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Review

Relationship between Craniocervical Posture and Sagittal Position of the Mandible: A Systematic Review

by
Gintarė Zokaitė
*,
Kristina Lopatienė
,
Arūnas Vasiliauskas
,
Dalia Smailienė
and
Giedrė Trakinienė
Department of Orthodontics, Faculty of Odontology, Lithuanian University of Health Sciences, J. Lukšos-Daumanto 6, 50106 Kaunas, Lithuania
*
Author to whom correspondence should be addressed.
Appl. Sci. 2022, 12(11), 5331; https://doi.org/10.3390/app12115331
Submission received: 6 April 2022 / Revised: 2 May 2022 / Accepted: 20 May 2022 / Published: 25 May 2022
Browse Figures
Review Reports Versions Notes

Abstract

:
Changes in craniocervical posture are a critical issue in modern society. Alterations of the mandible position in the anterior-posterior direction in association with head and neck posture are reported. The objective of the present review was to evaluate the relationship between craniocervical posture and sagittal position of the mandible and to evaluate the risk of bias inthe included studies. Electronic databases used to perform the search were PubMed, Wiley Online Library, and Cochrane. Only clinical trials that assessed sagittal craniocervical posture and mandible position in lateral cephalograms were included. Selected inclusion criteria were used to assess the finally selected studies. The upper and lower cervical spine was evaluated by seven and six studies, respectively. The risk of bias in the included studies varied from low to moderate. Literature research identified 438 records from 3 databases. Eventually, seven eligible clinical trials were included in this review. Evaluating the relationship between craniocervical posture and mandible position in the sagittal plane, it can be concluded that increased cervical inclination and head upright position are associated with the posterior position of the mandible. Attention to patients’ craniocervical posture should be paid as a part of clinical evaluation since it might be the reason for the changed mandible position.

1. Introduction

The head is an essential element of body posture and its position is determined by the neuromuscular balance and response to physiological and environmental conditions [1]. In the presence of a well-balanced posture, the body is aligned optimally in a position of least effort and maximum support. However, due to lack of physical activity and incorrect body posture, posturalimbalanceisrathercommonnowadays [2]. Forward head posture (FHP) is defined as cervical hyperlordosis and head extension. This is one of the most common disorders of cervical spine posture in the sagittal plane and manifests in different types of severity in almost all populations [3,4]. According to the studies, approximately 62% of school-attending teenagers and adult gamers have FHP [5,6]. Moreover, Singh S. et al. [7] found that 73% of students have this abnormal head position.
The change in one body segment can have consequences anywhere along the myofascial chain [8]. Usually, low body muscle tone is typical of FHP. Furthermore, increased thoracic kyphosis and lumbar lordosis are additional signs of hypotonia [9]. This craniocervical alignment alteration causes tension in joints, muscles, and tendons, particularly in the neck and head region. Other complications such as reduced range of motions in the neck, headache, neck pain, and body imbalance are possible as well [10,11,12,13]. Moreover, the sagittal body posture is related to mouth breathing pattern, temporomandibular disorders (TMD), occlusal and craniocervical skeletal changes [3,14,15].
Schwartz [15] started a discussion about the relationship between head posture and craniomandibular morphology and many clinical studies were performed in order to evaluate it [16,17]. Furthermore, several hypotheses have been proposed to describe the relationship between the changes in the sagittal position of the mandible and craniocervical posture. The association between the protrusion of the head, cervical spine and the mandible was reported in a number of studies [18,19,20]. Mandibular and maxillary prognathism can shift the center of gravity of the head and this could cause compensatory activity of the neck and head muscles and alterations of the cervical spine alignment [21]. Other researchers discussed cervical inclination and head extension in relation with mandibular retrognathism, and with greater kyphosis and lumbar lordosis [9,22]. Recently, it has been concluded that there is a probable interaction between body posture and mandibular position [17]. However, the absence of summarized evidence in literature concerning the position of the mandible and craniocervical posture in the anterior-posterior direction leaves considerable uncertainty. Therefore, the objective of the present review is to evaluate the relationship between craniocervical posture and sagittal position of the mandible and to evaluate the risk of bias in the included studies.

