ORIGINAL ARTICLE

L Sonnesen Cervical column morphology in patients

I Kjær
with skeletal open bite

Authors' affiliation: Structured Abstract

Liselotte Sonnesen, Inger Kjær, Department Authors – Sonnesen L, Kjær I
of Orthodontics, School of Dentistry,
Objectives – To examine and compare the cervical column morphology in adult
Copenhagen University, Copenhagen,
Denmark patients with skeletal open bite with the cervical column morphology of an adult
control group with neutral occlusion and normal craniofacial morphology.
Correspondence to:
Design – A retrospective case–control study.
Liselotte Sonnesen
Department of Orthodontics, School Setting and Sample Population – Thirty-eight open bite patients, 27 women, aged
of Dentistry 17–39 years, and 11 males, aged 18–40 years were compared with 21 controls,
Faculty of Health Sciences, Copenhagen 15 females, aged 23–40 years, and six males aged 25–44 years from profile
University
radiographs.
20 Nørre Allé
DK-2200 Copenhagen N Outcome measure – From each individual a visual assessment of the cervical
Denmark column and angular measurements of the craniofacial dimensions were performed
E-mail: [email protected] on profile radiographs.
Results – In the open bite group 42.1% had cervical column body fusion, and 13.2%
had posterior arch deficiency. The fusion always occurred between C2 and C3.
Cervical column deviations occurred significantly more often in the open bite group
compared with the control group (p < 0.05). Associations were found between
fusions of the cervical column and maxillary retrognathia (p < 0.05), large maxillary
inclination (p < 0.05) and large cranial base angle (p < 0.05). Associations were
also found between posterior arch deficiency and maxillary retrognathia (p < 0.05)
and cranial base angle (p < 0.05). The craniofacial parameter most important for the
fusions and posterior arch deficiency was the maxillary retrognathia (p < 0.01,
R 2 = 0.20; p < 0.05, R 2 = 0.26, respectively).
Conclusion – New associations between skeletal open bite and cervical column
deviations are described. It is suggested that this knowledge is incorporated in
future diagnostic and orthodontic treatment planning.

Key words: cervical column morphology; skeletal open bite

Dates: Introduction
Accepted 1 October 2007

To cite this article: Many cephalometric studies have been performed on patients with skeletal
Sonnesen L, Kjær I: open bite. Most of the authors agreed that the cephalometric characteristics
Cervical column morphology in patients
with skeletal open bite found in patients with skeletal open bite were increased anterior facial
Orthod Craniofac Res 2008;11:17–23 height, increased gonial angle and mandibular plane angles, shorter ante-
Copyright  2008 The Authors.
rior cranial base, upward and forward rotation of the maxilla and backward
Journal compilation  2008 Blackwell Munksgaard rotation of the mandible (1–8). Skeletal open bite develops as a result of
Sonnesen and Kjær. Cervical column and skeletal open bite

