saudi Arabia in 1988.
He received a Fellowship in Cranioman-
dibular and Orofacial Pain from the Gelb
Center at Tufts University in 1992 and an
M.S. degree in dental sciences from Tufts
University in 1992. She obtained a clini-
cal certificate in orthodontics from Tufts
University in 1994 and a D.Sc. degree in
public health from the Henry Goldman
Dental School, Boston University in 1997.
Dr. AlKofide is a Diplomate of the
Amercian Board of Orofacial Pain and is
board certified by the Amercan
Association of Orthodontists.
A
relationship between malocclusion and neck pos-
ture was proposed as early as 1926. In a study
conducted by Schwartz1 on the effect of upper
airway obstruction in children, he concluded that a rela-
tionship exists between the inability to breathe properly
and the development of malocclusion. This hypothesis
was based on the fact that a forward head posture, i.e., a
forward cervical inclination combined with an extended
position of the head (extended craniocervical angle),
could be found in subjects with airway obstruction.
Schwartz concluded that posture may be linked to the
development of certain types of malocclusion, especially
Class II malocclusion. The same finding was reported by
Gresham and Smithels,2 who concluded in their study
that a larger prevalence of Class II malocclusions and an
increase in vertical development of the face were present
in subjects with poor neck posture compared to subjects
with good neck posture. Woodside, et al.3 also proposed a
relationship between upper airway obstruction and the
development of malocclusion. In their study, they found
that subjects with impaired nose breathing due to nasal
mucosal swelling had a higher prevalence of lower ante-
rior crowding of the dental arch compared to normal
breathers.

