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Craniofacial Changes after Combined Atlas-Orthogonal and
Biomimetic Oral Appliance Therapy
__________________________________________________________________________________________
____________________________________________________________________________________________________________
Introduction
In a systematic review, Moon and Lee
1
determined that dental
occlusion/temporo-mandibular joint (TMJ) status exert an
influence on head, jaw and other muscles for proper body
posture, as well as body equilibrium (balance), center of
gravity fluctuation, and horizontal gaze stability. In contrast,
Marini et al.
2
suggest that occlusal interference does not
influence body posture. Earlier, Manfredini et al.
3
proposed
that the reason why posturographic techniques and devices
have not found firm associations between body posture and
dental occlusion is due to compensation mechanisms
Abstract
Objective: There are several chiropractic techniques available to improve head
and neck alignment but none use a combined approached in conjunction with an
oral appliance. A previous study demonstrated synergistic effects of biomimetic
oral appliance therapy (BOAT) and transdermal atlas positioning procedures
(TAPP) on leg length discrepancies in adults. Therefore, this current study
investigates changes in head and neck alignment using Cartesian analysis, to test
the hypothesis that combined TAPP and BOAT improves craniofacial alignment
in adults.
Subjects and Methods: A consecutive series of 11 adults (mean age 39.5yrs; 4
female, 7 male) were included in this study. Each subject was evaluated for the
presence of malocclusion by a dentist, and also for the presence of an atlas
subluxation by an atlas-orthogonal (AO) chiropractor. Pre-management cranio-
cervical relationships were evaluated from frontal, horizontal and axial
radiography, using strict positioning and analysis protocols. Following pre-
management assessment, each subject was treated for atlas subluxation by an
AO chiropractor, and the radiographic procedure was repeated. Next, the
subject inserted the oral appliance (a DNA appliance®) and the radiographic
procedure was repeated. For radiographic assessment, craniofacial parameters
were calculated: pre-care (T0); after AO adjustment (T1), and finally after oral
appliance insertion (T2).
Results: Of the following individual parameters: Atlas cephalic displacement;
Un-leveling/atlas frontal plane line; Cephalic tilt; Cervical spine-atlas angle;
Cervical spine angular rotation; Axis (C2) rotation, and Atlas-foramen magnum
angular rotation, showed improvements at both T1 and T2. The initial, total Z-
and Y-axis discrepancy for the sample had a mean value of 22.7
0
± 7.4. After AO
adjustment (T1), the mean change in craniofacial alignment improved to 9.7
0
±
6.3 (p < 0.001) but combining AO adjustment with the oral appliance (T2), the
mean change in craniofacial alignment improved further to 6.0
0
± 4.1 (p <
0.001). The total, mean decompensation was found to be 68.2%.
Conclusions: When a biomimetic oral appliance is used in combination with AO
adjustment, there appears to be a synergistic effect that significantly improves
craniofacial alignment in adults. However, further studies are required to
corroborate these preliminary findings.
Keywords: Atlas orthogonal, chiropractic adjustment, oral appliance therapy,
biomimetic
G. Dave Singh, DDSc, PhD, BDS
1
Chris Chapman, DC, BCAO
2
Myles Preble DMD
3
1. BioModeling Solutions, Inc.
Beaverton, OR
2. Private Practice of Chiropractic,
Provo, UT
3. Private Practice of Dentistry,
Provo, UT
4.
Original Research
A. Vertebral Subluxation Res. December 18, 2014 211
Oral Appliance Therapy
occurring within the neuromuscular system regulating body
balance. However, it has been suggested that disorders of the
masticatory system, such as malocclusions, can influence body
posture, and some studies show associations between occlusal
factors and postural alterations, but there is not enough
scientific evidence to support a causal relationship
4
.
Tingey et al.
