ORIGINAL ARTICLE

Inuence of temporomandibular joint disc

displacement on craniocervical posture
and hyoid bone position
Jung-Sub An,a Da-Mi Jeon,a Woo-Sun Jung,b Il-Hyung Yang,c Won Hee Lim,d and Sug-Joon Ahne
Seoul, Korea

Introduction: The purpose of this study was to evaluate craniocervical posture and hyoid bone position in orthodontic patients with temporomandibular joint (TMJ) disc displacement. Methods: The subjects consisted
of 170 female orthodontic patients who consented to bilateral magnetic resonance imaging of their TMJs.
They were divided into 3 groups based on the results of magnetic resonance imaging of their TMJs: bilateral
normal disc position, bilateral disc displacement with reduction, and bilateral disc displacement without reduction. Twenty-ve variables from lateral cephalograms were analyzed with 1-way analysis of variance to
investigate differences in craniocervical posture and hyoid bone position with respect to TMJ disc
displacement status. Pearson correlation coefcients were calculated to analyze the relationships between
craniofacial morphology and craniocervical posture or hyoid bone position. Results: Subjects with TMJ disc
displacement were more likely to have an extended craniocervical posture with Class II hyperdivergent patterns.
The most signicant differences were found between patients with bilateral normal disc position and bilateral disc
displacement without reduction. However, hyoid bone position in relation to craniofacial references was not
signicantly different among the TMJ disc displacement groups, except for variables related to the mandible.
Pearson correlation coefcients indicated that extended craniocervical posture was signicantly correlated
with backward positioning and clockwise rotation of the mandible. Conclusions: This suggests that craniocervical posture is signicantly inuenced by TMJ disc displacement, which may be associated with hyperdivergent
skeletal patterns with a retrognathic mandible. (Am J Orthod Dentofacial Orthop 2015;147:72-9)

isc displacement of the temporomandibular joint

(TMJ) is a common temporomandibular disorder
(TMD)1 and refers to an abnormal positional relationship between the articular disc and the condyle, fossa,
and articular eminence.2 TMJ disc displacement generally
progresses from a reducing to a nonreducing state and
may lead to TMJ clicking, crepitus, and in some cases,
pain and jaw movement limitations.2-4 Common causes
of TMJ disc displacement include trauma and
parafunctional habits, such as clenching and bruxism.4
From the Dental Research Institute and Department of Orthodontics, School of
Dentistry, Seoul National University, Seoul, Korea.
a
Postgraduate student.
b
Researcher.
c
Assistant professor.
d
Associate professor.
e
Professor.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
Address correspondence to: Sug-Joon Ahn, Dental Research Institute and
Department of Orthodontics, School of Dentistry, Seoul National University,
101 Deahak-ro, Jongno-Gu, Seoul 110-768, Korea; e-mail, titoo@snu.ac.kr.
Submitted, April 2014; revised and accepted, September 2014.
0889-5406/$36.00
Copyright 2015 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2014.09.015

72

Various imaging techniques are available for evaluation of the TMJ, such as transcranial radiography,
arthrography, tomography, computed tomography,
and magnetic resonance imaging (MRI).5 Among them,
MRI is the only modality that directly depicts the disc
and is the gold standard in determining articular disc position relative to the condyle and articular eminence
because of its high diagnostic accuracy.6 In addition, it
also offers other advantages, such as noninvasiveness,
lack of soft tissue distortion, minimal pain, minimal
risk potential, and lack of ionizing radiation exposure.7
Approximately 30% of asymptomatic adults and 82%
of symptomatic patients have some form of TMJ disc
displacement, as determined by MRI.6
Previous studies have investigated the relationship
between TMJ disc displacement and dentofacial characteristics in orthodontic patients, reporting that patients
with TMJ disc displacement have decreased posterior
facial height as well as backward positioning and clockwise rotation of the mandible.8,9 Since craniocervical
posture and hyoid bone position can be associated
with dentofacial morphology, both of these features
could be signicantly inuenced by TMJ disc