98
 ALKOFIDE AND ALNAMANKANI
The relationship between head posture and malocclu-
sion has not only been documented in subjects with
airway obstruction,4-13 but also in subjects with normal
breathing patterns.14-19 In a study conducted by Solow and
Sonnesen,19 in which subjects with severe malocclusal
problems and no airway subjects were examined, a pat-
tern of association between posture of the head and neck
and malocclusion was observed. They concluded that in
those individuals with severe malocclusion, a more
extended cervical inclination or forward postured neck
was present. When investigating which malocclusal
problem (crowding, overbite, overjet, spacing, different
classes of malocclusion, etc.) was more commonly pre-
Downloaded by [University of California, San Diego] at 03:18 01 April 2016
sent in conjunction with the variables of posture, it was
found that crowding was the most common malocclusal
trait that was associated with a large craniocervical angle.
When comparing molar relation, subjects with Class II
malocclusion had smaller craniocervical angles and
larger cervicohorizontal angles (cervical inclination to
the true horizontal) than subjects without this type of mal-
occlusion.
The rationale of the relation between extended cranio-
cervical angle and crowding in Solow and Sonnesen’s20
study was attributed to the soft tissue stretching mecha-
nism. This mechanism postulates that stretching of the
soft tissue of the head and neck creates a dorsal force
which, in turn, impedes the forward growth of the face, in
particular the mandible. This stretching leads to the
development of crowding. Other factors mentioned in the
literature that have been linked to the development of
crowding range from: change of diet from abrasive foods
to softer foods and the lack of interproximal wear between
teeth,21 soft tissue forces on the dental arches such as the
tongue and surrounding oral musculature, 22 and tooth-
size-jaw-size discrepancy.23
Since crowding is a common, modern day problem, it
is of interest to determine whether, in fact, lack of space,
or any other malocclusal problem, is related to differ-
ences in posture of the head and neck. Therefore, the pur-
pose of this study was to investigate the relationship
between malocclusion and head posture and to determine
which malocclusal trait was more strongly associated
with the postural angles.
Material and Methods
Subjects seeking orthodontic treatment at the College
of Dentistry, King Saud University were screened and
selected. Both male and female subjects were included in
the study, with an age range of 12-22 years. A total of 180
subjects were selected. Individuals with craniofacial
anomalies, systemic muscle or joint disorders, temporo-
APRIL 2007, VOL. 25, NO. 2
HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS
mandibular joint subjects, or subjects with upper airway
obstruction were excluded. Records were taken for each
subject which included models and lateral cephalometric
radiographs. Assessment of the occlusion was deter-
mined during the clinical examination and on the casts of
the dental arches. Angle’s classification was used to clas-
sify the molar relationship of each subject. In addition,
various malocclusal traits were recorded: overjet, over-
bite, openbite, upper midline position, lower midline
position, upper crowding, lower crowding, upper spaces,
lower spaces, crossbites (anterior or posterior), lingual, or
buccal (scissors-bite), missing teeth, anomalies of tooth
formation (peg-shaped laterals), habits, and impacted
teeth (Table 1).
A lateral cephalometric radiograph was taken for each
subject using the PM 2002 CC Proline Cephalostat
(Planmeca, Helsinki, Finland). Exposure data was 60-80
kV and 4-12 mA, with an exposure time of 0.2-5 sec.
Magnification factor was 1.10, with fixed film to focus
plane distance of 165 cm, using an 18x24 cm cassette
film with the rare earth screen. Each radiograph was
taken in the natural head position (NHP) with the teeth in
occlusion. The method described previously in the litera-
ture by Siersbak-Nielsen and Solow24 and by Solow and
Sandham25 was used to obtain the NHP and to standard-
ize the position of the subject in the cephalometer.
After the profile radiographs were taken, reference
points and lines on the head (cranium and maxilla) and
cervical column (2 nd and 4 th cervical vertebra) were
marked and traced for each radiograph26 (Table 2). In
order to determine if a relationship exists between head
posture and malocclusion, postural angles between the
head and neck were calculated utilizing these references
points and lines and were termed: craniovertical, cranio-
cervical, and craniohorizontal angles (Figure 1). The
craniovertical angles are those angles that relate posture
of the head (NSL, NL) to an environmentally determined
vertical (VER) and are represented by NSL/VER and
NL/VER. The craniocervical angles are those angles that
relate the posture of the head (NSL, NL) to a line repre-
senting the cervical column (OPT, CVT): These are
NSL/OPT, NSL/CVT, NL/OPT, and NL/CVT. Lastly,
the craniohorizontal angles are those angles that express
the cervical inclination (OPT, CVT) in relation to the
environmentally determined true horizontal (HOR) and
are expressed as angles OPT/HOR and CVT/HOR
(Table 2).26
The reliability of the cephalometric measurements was
re-assessed by measuring 20 lateral cephalometric radi-
ographs, taken three weeks after the initial analysis. The
error of the method was calculated using Dahlberg’s for-
mula.27 No significant mean differences were found, with
THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 99
 HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS ALKOFIDE AND ALNAMANKANI

Table 1
Description of Malocclusion Categories
Malocclusal trait Description
Molar relation Angle Class I; mesiobuccal cusp of U6 in buccal grove L6
Angle Class II; mesiobuccal cusp of U6 1/2 cusp distal to L6
Angle Class III; mesiobuccal cusp of U6 1/2 cusp mesial to L6

Overjet Reverse=0-negative 4 mm; mild overjet=1-4 mm; moderate

overjet=5-6 mm; severe overjet=7-10 mm

Overbite Open bite=0-negative 4 mm; mild overbite=1-2 mm; moderate

Downloaded by [University of California, San Diego] at 03:18 01 April 2016

overbite=3-4 mm; severe overbite=5-7 mm; extreme

overbite > 7 mm

Midline (upper/lower) > 2 mm

Crowding (upper/lower) incisors Mild crowding=2-3 mm; moderate=4-6 mm; severe=7-10 mm;
extreme > 10 mm

Spaces Mild=1-3 mm; moderate=3-4 mm; severe > 4 mm

Crossbites (anterior/posterior) Ranging from simple anterior one tooth involvement to bilateral
full posterior