2. Materials and Methods

This systematic review was registered on PROSPERO (PROSPERO 2021, ID: CRD42021285356) and conducted according to Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines.

2.1. Literature Search Strategy

To determine whether a systematic literature review on this topic had existed, the Cochrane Library, PubMed, Google Scholar, Wiley Online Library, and ScienceDirect databases were searched and none was found. The electronic databases PubMed, Wiley Online Library, and Cochrane Clinical Trials Register were reviewed independently by two investigators (K.L. and G.Z.) A mix of free-text terms and Medical Subject Headings (MeSH) was used to search all eligible studies. The chosen keywords were: craniocervical posture, head posture, head position, head, and cervical spine posture, mandible, cephalometry, cephalogram, three-dimensional, and SNB. The combinations of them are shown in Table 1. The databases were searched from 2016 until 2021. To specify the research, a language filter was applied to show studies in English or Lithuanian. The search was performed from 16 October–16 December 2021.

2.2. Selection Criteria

Both reviewers (K.L. and G.Z.) independently performed the research, and disagreements were resolved by consensus. All papers from the aforementioned databases were imported into ZOTERO (version 5.0.96.3) where duplicates were removed. Potential publications were selected by screening titles and abstracts. Full-text articles were read to determine whether they met the inclusion criteria (shown in Table 2). Included studies were grouped for the synthesis according to the classification of the participants arranged by the authors of the studies. No automation tools were used.

2.3. Data Extraction

The following information on the selected clinical studies was independently extracted by two reviewers (K.L. and G.Z.): authors, year of publication, country of origin, study design, number and age of participants, terms and parameters related to the evaluation of craniocervical posture and position of the mandible in the sagittal plane, sample description, statistical analysis, results (prevalence of craniocervical posture distortion and its relationship with mandible sagittal position) and conclusions. Then the findings were compared to ensure that all appropriate data were extracted. No automation tools were used. An attempt was made to contact the authors for any missing information.

2.4. Assessment of Risk of Bias

Assessment of the risk of bias in the selected articles was performed using the Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies [23]. The qualitative assessment of the risk of bias was made by two independent reviewers (K.L. and G.Z.). In case of disagreement on the risk of bias assessment, it was resolved by consensus. All articles were evaluated and judged as “high risk” when the study reached up to 49% score “yes”, “moderate risk” when the study reached 50–69% score “yes”, and “low risk” when the study reached more than 70% score “yes”.

2.5. PICOs

The clinical question of this systematic review was made according to Population, Intervention, Comparison, Outcomes, and study design (PICOs) format.
  •  Population:
Patients who have been examined for craniocervical posture and position of the mandible evaluation and met all of the inclusion criteria.
  •  Intervention:
  •  Comparison:
The sagittal mandible position taking into account different craniocervical postures (level of head extension and neck flexion).
  •  Outcomes:
Craniocervical posture and position of the mandible assessment in the sagittal plane.
  •  Study design:
Retrospective, cross-sectional clinical trials and a pilot randomized controlled trial.

3. Results

3.1. Search Results

The electronic search of selected databases identified a total of 438 records: 232 articles were found in PubMed, 173 in Wiley Online Library, and 33 from Cochrane. 278 remained after removing duplicates of searched databases and 17 remained after reading the titles and abstracts. The latter ones were assessed for eligibility and 10 of them were excluded for not meeting the inclusion criteria. Finally, seven were included in this systematic review and their risk of bias and quality of evidence were assessed. The flow diagram of the selection process of the studies according to the PRISMA guidelines is shown in Figure 1 [23].

