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Senior Resident, Department of Orthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
Associate Professor, Department of Orthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 26 September 2014
Received in revised form
13 June 2015
Accepted 29 June 2015
Background: The authors sought to evaluate the three-dimensional effects of a twin block (TB) appliance
on the pharyngeal airway parameters in a sample of Class II patients with mandibular retrusion in
comparison with a control group, by using cone-beam computed tomography (CBCT).
Methods: A sample of 36 female Class II malocclusion patients with mandibular retrusion participated in
this study; 18 patients were treated with the TB appliance for 8 months, and the other 18 had no
treatment and formed the control group. The airway volumetric parameters were assessed by using
CBCT; three-dimensional measurements were performed before treatment and 8 months later in both
groups. Statistical analysis of the collected data was performed.
Results: Airway parameters increased signicantly in the treatment group and after the control period in
the control group. However, the mean changes in the treatment group were signicantly higher than
those of the control group.
Conclusion: The use of the TB appliance in the treatment of Class II mandibular retrusion patients resulted
in a signicant increase in all pharyngeal airway parameters.
2015 World Federation of Orthodontists.
Keywords:
Class II mandibular retrusion
Twin block appliance
Pharyngeal airway
Cone-beam computed tomography
1. Introduction
Class II malocclusion is one of the mostly encountered problems
in the orthodontic practice [1]. It causes aesthetic, functional, and
psychological problems of varying intensities. Patients with Class II
Division 1 malocclusion can exhibit maxillary protrusion, mandibular retrusion, or both [2,3].
Awareness of mandibular deciency as the main contributing
part of the Class II structural etiology [4] had led to the increased
popularity of mandibular advancement appliances or the functional
appliances. The twin block functional appliance, originally developed by William J. Clark [5], has gained increasing popularity and
been shown to be effective in correcting Class II malocclusion [6,7].
Concurrently, the pharyngeal airway has been an area of interest
in orthodontics, with topics such as the relationships between
different skeletal malocclusions and facial types and airway shape
and volume, and the clinicians potential to modify the airway.
Narrowing of the upper airway has been increasingly recognized
as a physiological characteristic in growing patients of Class II
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
* Corresponding author: Cairo University Faculty of Dentistry, 11 Sarayat ElManial
Street, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
E-mail address: monasfayed@yahoo.com (M.M.S. Fayed).
2212-4438/$ e see front matter 2015 World Federation of Orthodontists.
http://dx.doi.org/10.1016/j.ejwf.2015.06.001
division 1 malocclusion with mandibular retrusion [8,9]. The retruded mandible induces a retrodisplacement of the tongue and
hyoid bone that may lead to a concomitant reduction in the upper
airway volume [10,11]. Many studies have demonstrated that the
airway constriction is the most dominating contributor to
obstructive sleep apnea (OSA), among other factors such as postural
changes that might affect structures of the head and neck and
sagittal jaw relationships. OSA affects at least 2% of children and
was conrmed to have long-term adverse effects [12]. Other
possible factors are anatomical variations, pharyngeal dilator
muscle function, lowered arousal threshold, and ventilator control
instability.
One of the rst attempts to evaluate pharyngeal airway in
different anteroposterior malocclusions was carried out by Mergen
and Jacobs [13], followed by Trenouth and Timms [14]; both studies
used cephalometric measurements to evaluate nasopharyngeal
space and functional oropharyngeal airway. They concluded that
the nasopharyngeal area and depth were signicantly larger in
subjects with normal occlusion than in subjects with Class II
malocclusion and that the oropharyngeal airway was positively
correlated with length of the mandible.
Most studies evaluating the airway have been conducted with
two-dimensional lateral or frontal cephalograms with limited
evaluation of lengths and area.
H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119
Table 1
Demographic data and cephalometric measurements showing no signicant differences between the treatment and the control group before the start of treatment
and control period
Measurements
Group
Mean
(pre)
Age
Control
11.27
Treatment
11.89
A point, nasion,
Control
7.51
B point ( )
Treatment
8.28
A-B diff Nv
Control
9.77
(mm)
Treatment
11.29
AFH
Control
107.21
(mm)
Treatment 107.97
PFH
Control
63.16
(mm)
Treatment
61.80
S-InGo/N-menton Control
0.59
Treatment
0.55
Sella nasion point Control
81.75
A ( )
Treatment
81.27
A-Nv
Control
1.57
(mm)
Treatment
1.06
Sella nasion point Control
73.97
B ( )
Treatment
73.00
B-Nv
Control
8.71
(mm)
Treatment 10.05
SD
2.19
1.85
1.81
1.19
2.19
1.85
4.24
3.73
2.14
3.95
0.04
0.04
3.52
3.58
1.40
2.75
2.30
3.24
2.57
3.29
Diff. of SEM T
means
P Value
Table 3
Landmarks and reference planes for the pharyngeal airway analysis
Landmarks
(Abbreviation)
Denition
1. Posterior nasal
spine (PNS)
2. Pterygomaxillary
points (PTM)
0.62
0.26
1.21 0.335453
0.77
0.86
0.22 0.824477
1.52
0.22
0.66 0.515559
0.76
0.56
1.36 0.183461
3. C3
Reference planes
1. PTM-PNS
2. PNS plane
1.3
0.60
1.35 0.187069
3. C3 plane
0.04
0.48
0.5
0.97
1.3
Nv, Nasion vertical; AFH, anterior facial height; PFH, posterior facial height; s-InGo/
N-menton, Sella-intergonion/nasion-menton
* Signicant P < 0.05.
