Journal of Oral Rehabilitation

Journal of Oral Rehabilitation 2013 40; 810--817

Cervical column posture and airway dimensions in clinical

bruxist adults: a preliminary study

V A R E Z , J . J A I M E S & A . F . G OM
C . C . R E S T R E P O , C . P AL
EZ CES-LPH Research Group,
Universidad CES, Medell
ın, Colombia

SUMMARY The aim of this study was to compare dimensions of the oropharynx and nasopharynx
the cervical column posture and the upper airway were evaluated in agreement with Sayinsu. The
dimensions between sleep bruxist and non-bruxist data were analysed with independent-samples
young adults. Twenty-three sleep-grinders and 22 t-tests and Mann–Whitney U-test. Significance was
asymptomatic subjects, selected according to the set at P < 0
05. Sleep bruxist young adults
American Academy of Sleep Medicine (AASM) presented more forwarded cervical column
criteria (report by a sleep partner and the presence posture and narrower measures of the oropharynx,
of dental wear, according to Wetselaar et al.), were when compared with controls (P < 0
05). As in
evaluated. The mean age was 23
8 years (range children, anterior cervical column posture was
18–30). All the subjects had complete permanent found to be associated with sleep bruxism.
dentition and skeletal and occlusal class I. A digital KEYWORDS: Cervical column posture, airway, sleep
cephalometric radiograph with natural head bruxism, adults
posture was performed for each subject. The
craniocervical posture was traced and evaluated Accepted for publication 21 August 2013
according to Solow and Tallgren, and the airway

column posture and airway patency also depend par-

Introduction
tially on these innervations.
Bruxism is as a repetitive jaw muscle activity charac- Rhythmic masticatory muscle activity (RMMA) is
terised by clenching or grinding of the teeth and/or frequently observed during sleep in normal subjects
by bracing or thrusting of the mandible (1). Different and sleep bruxers (9). However, values are higher in
characteristics have been associated with the occur- subjects with bruxism. Khoury et al. (10). stated the
rence of sleep-grinding (2–4). hypothesis that an increase in respiration also cha-
In previous studies (5,6), forwarded head posture racterises the onset of sleep bruxism (SB) within the
was found in bruxist children, with both X-rays and arousal sequence. They found a positive and signifi-
photographs. It might be interesting to verify the exis- cant correlation between the frequencies of RMMA
tence of such differences also in adults. The forwarded episodes and the amplitude of breath.
position of the head has been correlated before with Considering the emerging associations between
hypertrophy of the masticatory muscles (7), which bruxism and breathing disorders during sleep (11)
also has been considered a symptom of bruxism. and the fact that mandibular advancement devices are
The upper airway muscles are innervated by tri- helpful to reduce both bruxism episodes and AHI
geminal, glossopharyngeal, vagus and hypoglossal index (12,13), it might be interesting to assess the cer-
motor axons (8). Parts of the same innervations are vical column posture of bruxers, with the hypothesis
comprised also with the muscles of neck and tongue, that it is more forwarded as an attempt to increase
masticatory muscles and respiration. Thus, cervical airway patency.

