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Assessment of upper airway size after orthopedic treatment for maxillary

Article  in  American journal of orthodontics and dentofacial orthopedics: official publication of the American Association of Orthodontists, its constituent societies, and the American
Board of Orthodontics · September 2017
DOI: 10.1016/j.ajodo.2016.12.027

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Muge Aksu Hande Gorucu Coskuner

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Assessment of upper airway size after

Introduction: The aim of this retrospective study was to find out whether different Class II treatments would
affect the airway sizes of patients having maxillary protrusion or mandibular retrusion. Methods: The study
sample comprised 57 Class II patients whose upper airway sizes were not significantly different at the start of
treatment and whose sagittal skeletal jaw relationships showed that they had maxillary protrusion or mandibular
retrusion. Twenty-two of them were treated with cervical headgear, 16 with activator, and 19 were selected as a
control. Lateral cephalograms at the start of treatment and the end of orthopedic treatment were assessed. The
intragroup comparisons were performed by using the paired-samples t test, and intergroup comparisons of the
skeletal features and upper airways were performed with 1-way analysis of variance, with the Tukey test as a
second step, at P \ 0.05. Results: The ANB angle decreased significantly in the treatment groups. The middle
airway space and the SNB angle were significantly increased after the activator therapy (P \ 0.05). The SNB
angle increased and SN-1 decreased in the mandibular retrusion group when compared with both maxillary
protrusion and control groups. No statistically significant difference between the maxillary protrusion and the
mandibular retrusion groups was found regarding the upper airway sizes after cervical headgear or activator
treatments, respectively (P . 0.05). The only significant differences observed in airway variables were at the
middle airway space of the activator and control groups with an increase of 1.6 6 2.5 mm and a decrease of
1.5 6 2.3 mm, respectively. Conclusions: Orthopedic treatment with either cervical headgear or activator did
not result in different upper airway changes, but activator treatment resulted in increased middle airway space
with regard to the Class II control group. (Am J Orthod Dentofacial Orthop 2017;152:364-70)

T
he skeletal and dentoalveolar effects of orthopedic Initially, the major focus of the skeletal Class II treat-
treatment in subjects with Class II malocclusions ment was related to skeletal correction and reduction in
have been well documented in the orthodontic maxillomandibular relationship discrepancy. After a
literature. Headgear treatment has been used for treat- while, more attention has been paid to detect the Class
ing growing skeletal Class II maxillary protrusion II treatment effects, as the close association between
patients,1-3 and functional appliances were used for malocclusion and upper airway morphology has been
forward movement of the mandible in growing skeletal understood. Mergen and Jacobs7 reported that the
Class II mandibular retrusion patients.4,5 Studies have nasopharyngeal area is significantly smaller in subjects
shown that continuous protraction force causes with Class II malocclusion than in those with normal
significant anterior displacement concurrently with occlusion. More recently, the studies have intensively
histologic changes in the mandible and the mandibular focused on assessing the upper airway changes
condyle.6 associated with skeletal features.8-10
The assessment of the nasal and pharyngeal airways
from lateral cephalograms has shown that Class II
Department of Orthodontics, Faculty of Dentistry, Hacettepe University, Ankara,
Turkey. patients have a tendency for narrower anteroposterior
All authors have completed and submitted the ICMJE Form for Disclosure of Po- pharyngeal dimensions, specifically in the nasopharynx
tential Conflicts of Interest, and none were reported. at the level of the hard palate and in the oropharynx at
Address correspondence to: Muge Aksu, Department of Orthodontics, Faculty of
Dentistry, Hacettepe University, Sıhhıye, 6100, Ankara, Turkey; e-mail, the level of the tip of the soft palate and the mandible.8
[email protected]. Muto et al11 identified a significant relationship between
Submitted, August 2016; revised and accepted, December 2016. the posterior airway space and the position of the
0889-5406/$36.00
Ó 2017 by the American Association of Orthodontists. All rights reserved. maxilla, mandible, and soft palate. Therefore, any alter-
http://dx.doi.org/10.1016/j.ajodo.2016.12.027 ation of the facial skeleton that is associated with these
364
Aksu, Gorucu-Coskuner, and Taner 365

Table I. Means, standard deviations, and multiple comparisons representing demographic variables at pretreatment
among the 3 groups
Cervical headgear Activator Control

