Craniofacial features of children with spinal deformities
© Segatto et al; licensee BioMed Central Ltd. 2008
Received: 09 June 2008
Accepted: 22 December 2008
Published: 22 December 2008
The objective of this epidemiological study is to map the dentofacial anomalies that can be correlated to the two most frequent spinal diseases responsible for postural abnormalities and that can be clinically identified by the orthodontic examination.
Twenty-three children with Scheuermann's disease participated in the study (mean age: 14Y8M; SD: 1Y8M), 28 with Scoliosis (mean age: 14Y7M; SD: 2Y3M) and a control group of 68 orthopedically healthy children (mean age: 14Y8M; SD: 0Y11M). Standardized orthodontic screening protocols were used to map the occlusal relations in the sagittal, vertical, and transversal dimensions, space relations of the maxillary and mandibular frontal segment, and the TMJ status and function. The examinations for the children with orthopedic disorders were supplemented by the evaluation of routine orthodontic radiograms – lateral cephalograms and panoramic X-rays.
The majority of the dentofacial features examined revealed more and greater abnormalities among patients in the Scheuermann's disease group than in the scoliosis group. In the latter group the proportion of the TMJ symptoms and the consecutive functional deviations were greater. When comparing the values of the two spinal-disorder groups and the control group, statistically significant differences (p < .05) occurred for the following measurements: frequency of unilateral Cl.II. molar occlusion, overjet and extreme overjet mean value (Scheuermann's disease group), as well as the frequency of TMJ pathological symptoms (scoliosis group). The evaluation of the panoramic X-rays showed significant differences among the mandibular measurements of the two spinal-disorder groups. Within the framework of the evaluation of the cephalograms significant differences (p < .05) were found only in the case of dental relations. However, several values differed significantly from the Ricketts' norms, none of the indices strictly characterized any of the groups with spinal disorders.
The more extended treatment of the malocclusions closely correlated to postural disorders draws attention to the indicators of a higher frequency and severity occurring in the case of the dentofacial deviations in the patients of the MSCH group who had previously been less examined.
The literature exploring the reasons for the development of malocclusions concentrates very much on the connections to the different postural anomalies. Those postural anomalies are mainly highlighted which could contribute to the development of the different dentofacial anomalies and later to the sustenance thereof by their chronic influence on the head posture [1, 2]. Thus, those orthopedic disorders become very important that mainly become manifest in pathological curves of the spine . According to literature sources, the frequency of various malocclusions in the orthopedic patient group amounts to 83–87% .
The role of the head posture that is tilted forwards and backwards evolved as a consequence of the pathological curves of the sagittal plane (kyphosis and lordosis) which were mainly examined within the framework of the study of the development of the sagittal and vertical jaw anomalies [5–10]. In their opinion, the scoliotic curves occurred in the frontal plane – through the head posture that is tilted sideways – and played an important role in the development of the different dentofacial asymmetries . The alteration of the head posture may lead to the development of TMJ dysfunction and TMJ structural deformity . Because of their similar epidemiologic characteristics – incidence, stability of the developed deformations, time of appearance – the two spinal diseases which are considered as the most appropriate in terms of the examinations are the Scheuermann's disease (or kyphosis dorsalis juvenilis) and the idiopathic scoliosis . The occurrence of the Scheuermann's disease varies between 0.4 and 11%. The pathological kyphotic curvature which is liable for the head posture tilted forward and hunchbacked appearance is primarily pronounced and stabilized in the dorsal spinal region. Its development begins during pre-puberty and is not characterized by gender deflection [13–15]. The frequency of the idiopathic scoliosis alters between 11.9 and 16.2%. The main curvature may be localized in any part of the vertebral column, the most common being the right convex dorsalis scoliosis which – in the non-compensated forms – induces the head posture to be tilted to the left. Its development starts during the pre-puberty, and – as regards the gender distribution – it occurs 7–10 times more often in girls than in boys [13, 16, 17]. The conservative treatment in the early stage of both spinal diseases consists in posture strengthening and the improvement of the muscle tone by physical therapy, while in late, severe stages of the disease, it is necessary to wear a corset. The reason for this is the deformed vertebra's malformation stage in the case of Scheuermann's disease, while in patients with scoliosis the Cobb value of more than 20 degrees warrants the corset [16, 18]. However, the severe deterioration cannot be improved by the conservative treatments but only with the help of surgical interventions.
