archives of oral biology 55 (2010) 670678

available at www.sciencedirect.com

journal homepage: http://www.elsevier.com/locate/aob

Radiographic measurement of the cervical spine in patients

with temporomandibular dysfunction

Jader Pereira de Farias Neto a,b, Josimari Melo de Santana c,

Valter Joviniano de Santana-Filho c, Lucindo Jose Quintans-Junior d,
Ana Paula de Lima Ferreira c, Leonardo Rigoldi Bonjardim d,*
a
Federal University of Sergipe, Brazil
b
FASE, Brazil
c
Department of Physiotherapy, Federal University of Sergipe, Brazil
d
Department of Physiology, Federal University of Sergipe, Brazil

article info abstract

Article history: Aim: To compare the craniocervical angles and distances between temporomandibular
Accepted 6 June 2010 dysfunction (TMD) and free TMD subjects.
Casuistic and methods: The sample consisted of young adults, of both genders, with age
Keywords: ranging between 18 and 30 years. TMD diagnosis was based on the clinical criteria of the
Temporomandibular joint Research Diagnostic Criteria for TMD (RDC/TMD), associated with self-reported symptoms
dysfunction syndrome of TMD. For radiological analysis we measured three angles and two distances of cranio-
Craniocervical posture cervical region.
Radiograph Results: Of the 56 subjects, only 23 completed all stages of research, which were divided into
two groups: (1) free TMD group composed of 11 individuals; (2) TMD group constituted of
12 subjects. The most common clinical diagnosis of TMD was arthralgia (75.0%) followed by
myofascial pain without limited mouth opening (58.4%). Among the self-reported symp-
toms of TMD, the most frequents were facial (83.4%) and neck (66.6%) pain. Of radiological
measurement, only plane atlas angle (APA) ( p = 0.026) and anterior translation distance (Tz
C2C7) ( p = 0.045) showed statistical difference between groups TMD (APA = 16.7  1.63; Tz
C2C7 = 28.7  2.58) and free TMD (APA = 21.64  1.24; Tz C2C7 = 19.82  3.29).
Conclusion: It could be verified that the symptomatic TMD patients presented a flexion of the
first cervical vertebra associated with an anteriorization of the cervical spine (hyperlordosis).
# 2010 Elsevier Ltd. All rights reserved.

1. Introduction of joint clicking.1 Epidemiological studies have shown that

Temporomandibular dysfunction (TMD) is a generic term that
defines a subgroup of orofacial disturbances, involving
complaints of pain in the temporomandibular joint (TMJ),
craniocervical muscular fatigue (especially of the masticatory
muscles), limitation of mandibular movements and presence
signs and symptoms of TMD are appearing with greater
frequency in adolescents and young adults, and around 50% of
the population presents one or more signs.26
There is agreement in the literature as regards the
multifactorial etiology of TMD, with alterations in occlusion,7
psychological alterations, such as anxiety,8,9 stress10 and