Demographic variables (n 5 22) (mean 6 SD) (n 5 16) (mean 6 SD) (n 5 19) (mean 6 SD) Multiple comparisons*
Age (y) 10.6 6 1.0 10.3 6 1.5 10.2 6 1.4 0.501
Sex (n) 0.18
Female 10 12 10
Male 12 4 9
Duration between records (y) 1.1 6 0.6 1.3 6 0.8 1.0 6 0.0 0.259

*Significant differences between the groups are presented.

structures has been thought to result in a positive or than 5 with a clinically protrusive maxilla or retro-
negative effect on airway space. gnathic mandible, (2) Angle Class II molar relationship,
In growing children with mandibular retrusion, and (3) no respiratory problems and no adenoidectomy
functional appliances are thought to enlarge the upper or tonsillectomy before or during the treatment.
airway by holding the mandible in a forward position, These subjects were then divided into control and
whereas forward growth of the mandible is main- orthopedic treatment groups. The patients who were
tained.12 This positive effect of functional appliances either treated with fixed appliances or not treated because
has gained popularity among researchers, since they of lack of compliance and whose 1-year follow-up records
are noninvasive and relatively risk free.12-14 were available were selected as controls (n 5 19). The
For a Class II malocclusion with maxillary progna- patients whose posttreatment records were available after
thism, cervical headgear is a simple and commonly orthopedic treatment were selected as the orthopedic
used appliance, which is directed to the maxilla to inhibit treatment group. The orthopedic treatment group was
further maxillary growth or to perform distalization. then divided into cervical headgear (n 5 22) and activator
Even without mandibular retrognathia, Class II Division (n 5 16) groups according to the treatment protocols.
1 malocclusion is associated with a narrower upper The demographic data are shown in Table I. The
airway structure.10 Therefore, maxillary orthopedic mean ages of the subjects in the cervical headgear, acti-
treatment procedures may induce an adverse change vator, and control groups at the beginning of treatment
to the upper airway space that promotes or aggravates were 10.6 6 1.0, 10.3 6 1.5, and 10.2 6 1.4 years,
a breathing disorder, in contrast with the positive effects respectively. The durations between pretreatment and
of mandibular orthopedic treatment procedures that follow-up records were 1.1, 1.3, and 1.0 years for the
were suggested to enhance the airway and lead to the cervical headgear, activator, and control groups, respec-
resolution of preexisting airway disturbance. tively. Lateral cephalograms were assessed at pretreat-
The effects of orthopedic appliances used for Class II ment and posttreatment or follow-up. Cephalometric
treatments, either with functional appliances or cervical variables representing the dentoskeletal pattern (Fig 1)
headgear, have been reported in the literature. However, were assessed by the combination of the cephalometric
the influence of orthopedic appliances on the upper analyses of Steiner15 and Downs.16 Analysis of pharyn-
airway of patients with maxillary protrusion or mandib- geal airway size (Fig 2) was based on the method of Mo-
ular retrusion in comparative studies is limited. The chida et al.17 All lateral cephalometric radiographs were
purpose of this study was to test the null hypothesis traced manually, and all angular and linear measure-
that the use of functional appliance for treatment of ments were done by 1 author (H.G.C.).
mandibular retrognathism or cervical headgear for
maxillary prognathism causes no change on the upper Statistical analysis
airway in Class II malocclusion. The descriptive statistics were calculated as means and
standard deviations. The data were analyzed using SPSS
MATERIAL AND METHODS statistical software (version 21.0; IBM, Armonk, NY).
Class II subjects were selected from the archive of The intraclass correlation coefficients were calculated
Department of Orthodontics, School of Dentistry, for the assessment of intraexaminer reliability. The
Hacettepe University, in Ankara, Turkey, according to intragroup comparisons were performed by using paired-
the following selection criteria: (1) ANB angle greater samples t tests, and intergroup comparisons of the skeletal

American Journal of Orthodontics and Dentofacial Orthopedics September 2017  Vol 152  Issue 3
366 Aksu, Gorucu-Coskuner, and Taner