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 CERVICAL COLUMN POSTURE AND AIRWAY DIMENSIONS IN BRUXIST 811

The objective of this investigation was to compare All the individuals were tested for the minimal cri-
the cervical column posture and the upper airway teria for sleep bruxism of the American Academy of
dimensions between sleep-grinders and asymptomatic Sleep Medicine (AASM)(15):
young adults.
1 The sleep partner indicated, in an interview with
one of the examiners, the occurrence of tooth
Materials and methods grinding or tooth clenching during sleep at least
once during the night for at least five nights in a
A cross-sectional study was carried out to evaluate
2-week period.
the cervical column posture and the airway dimen-
2 No other medical or mental disorders (e.g. sleep-
sions, through a digital cephalometric radiograph with
related epilepsy, accounts for the abnormal move-
natural head posture.
ments during sleep) were present.
3 Other sleep disorders (e.g. obstructive sleep apnoea
Subjects syndrome) were absent.
4 The 8-point scale described by Wetselaar et al. (16).
Twenty- to 30-year-old adults who studied or work at
was utilised to determine the occlusal/incisal wear
CES University, Medellin, Colombia (N = 272), and
of the permanent teeth (0 = no wear; 1a = mini-
who were seeking for treatment at the dental clinics
mal wear within the enamel of cusps or incisal tips;
or physiotherapy centre of the same university
1b = facets within the enamel parallel to the nor-
(n = 122), were evaluated to participate in this pres-
mal planes or contour; 1c = noticeable flattening of
ent study. The patients were evaluated by a dentist
cusps or incisal edges within the enamel; 2 = wear
and a physiotherapist. All the patients were required
with dentine exposure and loss of clinical crown
to be healthy (no altered medical conditions related
high <1/3; 3a = wear with dentine exposure and
by the participants) and to have normal facial mor-
loss of clinical crown high of 1/3–½; 3b = wear
phology (Absence of cleft lip and palate or other syn-
with dentine exposure and loss of clinical crown of
dromes that imply facial alterations); complete
½–2/3; and 4 = wear with dentine exposure and
permanent dentition, history of trauma, restorations;
loss of clinical crown of >2/3). The 3-point scale
and absence of other type of oral habits, such as nail
described by the same authors (16) was employed
biting. The sample size was calculated for the studied
to check the non-occlusal/non-incisal wear (0 = no
variables with a confidence of 95% and power of
wear; 1 = wear confined to the enamel; 2 = wear
80%, using the data by Restrepo et al. (14) and Velez
into the dentine). The dental wear was always eval-
et al. (5).
uated by the same investigator ICC = 0
89 in a
The procedures, possible discomforts or risks, to
dental chair and under the same conditions of light
which the subjects were going to be exposed, as well
and dryness.
as possible benefits were fully explained to the partici-
pants, and the written informed consent was obtained All subjects were required to sleep with a partner
prior to the investigation. for a two-week period before starting the study.
The institutional ethics committee of CES Univer- Subjects whose sleep partner related sleep-grinding
sity was informed about the whole methods and of the teeth for five days during the last two weeks
approved the study. The inclusion criteria were the and presented dental wear were classified as brux-
absence of mental problems, syndromes or retarda- ers and the ones who did not relate the presence
tion; and angle molar and canine class I and adequate of sleep-grinding of the teeth and did not present
anterior teeth relationship (Overjet between dental wear were included in the non-bruxist
1–3 mm). group.
The exclusion criteria were medical or anatomical From the eligible subjects (n = 74), twenty-three of
alterations (e.g. scoliosis, lordosis, etc.) that could lead thirty-two sleep-grinders (11 women and 12 men)
to postural problems evaluated by a physiotherapist: were randomly selected through the sauteed list
previous orthopaedic treatment or maxillofacial sur- method, and twenty-three of forty two asymptomatic
gery and the presence of transversal malocclusion were included in the control group with the same
(uni- or bilateral cross-bites). method. When the X-rays were going to be taken,

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812 C . C . R E S T R E P O et al.

