Home Print this page Email this page Small font size Default font size Increase font size   Users Online: 3166
Home About us Editorial board Search Browse articles Submit article Instructions Subscribe Contacts Login 

 Table of Contents  
Year : 2022  |  Volume : 11  |  Issue : 1  |  Page : 13

Cranio-cervical posture and rapid palatal expansion therapy

1 Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome, Italy
2 Faculty of Dentistry, Central University of Venezuela, Caracas, Venezuela

Date of Submission15-Apr-2021
Date of Decision16-Oct-2021
Date of Acceptance25-Nov-2021
Date of Web Publication04-May-2022

Correspondence Address:
Emanuela Serritella
Department of Oral and Maxillofacial Sciences, “Sapienza” University, Via Caserta, 6-00161 Rome
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jos.jos_128_21

Rights and Permissions

Objective: Connections between craniocervical posture (CCP) and changes in teeth position have already been demonstrated; however, the defined pathway of relationship is still not clear. The aim of this study was to evaluate CCP modifications after rapid maxillary expansion therapy using rapid palatal expansion therapy (REP)/McNamara appliances.
Materials and Methods: A consecutive series of 35 subjects, aged between 6 and 14 years, with no prior history of orthodontic treatment, and requiring skeletal expansion of the upper arch, were selected and analyzed. All patients were treated with REP or Mcnamara appliance: the active phase of 15 days and retaining phase of 6 months. Cephalometric analysis was carried out before (T0) and after (T1) orthodontic therapy evaluating changes in the craniofacial area and those related to CCP. The obtained data were statistically analyzed for the pre-post changes.
Results: No statistically significant difference emerged indicating a modification in the CCP measured at T0 and T1 (P > 0.05). Patients treated with the McNamara appliance, compared to those treated with REP, showed a higher value of the angle OPT ^ Ver (P = 0.021), and a lower measure of the angles CVT^EVT (P = 0.035) and EVT^Ver (P = 0.023). Furthermore, patients treated with REP showed a higher hyoid angle value than those treated with McNamara (P = 0.047).
Conclusion: This study did not reveal any relationship between the application of palatal expansion therapy and changes in CCP.

Keywords: Craniocervical posture, malocclusion, orthodontic therapy, rapid palatal expansion

How to cite this article:
Serritella E, Impellizzeri A, Musone L, De Stefano AA, Gabriella G. Cranio-cervical posture and rapid palatal expansion therapy. J Orthodont Sci 2022;11:13

How to cite this URL:
Serritella E, Impellizzeri A, Musone L, De Stefano AA, Gabriella G. Cranio-cervical posture and rapid palatal expansion therapy. J Orthodont Sci [serial online] 2022 [cited 2023 Oct 2];11:13. Available from: https://www.jorthodsci.org/text.asp?2022/11/1/13/344717

  Introduction Top

Understanding the relationship between the development of craniofacial morphology, and head and neck posture is essential for the diagnosis and treatment of several morphological and functional alterations of the masticatory district and adjacent structures.[1],[2]

Several studies investigated, and sometimes found, a correlation between head and neck posture and some features of the craniofacial district: the length of the mandibular body, the mandibular divergence, the length, and the angulation of the cranial base or facial growth direction.[3],[4] An interesting study by Arntsen and Sonnesen reported a significant association between alterations in cervical column morphology (deviation, fusion anomalies) and skeletal overjet, large sagittal jaw relationship, retrognathia or large inclination of the jaws, and extended head posture.[3]

Craniocervical posture (CCP) was also related to several aspects or functions of the stomatognathic system: occlusion, malocclusions, parafunctions, temporomandibular dysfunctions, use of functional orthodontic devices, and patency of the upper airways.[5],[6],[7] Westersund et al.[5] suggested possible interconnectivity between the craniocervical junction and occlusal contacts. A study by An et al., evaluated the craniocervical posture and the hyoid bone position in orthodontic patients with temporomandibular joint (TMJ) displacement, suggesting that these subjects present more likely an extended CCP with Class II hyperdivergent patterns.[6]