3.2. Study Characteristics

3.2.1. Design

Four retrospective studies [24,25,26,27] two cross-sectional studies [28,29] and one pilot randomized controlled trial [12] were included in the present systematic review. The studies were conducted in Chile [24], China [25], Morocco [26], Pakistan [27], Serbia [28], Spain [29] and Syria [12]. The number of participants ranged from 30 to 98; a total of 486 subjects participated in these studies. Five studies [24,25,27,28,29] indicated craniofacial or craniocervical anomalies as exclusion criteria for involved patients. Moreover, six papers specified eliminating participants with a history of orthodontic treatment [12,24,25,26,28,29]. Considering respiratory anomalies, obstructive sleep apnea was mentioned as an exclusion criterion in three studies [26,28,29]. Lastly, four studies [24,26,27,29] stated including patients with no history of surgery in the head area. In terms of classification of the participants, three studies [24,25,28] grouped them by the class of malocclusion, while a retrospective cohort study [27] and a pilot randomized controlled trial [12] analyzed orthodontic functional appliances and divided subjects into ortho-treatment groups and controls. One retrospective study [26] and cross-sectional study [29] focused on mouth and nose breathers.

3.2.2. Outcome Measures

Two-dimensional cephalometry was used to assess craniocervical posture and mandible position in seven studies [12,24,25,26,27,28,29]. Regarding analyzed parameters, craniocervical posture included OPT-SN and CVT-SN angles. As for mandible position evaluation, SNB angle was used in five [12,26,27,28,29], and SN-RL angle in two [24,25] studies. Mean values for variables were given in seven papers [12,24,25,26,27,28,29], while the correlation coefficient was given in two [24,28]. No methods were required to prepare the data for presentation and synthesis. The characteristics of the studies included in this systematic review are shown in Table 3 and Table 4 [1,30].

3.2.3. Risk of Bias

Two studies [12,28] were judged as with a low risk of bias and five with moderate risk [25,26,27,29,30]. Regarding the questions “Were confounding factors identified?” and “Were strategies to deal with confounding factors stated?”, only two studies [12,28] provided clear details about the confounding factors and methods to deal with them. Further information about the risk of bias classification criteria is described in Figure 2.

3.3. Main Outcomes

3.3.1. Craniocervical Posture and SN-RL Angle

Two studies [24,25] measured SN-RL angle to determine the position of the mandibular ramus in relation to the cranium. According to the results of both studies, angle SN-RL angle was statistically significantly higher in Class II and Class III (p < 0.001 and p < 0.05). Only Liu Y. et al. [25] found a statistically significant difference in a CVT-SN angle between Class II and Class III (p < 0.05). The angle was higher in Class II subjects. Sandoval C. et al. [24] reported a statistically significant (p < 0.05) positive correlation between SN-RL and CVT-SN angles in Class II patients. In these two studies, no statistically significant difference was observed in the OPT-SN angle between the groups.

3.3.2. Craniocervical Posture and SNB Angle

Mandibular prognathism was evaluated in two studies with low [12,28] and three with moderate [26,27,29] risk of bias. In the latter study [28], it was found that Class II patients had statistically significantly (p < 0.05) higher values of OPT-SN angle than Class I and Class III patients. Also, it was noted that Class III had statistically significantly (p < 0.01) higher values of SNB angle. No significant correlation between OPT-SN and SNB angles was found. In two studies [26,29] participants were diagnosed as mouth or nose breathers. However, no significant differences were found in craniocervical and mandibular prognathism angles between the groups. Two studies [12,28] investigated patients before functional orthodontic treatment and the controls. According to the baseline results, Alsheikho H. O. et al. [12] found no significant difference in the values of OPT-SN, CVT-SN, and SNB angles between the groups, while in Kamal A. T. et al. [27] study the difference was not measured (Table 4).