5
undertook measurements of mandibular rest
position in males with Class I occlusion/skeletal patterns, and
normal TMJ function. Jaw movements were tracked using an
optoelectric computer system, and their results showed that the
pattern of jaw movement is influenced by head support and
body postures. Thus, a tentative relationship appears to exist
between jaw position and body posture, and in to order to
synchronize these two components, cranio-cervical
relationships need to be evaluated objectively.
Similarly, Kibana et al.
6
examined the relationship between
occlusal support and head posture, using an electromagnetic
tracking instrument with 6-degrees-of-freedom. They reported
that with lateral imbalance of occlusal support, EMG activity
of the jaw closing muscles and sternocleidomastoid (SCM)
muscle on the occlusal support side was greater than those on
the non-occlusal support side, and the neck was bent in the
direction of the occlusal support side. Thus, lateral imbalance
of the occlusal support may promote imbalance in SCM
activity, causing lateral bending and contralateral rotation of
the neck from the ipsilateral, hypertonic SCM.
This postural compensational effect was also observed by
Maeda et al.
7
along the postural (spinal and pelvic) kinetic
chain, as observers experimentally-induced postural and
occlusal changes using 1mm increment heel lifts. Based on
their findings, it was concluded that leg length discrepancy
affected pelvic tilt, body posture and occlusion in a
predictable, ipsilateral fashion with a discrepancy as little as
4mm. From these studies, it is suggested that there is a close
relationship between occlusal support, head posture and body
posture.
In this present study, we define compensation as deviation or
displacement from the ideal physiological rest points, which
can be measured in degrees. Thus, craniofacial
discrepancies/deviations from normal axes during resting
posture are likely representative of craniofacial postural
compensation. Therefore, the aim of this study is to
investigate changes in head and neck alignment, to test the
hypothesis that combined atlas-orthogonal and BOAT
improves head and neck alignment in adults.
Methods and Sample
For this study, we recruited 14 consecutive subjects that
reported to a multi-disciplinary clinic for chiropractic
consultation. The rights of the subjects were protected by
following the Declaration of Helsinki.
In addition, the following inclusion criteria were applied:
adults >21yrs diagnosed with atlas subluxation (following
clinical examination by a chiropractor); no history of
hospitalization for craniofacial trauma or craniofacial surgery;
no congenital craniofacial anomalies, and fully-dentate upper
and lower arches. The exclusion criteria included: age <21yrs;
positive history of cervical surgery; and drug therapy for
vestibular dysfunction, balance and equilibrium. After
obtaining informed consent, a clinical history was taken, as
well as a chiropractic examination and a craniofacial
examination for each subject. In addition, pre-treatment
craniocervical relationships were assessed using standard,
frontal, horizontal and axial radiography, using strict, upper
cervical chiropractic positioning protocols.
Each subject was assessed for the presence of a Type 1 atlas
subluxation (atlanto-axial rotation ≤ 3mm), and a transdermal
atlas positioning procedure (TAPP), which reduces the atlas
cephalic displacement (ACD) and atlas-axis distortion (AXSP)
around Cartesian axes, was performed by an atlas orthogonist
following a positive diagnosis. The atlas subluxation
assessment consisted of 4 definitive examinations: 1) bilateral
scanning palpation of the posterior sub-occipital regions in the
area superficial to the C1 nerve root, the vertebral arteries and
the dorsal root ganglion of C2; 2) George’s vertebro-basilar
insufficiency test; 3) supine leg length assessment against a
fixed grid with photographic record; and 4) radiographic
and/or cone-beam computerized axial tomographic scan
(CBCT) assessment. Following pre-treatment assessment,
each subject was treated for atlas subluxation by a chiropractor
and the radiographic procedure was repeated.
Each subject was evaluated also for the presence of
malocclusion by a dentist, and a DNA appliance® was
prescribed following a positive diagnosis. The DNA
appliance (Fig. 1) putatively differs from traditional dental
appliances
8
as it has a biomimetic approach that has been
successfully deployed in children
10
and adults
11-16
in an
attempt to mimic or harness developmental mechanisms.
