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417Craniocervical posture: cephalometric and biophotogrammetric analysis
individual body segments. Such measures can be viewed
and interpreted in digital photographic records. With the
advancement of technology is considered the most requested
method by professionals who perform postural assessment,
both for investigative slant as to aid in the clinical diagnosis
and in the therapeutic approach4. Moreover, the great
advantage of biophotogrammetry is to allow changes in
craniocervical posture to be quantified and small changes to
be detected5.
Currently, the most accurate craniocervical postural
analysis method is the cephalometry, in which it is used the
lateral radiograph of the skull and of the cervical spine to
perform cephalometric measurements. By means of the
radiography, it is possible a more objective visualization of
the craniocervicomandibular structures, without the influence
of soft tissues, as occurs in the biophotogrammetry1. However,
cephalometric analysis has little impact on clinical practice
because the limitation of its applicability is related to high
costs and technique complexity6.
Recent studies have sought to investigate the correlation
between measurements of posture, obtained by biophoto-
grammetry and by visual analysis3,5. On the other hand, there
are few studies investigating the correlation between the
findings obtained by the biophotogrammetric and
cephalometric analyses.
Considering the increasing number of studies using the
biophotogrammetric analysis, because of the easy access to
it in the clinical practice, it is necessary to develop studies
to verify the agreement of the photographic method of the
postural analysis with the radiographic method, which is more
objective, but more expensive and with the individual’s
exposure to radiation. In other words, are biophotogrammetric
measures related to head posture and does the cervical spine
reflect the postural changes observed in the cephalometric
analysis?
For its interdisciplinary approach, it is believed that
this research is of interest to dentists, physical therapists,
speech therapists and other professionals since it may assist
them in the reflection of their clinical practice and in the
context of scientific research.
Material and methods
Eighty women with mean age of 23.8 ± 3.65 years (19-
35 years) and BMI of 22.4 ± 3.83 kg/cm2 recruited
voluntarily through the print media participated in this study.
This research project was approved by the Ethics
Committee in Health Research under the number
0048.0.243.000-08, recognized by the National Research
Ethics (CONEP). All individuals who participated in the study
were included by accepting and signing a free informed
consent form.
The exclusion criteria of the study were: history of facial and of the cervical spine in a normal standing position, thus
and/or craniocervical trauma, presence of acute and severe
musculoskeletal pain, musculoskeletal deformities (scoliosis,
congenital bone malformation), craniomandibular orthopedic
surgical procedures and/or neck, and a previous diagnosis
of cervical disc herniation.
Biophotogrammetric evaluation
The posture of the head and of the cervical spine was
evaluated by means of digital photograph, with
biophotogrammetric analysis by the postural assessment
software (SAPO®). Pictures were taken in standing position
in right lateral view.
Anatomic points were marked in the subject’s body with
white Styrofoam balls wrapped in reflective tape and
previously prepared with double-sided tape for attachment
to the skin. During the image acquisition, the volunteers
were oriented to keep the usual body posture with opened
eyes glancing to the horizon line.
The participants with suitable clothing, hair tied back
and barefoot were photographed in a scenario constituted
by a black background of 3x1.5 meters, a plumb line
suspended in the roof beside the volunteer, a base with
10x40x20 centimeters of dimensions with the foot outline
drawn in a rubber rug. A tripod (Vanguard® - VT 131) was
positioned at a distance of, at least, 3 meters from the digital
camera (Sony® Cybershot 7.2 megapixels) and in a 1.20 meter
height from the floor. In order to reproduce the natural
position of the head, the individual was instructed to look
at the reflection of his eyes in a mirror positioned at one
meter of distance7-10.
Four variables related to the craniocervical posture were
evaluated (Figure 1). Three angles measured the position of
the head, being two related to the forward head posture: A1
- angle formed between the tragus, spinous process of the
seventh cervical vertebra (vertex) with the horizontal11-12 and
A2 - angle formed between the external acoustic meatus
(vertex), chin and sternal notch12. The third angle was related
to the flexion-extension head position (FE) and it was formed
by the points marked in the spinous process of the seventh
cervical vertebra, tragus (vertex) and palpebral commissure11.
The smaller the A1 angle and the greater the A2 angle, the
more forward the head. Regarding the FE, the greater the
angle, the greater the hyperextension of the head on the
upper cervical spine.
The curvature of the cervical spine was measured by
the horizontal distance from a vertical line tangent, by the
apex of the thoracic kyphosis, called as thoracic plan, and
by the point of the apex of the cervical concavity13.
With a one-week interval, the images of 20 individuals
were randomly assigned to a second analysis of the variables
to verify the intra-examiner reliability of the measurements.
Cephalometric evaluation
Subjects underwent a right lateral radiograph of the skull
preserving the true resting position of the head and of the
cervical spine. The posture adopted by the individual in the
cephalometric evaluation of the right profile was the same
as required for the acquisition of the photographic record,
so that the natural position of the head was also reproduced.
Braz J Oral Sci. 11(3):416-421