4. Discussion

Nowadays, an increased prevalence of malocclusions and poor craniocervical posture promptresearchers to assess this relationship and develop new prevention protocols. Recently, Kerbrat A. et al. [17] concluded that a correlation between posture and maxillomandibular deformity is possible. However, in this paper, the sagittal position of the mandible in association with the head and neck posture was not summarized. Also, no other studies concluding in favour of this relationship were found. Additionally, various reports on the relationship between the lower jaw position and craniocervical posture were found in the literature. Therefore, the aim of this systematic review was to screen the available evidence regarding the relationship between the craniocervical posture and the sagittal position of the mandible.
Two studies [25,26] of moderate risk of bias demonstrated the association between mandibular ramus angle and upper and lower craniocervical posture angles. Although children were included in one study and adults were included in the other, the results agreed in both studies. The authors noticed that higher values of SN-RL angle are associated with increased OPT-SN and CVT-SN angles, and vice versa. Furthermore, the aforementioned angles were largest in the Class II relationship, followed by the Class I relationship, and were smallest in the Class III relationship [25,26]. The results of the above authors [25,26] are in agreement with the results of an earlier study [31], which found a significantly smaller angle between ramus line and cervical tangent in Class III subjects than in Class I and II individuals. The results of five studies of low and moderaterisk of bias [12,26,27,28,29] that evaluated mandibular prognathism tend to follow the same pattern. Although SN-RL angle is measured in the sagittal plane, it is related to vertical growth. Increased SN-RL angle shows distal mandible position and rotation of the mandible downwards which is common to FHP. These changes lead to hypertension in cervical muscles, including supra- and infrahyoid muscles as well. It influences and changes mandible growth: prevents forward growth and stimulates vertical growth.
In two studies Class II subjects were assessed and compared before and after orthodontic treatment with functional appliances [12,27]. Alsheikho H. O. et al. [12] noticed no significant changes in craniocervical posture after functional orthodontic treatment in all of the groups. Conversely, Kamal A. T. et al. [27] found a significant increase in OPT-SN angle in untreated patients with Class II and a decrease in the exposed group. Although it was not statistically significant, the authors concluded that Twin Block causes craniocervical posture to be more upright and Class II patients have a greater forward inclination of the craniocervical posture [27]. Similar results were found in a prospective clinical study that measured high craniocervical angles by photometry method before treatment with Twin Block appliance [32]. The suggestion that cervical curvature may be linked to mandibular retrognathism has also been previously offered by other authors. It was noted that skeletal Class II children showed a significantly higher extension of the head upon the spinal column compared to Class I and Class III children [32]. Forward head posture predominates among retrognathic teenagers and adults compared to Class III individuals [33]. In addition, Vukicevic V. et al. [28] measured Pearson’s correlation coefficient between the mandibular protrusion and upper craniocervical posture and received results in agreement with the previous studies. The authors found that in all subjects, the OPT-SN angle had a positive correlation with the SNA and ANB angles, and a negative correlation with the SNB angle. However, it was statistically significant between the OPT-SN and ANB angles only. A possible explanation of this statistical relationship is as follows: in the presence of increased OPT-SN angle, SNA angle is increased and SNB angle is decreased, which leads to an increase in ANB angle. These changes summarise that Class II individuals have the highest value of the craniocervical angle [28]. Two studies evaluated the position of the mandible, forward head posture, and breathing pattern [26,29]. Evaluating cervical spine inclination, El Aouame A. et al. [26] measured OPT-SN, CVT-SN, VER-SN (angle between vertical and SN line), and VER-FH (angle between vertical and Frankfort Horizontal plane) angles for head position and CVT-HOR and OPT-HOR angles for cervical spine curvature evaluation. It was found that OPT-SN and CVT-SN angles were lower in mouth breathers, VER-SN angle was significantly higher in mouth-breathers than in nose-breathers, and VER-FH angle was significantly lower in mouth-breathers than in nose-breathers. The values of CVT-HOR and OPT-HOR angles were higher for mouth-breathers than for nose-breathers. The authors of this study concluded that hyperextension of the head and increased concavity of the cervical spine are bigger in mouth breathers. Chambi– Rocha A. et al. [29] concluded that nose and mouth-breathers presented high percentages of craniofacial hyperextension. All in all, OPT-SN and CVT-SN angles were high in both study groups, showing a relationship between mandibular retrusion and forward head posture [26,29]. This outcome supports previous findings by Sabatucci A. et al. [34]. Such craniocervical posture alteration, in other words, FHP, is a compensatory reaction to open up the airways that were blocked due to allergies, adenoid hypertrophy, or nose septum deviations. On the other hand, this cervical spine misalignment can be not a response, but a cause of respiratory function impairment [35,36,37]. In general, poor muscle tone at any part of the body can cause postural alterations in the craniocervical posture and mandible position which are sites of attachment for myofascial chains [8,38]. Therefore, a good body posture is important in the prevention methods of malocclusions, especially in growing patients. Moreover, a proper oral posture, and correct tongue resting position, maintain the normal function of maxillofacial muscles and the normal growth and development of them.
In our paper, we summarized the evidence of the position that the mandible takes in the anterior-posterior direction considering different craniocervical postures in the same plane. According to the included studies, increased neck flexion and head extension are associated with distal mandible position. These findings could be considered a reflection of poor public health in terms of the relationship between the high prevalence of malocclusion and low muscle tone [3,4]. The latter induces FHP that is associated with lower mandible and tongue position, which leads to crooked teeth due to a lack of support from the palatal side [15]. More importantly, this condition compromises airways and can cause obstructive sleep apnea that afflicts at least one in twenty people [39], whereas malocclusion affects one out of two individuals worldwide [40,41]. Therefore, efforts should be put in toreducing environmental factors such as bad posture.
Limitations of this review are a wide age range of participants, experimental heterogeneity, and the relatively low number of included studies. Also, one of the methodological weaknesses of some studies was a standardized fixation of the head, which prevented the assessment of natural head and neck position. Considering these limitations, more clinical trials with enhanced methodology are needed. It is very important that specialists such as dentists, pediatricians, family doctors, otolaryngologists, and physiotherapists would work as a team to prevent or correct poor body posture in adults and, even more significantly, in growing patients. Much attention should be paid to patients’ natural body posture as a mandatory part of clinical evaluation because body posture might be the reason for the changed mandible position and related malocclusions. However, in the future, our finding should be supported by more substantial research.