one woman became pregnant and could not partici- allows the clinician to evaluate the natural position of
pate in the study. Thus, the control group was com- the cervical vertebraes and the inclination of the cer-
posed by 22 young adults (11 women and 11 men). vical column and head posture. Based on the vertical
reference, a horizontal line (HOR) was traced perpen-
dicular to the vertical one (Fig. 1). These two lines
X-rays
were the references to calculate the angles between
Each X-ray was taken with digital technique with an head and neck in the cephalogram. All the measure-
Orthophos Plus Ceph* for lateral cephalograms in ments to evaluate the head and cervical column pos-
‘CERO 70’ (A dental diagnostic centre) in Medell
ın, ture can be seen in Figs 2 and 3.
Colombia. The machine was vertically adjustable; it
had a standardised focus – film distance of 190 cm
Head and cervical column posture
and a distance from the film to the medial plane of
10 cm. Each subject stood up without fixation in The points and planes can be seen in Fig. 1.
ortho-position after balancing forward and backward CV2ip: point located in the lower posterior angle of
three times, with the teeth together and the lips in the odontodes vertebrae.
rest, looking to a light in a mirror, located perpendic- CV4ip: point located in the lower posterior angle of
ular to the eyes of the subject. This position made the body of the fourth cervical vertebrae.
sure that the head and the neck were in natural posi- CVT: tangent to the posterior wall of the fourth
tion. The exposures were taken at 60–80 kv and cervical vertebrae that goes through CV4ip.
32 mAs. A vertical 0
5-mm-wide wire was put parallel OPT: tangent to the posterior wall of the odontodes
to Nasion to register the perfect vertical line (VV). that goes through CV2ip.
The technique used to take the lateral cephalogram
was the natural head posture, described previously by
different authors (17). It is reproducible (18,19) and

Fig. 1. Planes and points to measure cervical column posture. Fig. 2. Angles formed by CVT with VV and HOR.

© 2013 John Wiley & Sons Ltd

 CERVICAL COLUMN POSTURE AND AIRWAY DIMENSIONS IN BRUXIST 813

program developed under Matlab 5
3*. The validation

of the method was previously performed by other
authors with computed tomography in upright pos-
ture, using the size and position of soft palate and
uvula, volume and position of tongue, hyoid position,
mandibulomaxillary protrusion and size of the pha-
ryngeal airway space (21). It presented good internal
reliability coefficients (Cronbach’s a = 0
73) and high
test–retest reliability (Pearson’s r = 0
79). The analysis
considers as landmarks stable structures such as the
posterior nasal spine (PNS) that makes the analysis
reproducible. The measurements in the lateral cepha-
logram to calculate the anteroposterior airway size
were the following (Fig. 4):
ad1: the distance between the points that intersect
the anterior and posterior pharyngeal walls in a line
that goes from nasal spine (PNS) to basion (Ba).
ad2: the distance between the points that intersect the
anterior and posterior pharyngeal walls in a line that
goes from sella (S) to the posterior nasal spine (PNS).
Angle ad1-ad2: angle formed by ad1 and ad2.

Fig. 3. Angles formed by OPT with VV and HOR.

VV: a vertical 0
5-mm-wide wire was put in front

and parallel to the nasion of the cephalostat to reg-
ister the perfect vertical line (VV).
HOR: based on the vertical reference, a horizontal line
(HOR) was traced perpendicular to the vertical one.
The following angles were measures to analyse the
cervical column posture (Figs 2 and 3) (17).:
Angle between CVT and VV: the wider the angle,
the more forward posture of the cervical column.
Angle between CVT and HOR: the narrower the
angle, the more significant the forward inclination
of the cervical column.
Angle between OPT and VV: the wider the angle, the
more forward the posture of the cervical column.
Angle between OPT and HOR: the narrower the
angle, the more relevant the anterior inclination of
the cervical column.

Airway dimensions

The digital record of lateral cephalograms was pro- Fig. 4. Diagram of measurements taken to evaluate the airway
cessed in agreement with Sayinsu et al. (20) using a dimensions.

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814 C . C . R E S T R E P O et al.