many different aetiological factors including thumb and orthodontic surgical patient archive (378 records) at the
finger sucking, lip and tongue habits, airway obstruction Department of Orthodontics, Copenhagen School of
and true skeletal growth abnormalities (e.g. 9–16). Dentistry, Denmark.
So far, no study has included the cervical column The control group consisted of 21 subjects, 15
morphology as a skeletal sign associated with skeletal females, aged 23–40 years (mean age 29.2), and six
open bite. Recently, an association between fusion of males aged 25–44 years (mean age 32.8). The subjects
the bodies in the cervical column and deviations in the were either students or staff members at the Aarhus
vertical and sagittal craniofacial morphology were Dental School, Denmark. Selection criteria: 1) neutral
found (17, 18). The location of fusion in the vertebral occlusion or minor malocclusion not requiring ortho-
column was shown to be different in patients with dontic treatment according to the Danish procedure for
condylar hypoplasia, patients with skeletal deep bite screening the population for malocclusion entailing
and skeletal mandibular overjet (17–19). Furthermore, health risks (21, 22); 2) no previous history of ortho-
the frequencies of malformations in the cervical dontic treatment; 3) sagittal and vertical jaw relation-
column were different in the different malocclusion ship within 1 SD according to the standard material
traits (17–19). Therefore, it is also relevant to look at the described by Björk (20), assessed by lateral radiographs
morphology of the cervical column in patients with of each individual; 4) at least 24 permanent teeth
skeletal open bite. present; 5) no craniofacial anomalies or systemic
The aims of the present study were therefore: 1) to muscle or joint disorders; 6) availability of a profile
describe the morphology of the cervical column in radiograph with the five first cervical vertebrae units
adult patients with skeletal open bite; 2) to compare the visible. The control group is previously described in
morphology of the cervical column in a group of adult detail by Sonnesen et al. (19).
patients with skeletal open bite (open bite group) with
the morphology of a control group with neutral
occlusion and normal craniofacial morphology (control Methods
group); and 3) to analyse associations between the Morphology of the cervical vertebrae
morphology of the cervical column and craniofacial
dimensions in the total group (open bite and control The visual assessment of the cervical column included
group). the first five cervical vertebral units that are normally
seen on a standardized lateral skull radiograph. Char-
acteristics of the cervical column were classified
Subjects according to Sandham (23) and divided into two cate-
gories: Posterior Arch Deficiency and Fusion Anoma-
The open bite group consisted of 38 patients, 27 lies. Posterior Arch Deficiency consisted of partial cleft
women, aged 17–39 years (mean 21.7), and 11 males, and dehiscence. Fusion Anomalies were registered in
aged 18–40 years (mean 24.6). Inclusion criteria for the cases with fusion of two cervical bodies, block fusion
open bite group: 1) adult patients between 17 and when more than two bodies were fused and occipital-
40 years of age; 2) no history of orthodontic treatment ization of C1 and the occipital bone. Only anomalies
during childhood; 3) skeletal open bite [vertical jaw that were verified on at least two profile radiographs
relationship larger than 1 SD according to the standard before and after surgery from each individual were
material described by Björk (20), assessed by lateral registered as anomalies of the cervical column.
radiographs of each individual]; 4) at least 24 permanent
teeth present; 5) no craniofacial anomalies or systemic Craniofacial dimensions
muscle or joint disorders; 6) accessibility of a profile
radiograph before pre-surgical orthodontic treatment For the control group the profile radiographs were
with the first five cervical vertebrae units visible. taken with the teeth in occlusion and in the standar-
Thirty-eight profile radiographs were systematically dized head posture, the mirror position, as described
selected according to the above-mentioned inclusion by Siersbæk-Nielsen and Solow (24). The radiographs
criteria from patients registered since 1975 in the were taken at the Department of Oral Radiology,

18 Orthod Craniofac Res 2008;11:17–23

 Sonnesen and Kjær. Cervical column and skeletal open bite

showed Ôvery goodÕ agreement (K = 0.82) as assessed by

the kappa coefficient (25).
The reliability of the variables describing the cranial
base, vertical and sagittal craniofacial dimensions was
assessed by remeasurement of 20 lateral radiographs
selected at random from the previously recorded
radiographs. The radiographs were re-digitized, and the
differences between the two sets of recordings were
calculated. No significant differences between the
two sets of recordings were found. The method errors
ranged from 0.09 to 0.69 (26) and the reliability
coefficients from 0.99 to 1.00 (27).

Statistical methods

The normality of the distributions was assessed by

parameters of skewness and kurtosis and by Shapiro–
Wilks W-test. The cephalometric measurements were
normally distributed except for the overjet and overbite.
Fig. 1. Reference points and lines according to Solow and Tallgren,
Differences in means of the craniofacial dimensions
1976 (35). between genders and between the groups were assessed
by unpaired t-test. Differences in occurrence of
Aarhus Dental School, Denmark, in a Hofman Selec- morphological characteristics of the cervical column
tomat with a film-to-focus distance of 180 cm and a between genders and between the groups were assessed
film-to-median plane distance of 10 cm. No correction by FisherÕs exact test. Associations between morphology
was made for the constant linear enlargement of 5.6%. of the cervical column and the craniofacial dimensions
A plumb line was suspended from the ceiling to mark and the possible effect of age and gender were tested by
the true vertical line on the radiographs. The digital logistic regression analyses. A multiple logistic regres-
radiography system was a photostimulable phosphor sion analysis with stepwise backwards elimination was
plate, Digora (Soredex, Helsinki, Finland) placed in a then performed to determine the relationship between
traditional cassette without intensifying screen. The the morphology of the cervical column as the dependent
reference points were marked and digitized in variable and the variables that were significantly corre-
PorDiosW (Fig. 1), and 10 variables representing the lated with the morphology of the cervical column as the
cranial base angle, the vertical and the sagittal cranio- independent variables. The correlation coefficients (R 2)
facial dimensions were calculated. in the logistic regression analyses were calculated
For the open bite group, the 38 profile radiographs according to Nagelkerke (28). In all the logistic regres-
were taken in a cephalostat with a film-to-focus dis- sion models the linearity of the effect was tested by
tance of 180 cm and a film-to-median plane distance of Hosmer–Lemeshow goodness-of-fit. The results from
10 cm. No correction was made for the constant linear the tests were considered to be significant at p-values
enlargement of 5.6% (1). A list of the variables is shown below 0.05. The statistical analyses were performed
in Table 2. using SPSS 13.00 (SPSS Inc., Chicago, IL, USA).