An et al

displacement.10,11 However, the associations between

TMJ disc displacement and craniocervical posture or
hyoid bone position have not yet been fully
investigated. Although the effects of TMD on
craniocervical posture and hyoid bone position have
been investigated, the results remain controversial.
Several studies have reported an association between
TMD and craniocervical posture,12-16 but others do
not support the connection between TMD and
craniocervical posture or hyoid bone position.17-20 The
purpose of this study was to investigate the
relationships between TMJ disc displacement and
craniocervical posture, and between TMJ disc
displacement and hyoid bone position, using MRI. The
null hypothesis was that no signicant relationships
would be found between TMJ disc displacement and
craniocervical posture, or between TMJ disc
displacement and hyoid bone position.
MATERIAL AND METHODS

Female subjects were recruited from patients who

consented to bilateral MRI of their TMJs. All subjects
had a primary complaint of malocclusion, and routine
lateral cephalograms were taken in natural head position
with an Asahi CX-90SP II (Asahi Roentgen, Kyoto, Japan).
Natural head position was determined by having the subjects look straight into a mirror in a standing position.21 A
chain plumb line was suspended in front of the cassette
to indicate a true vertical line. The MRI images were taken
to evaluate TMJ status mainly because of TMJ symptoms
including TMJ sounds, pain, masticatory muscle tenderness, limited mandibular movement, and locking. Exclusion criteria were (1) age less than 17 years, (2) any
systemic disease, (3) history of orthodontic treatment,
(4) history of facial cosmetic or orthognathic surgery,
(5) history of trauma involving the TMJ, (6) juvenile rheumatoid arthritis, (7) history of TMJ treatment, (8) airway
obstruction, (9) oral habits, (10) TMJ disc displacement of
a greater severity on the unilateral side, and (11) partial
TMJ disc displacement or TMJ disc displacement with
partial reduction. This research protocol was approved
by the institutional review board of the Seoul National
University Dental Hospital (CRI11040).
Radiologists with MRI experience with the TMJ interpreted the images blinded to the clinical information.
According to disc position, TMJ disc status was divided
into 3 categories as follows.
1

Normal disc position. In the closed-mouth position, the

intermediate zone of the disc was interposed between
the condyle and the posterior slope of the articular
eminence, with the anterior and posterior bands
equally spaced on either side of the condylar load point.

73

Disc displacement with reduction. The disc was anteriorly displaced relative to the posterior slope of the
articular eminence and the head of the condyle in the
closed-mouth position, but the disc was reduced on
mouth opening.
Disc displacement without reduction. The disc was
anteriorly displaced relative to the posterior slope
of the articular eminence and the head of the
condyle, and the disc was not reduced on mouth
opening.

The position and shape of the articular disc of the

TMJ were carefully evaluated according to the classication criteria. We excluded patients with a unilaterally
different disc displacement status because the possible
skeletal morphologies associated with unilateral disc
displacement would be obscured by averaging of the
right and left landmarks used to determine their location, and unilaterally different disc displacement status
may asymmetrically inuence craniocervical posture or
hyoid bone position, which is difcult to measure in
lateral cephalometric analysis.22 From the originally
selected patients, only those with bilateral normal disc
status (BN), bilateral disc displacement with reduction
(DDR), and bilateral disc displacement without reduction
(DDNR) were included in this study.
One investigator (S-J.A.), who was blinded to the
clinical information and the disc position, traced all
lateral cephalograms. Eighteen landmarks were recorded
on each radiograph using a digitizer with a desktop
computer, and 25 variables were calculated from these
landmarks: 9 variables for craniocervical posture, 7
for hyoid bone position, and 9 for craniofacial
morphology (4 for vertical and 5 for sagittal craniofacial
morphologies). The positions and denitions of the
landmarks are shown in Figure 1, and the locations of
the reference planes are shown in Figure 2. Measurements for craniocervical posture, hyoid bone position,
and craniofacial morphology are shown in Figures 3, 4,
and 5, respectively.
Lateral cephalograms of 20 randomly selected subjects were measured again to test the magnitude of measurement errors. The intraclass correlation coefcients
for the reliability of tracing, landmark identication,
and analytic measurements were greater than 0.98.
Descriptive statistics were calculated for all variables. The differences in the cephalometric variables
for craniocervical posture, hyoid bone position, and
craniofacial morphology with respect to the TMJ disc
displacement status (BN, DDR, and DDNR) were tested
with 1-way analysis of variance. Scheffe multiple comparisons were performed at a signicance level of 0.05
to analyze between-group relationships. To investigate