* Corresponding author at: Departamento de Fisiologia, Centro de Ciencias Biologicas e da Saude, Universidade Federal de Sergipe, 49100-
000, SE, Brazil. Tel.: +55 79 2105 6645; fax: +55 79 2105 6494.
E-mail address: lbonjardim@yahoo.com.br (L.R. Bonjardim).
00039969/$ see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.archoralbio.2010.06.002
 archives of oral biology 55 (2010) 670678
bruxism1,11 being some of the main causes. Furthermore,
various authors have reported that postural problems involv-
ing the cranium and cervical spine could trigger TMD.12,13
The association between craniocervical posture and TMD
has been widely researched and discussed in the literature for
years, but up until now the results are inconclusive. Some
studies have demonstrated that individuals with TMD present
some type of alteration in the positioning of the cranium and
in the angulation of the cervical spine.1418 However, Visscher
et al.,19 Munhoz et al.20 and Matheus et al.21 did not find such
relationship.
Among the craniocervical alterations commonly found in
TMD patients rectification of the cervical spine,18,2224 had
been described elevation of the hyoid bone,22,23 greater
protrusion of the head,7,25 greater posterior rotation of the
cranium associated with an increase in spine curvatures
(hyperlordosis),14,16,26 airway obstruction,27 reduction of the
occipital-atlas space.28
Although various studies have analysed the relationship
between TMD and craniocervical posture, different criteria
have been used for the diagnosis of TMD, or it is even made
only by evaluating signs and symptoms. Moreover, there are
also several methods of postural evaluation, such as comput-
erized postural analyses, visual photographic analyses and
different types of radiographic measurements. Therefore, this
study is fundamental, since it was based on the criteria of the
Research Diagnostic Criteria for TMD (RDC/TMD),29 considered
the gold standard for the diagnosis of TMD, associated with following: muscle disorders (group I), disc displacement (group
the self-reporting symptoms of this dysfunction.30 Moreover,
in the present study was used angles and distances for
measuring the craniocervical posture, which had previously
been used in studies about the relationship between TMD and
posture15,31,23 as well as measure described in the scientific
literature for the diagnosis of alterations in craniocervical
posture.3134
Based on above explanation, the aim of this study was to
compare the craniocervical posture between TMD patients
and subjects without TMD.
2. Casuistic and methods
2.1. Sample
The sample consisted of subjects of both genders, aged
between 18 and 30 years recruited from the Federal
University of Sergipe who had voluntarily attended in the
Laboratory of Orofacial Pain (UFS) between April 2008 and
September 2009. Exclusion criteria were subjects with no
physical or cognitive conditions to answer the questionnaire
or to be evaluated to detect signs and symptoms of TMD, who
had undergone any previous spinal and orthodontic treat-
ment, with malocclusion, craniocervical anomalies, any
previous direct or surgical injuries in the orofacial region,
systemic or degenerative diseases and who decided to not
participate in the research.
Subjects gave written consent to participate in the study.
The study was conducted in accordance with the current good
clinical practice guidelines and it was approved by the Ethics
Committee of the Federal University of Sergipe.
671
3. Study design
3.1. Anamnesis
The subjects characteristics such as age, gender, marital status,
educational level and body mass index (BMI) were recorded.
3.2. TMD diagnosis
3.2.1. Subjective symptoms of TMD
Subjective symptoms of TMD were assessed using the
questionnaire developed by Conti et al.,30 which contains
questions about presence/absence of facial pain, bruxism,
headache, neck pain, difficulty with chewing, pain or morning
stiffness in the mouth and joint sounds.
3.2.2. Clinical examination of TMD
For clinical TMD evaluation, we used part of a systematically
translated Brazilian version of the Research Diagnostic
Criteria for TMD (RDC/TMD axis I).30,35
The RDC/TMD axis I provides standardized criteria for TMD
diagnosis, which facilitate the achievement of a good intra- and
inter-examiner reliability for non-expert examiners as well.36 In
the present investigation, all RDC/TMD examinations were
conducted by an examiner who was previously trained and
calibrated by one investigator who was an expert on RDC/TMD
criteria. The RDC/TMD examinations allowed diagnosis of the
II), and arthralgia, osteoarthritis and osteoarthrosis (group III).
The diagnoses were divided into three groups: (1) muscular
diagnosis: (a) myofascial pain and (b) myofascial pain with
limited opening; (2) displaced disc: (a) displaced disc with
reduction, (b) displaced disc without reduction, with limited
opening and (c) displaced disc without reduction, without
limited opening and (3) arthralgia, arthritis, arthrosis: (a)
arthralgia, (b) osteoarthritis and (c) osteoarthrosis.
4. Craniocervical posture evaluation
4.1. Radiographic examination
The radiographs were taken in a Radiology Clinic from Aracaju,
Sergipe, Brazil by the same technician (in all exams), previously
trained and calibrated by the investigator. The technician was
blinded to each group. To have a radiograph taken of the cervical
spine, the subjects were positioned between the X-ray source
and the film, in the sagittal plane parallel to the plane of the film,