We performed the orthodontic examination on children suffering from Scheuermann's kyphosis and from idiopathic scoliosis in order to collect data for further related studies. Based on the results we wanted to get a more accurate image of the craniofacial characteristics, the functional habits and the occlusal patterns of patient groups with spinal deformities in the sagittal and frontal plane. The patients participating in the epidemiological survey received detailed information on the examinations in advance; their parents provided their written consent to the performance thereof. The examinations complied with the requirements of the local Ethics Committee.
For the examination of the selected children the standardized orthodontic protocol was used, including clinical examination and orthodontic impressions. In order to get an exact evaluation the results were tabulated on the WHO broadsheet used for epidemiological studies. The clinical examinations were supplemented for the patients with spinal diseases by the routine lateral cephalogram and the panoramic X-ray pictures (Orthophos DS Ceph, Siemens, Bensheim, Deutschland; Focus-CCD sensor distance 1.2 m; tube values: 60–90 kV, 9–16 mA).
c) Cephalometric examination
The panoramic X-ray evaluation was done on the basis of the measuring method by Habets et al  under similar conditions. With the help of the distances measured on the two mandibular ramuses (codylar/CH/, ramal/RH/, and condyle plus ramal/CH+RH/height) determined asymmetry indices served for mapping the skeletal asymmetry present at this bone level. For all the three distances the determination of the asymmetry index characteristic to the given length occurred with the help of the formula [(R-L)/(R+L)] × 100, by using the values measured on the right (R) and on the left (L) ramuses.
d) Orthodontic examination
The examination of the orthodontic characteristics are grouped around three issues:
• Mapping of the occlusal and skeletal characteristics in the sagittal, transversal and vertical direction
• Examination of the jaw space relations
• Examination of temporomandibular joint
The measurement of the occlusal characteristics in the sagittal plane was based on the determination of the molar relation (Angle classification), and on the overjet of the incisors. This was supplemented by sagittal features like the maxillary depth (MD) and ramus position (RP) taken from the cephalometric analysis. The presence of the transversal abnormalities was measured by the registration of the crossbite in the molar region, of the upper and lower midline in relation to the facial midline and of the midline deviation measured between upper and lower dental midlines. In order to study the vertical abnormalities the lateral open bite was registered and the overbite of the incisors was measured. The facial axis (FA), the lower facial height (LFH) and the mandibular plane (MP) are the vertical skeletal characteristics derived from the cephalometric evaluation. For the examination of the jaw space relations the crowding and the presence of spaces in the incisor region were recorded. In the pursuance of the profound examination of the TMJ the abnormal symptoms (clicking of the joint, pain, limited mouth opening), the mentum deviation during mouth opening, and the rate of the lateral movement were marked and measured.
e) Data analysis
The sheets were evaluated and the values statistically analyzed by means of SPSS (Lead Tech Chicago, Ill, USA) with the significance level in all tests being determined to be p < .05. Additional tables were prepared using Excel 2002 (Microsoft Corporation, USA).
Frequency of the sagittal occlusal anomalies on the posterior region.
Scheuermann's disease group
Normal molar occlusion
(Angle Cl.I) frequency(%)
Distal molar occlusion
(Angle Cl.II) frequency(%)
Mesial molar occlusion
(Angle Cl.III) frequency(%)
Comparison of the occlusal characteristics of the frontal region (Student's t-test).