Fig 1. Skeletodental measurements ( ): 1, SNA: the Fig 2. Pharyngeal airway measurements (mm): 7, poste-
angle between the SN and NA planes; 2, SNB: the angle rior airway space: the anteroposterior depth of the phar-
between the SN and NB planes; 3, ANB: the angle be- ynx measured between the posterior pharyngeal wall
tween the NA and NB planes; 4, FMA: the angle between and the posterior nasal spine on a line parallel to the
the Frankfort horizontal plane and the mandibular plane; Frankfort horizontal plane through the posterior nasal
5, SN-1: the angle between the maxillary incisor long spine; 8, superoposterior airway space: the anteroposte-
axis and the SN plane; 6, IMPA: the angle between the rior depth of the pharynx measured between the posterior
mandibular incisor long axis and the mandibular plane. pharyngeal wall and the dorsum of the soft palate on a line
parallel to the Frankfort horizontal plane through the mid-
dle of the line from the posterior nasal spine to the tip of
features and upper airways were performed with 1-way the soft palate; 9, middle airway space: the anteroposte-
analysis of variance, with the Tukey test as a second step. rior depth of the pharynx measured between the posterior
P \ 0.05 was considered statistically significant. pharyngeal wall and the dorsum of the tongue on a line
parallel to the Frankfort horizontal plane through the tip
RESULTS of the soft palate; 10, inferior airway space: the anteropos-
terior depth of the pharynx measured between the poste-
The intraclass correlation coefficient values differed rior pharyngeal wall and the surface of the tongue on a
between 0.916 and 0.988 for airway variables and line parallel to the Frankfort horizontal plane through the
0.941 and 0.991 for skeletodental variables. most anteroinferior point on the body of the second cervi-
Means, standard deviations, and multiple compari- cal vertebra; 11, epiglottic airway space: the anteroposte-
sons representing skeletal and airway differences at rior depth of the pharynx measured between the posterior
pretreatment among the 3 groups are shown in Table II. pharyngeal wall and the surface of the tongue on a line
No statistically significant differences were found in parallel to the Frankfort horizontal plane through the tip
SNA, SNB, ANB, FMA, and IMPA or in airway variables of the epiglottis.
at pretreatment (P . 0.05). The only statistically signifi-
cant difference was in the SN-1 angle. The maxillary Mean changes from pretreatment to follow-up in
incisors had significantly greater protrusion in activator airway variables during the treatment and follow-up
group than in the cervical headgear group (P \ 0.05). periods are shown in Table III. Cervical headgear
Mean changes from pretreatment to follow-up in treatment resulted in decreases in posterior airway
skeletodental variables during the treatment and space ( 1.4 6 4.8 mm), superoposterior airway
follow-up period are shown in Table III. Among the space ( 0.4 6 2.1 mm), inferior airway space
skeletodental variables, in the cervical headgear group, ( 0.3 6 2.3 mm), and epiglottic airway space
the SNA ( 1.0 6 1.4 ) and ANB ( 1.1 6 0.7 ) angles ( 0.1 6 2.3 mm) that were not statistically signifi-
decreased significantly (P \ 0.05). In the activator cant. Activator treatment resulted in increases in pos-
group, there were statistically significant increases in terior airway space (1.1 6 4.7 mm), superoposterior
the SNB angle and significant decreases in the ANB airway space (0.9 6 1.9 mm), inferior airway space
and SN-1 angles. No significant difference was seen in (0.5 6 2.7 mm), and epiglottic airway space
the control group at follow-up for the skeletodental (0.2 6 2.7 mm) that were not statistically significant,
variables. but there was a significant increase of 1.6 6 2.5 mm

September 2017  Vol 152  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Aksu, Gorucu-Coskuner, and Taner 367