OAW1: the distance between the points where the

Results
functional occlusal plane intersects the anterior
and posterior pharyngeal walls. Twelve women and eleven men composed the bruxist
OAW2: the distance between points where a line group, while eleven women and eleven men were
passing through hyoid (hy) and C2 i intersects the part of the control group. More forward inclination of
anterior and posterior pharyngeal walls. the head and cervical column was found for the brux-
OAW3: the distance between the points where a ist group only for the measurements dealing with the
line passing through hy and C4 i intersects the tangent to cv2ip (OPT) with both planes, the VV and
anterior and posterior pharyngeal walls. HOR (Table 1). The mean value for the variable OPT-
Angle OAW2-OAW3: angle formed by OAW2 HOR presented less value for bruxist than for controls,
and OAW3. and the variable OPT-VV presented a mean value
SPPS: anteroposterior width of the pharynx mea- higher for bruxist than for controls. All other mea-
sured between the posterior pharyngeal wall and surements regarding the cervical column posture did
the dorsum of the soft palate on a line parallel to not present statistically significant differences when
the Frankfort horizontal (FH) plane that runs comparing both groups.
through the middle of a line from PNS to the Regarding the airway dimensions, IPS and OAW3
extreme point of the soft palate (P). (oropharynx) were found to have smaller dimension
MPS: anteroposterior width of the pharynx mea- for bruxist adults when comparing both groups. Mea-
sured between the posterior pharyngeal wall and surements of the nasopharynx were not found to
the dorsum of the tongue on a line parallel to the
FH plane that runs through P.
IPS: anteroposterior width of the pharynx mea-
Table 1. Comparison of head and cervical column posture
sured between the posterior pharyngeal wall and between bruxist and non-bruxist young adults
the dorsum of the tongue on a line parallel to the
FH plane that runs through C2 i. Variable Group Angles (s.d.) P-value
The examiners evaluating the condition of bruxism CVT_HOR Bruxist (n = 23) 75 435 (4843) 0
091
were not aware of who were those that analysed the Non-bruxist (n = 22) 77 230 (4466)
X-ray images. OPT_HOR Bruxist (n = 23) 81 534 (4611) 0
004
Non-bruxist (n = 22) 85 151 (5937)
CVT_VV Bruxist (n = 23) 14 145 (8117) 0
102
Error of method Non-bruxist (n = 22) 13 925 (3583)
OPT_VV Bruxist (n = 23) 5085 (3650) 0
009
A calibration of the X-ray technique and a standardi- Non-bruxist (n = 22) 1203 (4195)
sation of the digital tracing of the cephalogram were
performed. The tracing of the cephalogram was stan-
dardised between two investigators with 10 X-rays, Table 2. Comparison of the airway dimensions between the
bruxist and control groups
scanned and traced three times each by each of two
of the investigators (ICC >0
7 and Kappa > 0
6 for the
Bruxist Control
head and cervical column posture and ICC> 0
9 and
n = 23 n = 22
Kappa > 0
7 for the airway dimensions). Variable Mean s.d. Mean s.d. P-value

ad1 (mm) 12
8  3
8 14
4  4
2 0
17

Statistical analysis ad2 (mm) 7
8  3
0 8
2  2
6 0
54
OAW1 (mm) 7
4  4
5 7
8  3
8 0
47
Univariated analysis was performed. Distributions OAW2 (mm) 6
8  2
1 11
3  1
6 0
06
were tested using the Shapiro–Wilk test. The data OAW3 (mm) 6
2  2
9 9
2  3
8 0
04
were compared using the Mann–Whitney U-test or t- SPPS (mm) 11
4  4
3 10
0  3
1 0
34
IPS (mm) 5
6  3
1 9
5  2
8 0
03
test depending on the normality of the quantitative
ad1-ad2 (°) 33
5  5
9 31
2  4
3 0
28
variables. For all tests, significance was set at 5%
OAW2-OAW3 (°) 34
5  5
0 34
3  5
1 0
58
(P < 0
05).