Scheuermann's disease group
4.27 ± 3.973
3.25 ± 2.188
2.21 ± 1.201
mean ± SD (mm)
2.74 ± 1.851
2.55 ± 1.509
4.27 ± 3.150
2.75 ± 3.195
3.10 ± 1.585
mean ± SD (mm)
2.58 ± 2.168
2.78 ± 1.715
1.43 ± 0.724
1.67 ± 1.061
1.47 ± 0.898
mean ± SD (mm)
2.08 ± 1.121
1.76 ± 0.972
Cephalometric measurements in Scheuermann's disease and scoliosis group.
Direction of the measurement
Scheuermann's disease group
Maxillary depth (MD)
Norm:90.0 ± 3°
Ramus position (RP)
Norm:76.0 ± 3°
Facial axis (FA)
Norm:90.0 ± 3°
Lower facial height (LFH)
Norm:47.0 ± 4°
Mandibular plane angle (MP)
Norm:27.2 ± 4.5°
The mean value of the three examined skeletal parameters with a vertical direction was lower than the normal values according to Ricketts. The facial axis values of the MSCH group were lower than the ones of SC group; in both patient groups, the measured values differentiated from the normal values concomitantly to the severity of the orthopedic malformation (90 ± 3°). This tendency was not characteristic in the case of values related to the lower facial height and the mandibular plane. In both cases, the values of the SC group showed a higher deviation from the normal values – lower facial height (47.0 ± 4°), mandibular plane (27.2 ± 4.5°) [Table 3].
The study of the occlusal anomalies characteristic to the studied groups was finalized with the analysis of the transversal relations. One child in the MSCH group and three children in the SC group were registered with a unilateral crossbite and there were 1-1 bilateral crossbites in both groups. In the CTRL group two bilateral crossbite cases matched three unilateral crossbite cases. The evaluation of the records of the frontal region gave a better picture. Comparable to the upper midline's deviation, the lower midline's deviation from the facial midline was more frequent in the MSCH group than in the SC group. The higher number of midline deviations was characteristic for the MSCH group; however the SC group was found to have higher deviation mean values. Having examined the repartition within the groups the midline deviation cases occurred three times more in the groups with severe type of spinal disease than in the group with moderate type of spinal disease. Regarding the degree of the deviation the severe type of SC group was characterized by significantly higher values compared to the CTRL group [Table 2]. Beside a similar manifestation frequency the CTRL group had lower deviation mean values in contrast to the patient groups.
The evaluation of the space anomalies in the jaws included the recording of the crowding and spacing in the upper and lower frontal regions. With almost equivalent crowding and upper spacing values, the occurrence of the spacing in the lower region showed a significant deviation, being lower in the CTRL group.
Comparison of the asymmetry indicators characteristic to the examined orthopedic patient groups (Student's t-test).
Scheuermann's disease group
Asymmetry indexes of the mandible in different orthopedic groups.
Scheuermann's disease group
Condylar index mean ± SD
12.02 ± 11.32
11.06 ± 17.02
12.45 ± 8.53
12.24 ± 10.79
Ramal index mean ± SD
3.16 ± 2.18
2.47 ± 5.35
3.32 ± 3.18
1.72 ± 0.89
Condylar+ramal index mean ± SD
2.66 ± 2.25
1.54 ± 2.44
2.58 ± 2.41
0.56 ± 0.47
Numerous studies discuss the relationship between the multiple postural disorders and spinal illnesses causing these disorders and the dental complex. Among the examined spinal disorders, idiopathic scoliosis characterized by the pathologic curvature occurring in the frontal plane is relatively frequent, while the Scheuermann's disease with the pathological curvature in the sagittal plane is uncommon . In the reviewed studies, the pathological postures correlating with the dominant kyphotic curvature are often encountered, however, the Scheuermann's kyphosis is not only evident in the case of the increased curvature values but also in the case of degenerative vertebral changes of the affected spinal section which cause the posture abnormality to become permanent [21, 22]. The statistically high incidence values, the advancement of the disease over time and the pathological curvature that is normal for the scoliotic curvature were the reasons that the children with Scheuermann's disease participated in this epidemiological study. There are only few articles which describe the orthodontic examination as an opportunity for the early detection of spinal disorders or which emphasize the necessity of early orthodontic check-ups for children with diagnosed spinal disorders, highlighting the application of minimal-invasive methods of screening the affected population [4, 9]. For these practical reasons, this study is also based on these methods.