Others Scissors bite, missing teeth, anomalies, habits, impacted teeth

the method error ranging from 0.25-0.62. Data were
analyzed using the SPSS program.28 Descriptive statis-
tics were calculated for all variables. Spearman correla-
tion coefficients between malocclusion traits and postural
variables were estimated. Stepwise multiple regression
analysis was used to further test the effect of gender and
age for each significant correlation. Effects of categories
and class of malocclusion on postural variables were
tested using the General Linear Model, considering age
and sex as covariates. LSD was used to test the significant
differences between means of postural variables. The
results were considered statistically significant at
p-values below the 0.05 level.
Results
Descriptive statistics for postural variables are shown
in Table 3. Means and standard deviations of cranioverti-
cal, craniocervical, cervicohorizontal, and cervical curva-
ture angles are all displayed.
Spearman correlation coefficients between posture of
the head and malocclusion are shown in Table 4. Molar
occlusion (p<0.001), overjet, overbite, and crossbite
(p<0.05) showed a significant correlation with craniover-
tical angle NSL/VER and with all craniocervcial (NSL/
OPT, NSL/CVT, NL/OPT, NL/CVT) and cervicohori-
zontal angles (OPT/HOR, CVT/HOR). When each corre-
lation was tested for the effects of gender and age, a
significant correlation between overbite and gender was
found with craniocervical angles NSL/CVT, NL/CVT,
NL/CVT, and all cervicohorizontal angles (OPT/HOR,
CVT/HOR) (p<0.05). The effect of posture and gender
on overbite was seen in craniocervical angle NSL/OPT
only (p<0.05). Table 5 shows the differences between
means of postural variables of subjects with and without
malocclusion. A significant difference could be found
between subjects with and without overbite in all cate-
gories of craniocervical and cervicohorizontal measure-
ments (p<0.01 and p<0.001). Lower mean values for all
craniocervical angles, and higher mean values for all cer-
vicohorizontal angles was noted.
When determining if crowding had any significant
affect on posture, only the means of upper arch crowding
was found to have any significance when compared
between subjects with and without crowding (p<0.01)
(Table 5). This significance was observed for cervical
curvature angle OPT/CVT. The means of the cranio-
cervical (NSL/OPT, NL/OPT) and cervicohorizontal

100 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2007, VOL. 25, NO. 2
 ALKOFIDE AND ALNAMANKANI HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS

Table 2
Reference Points and Lines
Reference points Description
S Sella; the center of the sella turcica. The upper limit of the sella turcica
is defined as the line joining the tuberculum and the dorsum sellae

N Nasion; the most anterior point on the frontonasal suture

SP Spinal point; the apex of the anterior nasal spine

PM Pterygomaxillare; the intersection between the nasal floor and the posterior contour
of the maxilla
Downloaded by [University of California, San Diego] at 03:18 01 April 2016

Cv2tg The tangent point of OPT on the odontoid process of the second cervical vertebra

Cv2ip The most postero-inferior point on the corpus of the second cervical vertibra

Cv4ip The most posterior-inferior point on the corpus of the fourth cervical vertebra

Reference lines
NSL Nasion-sela line; the line through N and S

NL Nasal line; the line through SP and PM

OPT Odontoid process tangent; the posterior tangent to the odontoid process through Cv2ip

CVT Cervical vertebrae tangent; the posterior tangent to the odontoid process through Cv4ip

VER True vertical line; the vertical line projected on the film

HOR True horizontal line; the line perpendicular to VER

Figure 1
Cephalometric drawing of reference points
and lines of postural variables on the head
and cervical column.