Table II. Means, standard deviations, and multiple comparisons representing skeletal and airway differences at pre-
treatment among the 3 groups
Skeletodental Cervical headgear Activator Control
variables (n 5 22) (mean 6 SD) (n 5 16) (mean 6 SD) (n 5 19) (mean 6 SD) Multiple comparisons*
SNA ( ) 81.2 6 2.9 82.2 6 3.4 80.2 6 2.8
SNB ( ) 75.2 6 3.2 76.0 6 3.2 75 6 3.0
ANB ( ) 5.9 6 1.8 6.2 6 1.2 5.3 6 1.1
FMA ( ) 24.1 6 5.6 21.1 6 4.4 24.8 6 5.3
SN-1 ( ) 104.3 6 5.6 109.3 6 6.1 106.1 6 56.4 1-2
IMPA ( ) 100.2 6 6.7 99.5 6 7.9 95.3 6 6.2
Airway variables
PAS (mm) 23.9 6 4.8 23.8 6 5.1 24.4 6 5.2
SPAS (mm) 11.7 6 2.8 11.4 6 2.5 11.9 6 3.2
MAS (mm) 14.5 6 4.0 13.8 6 4.8 12.5 6 3.2
IAS (mm) 10.4 6 3.9 9.9 6 3.0 11.6 6 3.1
EAS (mm) 7.9 6 3.8 7.3 6 2.6 8.2 6 3.5
PAS, Posterior airway space; SPAS, superoposterior airway space; MAS, middle airway space; IAS, inferior airway space; EAS, epiglottic airway
space.
*Significant differences between the groups are presented.

Table III. Mean changes from pretreatment (T1) to follow-up (T2) in skeletodental and airway variables during
treatment
Cervical headgear Activator Control
(n 5 22) (mean 6 SD) (n 5 16) (mean 6 SD) (n 5 19) (mean 6 SD)
Skeletodental
variables T1 T2 P value* T1 T2 P value* T1 T2 P value*
SNA ( ) 81.2 6 2.9 80.1 6 3.3 0.03 82.2 6 3.4 82.3 6 3.1 80.2 6 2.8 80.5 6 2.8
SNB ( ) 75.2 6 3.2 75.3 6 3.4 76.0 6 3.2 77.6 6 3.4 0.007 74.9 6 3.0 75.2 6 3.1
ANB ( ) 5.9 6 1.8 4.8 6 1.9 0.00 6.2 6 1.2 4.7 6 1.5 0.00 5.3 6 1.1 5.3 6 1.3
FMA ( ) 24.1 6 5.6 24.2 6 5.7 21.1 6 4.4 21.2 6 3.6 24.8 6 5.3 24.7 6 5.3
SN-1 ( ) 104.3 6 5.6 103.2 6 4.7 109.3 6 6.1 102.7 6 5.9 0.00 106.1 6 6.4 103.9 6 6.6
IMPA ( ) 100.2 6 6.7 99.5 6 7.2 99.5 6 7.9 100.6 6 8.0 95.3 6 6.2 95.2 6 6.9
Airway variables
PAS (mm) 23.9 6 4.8 22.5 6 6.1 23.8 6 5.1 24.9 6 6.3 24.4 6 5.2 24.1 6 5.4
SPAS (mm) 11.7 6 2.8 11.3 6 2.8 11.4 6 2.5 12.3 6 3.3 11.9 6 3.2 12.2 6 2.6
MAS (mm) 14.5 6 4.0 14.6 6 3.9 13.8 6 4.8 15.4 6 4.5 0.021 12.5 6 3.2 10.9 6 2.9 0.01
IAS (mm) 10.4 6 3.9 10.1 6 3.5 9.9 6 3.0 10.4 6 3.1 11.6 6 3.1 10.7 6 2.9
EAS (mm) 7.9 6 3.8 7.9 6 2.4 7.3 6 2.6 7.4 6 3.5 8.2 6 3.5 7.5 6 3.4
PAS, Posterior airway space; SPAS, superoposterior airway space; MAS, middle airway space; IAS, inferior airway space; EAS, epiglottic airway
space.
*P \ 0.05.

at middle airway space. The Class II control group of the ANB angle with the cervical headgear and acti-
showed nonsignificant decreases in posterior airway vator treatments did not show statistically significant
space ( 0.3 6 2.6 mm), inferior airway space differences (P . 0.05), but the decreases of the ANB
( 0.8 6 1.9 mm), and epiglottic airway space angle in the activator and cervical headgear groups
( 0.7 6 1.8 mm) and a significant decrease at mid- were significantly different from the control group
dle airway space ( 1.5 6 2.3 mm). (P \ 0.05). According to the SN-1 angle, the amount
The comparison of treatment changes in the skeleto- of retrusion of the maxillary incisors with treatment
dental and airway variables in the cervical headgear, was significantly greater in the activator group than in
activator, and control groups is shown in Table IV. The the cervical headgear and control groups (P \ 0.05).
increase of the SNB angle with treatment was signifi- When the airway variables were evaluated, the only sig-
cantly greater in the activator group than in the cervical nificant difference was found between the middle airway
headgear and control groups (P \ 0.05). The decreases spaces of the activator and control groups (P \ 0.05);