Based on the previous results, a dominancy of the dentofacial asymmetry in the SC group, and sagittal and vertical alterations caused by the forward-tilted head posture and an increase in the numbers of the TMJ abnormalities in MSCH group were expected [1, 3, 5].
After the evaluation, in most cases our values were similar to those in the studies; however, we found some exceptions.
The frequency of the asymmetric deviations of posterior region occurring in the sagittal dimension was similar in the groups with spinal deformities and this value was double than the one registered in the CTRL group. The frequency of the symmetric normocclusions was the greatest in the CTRL group while the incidence values of malocclusions were the highest in the MSCH group. The frontal crossbites characterizing mostly the patients with scoliosis were not registered in our patient groups .
An examination of the incisor relation proved the previously found correlation between the alterations in the sagittal plane and the pathological kyphotic curvature; just like the extreme overjet, the deep bite was significantly more frequent in patients affected by Scheuermann's disease, in contrast to the SC or the CTRL group.
On the basis of the evaluation of cephalograms of the groups with spinal disorders, a slightly protrusive maxilla and a slightly retrusive mandibula are characteristic for a skeletal deep bite which is more pronounced in the SC group than in the MSCH group.
The quantity of lateral crossbites was minimal in both examined groups; however the transversal deviations of the frontal region could be evaluated. The incidence indicators of the dentofacial asymmetry characterizing the patients with scoliosis were exceeded by the values of the MSCH group in respect of the deviation of the upper and lower midline in relation to the facial midline as well as the midline deviation. The mean asset of the midline deviation was significantly higher in the scoliotic group, of which importance is increased by the lower mean value typical for the CTRL group, this value being even lower than of the MSCH group.
In literature, the opinions on the correlation between the poor head posture and alterations of the TMJ differ . Some authors favor the theory that in case of the forward-tilted head position, the displaced centre of gravity can be a risk factor causing the development of the TMJ dysfunctions, others say that a laterally tilted head posture favors the mandible deviation loading the articulation asymmetrically [2, 11]. The latter hypothesis seems to be proved by the numerous pathological symptoms of the TMJ registered among scoliotic patients, together with the significant number of asymmetrical values found in respect of the lateral movements. Despite the significant difference among them, the functional asymmetry index of both groups is twice greater than the values measured in the control group. The panoramic X-ray analyses show highest facial asymmetry indicators in case of the MSCH group. As a result of this the adequate asymmetry index comes from the comparison done after the condylar, ramal and condylar plus ramal height measurements performed on the two mandibular ramuses. As opposed to the condylar index both the ramal and the condyle plus ramal indices were higher in the MSCH group and therefore showed a greater asymmetry. The already mentioned asymmetry indicators are collaterally changing with the severity of the orthopedic deviations.
The difficulty of this range of subjects is shown by the concordant or the contrary results of this study compared to the ones previously found in the literature studying the etiological roles of the spinal deformities with unclear origins in the development of the craniofacial deformities .
The data of this epidemiological study prove and partially complete the results of numerous studies in literature reporting a high number of dentofacial anomalies in children with various spinal diseases.
In both groups with spinal disorders there were differences shown between the size and the frequency of the occurrence of several deviations. The observed more frequent and more severe dentofacial deviation in the MSCH groups draws the attention to the necessity of the early examination of this less examined patient group from an orthodontics point of view.
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