barefooted, with feet placed together, in orthostatic posture,
and instructed to look at the horizon, with the head in the rest
position, which is highly reproducible in the literature.3739
Whereas the type of imaging technique was static radiograph,
subjects remained immovable until the radiographic examina-
tion was completed. For this, all volunteers were oriented to not
move their head or other parts of body throughout the
radiographic examination, which was supervised by the
technician who was previously calibrated by the examiner.
Moreover, to ensure consistent magnification and to minimize
head and body posture recording errors, the same operator,
using the same X-ray machine, exposed all standardized
672 archives of oral biology 55 (2010) 670678
radiographs for the subjects in the study. These rules were
implemented with the intention of allowing reproducibility of
the exam and minimize possible dynamic influences of the
head and neck position, which could alter the final result of the
exam. It is worth pointing out that the distance between the X-
ray source and the radiographic film was standardized at
180 cm, in accordance with the procedure of the above-
mentioned clinic.
After taking the radiographs, as a standardization proce-
dure, the following points were determined: posterior nasal
spine, inferior nuchal line of the occipital bone, posterior
surface of the odontoid apophysis, posterior surface (superior
and inferior) of the vertebral bodies of C2, C3, C4 and C7, inferior
arch of C1 and mid-point of the posterior superior tubercle of
C1 (Fig. 1).
Subsequently, the above-mentioned points had been
demarcated, three angles and two distances of craniocervical
posture were measured. The methodology of the specific
radiographic tracings of each angle and each distance, as well
as their applicability is described as follow: (Fig. 2):
- High cervical angle (HCA) (odontoidcranial base angle)
described by Huggare and Raustia14: Posterior nasal spine up
to the most inferior surface of the occipital bone line; line
[(Fig._1)TD$IG] tangent to the posterior surface of the odontoid apophysis of
Fig. 1 Anatomical markings on the cervical radiograph in
the sagittal plane. 1 Posterior nasal spine up to the
inferior nuchal line of the occipital bone, 2 posterior
surface of the odontoid apophysis, 3 posterior superior
surface of C3 and the posterior inferior surfaces of C4 and
C7, 4 inferior arch of C1, 5 mid-point of the posterior
superior tubercle of C1.
C2. The intersection of the two tracings forms an angle that
measures the extension degree of the head on the high
cervical spine; so, the greater HCA the greater will be the
head flexion on the cervical spine.
- Low cervical angle (LCA) (odontoid angle C3/C4)14: The LCA
is traced from a line tangent to the vertebral bodies of the
third and fourth cervical vertebrae (C3C4) by two distinct
points. The highest point of the posterior surface of the
vertebral body of C3 and the lowest point of the posterior
surface of the vertebral body of C4, its intersection with the
tracing also made in HCA (posterior nasal spine up to the
most inferior surface of the occipital bone line) forms an
angle that indicates the relationship between the high and
low cervical spine; that is, the greater LCA the greater the
cervical lordosis and the greater the extension of the high
cervical spine on the low cervical spine.
- Atlas plane angle (APA): It represents the plane of the atlas
vertebra (C1) and its radiographic tracing was made
between a line parallel to the horizontal and another line
traced in the inferior part of the anterior and posterior ring
of the atlas. The increase in APA suggests an increase in
high cervical (extension of C1) and its reduction, a reflection
or rectification.32
- The anterior translation distance: This was measured in
millimetres and its tracing was made by means of the
distance between the posterior superior edge of the vertebral
body of C2 and a vertical line perpendicular to the inferior
edge of the vertebral body of C7.32,34 This measurement was
important for determining a mean value for the anterior
transport of the head, and this posture was clinically
relevant because it causes a retraction of the neck muscles.40
- Occipitalatlas distance (OAD): This was measured in
millimeters between the following two points: the lowest
point of the surface of the occipital bone line and the
posterior ring of the atlas. The normal value was between 4
and 9 mm, a distance of less than 4 mm suggests a posterior
rotation of the occipital bone and a distance exceeding 9 mm
suggests an anterior rotation of the occipital bone.23,31
The examiner that marked all above-mentioned points and
measured three angles and two distances of craniocervical
posture was blinded to each group (Free TMD and TMD groups).
4.2. Statistical analysis
GraphPad Prisma version 3.02 was used for statistical analysis.
Data were presented as mean values, standard error of means
(SEM) and percentages. The normality of data was tested by
the KolmogorovSmirnov test ( p < 0.05), assuming that the
distribution approaches a Gaussian for all values. Thus, it was
possible to apply the student t test (two-tailed), for indepen-
dent samples, for comparative analysis of quantitative
variables (craniocervical angles and distances) between the
groups, considering a significance level of 5%.
5. Results
The results are presented as flow diagram of subjects during
all steps of research, formation and characterization of the
 archives of oral biology 55 (2010) 670678 673
[(Fig._2)TD$IG]