5. Conclusions

Evaluating the relationship between craniocervical posture and mandible position in the sagittal plane, it can be concluded that increased cervical inclination and head upright position are associated with the posterior position of the mandible.

Author Contributions

Conceptualization, G.Z. and K.L.; methodology, G.Z. and K.L.; validation, A.V., D.S. and G.T.; formal analysis, G.Z., K.L. and A.V.; investigation, K.L. and D.S.; resources, G.Z.; data G.Z. and K.L.; writing—original draft preparation, G.Z. and K.L.; writing—review and editing, A.V. and D.S.; visualization, G.T.; supervision, K.L., A.V., D.S. and G.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Not applicable.

Conflicts of Interest

The authors declare no conflict of interest.

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Applsci 12 05331 g001 550
Figure 1. PRISMA flow diagram.
Figure 1. PRISMA flow diagram.
Applsci 12 05331 g001
Applsci 12 05331 g002 550
Figure 2. Summary assessment of the risk of bias of the included studies [12,25,26,27,28,29,30] performed using Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies.
Figure 2. Summary assessment of the risk of bias of the included studies [12,25,26,27,28,29,30] performed using Joanna Briggs Institute Critical Appraisal Checklist for Analytical Cross-Sectional Studies.
Applsci 12 05331 g002
Table
Table 1. Searched databases and combinations of keywords.
Table 1. Searched databases and combinations of keywords.
DatabaseNo. of PapersKeywords and Combinations of Them
PubMed35craniocervical posture OR head posture AND “Cephalometry” [Mesh]
20craniocervical posture OR head posture AND cephalogram
48head position AND mandible AND three dimensional
14craniocervical posture AND cephalometry
5craniocervical posture OR head posture AND SNB
75head position AND mandible AND “Cephalometry” [Mesh]
5head and cervical spine posture AND “Cephalometry” [Mesh]
27head position AND mandible AND cephalogram
3craniocervical posture AND three dimensional
Total232
Wiley Online Library8craniocervical posture AND cephalometry
61head posture AND cephalometry
58craniocervical posture AND three dimensional
39head and cervical spine posture AND SNB
7craniocervical posture AND SNB
Total173
Cochrane1craniocervical posture in All Text AND cephalometry in All Text-(Word variations have been searched)
11head position in All Text AND cephalometry in All Text-(Word variations have been searched)
19head posture in All Text AND three dimensional in All Text-in Trials (Word variations have been searched)
1head and cervical spine posture in All Text AND SNB in All Text-in Trials (Word variations have been searched)
1head position in All Text AND mandible in All Text AND three dimensional in All Text-in Trials (Word variations have been searched)
Total33
Table
Table 2. Inclusion and exclusion criteria.
Table 2. Inclusion and exclusion criteria.
Inclusion CriteriaExclusion Criteria
Clinical studies, evaluating craniocervical posture and mandible position in the sagittal plane
Lateral cephalograms or head CT scans evaluatedDigital photographs evaluated