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 CERVICAL COLUMN POSTURE AND AIRWAY DIMENSIONS IN BRUXIST 815

present statistically significant differences, when com- ciated with the occurrence of sleep bruxism (22–24),
paring both groups (Table 2). the airway dimensions of bruxist have not been tested
before. In the present study, measurements related to
the oropharynx were found to be narrower in bruxist
Discussion
adults than in non-bruxist. Attempts have been made
The present cross-sectional study aimed to compare to expand the airway dimensions through intra-oral
the head and cervical posture and the airway dimen- devices to advance the mandible (25) to reduce the
sions in cephalograms of young adults with and with- grinding activity. Actually in children, reduction in
out report of bruxism. The hypothesis was that sleep bruxism had also been reported after adenoton-
cervical column posture must be more forwarded in sillectomy (26).
bruxist subjects, as an attempt to increase airway The forwarded position of the head and cervical col-
patency. The oropharynx was found to have less umn, was found only for the measurements taken
dimensions, and the cervical column posture, to be with the second cervical vertebra. Previous studies
more forwarded in bruxist adults, when compared about the interactions between airway adequacy and
with controls. head posture, have demonstrated that minor adapta-
Investigations in children found more forwarded tions in natural head posture to an altered dimension
positions of the cervical column and anterior head of the airway, are mainly caused by cranial extension
posture in bruxist subjects (5,6). The study by Velez (27). Cervical column posture is an important factor
et al. (5), performed in children, found differences in in maintaining airway patency (27). The forwarded
all the measurements, using the same method by cervical column posture found in this investigation,
Solow and Tallgren (17). However, in this investiga- has also been found in patients with severe obstruc-
tion, differences were found only for the measure- tive sleep apnoea (27). The tendency for a forwarded
ments taking the Atlas vertebrae (cv2ip) as a and extended cervical column posture in subjects with
reference, but for both measurements with HOR and obstructive sleep apnoea (27) and with bruxism may
VV. The angles CVT-HOR, OPT-HOR and OPT-VV be an indication of a threshold level at which certain
presented almost the same differences between brux- anatomical and/or physiological characteristics of the
ist and non-bruxist in children (5) and adults upper airway and related structures trigger changes in
(approximately 2°, 4° and 4°, respectively). When natural head posture.
comparing the angle CVT-VV between adults and The oral airway resistance increases with modest
children, strong differences can be seen. Children pre- degrees of head and neck flexions in healthy adult
sented a 4-degree disparity when comparing sleep- humans (28). Actually in healthy infants, hyperflex-
grinders and asymptomatic subjects, while adults ion of the head has been shown to affect the airflow,
presented in this investigation only 1 degree of differ- airway patency and pulmonary mechanisms (29,30).
ence, when comparing both groups. Sleep bruxism has been correlated to hypopnea (31).
Even though, the instrument defined by Solow and Additionally, rhythmic jaw movements have shown
Tallgren was strictly used and interpreted in this to increase the oxygenated haemoglobin concentra-
investigation (17), it lacks the inclusion of a tangent tions in sensorimotor cortex (32). In this investiga-
line to connect the inferior – posterior angle of C7 to tion, anterior cervical posture was found for the
the posterior wall of C2. With this line, compared sleep-grinders group. This characteristic could affect
with VV, it could be better exposed the forward pos- the airflow in the bruxist adults and be part of the
ture of the cervical column. The angulation of one aetiology of their parafunction (5). The mechanisms
vertebra does not necessary means that the whole and pathophysiology of these changes in bruxism are
cervical column is in a forward position. Thus, the still topics for future investigations. Cohort studies are
results about posture should be interpreted cautiously, necessary to evaluate, in a long term, the relationship
and further investigations are needed both to validate between bruxism and narrow airway dimensions.
an instrument using this new proposed measurement Thus, the interpretation should be taken with caution
and to use it in larger samples. until the results are further confirmed. Also, other
Regarding the airway dimensions, even though conditions, such as abnormal posture habits resulting
respiratory alterations have been identified to be asso- from desk work, TV and games, should be evaluated

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816 C . C . R E S T R E P O et al.

in future investigations, as could be confusion vari- 8. Lavigne GJ, Kato T, Kolta A, Sessle BJ. Neurobiological
ables. mechanisms involved in sleep bruxism. Crit Rev Oral Biol
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9. Lavigne GJ, Rompr
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in humans. J Dent Res. 2001;80:443–448.
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Tamayo and Veronica Tamayo who helped them to JY, Lavigne GJ. A significant increase in breathing ampli-
make the physiotherapeutic evaluation to the tude precedes sleep bruxism. Chest. 2008;134:332–337.
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included subjects. This study was supported by CES
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M. Reliability of an occlusal and nonocclusal tooth wear
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