Fig. 2 Illustrative diagram of the radiographic measurements. 1 High cervical angle, 2 low cervical angle, 3 atlas plane
angle, anterior translation distance (Tz C2/C7), 4 occipitalatlas distance.

groups and, finally, craniocervical distances and angles, which
were compared between TMD and free TMD groups.
After the initial evaluation of 56 subjects, 11 were
diagnosed as free TMD and 45 with clinical diagnosis of
TMD according to the criteria of RDC/TMD. From 45 subjects
diagnosed with TMD, four were excluded due to a clinical
diagnosis of osteoarthrosis and osteoarthritis, which could not
be confirmed radiographically. These 41 remaining subjects
were referred for radiologic examination, but only 21 attended
for the exam. From 21 radiologic procedures, only 12 were
considered in this study. The rest of them presented lack of
precision in identifying anatomical points due to lack of
sharpness in the exam, which avoided errors and mistakes in
measuring craniocervical angles and distances (Fig. 3).
The subjects were divided into two groups:
- Free TMD group: This group was composed of 11 subjects
with no TMD according to RDC/TMD criteria and no
subjective symptoms reported. The mean age was 20.0
years old.
- TMD group: This group was composed of 12 subjects with
muscular and/or articular TMD based on RDC/TMD criteria
and at least three subjective symptoms of TMD. The mean
age was 22.5 years old.
The Free TMD group was formed by four men (mean age of
19 years; mean BMI of 29.7 kg/m2) and seven women (mean
age of 20.6; mean BMI of 19.9 kg/m2). The TMD group consisted
of five men (mean age of 24 years; mean BMI of 24.8 kg/m2) and
seven women (mean age of 21.4; mean BMI of 24 kg/m2).
Regarding to educational level and marital status, 20 subjects
had completed high school and 21 were single (Table 1).
Formation of the groups in accordance with the differences
diagnoses of TMD according to the RDC/DTM criteria and with
the presence of subjective symptoms is shown in Table 2. It can
be verified that the subjects in the free TMD group presented no
clinical or anamnestic diagnose for TMD. On the other side, the
TMD group presented at least one of the different diagnoses of
RDC/TMD; in addition the subjects of TMD group reported a
minimum of three subjective symptoms. Diagnoses of arthral-
gia (n = 9) and myofascial pain without limited mouth opening
(n = 7) were the most frequent among the diagnoses of TMD
according to RDC/TMD. It is pointed out that according to RDC/
TMD the same individual could be diagnosed in more than one
subgroup of TMD. Among the self-reported symptoms, the most
frequent was facial pain which affected 10 individuals, and the
least frequent was tiredness when chewing, together with
malocclusion self-perception, which affected two individuals.
The mean number of symptoms reported was 5.3.
674 archives of oral biology 55 (2010) 670678
[(Fig._3)TD$IG]

Fig. 3 Flow diagram of the subjects progress through the phases of randomized clinical trial.

The craniocervical angles (8) and distances (mm) measured
by profile radiography (sagittal plane), between subjects with
and without diagnosis of TMD are shown in Figs. 4 and 5.
No statistical difference (HCA p = 0.378; LCA p = 0.686;
OAD p = 0.877) was found between subjects of free TMD
group (HCA 85.68  7.44; LCA 10.36  6.20; OAD
7.82  1.54) and TMD group (HCA 82.90  7.28; LCA
9.3  5.93; OAD 7.6  4.74) for high and low cervical angles
(HCA and LCA) and for occipitalatlas distance (OAD).
The atlas plane angle measurement (Fig. 4) was statistically
different ( p = 0.026), with the mean values in the TMD group
(16.7  5.65) lower than the free TMD group (21.64  4.10).
The anterior translation distance (Tz C2/C7) (Fig. 5) was also
statistically different ( p = 0.045) between the groups, however
the mean values in TMD group (28.7  8.95) was higher than
free TMD group (19.82  10.93).
6. Discussion
The aim of this study was to evaluate the possible alterations
in craniocervical posture, in the sagittal plane, in patients with
TMD. It has been discussed in scientific literature this
relationship for years.1217,22 However, in a recent systematic

Table 1 Characterization of the sample according to age, body mass index (BMI), educational level and marital status.

Free TMD group TMD group

Men (n = 4) Women (n = 7) Total (n = 11) Men (n = 5) Women (n = 7) Total (n = 12)

x  SEM x  SEM x  SEM x  SEM x  SEM x  SEM

Age 19  0.8 20.6  3 20  2.5 24  3.1 21.4  4.4 22.5  4

BMI 29.7  6 19.9  2.3 23.5  6.2 24.8  3.9 24  4.3 24.4  4

Free TMD group TMD group

Men (n) Women (n) Total (n) Men (n) Women (n) Total (n)

Educational level
High school 4 6 10 3 7 10
College 0 1 1 2 0 2

Marital status
Single 4 7 11 5 5 10
Married 0 0 0 0 2 2
 archives of oral biology 55 (2010) 670678 675