APRIL 2007, VOL. 25, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 101
 HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS ALKOFIDE AND ALNAMANKANI

p<0.01). When Class III malocclusion was studied, a sig-

nificant difference was found between Class III and Class
I malocclusion in craniovertical (NSL/VER) and cervical
Table 3 curvature (OPT/CVT) (p<0.05). When Class II and III
Descriptive Statistics for Postural Variables were compared, a significant difference was found in
(n=180) craniocervical NSL/OPT angle and cervicohorizontal
Postural variable Mean SD angles (OPT/HOR, CVT/HOR) (p<0.05 and p<0.01).
Craniovertical When observing the means of Class II malocclusion sub-
NSL/VER 98.73 4.42 jects, a difference was noted in craniocervical (NSL/OPT,
NL/VER 90.77 4.47 NSL/CVT, NL/OPT, NL/CVT) and cervicohorizontal
Craniocervical
NSL/OPT 97.73 7.80
angles (OPT/HOR, CVT/HOR) as compared to Class I or
NSL/CVT 102.33 7.98 Class III malocclusion.
NL/OPT 89.96 8.15
Discussion
Downloaded by [University of California, San Diego] at 03:18 01 April 2016

NL/CVT 94.43 8.37

Cervicohorizontal
OPT/HOR 90.87 6.96
CVT/HOR 86.40 7.05
When comparing the postural variables of the current
Cervical curvature study with that of Solow and Sonnesen’s19 study, a differ-
OPT/CVT 4.88 2.44 ence could be found between them. The means of the
craniovertical, craniocervical, and cervical curvature
angles in the Saudi sample were higher than those re-
(OPT/HOR) variables showed an average 3-5 degrees ported for the Danish sample. The cervicohorizontal
difference when compared with the noncrowding sub- angles, on the other hand, showed lower means. These
jects, but this was not statistically significant. measurements should be taken into account when study-
Table 6 demonstrates the effects of categories and ing head posture in Saudis because their postural vari-
classes of malocclusion on postural variables. Results ables differ from Europeans.
show that Class II malocclusion was significantly differ- Previous reports of a relationship between lack of
ent in all craniovertical and cervicohorizontal angles space in the dental arches and posture of the head could
when compared with Class I malocclusion (p<0.05 and not be verified in the current study. A relationship

Table 4
Spearman Correlation Coefficients Between Head Posture and Malocclusion
Postural variables
Craniovertical Craniocervical Cervicohorizontal Cervical
NSL/ NL/ NSL/ NSL/ NL/ NL/ OPT/ CVT/ OPT/
Malocclusion traits VER VER OPT CVT OPT CVT HOR HOR CVT
Class malocclusion 0.20** - - - - - - - -
Overjet 0.17* - - - - - - - -
Overbite - - -0.181 -0.172 -0.172 -0.152 0.152 0.152 -
Midline upper - - - - - - - - -
Midline lower - - - - - - - - -
Crowding upper - - - - - - - - -
Crowding lower - - - - - - - - -
Crossbite - - 0.26* 0.26* 0.28* 0.32* - - -
Others - - - - - - - - -
Nonsignificant correlations have been deleted.
Each significant correlation was tested for the effects of gender and age by stepwise multiple regression analyses.
Sample size = 180 for all traits; except for crossbite = 64, and others = 30.
*p<0.05; **p<0.01; no significant effect of gender or age.
1p<0.05; due to effects of posture and gender.
2p<0.05; due to effect of gender.

102 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE APRIL 2007, VOL. 25, NO. 2
 ALKOFIDE AND ALNAMANKANI HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS

Table 5
Mean Differences in Postural Variables Between Subjects With and Without
the Categories of Malocclusion Listed
Postural variables
Cervical
Craniovertical Craniocervical Cervicohorizontal curvature
Malocclusion NSL/ NL/ NSL/ NSL/ NL/ NL/ OPT/ CVT/ OPT/
traits VER VER OPT CVT OPT CVT HOR HOR CVT
Overjet 0.85 0.24 -1.43 -1.96 -2.45 -2.44 2.19 2.51 -0.15
Overbite 0.13 -0.18 -3.52** -3.80** -4.12** -3.88* 3.68*** 3.88*** -0.14
Midline upper -0.02 0.70 -1.10 -0.67 -0.59 -0.78 1.06 1.11 0.28
Downloaded by [University of California, San Diego] at 03:18 01 April 2016