The use of orthopedic devices to correct the maxillary transverse deficiency is widely accepted and studied. Its use is related to the skeletal contraction of the upper arch, which is often associated with functional alterations such as oral breathing, finger sucking, or altered tongue posture. It was seen that the application of rapid palatal expansion therapy (RPE) determines several changes in facial morphology due to the improvements in the sagittal intermaxillary relationship, overjet and molar relation, but also due to mandibular changes with significant long-term effects.[8] Some authors hypothesized that the changes in the palatal obtained with RPE appliances can involve other bone structures such as the tongue's muscles and the suboccipital muscles.[9]

Furthermore, RPE resulted in effectively improved respiration, and some cognitive functions (i.e., concentration, cessation of nocturnal enuresis).[9],[10],[11] Ortu et al.[9] reported that the role of RPE in postural changes may be connected to the resulting enlargement of the pharyngeal airway space, improvement in respiratory function, and flexion of the head on the cervical column, underlying the important role that the muscular–neural network could play.[10],[11],[12]

However, special attention to the effects of rapid expansion on the posture of the head and neck is lacking, and current orthodontic literature is still unclear about the nature of this relationship.[8],[9],[11]

The present study aimed to investigate the relationship between CCP and RPE. The main focus was on variations related to the craniocervical angulation, the cervical lordosis, and the position of the hyoid bone, analyzing growing patients with transverse deficiency of the upper jaw, associated or not with respiratory problems.

  Materials and Methods Top

A consecutive series of 47 patients, all spontaneously joining the Orthodontics Unit of a University hospital, from April 2, 2018, to January 30, 2019, was selected. The inclusion criteria were (1) need for orthopedic expansion of the upper arch, (2) growing age, (3) no systemic disease, (4) no congenital missing or extracted teeth before or during treatment, and (5) no previous orthodontic treatment. The exclusion criteria were (1) dental or dentoalveolar contraction of the upper arch not requiring skeletal expansion, (2) systemic disease, (3) presence of congenital or syndromic craniofacial deformities. This study was approved by the Institutional Ethics Committee (N.18-53-0000711) and informed consent was obtained from both parents of each patient.

The total patient population was thus made up of 35 subjects (11 males and 24 females) aged between 6 and 14 years (mean age: 11 years).

All subjects included in the study were Caucasian pediatric patients with potential residual growth, evaluated by the Cervical Vertebral Maturation (CVM) method, and considering stages CVM2 and CVM3.[13] In all patients, the following characteristics were evaluated: respiration (oral, nasal, mixed), deglutition (typical, atypical), and skeletal class (I, II, or III).

All patients were treated with one of the two fixed orthodontic appliances for rapid maxillary expansion generally used in our ward: REP (Rapid Expander of the Palate) fixed on bands on the upper first molars (20 patients) or McNamara appliance, built on resin splint extended from the upper first molar to the upper first premolar (15 patients). The choice of the device to be used was made on the clinical and skeletal divergence characteristics of each patient.

The activation protocol for both devices was \two activations per day for 15 days. Then, the device screw was blocked with a metallic ligation to prevent any unwanted turning back of the appliance. All patients kept the expander appliance as a restraint for the next 6 months.

To find any variations in the CCP, craniocervical angulation, and hyoid posture, all patients were asked for lateral cephalograms, before and after the expansion therapy. The radiographs were all obtained in habitual occlusion, free from intraoral devices, pre- and post-treatment, to highlight the real therapeutic effect.