Table 2 Formation of the groups according to the different diagnoses of TMD based on RDC/TMD criteria and with the
presence of subjective symptoms of TMD.
Free TMD group TMD group

n % n %

Symptoms
Facial pain? 0 0 10 83.4
Difficulty in mouth opening? 0 0 4 33.4
Difficulty to move the mandible? 0 0 3 25.0
Tiredness when chewing? 0 0 2 16.6
Headache? 0 0 7 58.4
Neck pain? 0 0 8 66.6
TMJ pain? 0 0 6 50.0
Joint sounds when chewing? 0 0 5 41.6
Tooth grinding or clenching? 0 0 6 50.0
Malocclusion self-perception? 0 0 2 16.6

Associated symptoms
3 0 0 4 33.4
5 0 0 3 25.0
>3 and <5 0 0 5 41.6

RDC/TMD diagnoses
Ia myofascial pain without limited opening 0 0 7 58.4
Ib myofascial pain with limited opening 0 0 5 41.6
IIa displaced disc with reduction 0 0 3 25.0
IIIa arthralgia 0 0 9 75.0
IIIb osteoarthritis 0 0 6 50.0

review article, Olivo et al.28 reported 12 articles that estab-
lished a correlation between TMD and craniocervical altera-
tions in accordance with their inclusion criteria, and, seven
from them found significant relationship. All 12 articles were
considered poor in their methodological design and insuffi-
cient to provide support for their results. Furthermore, the
authors mentioned that the absence of control group, poor
diagnostic criteria for TMD (9 of the 12 studies used clinical
signs, such as clicking and pain on muscular palpation, as
diagnostic tools), and for craniocervical alterations (the
studies used different ways to evaluate craniocervical pos-
ture-only two studies used radiographs), were the main
failures of the studies.
The present study evaluated the relationship of TMD with
craniocervical posture alterations. The diagnosis of TMD was
based on clinical and anamnestic criteria with the intention of
[(Fig._4)TD$IG]
Fig. 4 Mean values for atlas plane angle between the
groups. Each column represents the mean W SEM.
*p = 0.026, t test, indicates a significant decrease in
relation to free TMD group.
allowing a more complete and precise evaluation of this
dysfunction. Bonjardim et al.9 reported the importance of
evaluating the association between clinical diagnosis and self-
reported symptoms for better assessment of TMD. For the
clinical evaluation the Research Diagnostic Criteria instru-
ment29 (RDC/TMD) was used, which is considered the gold
standard for the diagnosis of TMD, accepted and validated in
several languages. This clinical exam was associated with the
presence of subjective symptoms of TMD as proposed by Conti
et al.30
In addition, we used for the evaluation of the craniocervi-
cal angles and distances, the measures described in studies
with TMD subjects and those ones for the diagnosis of
morphological alterations of the cervical spine (posture), of
great importance in the clinic.14,32,34 An important fact in this
study concerns the use of radiographic measurements, which
were able to evaluate, in a quantitative and faithful manner,
the morphology of the craniocervical posture, as opposed to
the computerized posturograms and postural evaluations.
These other techniques present some interferences, such as
photographic distortions and variability in the anatomical
markings, which may slide on the skin, being factors of bias in
the work, thus showing to be less reliable.41 Although, the
radiographic measurement appears to be the gold standard
and reliable tool to evaluate craniocervical posture, lack of
precision in identifying anatomical points in radiograph has a
limitation that may occur in the exam.42 For example, due to
lack of sharpness, it can interfere significantly in the
reproducibility of measurements. This difficulty occurred
in the present study in 9 from 32 radiographs, so the
examiner, who was always the same in all radiographic
measurements, only assessed the radiograph when there was
total precision of visualization and interpretation of anatom-
ic points to be marked in the film, trying to avoid mistakes and
676 archives of oral biology 55 (2010) 670678
[(Fig._5)TD$IG]
Fig. 5 Mean values for the anterior translation distance
between the groups. Each column represents the
mean W SEM. *p = 0.045, t test indicates a significant changes in mobility of intra-articular disc, thus limiting the
increase in relation to free TMD group.
errors in the evaluation of image, ensuring the scientific rigor
of this study.
In the present study, from five radiographic craniocervical
measurements performed, three the high cervical angle, low
cervical angle and occipitalatlas distance were not shown to
be statistically different between the free TMD and TMD
groups, corroborating previous studies.2022,31
Nevertheless, statistically significant difference was found
for the Tz C2C7 distance and for the APA, which, respectively,
had shown to be significantly increased and reduced, in the
TMD group in relation to free TMD group.
APA refers to the angulation of C1 in relation to the
horizontal plane. Because C1 is anatomically articulated with