Midline lower 0.14 0.19 2.47 2.05 2.37 1.97 -2.56 -2.13 -0.25
Crowding upper -0.30 -0.86 3.16 0.62 2.56 0.48 -3.47 -1.28 -2.10**
Crowding lower -1.56 -1.70 -1.56 -1.73 -1.77 -1.71 0.05 0.17 0.06
Sample size = 180
*p<0.05; **p<0.01; ***p<0.001

between both could only be found in subjects with upper
arch crowding. A more extended craniocervical posture,
hence extension of the head, was noted when crowding
was present in the upper arch. Hellsing, et al.29 reported
that a few degrees of extension of the head may lead to
increased labial pressure on the upper incisors, causing
crowding. It is noteworthy to mention that although a dif-
ference could be found in the current study in terms of
degrees, no significant difference could be found between
the mean differences of subjects with and without crowd-
ing, except for cervical curvature and upper crowding.
An interesting finding in the present study was the
association between overbite and posture. Craniocervical
and cervicohorizontal angles were all influenced by deep
overbite. The relationship between them has been men-
tioned previously,19 but with fewer postural variables. In
the current study, ventroflexion of the head (smaller cran-
iocervical angles) with retroinclination of the cervical
spine (larger cervicohorizontal angles) was accompanied
with deep overbite. This relation is usually seen in sub-
jects with horizontal growth patterns, or brachyfacial
types. When the effect of gender on overbite was investi-
gated, a significant correlation was present. This is in dis-
agreement with Solow and Sonnesen19 who showed that
none of the significant differences could be attributed to
either age or gender.

Table 6
Mean Differences in Postural Variables Between Subjects with Class Malocclusion
Postural variables
Cervical
Craniovertical Craniocervical Cervicohorizontal curvature
Malocclusion NSL/ NL/ NSL/ NSL/ NL/ NL/ OPT/ CVT/ OPT/
class VER VER OPT CVT OPT CVT HOR HOR CVT
I-II -2.26** -1.91* 0.90 1.03 1.18 1.32 -3.14** -3.14** 0.41
I-III -1.86* -1.03 -2.16 -1.41 -1.49 -0.40 0.49 -0.45 0.96*
II-III 0.40 0.87 -3.07* -2.44 -2.68 -1.73 3.63** 2.69* 0.55
Sample size = 180
*p<0.05; **p<0.01