The DNA appliance is preferentially worn for approx. 12-
16hrs during the afternoon, evening and at nighttime, but not
during the day and not while eating, partly in line with the
circadian rhythm of tooth eruption
17
. Thus, following
chiropractic and craniofacial examination, a DNA appliance
was custom-fabricated and delivered by a dentist. Therefore,
the subject inserted the oral appliance and the radiographic
procedure was repeated after occlusal equilibration of the
appliance by a dentist.
For radiographic assessment, the following parameters were
calculated pre-treatment (T0); after chiropractic adjustment
(but prior to oral appliance insertion; T1), and finally after oral
appliance insertion (T2):
• Z-axis: Atlas cephalic displacement (ACD)
• Z -axis: Un-leveling/atlas frontal plane line (APL)
• Z-axis: Cephalic tilt
• Z-axis: Cervical spine-atlas angle
• Z-axis: Cervical spine angular rotation
• Y-axis: Axis (C2) rotation
• Y-axis: Atlas-foramen magnum angular rotation
These parameters are illustrated in Figure 1 and Figure 2.
From these measurements the following additional parameters
were calculated:
• Total craniocervical discrepancy: Pre-treatment (T0)
• Change in discrepancy: Post-adjustment/pre-
appliance (T1)
• Change in discrepancy: Post-adjustment/post-
appliance (T2)
Oral Appliance Therapy
212 A. Vertebral Subluxation Res. December 18, 2014
All findings were subjected to statistical analysis using paired
t-tests.
Figure 1. Craniocervical relationships were evaluated
objectively from frontal, horizontal and axial radiography.
Components are thought to be in a decompensated state when
adjacent structures such as the spinal segments and the cranial
base are perpendicular and without angular rotation.
Results
From the consecutive series of 14 patients, three were
excluded from the study as two did not meet the age criteria,
and one had a history of craniofacial trauma. The mean age of
the study sample was found to be 39.5yrs, comprising 4
females and 7 males.
Table 1 shows that all craniofacial parameters assessed
improved significantly after both AO adjustment (T1) and oral
appliance therapy (T2) individually. For example, the atlas
cephalic displacement (ACD) improved from 2.5
0
± 1.9 to 1.1
0
± 1.1 (p < 0.01) at T1 and to 0.5
0
± 0.7 (p < 0.001) at T2.
Similarly, un-leveling/atlas frontal plane line (APL) improved
from 3.2
0
± 2.3 to 1.8
0
± 1.7 (p < 0.05) at T1 and to 0.9
0
± 1.6
(p < 0.001) at T2. The Cephalic tilt improved from 1.5
0
± 1.3
to 0.9 ± 1.1 (p < 0.01) at T1 and to 0.7 ± 1.0 (p < 0.05) at T2.
In addition, Cervical spine-atlas rotation improved from 3.1
0
±
2.6 to 1.6 ± 1.7 (p < 0.05) at T1 and to 0.6 ± 0.6 (p < 0.01) at
T2.
Similarly, the Cervical spine angle improved from 3.6
0
± 2.8 to
2.1 ± 1.5 (p < 0.01) at T1 and to 0.8 ± 0.9 (p < 0.001) at T2.
As well, Axis (C2) rotation improved from 6.6
0
± 4.9 to 2.8 ±
4.9 (p < 0.01) at T1 and to 1.5 ± 2.5 (p < 0.001) at T2.
Finally, the Atlas-foramen magnum rotation improved from
2.3
0
± 1.9 to 1.8 ± 1.7 (p < 0.05) at T1 and to 1.0 ± 1.3 (p <
0.001) at T2. These parameters are illustrated in Figure 1 and
Figure 2.