American Journal of Orthodontics and Dentofacial Orthopedics September 2017  Vol 152  Issue 3
368 Aksu, Gorucu-Coskuner, and Taner

Table IV. Comparison of treatment changes in skeletodental and airway variables in the cervical headgear, activator,
and control groups
Skeletodental Cervical headgear Activator Control
variables (n 5 22) (mean 6 SD) (n 5 16) (mean 6 SD) (n 5 19) (mean 6 SD) Multiple comparisons*
SNA ( ) 1.0 6 1.4 0.1 6 1.9 0.3 6 0.7 1-3
SNB ( ) 0.1 6 1.1 1.6 6 2.1 0.2 6 1 1-2, 2-3
ANB ( ) 1.1 6 0.7 1.5 6 0.9 0.0 6 0.8 1-3, 2-3
FMA ( ) 0.2 6 2.9 0 6 3.0 0.1 6 2.2
SN-1 ( ) 1.1 6 4.2 6.7 6 4.8 2.2 6 5.7 1-2, 2-3
IMPA ( ) 0.7 6 5.8 1.0 6 5.3 0.2 6 2.8
Airway variables
PAS (mm) 1.4 6 4.8 1.1 6 4.7 0.3 6 2.6
SPAS (mm) 0.4 6 2.1 0.9 6 1.9 0.2 6 2.1
MAS (mm) 0.1 6 3.3 1.6 6 2.5 1.5 6 2.3 2-3
IAS (mm) 0.3 6 2.3 0.5 6 2.7 0.8 6 1.9
EAS (mm) 0.1 6 2.3 0.2 6 2.7 0.7 6 1.8
PAS, Posterior airway space; SPAS, superoposterior airway space; MAS, middle airway space; IAS, inferior airway space; EAS, epiglottic airway
space.
*Significant differences between the groups are presented.

the middle airway space showed a significant increase in airways of patients with Class II malocclusions.
the activator group and a decrease in the control group. However, few studies have addressed the upper airway
outcomes with cervical headgear. This might be due to
DISCUSSION the findings of Hiyama et al25 and Pirila-Parkkinen
Class II malocclusion is derived from either the protru- et al,26 who found that cervical headgear reduced the
sive position of the maxilla or the retrusive position of the sagittal dimensions of the upper airway and might
mandible. The treatment often consists of orthopedic contribute to sleep apnea. Therefore, this study was
appliances, resulting in a restriction of the maxillary conducted to compare the effects of 2 orthopedic
growth with headgear1-3 or protrusion of the mandible appliances in terms of the upper airway.
with functional appliances.4,5 Because both types of Our results, while pointing to a statistically signifi-
appliances affect the retromaxillary and retromandibular cant improvement of maxillomandibular relationships
regions, near the nasopharyngeal area, one can assume with both headgear (SNA, 1.0 6 1.4 ; ANB,
that the upper airway may change because of the 1.1 6 0.7 ) and activator (SNB, 1.6 6 2.1 ; ANB,
 

orthodontic appliances used for changing the jaw 1.5 6 0.9 ), did not show any clinically significant
positions. The main purpose of this study was to change along the airway space except in the middle
examine the effects of treatment of maxillary protrusion airway space (1.6 6 2.5 mm) with the activator.
and mandibular retrusion on airway dimensions in Class Recently, Li et al21 reported enlargement of the
II patients. The patients having orthopedic treatment in oropharynx and hypopharynx 3 dimensionally after
this study had Class II malocclusions. The remarkable Twin-block therapy. Although 3-dimensional imaging
point of this study was that the SNA, SNB, ANB, and would be the appropriate method for the evaluation of
FMA angles and the airway measurements among the upper airway dimensions, the conventional lateral ceph-
groups were not significantly different at pretreatment. alogram remains a valuable and reliable diagnostic tool,
However, either headgear or a functional appliance was since high correlations between posterior airway size on
used for Class II treatment; this was inevitable because cephalometric radiographs and pharyngeal volume
of the subject-dictated appliance selection. To distinguish measured on tomographic scans have been reported.27
the normal development of the skeletal and airway Kirjavainen and Kirjavainen10 evaluated the effects of
structures, a control group was necessary. A Class II cervical headgear treatment on upper airway structures
control group that did not receive orthopedic treatment in children and compared the results with a Class I con-
was used to determine the isolated effect of the trol group. The children with Class II malocclusion had
orthopedic treatment. narrower oropharynges and hypopharynges before and
Many studies have been conducted for understand- after the treatment, but the retropalatal area was
ing the treatment effects of functional widened by cervical headgear treatment. In our study,
appliances13,14,18-23 and headgear10,14,23,24 on the in contrast to the findings of Kirjavainen and