Studies with the control group or pre-orthodontic diagnostic records of craniocervical posture and position of the mandibleStudies with patients who have craniofacial syndromes or clefts, previous surgical, orthodontic, or physical therapy treatment
Studies of children and adults
Articles in English and Lithuanian
Articles published from January 2016 to January 2021
Full text available
Table
Table 3. Parameters used to assess craniocervical posture and mandible position.
Table 3. Parameters used to assess craniocervical posture and mandible position.
Reference Line/PointDescription
SNNasion-sella line. Line through Nasion and Sella points
OPTOdontoid process tangent. Posterior tangent to the odontoid process through the most posterior and inferior point on the corpus of the second cervical vertebra
CVTCervical tangent. Posterior tangent to the most posterior and inferior point on the corpus of the second and fourth cervical vertebra
RLRamus line. Tangent to the posterior border of the mandibular ramus
BThe deepest point on the anterior contour of the mandible
Parameter for craniocervical posture
OPT-SNAngle describes the upper craniocervical posture. It is formed by SN and OPT
CVT-SNAngle describes the middle craniocervical posture. It is formed by SN and CVT
Parameter for position of the mandible
SNBAngle describes prognathism of the mandible. It is formed by SN and B
SN-RLAngle describes rotation of the mandibular ramus in relation to cranium. It is formed by SN and RL
Table
Table 4. A description of eligible studies.
Table 4. A description of eligible studies.
Author, Year, JournalDesign of a StudySample DescriptionCephalometric MeasurementsMain Outcomes (Mean Values and SD 1, Pearson’s r Value and p-Value at the Baseline)
Subjects classified by class of malocclusion
Sandoval C. et al., 2019, CRANIO [25]retrospective65 (34 for Class II and 31 for Class III);
From 18 years (min 3)		OPT-SN;
CVT-SN;
SN-RL		OPT-SN: Class II (101.89° ± 7.95) > Class III (98.55° ± 8.49), n.s. 2
CVT-SN: Class II (105.49° ± 8.39) > Class III (102.88° ± 7.7), n.s.
SN-RL: Class II (92.79° ± 5.50) > Class III (85.22°± 6.46), p < 0.001;
SN-RL vs. CVT-SN: Class II (0.38, p < 0.05), Class III (−0.071, n.s.)
Liu Y. et al., 2016, CRANIO [26]retrospective90 (30 for Class I, II, and II each);
11–14 years (min–max 4)		OPT-SN;
CVT-SN;
SN-RL		OPT-SN: Class II (98.22° ± 6.80) > Class III (95.55° ± 5.66) > Class I (95.42° ± 6.38), n.s.
CVT-SN: Class II (106.00° ± 8.10) > Class III (101.52° ± 7.18), p < 0.05; Class I (103.03° ± 7.77), n.s.
SN-RL: Class II (93.06° ± 4.11) > Class III (90.43° ± 3.79), p < 0.05, Class I (91.13° ± 5.06), n.s.
Vukićević V, et al., 2016, Med Pregl [29]cross-sectional90 (30 for Class I, II, and II each);
8–14 years (min–max)		OPT-SN;
SNB		OPT-SN: Class II (100.80° ± 11.10) > Class I (94.06° ± 1.81) and Class III (94.59° ± 1.80), p < 0.05
SNB: Class III (79.56° ± 0.69) > Class I (75.98° ± 0.52) and Class II (75.87° ± 0.31), p < 0.01
SNB vs OPT-SN: Class I (0.44, n.s.), Class II (−0.005, n.s.), Class III (0.179, n.s.)
Subjects classified by breathing pattern