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Fig 1. Landmarks used in this study: 1, nasion; 2, sella; 3,

orbitale; 4, porion; 5, basion; 6, anterior nasal spine; 7,
posterior nasal spine; 8, Point A; 9, Point B; 10, pogonion;
11, menton; 12, gonion; 13, RGn (most protrusive point of
retrognathion); 14, hyoidale (Hy, most superior and anterior point on the body of the hyoid bone); 15, cv2tg
(tangent point of the superoposterior extremity of the second cervical vertebra); 16, cv2ip (most posteroinferior
point on the second cervical vertebra); 17, cv3ia (most anteroinferior point on the third cervical vertebra); 18, cv4ip
(most posteroinferior point on the fourth cervical
vertebra).

the correlations between craniofacial morphology and

craniocervical posture or hyoid bone position, Pearson
correlation coefcients were calculated.
RESULTS

A total of 170 female subjects were included in this

study (Table I). Their age range was 17.0 to 50.8 years
(mean age, 24.5 6 5.7 years). There were no signicant
differences in age distribution among the 3 study groups
(data not shown).
Table II presents the differences in craniocervical
posture, hyoid bone position, and craniofacial
morphology with respect to TMJ disc displacement status (BN, DDR, and DDNR). Signicant differences were
found in craniocervical posture between the BN and
DDNR groups (Table II). Subjects with DDNR had larger
angles between the craniofacial reference planes and the
cervical vertebrae (FH/CVT, NL/CVT, FH/OPT, and NL/
OPT) than did the subjects with BN, indicating that subjects with DDNR had extended craniocervical posture
compared with those with BN. Although the subjects

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Fig 2. Craniocervical reference planes used in this study:

1, nasion-sella line (NSL, plane through nasion and sella);
2, true horizontal plane (HOR, true horizontal plane passing through sella); 3, Frankfort horizontal plane (FH, plane
through porion and orbitale); 4, nasal line (NL, line
through the posterior nasal spine and anterior nasal
spine); 5, mandibular plane (MP, line through gonion
and menton); 6, cervical vertebrae tangent (CVT, line
through cv2tg and cv4ip); 7, odontoid process tangent
(OPT, line through cv2tg and cv2ip).

with DDR demonstrated intermediate values, there was

no signicant difference in craniocervical posture between the BN and DDR groups, or between the DDR
and DDNR groups. Angles between the cervical vertebrae
and the true horizontal plane (HOR/CVT and HOR/OPT)
or the mandibular plane (MP/CVT and MP/OPT) were
not signicantly different among the 3 groups. Cervical
curvature (OPT/CVT) also did not vary signicantly
among the different TMJ disc displacement groups.
Among the variables for hyoid bone position, only
measurements related to the mandible were signicantly
inuenced by TMJ disc displacement status. Subjects
with DDNR had a decreased hyoid angle (Go/Hy/Me)
compared with those with BN or DDR (BN 5
DDR . DDNR). In addition, the hyoidale to the most protrusive point of retrognathion distance (Hy-RGn)
decreased as TMJ disc displacement status increased in
severity from BN to DDNR (BN . DDR . DDNR). However,
distances between craniocervical landmarks or reference
planes and the hyoid bone (Hy-Ba, Hy to NSL, Hy to NL,
Hy-cv3ia, and Hy to cv3ia-RGn) did not show signicant
differences according to TMJ disc displacement status
(Table II).