Table 2 shows the initial, total Z- and Y-axis discrepancy for
the sample had a mean value of 22.7
0
± 7.4. After AO
adjustment (T1), the mean change in craniofacial alignment
improved to 9.7
0
± 6.3 (p < 0.001) but combining AO
adjustment with the oral appliance (T2), the mean change in
craniofacial alignment improved further to 6.0
0
± 4.1 (p <
0.001). The total, mean decompensation was found to be
68.2% ± 18.2. Therefore, as expected the total, mean,
craniofacial alignment improved after atlas-orthogonal
adjustment and oral appliance insertion, indicating an
enhancement of craniofacial alignment after combined atlas-
orthogonal and BOAT in adults. The results are summarized
in Tables 1 and 2, and in Figure 3.
Discussion
The structural elements of the body are thought to be in a
maximally efficient and decompensated state when adjacent
structures, such as the spinal segments and cranial base, are
perpendicular and without angular rotation. While Amat
18
explored relationships between occlusion and scoliosis, we
define ideal bipedal posture using decompensation criteria.
Maximum resting postural efficiency occurs when the
anatomical mid-sagittal points of the axial skeleton are aligned
with the vertical axis and along the midsagittal plane; the axial
skeleton is symmetrically distributed outward from the aligned
axial skeleton, and the cranium, spine and pelvis are
maximally efficient in the sagittal plane through optimization
of the primary and secondary spinal curvatures (Fig. 4).
In this study, we define compensation as deviation or
displacement from the ideal physiological planes, and these
deviations from orthogonality can be measured in degrees and
millimeters. Thus, discrepancies and resting posture
deviations from normal axes are likely representative of
descending craniofacial developmental compensation or
ascending postural compensation
19
. But, the roles of
components that determine head posture remain controversial.
Since our previous study demonstrated synergistic effects of
BOAT and TAPP on leg length discrepancies in adults
19
, this
present study tested the notion that head and neck alignment
can also be improved in adults using the same procedure.
For example, Bergamini et al.
20
assessed resting activity of the
SCMs, erector spinae and soleus muscles in adults with
malocclusions. Their findings confirmed a beneficial effect of
occlusal equilibration (with an acrylic wafer) on the postural
Figure 3.
A. Vertebral Subluxation Res. December 18, 2014 213
Oral Appliance Therapy
muscles investigated. Therefore, occlusal and postural factors
can affect head alignment, and the findings of our present
study (Tables 1 and 2) show that the effect is enhanced when
the two modalities are used in conjunction.
In terms of functional impact, Muto et al.
21
investigated the
relationship between cranio-cervical inclination and upper
airway space. They concluded that an increase of 10
0
in
cranio-cervical angulation (or 10mm in C3-Me length)
increased the pharyngeal airway space by approx. 4mm in the
sagittal plane.
Later, Svanholt et al.
22
analyzed craniofacial profiles and head
posture in patients with obstructive sleep apnea (OSA).
Patients with fusion of cervical vertebrae (C2 and C3) showed
differences in jaw relationship from patients with no fusions,
even though both groups exhibited OSA. That study suggests
that in patients diagnosed with OSA, jaw position may be used
to ameliorate the effects of upper airway obstruction when
changes in cervical posture are limited.
But, when Inoko and Morita
23
assessed changes in the cervical
spine associated with the use of mandibular advancement
devices (MADs) in patients with OSA, cephalometric analysis
showed that the craniocervical angles with MADs were larger
than those without MADs. It appeared that MADs caused
significant flexion of the cranium on the upper cervical spine
with a concomitant increase in the craniocervical angle. Their
study implies that changes in the craniocervical relationship
should be evaluated periodically after a MAD has been
inserted, and reflects the protocol adopted in this present
study, following our previous findings
10, 12
.
Indeed, earlier McGuinness and McDonald
24
studied the
effects of rapid maxillary expansion (RME) on natural head
position. No significant changes were observed after
expansion but one year post-expansion, however, they found a
mild change in head posture, possibly due to a change in the
mode of breathing from oral to nasal as a result of RME.