Reliability
Results
The reliability of the visual assessment of the Morphology of the cervical column
morphological characteristics of the cervical vertebrae
units was determined by inter-observer examinations In the open bite group 42.1% had fusion of the cervical
between the authors. The inter-observer examinations column, and 13.2% had posterior arch deficiency

Orthod Craniofac Res 2008;11:17–23 19

Sonnesen and Kjær. Cervical column and skeletal open bite

(Table 1). The fusion always occurred between C2 and both fusion and posterior arch deficiency (Table 1).
C3, and the posterior arch deficiency occurred in The fusion always occurred between C2 and C3. No
combination with fusion except for one patient (Fig. 2). statistical gender differences were found in the occur-
No statistical gender differences were found in the rence of morphological characteristics of the cervical
occurrence of morphological characteristics of the column (women 13.3%, men 16.7%).
cervical column (women 51.9%, men 18.2%). The comparison of the open bite group and
As previously reported (19), in the control group the control group showed that fusions of the cervical
14.3% had fusion of the cervical column, and 4.8% had column occurred significantly more often in the open
bite group compared with the control group (p < 0.05,
Table 1).
Table 1. Prevalence of morphological characteristics of the
cervical column in patients with skeletal open bite (Open
Craniofacial dimensions
bite group) and in subjects with neutral occlusion and normal
craniofacial morphology (Control group)
The mean values for the craniofacial dimensions
Open bite Control are shown in Table 2. The sagittal jaw relationship
group group (ss-n-sm, p < 0.05), the vertical jaw relationship
Variable n % n % p-value
(NL-ML, p < 0.001), the mandibular inclination
(NSL-ML, p < 0.001) and the horizontal overjet (p <
Normal 21 55.3 18 85.7 * 0.01) were statistically larger in the open bite group
Fusion anomalies 16 42.1 3 14.3 * than in the control group, whereas the maxillary
Posterior arch deficiency 5 13.2 1 4.8 NS (s-n-ss, p < 0.05) and mandibulary prognathia (s-n-pg,
More than one deviation 4 10.5 1 4.8 NS

*p < 0.05, FisherÕs exact test. Table 2. Craniofacial dimensions in the open bite group and in
NS, not significant, FisherÕs exact test. the control group

Open bite Controls

(n = 38) (n = 21) Group Sex

Variable (degrees) Mean SD Mean SD p p

Sagittal dimensions
ss-n-pg 3.30 3.89 1.58 1.92 NS NS
ss-n-sm 4.11 3.49 2.14 1.59 * NS
s-n-ss 78.81 4.20 81.64 2.97 ** NS
s-n-pg 75.61 4.80 80.12 3.41 *** NS
Vertical dimensions
NL-ML 36.45 4.23 22.32 3.13 *** NS
à
NSL-NL 7.43 4.17 7.41 3.02 NS
NSL-ML 43.88 5.15 29.71 4.81 *** NS
Cranial base angle
n-s-ba 131.43 6.88 130.99 4.61 NS
Incisor-relations
à
Overjet (mm) 5.61 4.43 2.82 0.73 **
Overbite (mm) )3.24 2.98 2.30 0.96 *** NS

***p < 0.001, unpaired t-test.

Fig. 2. Morphological characteristics of the cervical column in **p < 0.01, unpaired t-test.
patients with skeletal open bite. 1) Fusion of the cervical column *p < 0.05, unpaired t-test.
vertebrae between C2 and C3 (fusion anomalies). 2) Partial cleft of the NS, not significant, unpaired t-test.
posterior portion of the neural arch of atlas (posterior arch p < 0.01, women larger than men, unpaired t-test.
à
deficiency). p < 0.05, women larger than men, unpaired t-test.