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Fig 3. Variables of craniocervical posture (all are angular

measurements): 1, true horizontal plane to cervical vertebrae tangent angle (HOR/CVT); 2, Frankfort horizontal
plane to cervical vertebrae tangent angle (FH/CVT); 3,
nasal line to cervical vertebrae tangent angle (NL/CVT);
4, mandibular plane to cervical vertebrae tangent angle
(MP/CVT); 5, true horizontal plane to odontoid process
tangent angle (HOR/OPT); 6, Frankfort horizontal plane
to odontoid process tangent angle (FH/OPT); 7, nasal
line to odontoid process tangent angle (NL/OPT); 8,
mandibular plane to odontoid process tangent angle
(MP/OPT); 9, the cervical curvature, downward-opening
angle between odontoid process tangent and cervical
vertebrae tangent (OPT/CVT, positive when the cv4ip is
located on the left side of odontoid process tangent).

As previously reported, subjects with TMJ disc

displacement have a retrognathic mandible with a hyperdivergent skeletal pattern (Table II).8,9 Our study
showed that increased ANB, and decreased SNB and N
perpendicular to pogonion (PNP), are specic sagittal
craniofacial morphologies in subjects with TMJ disc
displacement. In addition, these skeletal characteristics
became more severe as TMJ disc displacement
progressed from BN to DDNR. However, variables
representing maxillary position (SNA and N
perpendicular to point A [ANP]) were not signicantly
different among the 3 groups. Subjects with DDNR
had a hyperdivergent skeletal pattern: eg, increased
Frankfort-mandibular plane angle (FMA), decreased
posterior facial height (PFH), and decreased facial height
ratio (FHR) compared with those with BN or DDR. In
contrast to sagittal craniofacial morphology, vertical
craniofacial morphology did not vary signicantly between the BN and DDR groups (Table II).
Correlations between craniofacial morphology and
craniocervical posture or hyoid bone position are

75

Fig 4. Variables of the hyoid bone position (all are linear

measurements except for Go/Hy/Me): 1, linear distance
between the hyoidale and basion (Hy-Ba); 2, perpendicular distance between the hyoidale to nasion-sella line
(Hy to NSL); 3, perpendicular distance between the hyoidale to nasal line (Hy to NL); 4, linear distance between
the hyoidale and RGn (Hy-RGn); 5, linear distance between the hyoidale and cv3ia (Hy-cv3ia); 6, perpendicular
distance between the hyoidale and cv3ia-RGn plane (Hy
to cv3ia-RGn, positive when the Hy is located below the
cv3ip-RGn plane); 7, hyoid angle, angle of Go-Hy-Me
(Go/Hy/Me, the angle is larger when the hyoidale is
located above the mandibular plane).

presented in Table III. Generally, craniocervical posture

(FH/CVT, NL/CVT, FH/OPT, and NL/OPT) was signicantly correlated with variables representing sagittal
(ANB, SNB, and PNP) and vertical (FMA and FHR)
craniofacial morphologies, and subjects with extended
craniocervical posture had a retrognathic mandible
with a hyperdivergent skeletal pattern. However, cervical
curvature (OPT/CVT) was not signicantly correlated
with craniofacial morphology.
The hyoid angle (Go/Hy/Me) and the distance between the hyoidale and the most protrusive point of retrognathion (Hy-RGn) were signicantly correlated with
craniofacial morphologic variables (Table III). Both
values decreased as the skeletal pattern became more hyperdivergent (increased FMA and decreased FHR) and as
the mandible was located more posteriorly (increased
ANB and decreased SNB and PNP).
DISCUSSION