Therefore, 70 lateral cephalograms (35 before and 35 after the expansive therapy) were analyzed. Cephalometric values were calculated at T0 (before treatment), and at T1 (6 months after the expansion therapy). Cephalometric measurement was performed on each cephalogram; 22 points (20 anatomical and 2 geometric projection) were found in the anatomical area of the head and neck, 14 of which were in the craniofacial area, 1 on the hyoid bone, and 7 in the cervical spine. Fifteen plans were drawn, and 15 different variables were analyzed. The skeletal class was evaluated according to the method described by Downs.[14] The cephalometric tracing was performed according to that described by Solow, for the variables related to CCP (the angle of cervical lordosis was traced according to that described by Hellsing) and craniocervical angle, and according to that described by Rocabado for the variables related to the hyoid bone posture.[15],[16],[17]

The reference points and measurements are described in [Table 1] and [Figure 1].
Table 1: Reference points and measurements used on the cephalometry

Click here to view
Figure 1: Planes and angles considered on the lateral cephalograms

Click here to view

All data collected through the cephalometric study were compared and analyzed statistically, looking for a significant correlation between:

  • Angle of cervical lordosis (CVT ^ EVT) and expansion therapy;
  • Craniocervical angulation (SN ^ OPT, SN ^ CVT, SnaSnp ^ OPT, SnaSnp ^ CVT, ML ^ OPT, ML ^ CVT) and expansion therapy;
  • Type of respiration (nasal/oral) and CCP;
  • Skeletal class and craniocervical angle; and
  • Type of orthodontic device (band or splint expander) and CCP.

Statistical analysis

To assess errors due to landmark identification, duplicate measurements of 10 radiographs were made.[16] The error variance was calculated using Dahlberg's formula, where d is the difference between the first and the second measurements and N is the number of double registrations. All measurements were separately realized by two expert orthodontists (E.S. and A.I.), using Dahlberg's formula to test the measurement errors, and resulting in no significant error.

To examine the differences, a Student's t-test and one-way analysis of variance (ANOVA) were used (statistically significant for P < 0.05). For not normally distributed data, Mann–Whitney U test was used (data normality was tested using the Shapiro–Wilk test). Statistical analysis was conducted using the SAS software (Statistical Analysis System).

  Results Top

Epidemiological data analysis

The sample consisted of 35 subjects, mainly females, with a mean age of 10.97 years (median: 11 years; standard deviation: 10.97 years). The results concerning gender, type of respiration, deglutition, and a skeletal class of the study population are shown in [Figure 2].
Figure 2: General characteristics of the sample

Click here to view

Pre-post expansion analysis

The measurement of the following angles, at T0 and T1, resulted in no statistically significant differences (P > 0.05): angle of the cervical lordosis (CVT ^ EVT); CCP (SN ^ OPT/SN ^ CVT); posture of the hyoid bone (hyoid triangle) [Table 2].
Table 2: Temporal comparisons T0-T1

Click here to view

As for the relationship between CCP and type of respiration, no statistical significance resulted between the angle MGP ^ OP and the type of respiration (oral/nasal) (P > 0.05).

Also investigating the relationship between skeletal class and CCP, no significant relationship was found. In all different levels of skeletal classes (I, II, and III), the mean values of all variables considered showed no statistically significant differences (P > 0.05).

Statistically significant results emerged analyzing the type of device used and the postural variations at T1 [Table 3]: patients treated with McNamara expander, compared to those treated with REP, showed a higher value of the angle OPT ^ Ver (P = 0.021) and lower value of the angles CVT^EVT (P = 0.035) and EVT^Ver (P = 0.023). Furthermore, patients treated with REP showed a higher hyoid angle value than those treated with McNamara (P = 0.047).
Table 3: Type of device used and craniocervical posture at T1

Click here to view

  Discussion Top

This study tried to highlight the correlation between the CCP and expansion therapy of the upper jaw, investigating the differences related to the craniocervical angle, the curvature of the cervical spine, and the position of the hyoid bone, before and after the therapy, in growing patients with maxillary contraction, in combination or not with oral respiration.

The anatomical and physiological complexity of the craniofacial area requires different measurement methods to better estimate the actual modifications occurring in the craniocervical posture.[18] Although our cephalometric analysis was performed according to standardized techniques,[15],[16],[17] we believe the overlap on the radiograph of different anatomical structures, lying on different planes, and the magnification of the image, not always allowed an accurate quantification of the occurred changes.