APRIL 2007, VOL. 25, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 103
 HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS
Previous studies have mentioned the relationship
between the different classes of malocclusion and head
posture. A study2 comparing 61 children with poor neck
posture to their controls revealed that subjects with bad
posture had longer faces and a significant increase in
prevalence of Angle Class II occlusion. The relationship
of head posture to Class II malocclusion has also been
documented in a study by Balters,30 in which Class II sub-
jects had more pronounced problems with the spine when
compared to other classes of malocclusion. In the current
study, when comparing subjects with Class II and Class I
malocclusion, differences in craniocervical and cervico-
horizontal angles were noted. This dissimilarity indicates
Downloaded by [University of California, San Diego] at 03:18 01 April 2016
that an upright posture of the head, and a greater exten-
sion of the head on the spinal column, is more evident in
Class II malocclusion subjects. Similar findings have
been reported by other researchers.31-33 When comparing
Class III subjects with Class I, a more forward head pos-
ture was present with a straighter curve of the cervical
spine.
Another malocclusal trait that was significantly associ-
ated with head posture was crossbite. All craniocervical
angles showed a significant correlation with crossbite,
irrespective of age or gender. One may suggest that when
crossbite is present in an individual, a shift in position of
the head, and hence, the cervical column relationship
may be altered due to the faulty bite. Further study of the
relationship between both should be undertaken to deter-
mine if a true relationship exists, and if so, to what extent.
Findings of the current study also reveal a relationship
between overjet and head posture (craniovertical angles).
The more severe the overjet, the stronger the relationship
between both, irrespective of age or gender. This is in dis-
agreement with Solow and Sonnesen’s19 study, in which
a significant correlation was found between overjet and
posture of the head, but was due to the effects of gender
and age.
In light of the findings of the present study, a relation-
ship between certain malocclusal traits and head posture
was evident, but could not be verified in cases of crowd-
ing. Further studies are required to determine if crowding
plays a major role in posture and position of the head in
relation to the cervical column.
Conclusions
While studying the relationship between malocclusion
and head posture in Saudi subjects, the following was
noted:
1. The means for the postural variables were different
from those previously reported for European sub-
jects.
104 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE
ALKOFIDE AND ALNAMANKANI
2. A relationship between crowding and head posture
could only be found between cervical curvature
(OPT/CVT) and upper arch crowding.
3. Subjects with increased overbite appear to be associ-
ated with a more horizontal growth pattern. The
influence of gender on overbite and head posture was
strongly correlated.
4. Class II malocclusion showed a stronger relationship
with craniovertical and cervicohorizontal angles than
both other classes.
5. With regard to crossbite, a significant correlation
was found between all craniocervical angles and
crossbite.
6. A significant correlation was found between cran-
iovertical angles NSL/VER and overjet, irrespective
of gender or age.
References
1. Schwartz AM: Kopfhaltung und Kiefer. Zeitschrift fur Stomatologie 1926;
24:669-774.
2. Gresham H, Smithells PA: Cervical and mandibular posture. Dent Rec 1954;
74:261-264.
3. Woodside D, Linder-Aronson S, Stubbs DO: Relationship between mandibu-
lar incisor crowding and nasal mucosal swelling. Proc Finn Dent Soc 1991;
87:127-138.
4. Linder-Aronson S: The effect on mode of breathing and nasal airflow and
their relationship to characteristics of the facial skeleton and the dentition.
Acta Otoloryngol (suppl) 1970; 265:1-132.
5. Solow B, Greve E: Craniofacial angulation and nasal respiratory resistance.
In: McNamara JA, ed. Nasorespiratory function and craniofacial growth
[monograph No. 9]. Craniofacial Growth Series, Center for Human
Growth and Development; University of Michigan, Ann Arbor, 1979.
6. Wenzel A, Henriksen J, Melsen B: Nasal respiratory resistance and head pos-
ture: effect of intranasal corticosteroid (Budesonide) in children with
asthma and perennial rhinitis. Am J Orthod Dentofac Orthop 1983; 84:422-
426.
7. Solow B, Siersbaek–Nielsen S: Airway adequacy, head posture, and cranio-
facial morphology. Am J Orthod Dentofac Orthop 1984; 86:214-223.
8. Sosa FA, et al.: Postpharyngeal lymphoid tissue in Angle Class I and Class II
malocclusions. Am J Orthod Dentofac Orthop 1987; 81:299-309.
9. Solow B, Sandham A: Nasal airway characteristics in a normal sample. Euro
J Orthod 1991; 13:1-6.
10. Solow B, Siersbaek-Nielsen S: Cervical and craniofacial posture as predictors
of craniofacial growth. Am J Orthod Dentofac Orthop 1992; 101:449-458.
11. Solow B, Ovesen J, Wurtzen Nielsen P, Wildschiodtz G: Head posture in
obstructive sleep apnea. Eur J Orthod 1993; 15:107-114.
12. Makofsky HW: Snoring and obstructive sleep apnea: does head posture play
a role? J Craniomandib Pract 1997; 15:68-73.
13. Huggare J, Tellervo Laine-Alava M: Nasorespiratory function and head pos-
ture. Am J Orthod Dentofac Orthop 1997; 112:507-511.
14. Huggare J: Postural disorders and dentofacial morphology. Acta Odontol
Scand 1998; 56:383-386.
15. Mohl N: Head posture and its role in occlusion. NYS Dent J 1976; 42:12.
16. Solow B, Tallgren A: Dentoalveolar morphology in relation to craniocervical
posture. Angle Orthod 1977; 47:157-164.
17. Huggare J, Harkness E: Associations between head posture and dental occlu-
sion [abstract]. J Dent Res 1993; 72:255.
18. Makofsky H: The influence of head posture on dental occlusion. J Cranio-
mandib Pract 2000; 18:30-39.
19. Solow B, Sonnesen L: Head posture and malocclusion. Euro J Orthod 1998;
20:685-693.
20. Solow B, Kreiborg S: Soft-tissue stretching: a possible control factor in cran-
iofacial morphogenesis. Scand J Dent Res 1977; 85:505-507.
21. Begg PR: Begg orthodontic theory and technique. Philadelphia: WB
Saunders Company, Chap. 2, 1965.
22. Proffit WR: Equilibrium theory revisited. Angle Orthod 1978; 48:175-186.
23. Proffit WR, Fields HW: Contemporary orthodontics. 3rd ed. St. Louis,
Missouri: Mosby, Chap. 5, 2000.
APRIL 2007, VOL. 25, NO. 2
 ALKOFIDE AND ALNAMANKANI HEAD POSTURE AND MALOCCLUSION IN SAUDI SUBJECTS