Table 2
Parameters of GALILEOS CBCT scanner
Technical parameter
Value
85 KVp
21 mA
12 bit
Approx. 14 s
Pulsed
10e30 ms
42 mAs
2e6 seconds
204
200
Image intensier-charged coupled device
21.5 cm (8 in) diameter
6 in 15 cm 15 cm 15 cm
0.3 0.3 0.3 mm3
15 cm 15 cm 15 cm
512 512 512
Standing or seated with at occlusal plane
333 mm (131/8 in)
DICOM
ICRP 1990 29 mSv, ICRP 2007 54 mSv
0.5
Approx. 2.5 min
115
116
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H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119
117
Table 4
Description of the three-dimensional pharyngeal airway parameters investigated in the study
Variable
Description
Nasopharyngeal airway
The anterior border that is a line connecting pterygomaxillary point (PTM) and posterior nasal spine (PNS). The inferior border was a
Nasopharyngeal airway volume
plane parallel to the Frankfort through the PNS. The posterior border was the posterior wall of the pharynx (Fig. 1).
The volume between these landmarks calculated from the software (Fig. 2)
Oropharyngeal airway
The superior border was a plane parallel the Frankfort through the PNS and that was the inferior border of the nasopharyngeal airway.
Oropharyngeal airway volume
The inferior border was a plane passing through inferior anterior point of third cervical vertebra parallels the Frankfort horizontal
(FH) (Fig. 3).
The volume between these landmarks calculated from the software (Fig. 4)
Minimal constricted axial area The minimal constricted axial area of pharyngeal airway location was determined relative to posterior nasal spine plane was done
by using the software (Fig. 5).
2. The threshold, which is a Dolphin 3D software tool that controls the lling degree of the air, was adjusted to 73, which is
considered the proper threshold for airway measurements [22].
In our study, the airway volume sensitivity was measured at
threshold 73; below this threshold, no air was detected by the
software in most cases, which is why it was used as the standard threshold for all the cases.
3. The pharynx was isolated and divided into nasopharyngeal
according to Park et al. [23] (Figs. 1 and 2) and oropharyngeal
airways according to Oh et al. [15] (Figs. 3 and 4). The denitions of the airway parameters are described in Table 4, Fig. 5.
correlation showed high intraobserver reliability for all measurements (Table 6).
3.1. Control group results
There was a statistically signicant increase in the mean values
of nasopharyngeal airway volume, oropharyngeal airway volume,
and the minimal constricted area post control period (Table 7).
3.2. Treatment group results
3. Results
Demographic data and cephalometric measurements showed
no signicant differences between the treatment and the control
group before the start of treatment and control period (Table 1).
There was no signicant difference between the two groups before
treatment in all pharyngeal airway parameters (Table 5). Intraclass
4. Discussion
A reduction in the pharyngeal airway dimensions in skeletal
Class II patients with mandibular retrusion was demonstrated in
the orthodontic literature [9,10], consequently having a negative
effect on the facial and mandibular growth in those patients. The
twin block appliance is considered a well-accepted approach in
correcting Class II division 1 malocclusion with mandibular retrusion in recent years. Previous studies indicated that the twin
block appliance is effective in mandibular forward repositioning
and thereby achieves a more harmonious facial prole [6,7]. Lin
et al. [24] evaluated the pharyngeal airway after mandibular
advancement in growing patients with retrognathia and suggested that the anteroposterior dimension of pharyngeal airway
did not change signicantly. Other studies [17e19] found that
signicant changes in pharyngeal space, hyoid bone, and tongue
Table 5
Comparison between the mean differences in airway parameters between the two
groups before treatment and control period
Pharyngeal airway
parameter
Control group
Treatment group
Mean
Mean
SD
P Value
SD
118
H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119
Table 6
Intraobserver reliability of all pharyngeal airway measurements
Pharyngeal airway parameter
Intraclass correlation
95% Condence
interval
Lower
limit
Upper
limit
0.995
0.95
0.99
0.999
0.995
0.995
0.945
0.966
0.715
0.996
0.998
0.976
0.992
0.927
0.999
Minimum constricted
area (mm2)
Oropharyngeal
airway (mm3)
Nasopharyngeal
airway (mm3)
Precontrol period
Postcontrol period
Mean
Mean
SD
P Value
SD
211.99
51.87
243.77
52.97
<0.001y
14,981.63
2878.92
15,719.81
2996.84
<0.001y
4628.53
954.07
4779.78
952.74
<0.001y
Table 8
Comparison between airway parameters in the treatment group before and after
treatment (paired t-test)
Parameter
Minimum constricted
area (mm2)
Oropharyngeal
airway (mm3)
Nasopharyngeal
airway (mm3)
Pretreatment
Posttreatment
Mean
Mean
SD
P Value
SD
190.25
49.52
282.25
74.52
<0.001y
14,423.24
3123.05
17,475.69
3696.34
<0.001y
3750.5
1025.61
4251.84
1121.72
<0.001y
Control group
Treatment group
Mean
Mean
SD
P Value
SD
H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119
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