The relationships between TMJ status and craniocervical posture have not been fully addressed, specically
in orthodontic patients. This may be due to the

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Fig 5. Variables of craniofacial morphology: 1, Frankfort

horizontal plane to mandibular plane angle (FMA); 2,
anterior facial height (AFH, linear distance between nasion and menton); 3, posterior facial height (PFH, linear
distance between sella and gonion); 4, ANB angle; 5,
SNA angle; 6, SNB angle; 7, N perpendicular to Point A
(ANP); 8, N perpendicular to pogonion (PNP); 9, facial
height ratio (FHR, ratio of posterior facial height [3] to
anterior facial height [2]).

Table I. Number and age distribution of subjects with

BN, DDR, and DDNR
Group
BN
DDR
DDNR
Total
Subjects, n (%) 53 (31.2)
55 (32.4)
62 (36.5) 170 (100)
Age (y)
Mean
23.7 6 6.6 25.1 6 5.4 24.6 6 5.3 24.5 6 5.7
Range
18.3-50.8 17.3-42.0 17.0-41.0 17.0-50.8

methodologic problems of previous studies, such as

inadequate sample sizes and subjective criteria for classifying TMJ status.12,13,17,18,23 In this study, we used a
large sample size (170 subjects) including a control
group (BN TMJs). In addition, the subjects were
objectively classied with MRI of their TMJs, not with
subjective signs and symptoms. Furthermore, the
subjects were carefully controlled. Only subjects with
the same TMJ disc displacement conditions bilaterally
were included. Men were excluded to prevent skewing
the cephalometric measurements with sex-related differences. To prevent growth-related size differences,
only female patients over the age of 17 years were
selected.24
This study showed an association between TMJ disc
displacement and craniocervical posture. Subjects with

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DDNR had increased FH/CVT, NL/CVT, FH/OPT, and

NL/OPT compared with those with BN (Table II).
Although there were no signicant differences in the angles between the BN and DDR groups, or between the
DDR and DDNR groups, there was a tendency toward
increased angles between the craniofacial reference
planes and the cervical vertebrae as TMJ disc displacement progressed from BN to DDNR. This means that
head or cervical posture can change according to TMJ
disc displacement status. Since neither angle between
the cervical vertebrae and the true horizontal plane
(HOR/CVT and HOR/OPT) or the cervical curvature
(OPT/CVT) was signicantly different among the 3 disc
displacement statuses, head posture may rotate above
the second vertebra without changes in cervical vertebral
position in relation to the true horizontal plane.
Although direct comparison was not possible, our ndings are similar to those of previous studies reporting
that patients with TMD have a more extended craniocervical posture than the control group, without signicant
differences in cervical curvature,12 and that there are no
signicant differences in the curvature of the cervical
vertebrae between the third and seventh vertebrae after
comparing cervical vertebral alignment between subjects with TMD and volunteers without TMD.19
Despite changes in head posture, the positional relationships between the cervical vertebrae and the
mandibular plane (MP/CVT and MP/OPT) did not show
signicant differences among the 3 TMJ groups. This
might be because mandibular position is signicantly
associated with TMJ disc displacement status. Subjects
with TMJ disc displacement generally had an increased
mandibular plane angle with extended craniocervical
posture (Table II). Because both cervical vertebrae and
the mandible are rotated clockwise in relation to the
craniofacial reference planes in subjects with TMJ disc
displacement, there may be no signicant differences
in relationships between the cervical vertebrae and the
mandibular plane.
The association between TMJ disc displacement and
extended craniocervical posture can be explained in 2
ways. The rst possibility is that extended craniocervical
posture may inuence TMJ disc displacement. Previous
studies have reported that abnormal craniocervical
posture is an etiologic factor of TMD, postulating that
as the cranium rotates backward, the mandibular dentition will be located more posteriorly in relation to the
maxillary dentition; in turn, the mandible will be
advanced to obtain occlusal support.12,13 Increased
muscular activity that develops as a result will lead to
disc displacement.12,13 Although the subjects with TMJ
disc displacement had a more extended craniocervical
posture in this study, they had a more posteriorly