the articular facets of the occipital bone (occipital condyles),
this measurement has been used to verify the craniocervical
posture. Reduction of the APA suggests a flexion of the first
cervical vertebra, that indicates an anterior rotation of the
cranium, and thereby, the OAD would maintain itself
equilibrated without compression of the important vascu-
lar-nervous structures in this region, which may have been
responsible for the lack of significant difference in the
mentioned distance between the groups. However, according
to Rocabado and Tapia,23 and Bricot,43 it may also occur a
reactional and compensatory posterior rotation of the
cranium, in an attempt to maintain the horizontal orientation
of the eyes. This would cause a reduction of the OAD, which
did not occur in the present study. Although the APA has been
proposed by Harrison et al.32 as one of the angles used in the
creation of a geometric model for measurement of the
cervical spine in the sagittal plane, no studies were found
which had used this angle in TMD patients. So, the APA
reduction (C1 flexion) associated with a suboccipital space
unchanged could indicate that the upper cervical spine,
composed of C1 and C2, which may be responsible for the
compensation of those subjects, not necessarily influence the
flexionextension movement between C1 and the occipital
condyles (skull).
The increase in the distance Tz C2C7 may suggests an
anteriorization of the cervical spine, which are in accordance
with the findings of Huggare and Raustia,14 and Sonnesen
et al.,16 who found an increase in cervical curvature,
suggesting a hyperlordosis, but no corroborate with the
findings of Rocabado and Tapia,23 Rego Farias et al.,24 Dattilio
et al.,17 and Araujo22 who, in spite of using another measure-
ment (the craniocervical angle) verified the presence of
rectification of the cervical spine. One of the main forms of
compensation during the mouth opening where the condyle
rotates and translates in the glenoid fossa of the temporal
bone is the rotation of the skull associated with an increase
in the lordotic curvature of the spine. Biomechanically, mouth
opening is facilitated during the extension movement of the
craniocervical complex, as occurs in the hyperlordosis, since
the mandible during its movement uses different manners to
prevent compression of the upper airway. With the TMD,
translation of the mandibular condyle is affected mainly by
biomechanics of mouth opening. This could possibly trigger
compensation in extension of the skull and cervical spine. It is
important to make clear that, because of the divergent
findings in the literature, it is unclear whether such compen-
sation occurs in a dynamic or static manner.
Therefore, in the present study was verified in the TMD
group a tendency of subjects present anteriorization of the
cervical spine (hyperlordosis) associated with flexion of the
first cervical vertebra (C1). However, due to the sample size, the
results should be interpreted with caution. These findings
were different from the other ones,13,43 whose, of the
biomechanical point of view, suggested that a rectification
of the cervical spine represented by the distance Tz C2C7
would induce a reactional response of C1. This would enter
into flexion, or of the cranium in anterior rotation, with the
objective of maintaining the horizontal orientation of the eyes.
Therefore, it is clear that further studies using the same
methodological basis and diagnostic criteria should be
conducted to confirm this affirmation.
In conclusion, it could be verified that subjects with
symptomatic TMD had a tendency to present flexion of the
first cervical vertebra and an anteriorization (hyperlordosis) of
the cervical spine (C2C7). However, we emphasized that the
above-mentioned hypothesis should be interpreted with
caution due to the sample size of the present study. Even
though, it is not possible to affirm whether it was the TMD that
caused the alterations in the measurements of APA and Tz C2
C7 or vice-versa, since there was no possibility to verify the
sequence of appearance of the two disorders. Then, future
studies should monitor subjects with cervical spine without
TMD, and with TMD without cervical spine, trying to define
who is the main risk factor.
Additionally, future investigations about the relationship
between TMD and craniocervical posture should verify if the
static evaluation of cervical spine is the best method to
assessment the relationship between TMD and craniocervical
alteration, since the temporomandibular complex is a dynam-
ic joint.
Funding: This study was funded by Conselho Nacional de
Desenvolvimento Cientfico e Tecnologico National Counsel
of Technological and Scientific Development (CNPq).
Competing interests: None declared.
Ethical approval: Ethical Committee of Federal University
of Sergipe approved this study CAAE No. 0018.0.107.000-08.
 archives of oral biology 55 (2010) 670678
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