24. Siersbaek-Nielsen S, Solow B: Intra- and interexaminer variability in head 32. Gonzalez HE, Manns A: Forward head posture: its structural and functional
posture recorded by dental auxiliaries. Am J Orthod Dentofac Orthop 1982; influence on the stomatognathic system, a conceptual study.
82:50-57. J Craniomandib Pract 1996; 14:71-80.
25. Solow B, Sandham A: Cranio-cervical posture: a factor in the development 33. Festa F, Tecco S, Dolci M, Ciufolo F, Di Meo S, Filippi M, Ferritto A,
and function of the dentofacial structures. Euro J Orthod 2002; 24:447-456. D’Attillio M: Relationship between cervical lordosis and facial morphol-
26. Solow B, Tallgren A: Head posture and craniofacial morphology. Am J Phys ogy in Caucasian women with a skeletal Class II malocclusion: a cross-sec-
Anthropol 1976; 44:417-436. tional study. J Craniomandib Pract 2003; 21:121-129.
27. Dahlberg G: Statistical methods for medical and biological students. London:
George Allen and Unwin, Ltd, 1940.
28. SPSS Inc.: Statistical package for social science. Ver. 10, SPSS Inc, Chicago:
IL, 1999. Dr. Eman AlNamankani received a B.D.S. degree from King Saud
29. Hellsing E, L’Estrange P: Changes in lip pressure following extension and University, College of Dentistry, Riyadh, Saudi Arabia in 1997 and a
flexion of the head and changed mode of breathing. Am J Orthod Dentofac masters degree and clinical certificate in orthodontics from King Saud
Orthop 1987; 91:286-294. University, College of Dentistry in 2003. Dr. AlNamankani is a member
30. Balters W: Die Wirbelsaule aus der Sicht des Zahnarztes. Zahnartzl Mitt of the World Federation of Orthodontists.
1964; 9:408-412.
31. D’Attilio M, Caputi S, Epifania E, Festa F, Tecco S: Evaluation of cervical
posture of children in skeletal Class I, II, and III. J Craniomandib Pract
2005; 23:219-228.
Downloaded by [University of California, San Diego] at 03:18 01 April 2016

APRIL 2007, VOL. 25, NO. 2 THE JOURNAL OF CRANIOMANDIBULAR PRACTICE 105