20 Orthod Craniofac Res 2008;11:17–23

 Sonnesen and Kjær. Cervical column and skeletal open bite

p < 0.001) and the overbite (p < 0.001) were statistically with neutral occlusion and normal craniofacial
smaller in the open bite group. The maxillary inclina- morphology.
tion (NSL-NL, p < 0.05), the cranial base angle (n-s-ba, The cervical column morphology described in the
p < 0.01) and the horizontal overjet (p < 0.05) were skeletal open bite in the present study has not previ-
statistically significantly larger in women than in men. ously been reported in the literature. Similar studies
have been performed on patients with skeletal deep
Craniofacial dimensions related to the cervical column bite, skeletal mandibular overjet and patients with
morphology condylar hypoplasia (17–19). In the present study the
morphological deviations of the cervical column
In the total group, the logistic regression analysis occurred in 42.1%, and the fusions of the cervical ver-
after correction of the possible effects of age and tebral bodies always occurred between C2 and C3.
gender, showed that the maxillary retrognathia A similar pattern is seen in the skeletal deep bite group
(s-n-ss, p < 0.05), a large maxillary inclination where the morphological deviations of the cervical
(NSL-NL, p < 0.05) and a large cranial base angle column occurred in 41.5%, also between C2 and C3
(n-s-ba, p < 0.05) were significantly correlated with (17). Compared to these findings in the skeletal open
fusion of the cervical column (Table 3). bite and skeletal deep bite, the prevalence was even
The posterior arch deficiency was significantly cor- larger in a group of patients with skeletal mandibular
related with the maxillary retrognathia (s-n-ss, overjet (61.4%) (18) and in a group of patients with
p < 0.05) and a large cranial base angle (n-s-ba, condylar hypoplasia (72.7%) (19). Furthermore, the
p < 0.05) (Table 3). The significant regression coeffi- pattern of the cervical column morphology was differ-
cients (R) were low to moderate, numerical values ent in skeletal open bite and skeletal deep bite com-
ranging from 0.40 to 0.63 (Table 3). pared to the group of patients with mandibular overjet
The multiple logistic regression analysis showed that and condylar hypoplasia. In the condylar hypoplasia
the most important factor for fusion of the cervical group fusions occurred not only between C2 and C3
column and posterior arch deficiency was maxillary but also between C3 and C4, and in the mandibular
retrognathia (s-n-ss, p < 0.01, R 2 = 0.20; p < 0.05, overjet group fusions characterized as block fusion also
R 2 = 0.26, respectively). occurred. It can be concluded from this comparison
that the cervical column morphology differs pheno-
typically in the different skeletal malocclusion traits.
Discussion In the present study an association was found
between cervical column morphology, maxillary retro-
The aim of the present study was to examine the gnathia and increased maxillary inclination. With
cervical column morphology in adult patients with regard to the cephalometric registration of maxillary
skeletal open bite and compare the findings with the deviations it is interesting to compare the present
cervical column morphology in an adult control group findings with findings in cleft palate patients. Previ-
Table 3. Significant correlations (R ) after correction of age and ously, an association has been shown between isolated
gender effect between morphology of the cervical column and the cleft palate patients and maxillary retrognathia and
maxillary retrognathia (s-n-ss), inclination of the maxilla (NSL-NL), increased maxillary inclination (29, 30).
and cranial base angle (n-s-ba) in the total group (n = 59) Furthermore, an association has been found between
isolated cleft palate patients and malformations of the
Posterior arch More than
upper cervical vertebrae (23, 31, 32). This comparison
Fusion deficiency one deviation
may indicate that the aetiology behind the skeletal
s-n-ss )0.59à )0.51* )0.49* open bite is an abnormal development in the maxilla
NSL-NL 0.60à
NS NS during the early prenatal period. As the maxilla devel-
n-s-ba 0.62à 0.48* 0.40* ops from neural crest cell migration (33), it is under-
standable that the disturbance in the amount
*p < 0.05 (logistic regression).
à
p < 0.05 and negative effect of age (logistic regression). of migrating maxillary cells or the timing of the
NS, not significant (logistic regression). migration of the maxillary cells may influence the

Orthod Craniofac Res 2008;11:17–23 21

Sonnesen and Kjær. Cervical column and skeletal open bite

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