Thus, a combined TAPP and BOAT may provide a
potentially-useful method of capturing an improved upper
airway position in adults, and might provide a starting point
for managing patients diagnosed with OSA. Further studies
will be directed towards identifying this type of clinical
protocol.
References
1. Moon HJ, Lee YK. The relationship between dental
occlusion/temporomandibular joint status and general
body health: part 1. Dental occlusion and TMJ status
exert an influence on general body health. J Altern
Complement Med. 2011;17(11):995-1000.
2. Marini I, Gatto MR, Bartolucci ML, Bortolotti F,
Alessandri Bonetti G,Michelotti A. Effects of
experimental occlusal interference on body posture:
an optoelectronic stereophotogrammetric analysis. J
Oral Rehabil. 2013;40(7):509-518.
3. Manfredini D, Castroflorio T, Perinetti G, Guarda-
Nardini L. Dental occlusion, body posture and
temporomandibular disorders: where we are now and
where we are heading for. J Oral Rehabil.
2012;39(6):463-471.
4. Michelotti A, Buonocore G, Manzo P, Pellegrino G,
Farella M. Dental occlusion and posture: an
overview. Prog Orthod. 2011;12(1):53-58.
5. Tingey EM, Buschang PH, Throckmorton GS.
Mandibular rest position: a reliable position
influenced by head support and body posture. Am J
Orthod Dentofacial Orthop. 2001;120(6):614-622.
6. Kibana Y, Ishijima T, Hirai T. Occlusal support and
head posture. J Oral Rehabil. 2002;29(1):58-63.
7. Maeda N, Sakaguchi K, Mehta NR, Abdallah EF,
Forgione AG, Yokoyama A. Effects of experimental
leg length discrepancies on body posture and dental
occlusion. Cranio. 2011;29(3):194-203.
8. Singh GD. Epigenetic orthodontics: Developmental
mechanisms of functional (formational) orthodontic
appliances. J Amer Orthod Soc. 2010;10:16-26.
9. Singh GD, Lipka G. Case Report: Introducing the
wireframe DNA appliance
TM
. J Am Acad Gnathol
Orthop. 2009;26:8-11.
10. Singh GD, Wendling S, Chandrashekhar R. Midfacial
development in adult obstructive sleep apnea. Dent
Today. 2011;30;124-127.
11. Utama J, Singh GD. Effect of the DNA appliance
TM
on migraine headache: Case report. Int J. Orthod.
2013;24;45-49.
12. Singh GD and Callister JD. Use of a maxillary oral
appliance for the resolution of obstructive sleep
apnea. J Cranio Sleep Prac. 2013;31(3):171-179.
13. Singh GD, Harris W. Resolution of a 'Gummy Smile'
and Anterior Open Bite Using the DNA appliance®.
J Am Orthod Soc. 2013;13(4): 30-34.
14. Singh GD, Ataii P. Combined DNA appliance™ and
Invisalign™ therapy without interproximal reduction:
A Preliminary Case Series. J Clin Case Rep 2013;
3(5):1-3.
15. Singh GD, Cress SE. Singh GD, Cress SE.
Craniofacial enhancement using a biomimetic
oralappliance. Dent Today. 2013;32(12):92-94.
16. Singh GD, Heit T, Preble D. Changes in 3D
midfacial parameters after biomimetic oral appliance
therapy in adults. J Ind Orthod Soc. 2014;48(2):104-
108 .
17. Proffit WR, Frazier-Bowers SA. Mechanism and
control of tooth eruption: overview and clinical
implications. Orthod Craniofac Res. 2009;12:59-66.
18. Amat P. Occlusion, orthodontics and posture:are
there evidences? The example of scoliosis. J. Stomat.
Occ. Med. 2009;2:2–10.
19. Chapman DC and Singh GD. Combined effect of a
biomimetic oral appliance and atlas orthogonist
cervical adjustment on leg lengths in adults. Annals
Vert. Sub Res. 2013;46-50,.