For statistical analysis, the small sample was our main limitation, even more, evident in the evaluation of the variables CVT ^ EVT and EVT ^ Ver, because the image of the sixth vertebra was not present in all the radiographs. We expected statistically significant differences, pre- and post-treatment, of different angles values (CVT ^ EVT, SN ^ OPT, SnaSnp ^ OPT, ML ^ OPT), confirming what has already been highlighted in the literature.[11],[15] A statistically significant difference was also expected for the measurements of the hyoid angle, between T0 and T1. The maxillary expansion causes a disjunction of the midpalatal suture and therefore an increase in the upper arch dimension; its indirect effect is the anterior repositioning of the mandible, finally free from the contracted jaw that was forcing it into a posterior position. This expansion also involves a change in the position of point A (an advancement on the sagittal plane and a lowering on the vertical plane), determining a mandibular post-rotation and a repositioning of the hyoid bone.[19] Looking for a relationship between the breathing (oral, nasal) of the patient at T0 and the CCP, we would expect significant values of the angle MGP ^ OP (craniocervical angle). The volumetric inadequacy of the nasal airways leads, in the oral respirator, to a repositioning of the head resulting in hyperextension; our results, however, did not show a statistically significant correlation. These results disagree with those reported in the literature that a decrease in the craniocervical angle occurs by improving the nasal respiratory function due to a hyperextension of the head.[11],[20],[21]

Concerning the correlation between craniocervical angles and skeletal classes, the mean values of all the considered variables showed no statistically significant differences (P > 0.05). This evidence disagrees with the studies affirming that subjects with II skeletal class show a hyperextension of the head, compared to those with I and III skeletal classes.[20],[21]

A significant relationship between the type of device used and the postural changes to T1 was found [Table 3]. Patients treated with REP showed higher values of the hyoid angle after therapy, compared to those treated with McNamara (P = 0.047). This result can be related to a bite opening that causes a repositioning of the mandible, which results post-rotated. As a consequence, the hyoid bone is repositioned, resulting in a higher value of the hyoid angle. Patients treated with the McNamara device reported values of the OPT ^ Ver angle (inclination of the first section of the cervical spine) higher than those treated with REP and lower values of the angles CVT^EVT (P = 0.035) and EVT^Ver (P = 0.023). These values can be explained because the hyoid bone represents the point of connection between the mandible and neck. It is closely related to the cervical spine, but also influenced by the position of the mandible as well as by the divergence, the orientation of its greater horn, and the activity of the suprahyoid and infrahyoid muscles. All these results confirm the indications in the use of McNamara or RPE appliances depending on the patient's skeletal features and divergence.