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77

Table II. Comparisons of cephalometric variables among the BN, DDR, and DDNR groups
Variable
BN
Craniocervical posture
HOR/CVT ( )
98.7 6 6.9
FH/CVT ( )
96.6 6 8.2
96.1 6 8.7
NL/CVT ( )
MP/CVT ( )
67.3 6 8.8
HOR/OPT ( )
93.6 6 7.4
FH/OPT ( )
91.5 6 8.5
91.0 6 8.8
NL/OPT ( )
MP/OPT ( )
62.2 6 8.6
OPT/CVT ( )
5.1 6 2.8
Hyoid bone position
Hy-Ba (mm)
76.3 6 5.6
Hy to NSL (mm)
107.0 6 6.4
Hy to NL (mm)
60.7 6 5.2
Hy-RGn (mm)
38.4 6 5.7
Hy-cv3ia (mm)
36.2 6 3.8
Hy to cv3ia-RGn (mm)
1.5 6 6.1
Go/Hy/Me ( )
154.3 6 18.0
Vertical craniofacial morphology
FMA ( )
28.9 6 7.0
FHR (ratio)
0.63 6 0.06
AFH (mm)
132.8 6 5.5
PFH (mm)
83.7 6 7.6
Sagittal craniofacial morphology
ANB ( )
2.4 6 4.5
81.1 6 3.1
SNA ( )
SNB ( )
78.7 6 4.9
ANP (mm)
1.7 6 3.0
PNP (mm)
1.32 6 10.43

DDR

DDNR

Signicancez

99.5 6 5.8
98.3 6 6.3
98.3 6 6.4
67.6 6 7.0
94.9 6 7.1
93.7 6 7.3
93.7 6 7.2
63.0 6 7.9
4.6 6 2.9

99.6 6 5.9
100.3 6 7.1
99.6 6 6.9
64.7 6 8.5
94.7 6 6.4
95.4 6 7.4
94.7 6 7.1
59.8 6 8.5
4.9 6 2.5

NS
*
*
NS
NS
*
*
NS
NS

77.0 6 6.0
108.2 6 7.6
61.8 6 6.0
35.5 6 5.5
36.5 6 3.0
0.0 6 5.0
151.0 6 14.8

75.1 6 6.1
108.4 6 6.4
62.6 6 5.7
32.3 6 5.5
35.2 6 3.4
0.5 6 5.9
143.4 6 15.1

NS
NS
NS

30.6 6 6.7
0.62 6 0.05
133.7 6 6.5
82.6 6 6.6

35.5 6 7.0
0.59 6 0.06
133.3 6 6.0
77.9 6 6.7

5.1 6 2.4
81.6 6 3.2
76.5 6 2.9
2.3 6 2.8
6.32 6 6.65

7.7 6 2.8
81.4 6 2.8
73.8 6 3.6
1.5 6 3.2
14.05 6 7.73

NS
NS
*
y

Multiple comparisons

BN \DDNR
BN \DDNR
BN \DDNR
BN \DDNR

BN .DDR .DDNR
BN 5 DDR .DDNR
BN 5 DDR \DDNR
BN 5 DDR .DDNR

NS
y

BN 5 DDR .DDNR

BN \DDR \DDNR

NS
y

BN .DDR .DDNR

NS
y

BN .DDR .DDNR

NS, Not signicant.