20. Bergamini M, Pierleoni F, Gizdulich A, Bergamini C.
Dental occlusion and body posture: a surface EMG
study. Cranio. 2008;26(1):25-32.
21. Muto T, Takeda S, Kanazawa M, Yamazaki A,
Fujiwara Y, Mizoguchi I. The effect of head posture
on the pharyngeal airway space (PAS). Int J Oral
Maxillofac Surg. 2002;31(6):579-83.
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214 A. Vertebral Subluxation Res. December 18, 2014
22. Svanholt P, Petri N, Wildschiødtz G, Sonnesen L,
Kjaer I. Associations between craniofacial
morphology, head posture, and cervical vertebral
body fusions in men with sleep apnea. Am J Orthod
Dentofacial Orthop. 2009;135(6): 702.e1-9;
23. Inoko Y, Morita O. Influence of oral appliances on
craniocervical posture in obstructive sleep apnea-
hypopnea syndrome patients. J Prosthodont Res.
2009;53(3):107-110.
24. McGuinness NJ, McDonald JP. Changes in natural
head position observed immediately and one year
after rapid maxillary expansion. Eur J Orthod.
2006;28(2):126-34.
A. Vertebral Subluxation Res. December 18, 2014 215
Oral Appliance Therapy
Figure 2. The following parameters were measured from the radiographs
Z-AXIS: ACD (ATLAS CEPHALIC DISPLACEMENT)
Z -AXIS: APL (ATLAS FRONTAL PLANE LINE) UNLEVELING
Z-AXIS:CEPHALIC TILT
Y-AXIS AXIS ROTATION
Z-AXIS: CERVICAL SPINE-ATLAS ANGLE
Z-AXIS: CERVICAL SPINE ANGULAR ROTATION
Y-AXIS: ATLAS-FOREMAN MAGNUM ANGULAR ROTATION
Tables and Figures
Oral Appliance Therapy
216 A. Vertebral Subluxation Res. December 18, 2014
Figure 4. Optimal Posture Defined
Table 1.
C2 ROTATION
T0
C2 ROTATION
T1
C2 ROTATION
T2
ATLAS-
FM ROTATION
T0
ATLAS-FM
ROTATION
T1
ATLAS-FM
ROTATION
T2
2.00 0.75 0.00 4.00 2.50 1.50
2.00 0.75 1.00 2.25 2.25 1.50
15.00 14.00 7.00 4.00 2.50 2.00
11.00 12.00 6.00 4.25 3.00 2.25
13.00 0.00 0.00 3.00 2.75 0.50
9.00 3.00 1.00 2.00 0.75 0.25
14.00 5.00 3.00 6.50 6.50 4.50
10.00 1.00 3.00 0.50 1.00 0.75
8.00 1.00 0.00 0.75 1.50 0.25
7.00 2.00 0.00 0.75 0.00 0.25
1.00 0.00 0.00 4.75 1.75 0.25
6.57 2.82 1.50 2.34 1.75 1.00
4.95
4.89
2.55
1.92
1.69
1.31
0.0025
0.0001
0.0228
0.0007
A. Vertebral Subluxation Res. December 18, 2014 217
Oral Appliance Therapy
Table 2.
TOTAL
DISCREPANCY (
0
)
T0 T1 T2
%
DECOMPENSATION
SUBJECT
P 1
18.75 7.25 9.25 88
P2
16.25 1.75 4.75 40
P3
36.50 7.50 14.25 60
P4
35.50 11.75 7.75 55
P5
30.00 16.75 11.00 93
P6
24.50 14.00 4.00 73
P7
37.25 18.75 10.00 77
P8
36.00 21.00 8.25 81
P9
23.75 5.25 9.25 61
P10
31.75 18.75 7.25 82
P11
27.25 12.50 -1.50 40
MEAN
22.68 9.66 6.02 68.20
STD
7.4
6.3
4.1
18.2
Oral Appliance Therapy
218 A. Vertebral Subluxation Res. December 18, 2014