El Aouame A. et al., 2016, Int.Orthod. [27]retrospective53 (23 for Oral breathers and 30 for Nasal breathers);
Oral breathers: 16.8 years (mean),
Nasal breathers: 14.4 years (mean)		OPT-SN;
CVT-SN;
SNB		OPT-SN: Nasal breathers (111.16° ± 8.3) > Oral breathers (110.17° ± 6.89), n.s.
CVT-SN: Nasal breathers (115.26° ± 8.004) > Oral breathers (114.13 ± 7.75), n.s.
SNB: Oral breathers (73.47° ± 4.86) > Nasal breathers (73.46° ± 3.57), n.s.
Chambi-Rocha A. et al., 2018, Jornal de Pediatria [30]cross-sectional98 (56 for Oral breathers G1 and G2; 42 for Nasal breathers G1 and G2);
G1: 7–9 years (min-max), G2: 10–16 years (min-max)		OPT-SN;
CVT-SN;
SNB		OPT-SN: Nasal breathers G1 (83.813° ± 9.94) > Oral breathers G1 (83.361° ± 12.15), n.s. and Oral breathers G2 (85.808° ± 9.72) > Nasal breathers G2 (79.944° ± 9.26), n.s.
CVT-SN: Oral breathers G1 (106.194° ± 10.75) > Nasal breathers G1 (105.875° ± 7.94), n.s. and Oral breathers G2 (108.115° ± 10.22) > Nasal breathers G2 (101.444° ± 7.48), n.s.
SNB: Nasal breathers G1 (77.500° ± 4.50) > Oral breathers G1 (77.353° ± 3.81), n.s. and Nasal breathers G2 (77.688° ± 2.65) > Oral breathers G2 (74.250° ± 3.18), n.s.
Subjects divided into ortho-treatment groups and controls
Alsheikho H. O. et al., 2021, CRANIO [12]A pilot randomized controlled trial30 (10 for Control, Twin Block, and Bionator each);
9–13 years (min–max)		OPT-SN;
CVT-SN;
SNB		OPT-SN: Control (99.69° ± 5.34) > Twin Block (99.26° ± 5.2) >Bionator (98.30° ± 5.9), n.s.
CVT-SN: Control (105.9° ± 4.60) >Bionator (103.0° ± 5.22) > Twin Block (102.4° ± 5.3), n.s.
SNB:Control (75.65° ± 1.15) >Bionator (75.37° ± 2.18) > Twin Block (74.91° ± 1.25), n.s.
Kamal A. T. et al., 2019, AJO-DO [28]retrospective cohort60 (30 for Twin Block and Control each);
Twin Block: 11.8 years (mean),
Control: 11.6 years (mean)		OPT-SN;
CVT-SN;
SNB		Median values and interquartile range for:
OPT-SN: Twin Block (105.0° (100.0–110.5)), Control (95.0° (88.0–101.5))
CVT-SN: Twin Block (104.5° (100.8–113.0)), Control (100.0° (96.7–108.2))
SNB: Twin Block (75.0° (73.0–77.0)), Control (77.0° (75.0–77.0))
1 SD—standard deviation; 2 n.s.—not significant; 3 Min—minimum; 4 Max—maximum.
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Zokaitė, G.; Lopatienė, K.; Vasiliauskas, A.; Smailienė, D.; Trakinienė, G. Relationship between Craniocervical Posture and Sagittal Position of the Mandible: A Systematic Review. Appl. Sci. 2022, 12, 5331. https://doi.org/10.3390/app12115331

AMA Style

Zokaitė G, Lopatienė K, Vasiliauskas A, Smailienė D, Trakinienė G. Relationship between Craniocervical Posture and Sagittal Position of the Mandible: A Systematic Review. Applied Sciences. 2022; 12(11):5331. https://doi.org/10.3390/app12115331

Chicago/Turabian Style

Zokaitė, Gintarė, Kristina Lopatienė, Arūnas Vasiliauskas, Dalia Smailienė, and Giedrė Trakinienė. 2022. "Relationship between Craniocervical Posture and Sagittal Position of the Mandible: A Systematic Review" Applied Sciences 12, no. 11: 5331. https://doi.org/10.3390/app12115331

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