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Chiropractic Research Review

Does the Bite Line Affect Cervical Radiograph Measurements?

Some evidence suggests that the cervical curve is influenced by the position of the bite line. The authors of the current study evaluated several papers published by a team of researchers and found several conflicting conclusions.

Following this, the authors hypothesized that "upper cervical joint dysfunction may compromise the reliability of pre- and post-lateral cervical radiographs if consistent patient conditioning is not maintained" when said radiographs are taken.

To demonstrate how inconsistent bite-line positioning when taking pre- and post-lateral X-rays can impact radiographic results, the authors evaluated measurements of relative flexion and extension in the atlantal-occipital (AO) and atlantal-axial (AA) joints from neutral lateral cervical and lateral extension and flexion X-rays provided by various chiropractors in private practice. A total of 60 radiographs, taken from 20 patient files, were evaluated, yielding data on the position of the AO and AA joints; their positions in relation to one another; and relative amounts of flexion and extension at both joints.

Results: Most radiographs revealed extension and flexion deficits at both joints. More than half of the 20 subjects exhibited paradoxical motion at the AO during cervical flexion; half displayed excessive AO extension, according to the authors.

According to the authors: "If a bite-line deviation exists in pre- and post-lateral cervical radiographic examinations, dynamic cervical flexion and extension radiographs should be taken to calculate the maximum tolerances in the upper cervical spinal joints. If these tolerances are exceeded, the measurement of the cervical lordosis from the back of the second cervical vertebra and the seventh cervical vertebra may be altered, thus incorporating the possibility of a 20.3% measurement error on the post lateral cervical radiograph."

The risk of exposing patients to additional ionizing radiation must be weighed with the diagnostic yield and significance expected from such studies. In short, one must determine whether the additional studies will change the process of clinical care, regardless of the accuracy.

Stitzel CJ, Morningstar MW, Paone PR. The effects of bite line deviation on lateral cervical radiographs when upper cervical joint dysfunction exists: a pilot study. Journal of Manipulative and Physiological Therapeutics September 2003;26(7):e17.

Chiropractic Research Review

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