*P \0.05; yP \0.001; zScheffe multiple comparisons were used to analyze the intergroup difference at the level of a 5 0.05.

located mandible than did subjects with BN (Table II);

this differs from previous studies.
The second possibility is that TMJ disc displacement
may induce extended craniocervical posture. Previous
studies have reported that the severity of TMJ disc
displacement increases as the sagittal skeletal classication changes from skeletal Class III to skeletal Class II,
and the vertical skeletal classication changes from hypodivergent to hyperdivergent.8,9,25 As a result, subjects
with skeletal Class II or hyperdivergent deformities have
a high possibility of severe TMJ disc displacement. In
addition,
experimentally
induced
TMJ
disc
displacement leads to signicant impairment of
vertical and horizontal mandibular growth, and the
amount of vertical or horizontal skeletal change
gradually increased as TMJ disc displacement increased
in severity in animal studies.26,27 Because TMJ disc
displacement frequently occurs during puberty, it
seems that TMJ disc displacement can lead to a
retrognathic mandible with a hyperdivergent skeletal
pattern; this in turn may reduce upper airway space
with the same craniocervical posture.28 Therefore,

extended craniocervical posture associated with TMJ

disc displacement may result from protective responses
to maintain upper airway space. This hypothesis is supported by our ndings, indicating that extended craniocervical posture is positively related to a hyperdivergent
and Class II skeletal pattern (Table III). de Farias Neto
et al16 also postulated that in the patients with TMD,
altered mobility of the articular disc limits the biomechanics of mouth opening and triggers compensatory
extension of the cervical vertebrae to prevent compression of the upper airway. However, the cause-andeffect relationships are not clear because the results
were derived from cross-sectional data.
Interestingly, TMJ disc displacement did not signicantly inuence the positional relationships of the hyoid
bone to the craniofacial references and the cervical
vertebrae, but it signicantly inuenced the positional
relationships of the hyoid bone to the mandible (Go/
Hy/Me and Hy-RGn) (Table II). Subjects with TMJ disc
displacement, and specically those with DDNR, had a
smaller hyoid angle (Go/Hy/Me) and a shorter hyoidale
to the most protrusive point of retrognathion distance

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Table III. Correlations between craniofacial morphology and craniocervical posture or hyoid bone position
Correlation
Variable
Craniocervical posture
HOR/CVT ( )
FH/CVT ( )
NL/CVT ( )
MP/CVT ( )
HOR/OPT ( )
FH/OPT ( )
NL/OPT ( )
MP/OPT ( )
OPT/CVT ( )
Hyoid bone position
Hy-Ba (mm)
Hy to NSL (mm)
Hy to NL (mm)
Hy-RGN (mm)
Hy-cv3ia (mm)
Hy to cv3ia-RGn (mm)
Go/Hy/Me ( )

FMA

FHR

AFH

PFH

ANB

0.241y
0.381y
0.256y
0.547y
0.258y
0.396y
0.283y
0.498y
NS

NS
0.247y
0.192*
0.556y
0.154*
0.256y
0.208y
0.519y
NS

0.196*
0.270y
0.262y
NS
0.153*
0.234y
0.231y
NS
NS

NS
NS
NS
0.512y
NS
NS
NS
0.468y
NS

NS
NS
0.237y
0.519y
0.181*
NS
0.385y

0.152*
NS
NS
0.388y
0.191*
NS
0.358y

0.247y
0.341y
0.247y
NS
0.165*
NS
0.168*

0.281y
0.289y
NS
0.396y
0.278y
NS
0.447y

SNA

SNB

ANP

PNP

0.240y
0.399y
0.315y
NS
0.242y
0.399y
0.326y
NS
NS

0.169*
0.205y
0.248y
NS
0.168*
0.207y
0.253y
NS
NS

0.332y
0.499y
0.454y
NS
0.333y
0.501y
0.467y
NS
NS

0.153*
0.316y
0.193*
NS
NS
0.290y
0.178*
NS
NS

0.334y
0.591y
0.416y
NS
0.325y
0.578y
0.422y
NS
NS

0.162*
NS
0.236y
0.584y
NS
0.174*
0.324y

0.162*
0.281y
NS
NS
NS
NS
NS

0.257y
NS
0.161*
0.421y
NS
NS
0.339y

NS
NS
NS
NS
NS
NS
0.151*

0.174*
NS
0.267y
0.562y
NS
NS
0.367y

NS, Not signicant.