  Conclusions Top

The results obtained from this study did not show a direct relationship between palatal expansion therapy and the CCP. The position of the hyoid bone seems to be not influenced by the therapy, but only by the type of device used. These results support the importance of considering the patient's clinical and skeletal characteristics when choosing the most appropriate type of appliance to use for palate expansion therapy. Furthermore, they underline the role of the hyoid bone as a connecting structure between the skull, cervical spine, and mandible. In this study, the improvement of the nasal respiratory function after the expansion therapy, as well as the skeletal class of the patients, resulted not directly connected to modifications of the cranial and cervical postures. Given the conflicting evidence in the literature about these correlations, further investigations are needed to deepen and better understand the influence of the palatal expansion therapy on the posture of the craniocervical area.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Akcam MO, Koklu A. Investigation of natural head posture in different head types. J Oral Sci 2004;46:15-8.  Back to cited text no. 1
Romani V, Di Giorgio R, Castellano M, Barbato E, Galluccio G. Prevalence of craniomandibular disorders in orthodontic pediatric population and possible interactions with anxiety and stress. Eur J Paediatr Dent 2018;19:317-23.  Back to cited text no. 2
Arntsen T, Sonnesen L. Cervical vertebral column morphology related to craniofacial morphology and head posture in preorthodontic children with Class II malocclusion and horizontal maxillary overjet. Am J Orthod Dentofacial Orthop 2011;140:e1-7.  Back to cited text no. 3
Castellano M, Lilli C, Barbato E, Santilli V, Galluccio G. Craniofacial asymmetry in non-syndromic orthodontic subjects: Clinical and postural evaluation. Cranio 2016;34:144-54.  Back to cited text no. 4
Westersund CD, Scholten J, Turner RJ. Relationship between craniocervical orientation and center of force of occlusion in adults. Cranio 2017;35:283-9.  Back to cited text no. 5
An JS, Jeon DM, Jung WS, Yang IH, Lim WH, Ahn SJ. Influence of temporomandibular joint disc displacement on craniocervical posture and hyoid bone position. Am J Orthod Dentofacial Orthop 2015;147:72-9.  Back to cited text no. 6
Impellizzeri A, Serritella E, Putrino A, Vizzielli G, Polimeni A, Galluccio G. Assessment of masticatory and cervical muscles' thickness by ultrasonography in patients with facial asymmetry. Clin Ter 2019;170:e272-7.  Back to cited text no. 7
Franchi L, Pavoni C, Faltin K Jr, McNamara JA Jr, Cozza P. Long-term skeletal and dental effects and treatment timing for functional appliances in Class II malocclusion. Angle Orthod 2013;83:334-40.  Back to cited text no. 8
Ortu E, Pietropaoli D, Ortu M, Giannoni M, Monaco A. Evaluation of cervical posture following rapid maxillary expansion: A review of literature. Open Dent J 2014;8:20-7.  Back to cited text no. 9
Al-Taai N, Alfatlawi F, Ransjö M, Fakhry S. Effect of rapid maxillary expansion on monosymptomatic primary nocturnal enuresis. Angle Orthod 2015;85:102-8.  Back to cited text no. 10
Liu S, Xu T, Zou W. Effects of rapid maxillary expansion on the midpalatal suture: A systematic review. Eur J Orthod 2015;37:651-5.  Back to cited text no. 11
McGuinness NJ, McDonald JP. Changes in natural head position observed immediately and one year after rapid maxillary expansion. Eur J Orthod 2006;28:126-34.  Back to cited text no. 12
Baccetti T, Franchi L, McNamara JA Jr. The cervical vertebral maturation method: Some need for clarification. Am J Orthod Dentofacial Orthop 2003;123:19A-20A.  Back to cited text no. 13
Downs WB. Variations in facial relationships; Their significance in treatment and prognosis. Am J Orthod 1948;34:812-40.  Back to cited text no. 14
Solow B, Tallgren A. Head posture and craniofacial morphology. Am J Phys Anthropol 1976;44:417-35.  Back to cited text no. 15
Hellsing E, McWilliam J, Reigo T, Spangfort E. The relationship between craniofacial morphology, head posture and spinal curvature in 8, 11 and 15-year-old children. Eur J Orthod 1987;9:254-64.  Back to cited text no. 16
Rocabado M. Biomechanical relationship of the cranial, cervical, and hyoid regions. J Craniomandibular Pract 1983;1:61-6.  Back to cited text no. 17
Yagci A, Uysal T, Usumez S, Orhan M. Rapid maxillary expansion effects on dynamic measurement of natural head position. Angle Orthod 2011;81:850-5.  Back to cited text no. 18
Carvalho FR, Lentini-Oliveira DA, Prado LB, Prado GF, Carvalho LB. Oral appliances and functional orthopaedic appliances for obstructive sleep apnoea in children. Cochrane Database Syst Rev 2016;10:CD005520.  Back to cited text no. 19
Beugre JB, Sonan NK, Beugre-Kouassi AM, Djaha K. Cranio-cervical posture and hyoid-mandibular-pharyngeal equilibrium in the presence of factors related to respiratory dysfunction. Odontostomatol Trop 2008;31:13-27.  Back to cited text no. 20
Tecco S, Festa F, Tete S, Longhi V, D'Attilio M. Changes in head posture after rapid maxillary expansion in mouth-breathing girls: A controlled study. Angle Orthod 2005;75:171-6.  Back to cited text no. 21


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3]


Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

  In this article
Materials and Me...
Article Figures
Article Tables

 Article Access Statistics
    PDF Downloaded245    
    Comments [Add]    

Recommend this journal