September 2017  Vol 152  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Aksu, Gorucu-Coskuner, and Taner 369

Kirjavainen,10 there were no statistically significant dif- a quiescent period for pharyngeal structures has been
ferences at pretreatment in the airway dimensions reported.31 Contrary to the expectations of Class II
among the activator, cervical headgear, and control subjects, a minimal airway distance was not found to
groups, and no statistically significant differences were be correlated with the SNA, SNB, and ANB angles or
observed in the airway measurements after cervical any vertical dimensions. The size of the airway shows
headgear treatment. On the other hand, our findings wide interindividual variations and is generally quite
agree with the study of Zheng et al,24 who concluded independent of the skeletal parameters.32
that the upper airway dimensions were not decreased In our study, the only significant increase was shown
with headgear treatment. in middle airway space with activator treatment; although
A study with a similar purpose and method to our the change was not significantly different from that in the
study was the cephalometric study by Godt et al,23 cervical headgear group, it was significantly different
who investigated 3 treatment protocols (headgear, acti- from the control group. During the follow-up period,
vator, and bite-jumping appliance) to compare the the Class II control group showed a significant decrease
changes in upper airway width. According to the at middle airway space, so one can assume that mandib-
authors, Class II treatment had no or only minor effects ular forward positioning with activator treatment has the
on anteroposterior pharyngeal width. Their findings potential for increasing pharyngeal airway passage only
agree with ours that upper airway changes do not vary at the middle airway space level. On the other hand,
between different treatment protocols. headgear treatment resulted in no significant change at
In addition to the consistent findings, contraversial any level of the airway.
results have also been reported. In a study by H€anggi In this study, 2-dimensional imaging was used to
et al,14 the changes in the pharyngeal airway during evaluate 3-dimensional pharyngeal structures. Cephalo-
growth in children and adolescents were measured and grams are still widely used to evaluate pharyngeal
compared with those of a group whose distocclusion airways. However, only the static position of the airway
had been treated by activator headgear therapy. The structures could be evaluated by lateral cephalometric
results showed significant differences between the 2 radiographs. Another limitation of this study was that
groups before and after treatment: in the activator head- it is difficult to reliably interpret skeletal and airway
gear group, the mandibular malposition decreased more changes in a study with a retrospective design. There-
markedly, and there were greater increases in pharyngeal fore, we suggest that these results should be interpreted
area, pharyngeal length, and the narrowest distance cautiously because of the 2-dimensional evaluation and
between the tongue and the posterior pharyngeal wall. the retrospective design of the study.
Jena et al18 compared the effects of the Twin-block
and the mandibular protraction appliance IV and stated CONCLUSIONS
that the Twin-block was more efficient than the mandib- Maxillary protrusion and mandibular retrusion
ular protraction appliance IV in the improvement of decreased when cervical headgear and activator were
pharyngeal airway passages. Likewise, Ghodke et al22 used, respectively. Although significant skeletal
and Li et al21 evaluated the effectiveness of the Twin- improvements were found in all groups, the upper
block appliance on lateral cephalograms and cone- airway sizes of Class II patients did not show any differ-
beam computed tomography images, respectively, and ences after cervical headgear or activator treatment. The
pointed out that the correction of mandibular retrusion middle airway space in the activator group increased
by the Twin-block appliance in patients with Class II significantly when compared with the Class II patients
malocclusion increased the pharyngeal airway passages. who did not receive orthopedic treatment.
In a study by Restrepo et al,28 50 prepubertal patients
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September 2017  Vol 152  Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
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