*Pearson correlation is signicant at the .05 level; yPearson correlation is signicant at the .01 level.

(Hy-RGn) than did the subjects with BN, whereas the distances between the hyoid bone and the craniofacial references (Hy-Ba, Hy to NSL, and Hy to NL) or the cervical
vertebrae (Hy-cv3ia), and the relationship between the
hyoid bone and the craniocervical reference (Hy to
cv3ia-RGn), were not signicantly different among the
3 TMJ disc displacement groups. The relationship between the hyoid bone and the mandible can be explained
by the compensatory response of the hyoid bone to preserve upper airway space. It seems that the position of
the hyoid bone may not signicantly change during
the protective process, which maintains the pharyngeal
airway space and swallowing functions against backward positioning and clockwise rotation of the mandible
associated with TMJ disc displacement. As a result, the
subjects with TMJ disc displacement have backward
positioning and clockwise rotation of the mandible
with a relatively stable hyoid bone position, which may
change the positional relationships of the hyoid bone
to the mandible signicantly. This hypothesis is partly
supported by previous research that found no signicant
differences in hyoid bone positions between subjects
with and without TMD.19 Other research regarding
TMJ disc displacement status with MRI also documented
that the position of the hyoid bone was not signicantly
different between subjects with a normal disc position
and those with disc displacement.20
Generally, the facial prole is important in the diagnosis and treatment planning for orthodontic patients.
This study showed that TMJ disc displacement can

January 2015
Vol 147
Issue 1

inuence craniocervical posture, although the causeand-effect relationship remains unclear. As a result,
in subjects with TMJ disc displacement, the retrognathic prole is compromised by extending their
craniocervical posture despite the backward positioning
and rotation of the mandible. Recently, the importance
of the soft tissue paradigm has been emphasized, and a
normal soft tissue proportion is considered a primary
treatment goal in orthodontic or surgical-orthodontic
treatment.29-31 Because craniocervical posture is
directly related to the soft tissue prole of the face,
this study suggests that clinicians should carefully
evaluate relationships between the craniocervical
posture and the facial prole in patients with
potential TMJ disc displacement before orthodontic
treatment.
This study has the following limitations. The causal
relationships between TMJ disc displacement and craniocervical posture, or between TMJ disc displacement
and the hyoid bone position, are not clear because
our results were derived from cross-sectional data. In
addition, these results are based on lateral cephalograms with static posture; hence, they do not show
the function associated with mandibular kinetics.
Further studies with longitudinal data are needed to
clarify the relationships of intra-articular distance,
mandibular kinematics, and mandibular loading with
craniocervical posture. This would be helpful for the
diagnosis and treatment planning of patients with
TMJ disc displacement.

American Journal of Orthodontics and Dentofacial Orthopedics

An et al

CONCLUSIONS

This study was performed to evaluate the relationships between TMJ disc displacement and craniocervical
posture, and between TMJ disc displacement and hyoid
bone position, in adult orthodontic patients. The subjects with TMJ disc displacement were more likely to
have an extended craniocervical posture with Class II hyperdivergent patterns. In contrast, hyoid bone position
was relatively stable irrespective of TMJ disc displacement status. Therefore, the null hypothesis of our study
was partially rejected. Extended craniocervical posture
was signicantly correlated with backward positioning
and clockwise rotation of the mandible. This study suggests that craniocervical posture is signicantly inuenced by TMJ disc displacement, which may be
associated with a hyperdivergent skeletal pattern with
a retrognathic mandible.
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American Journal of Orthodontics and Dentofacial Orthopedics

January 2015
Vol 147
Issue 1