European Journal of Orthodontics 30 (2008) 61–66
doi:10.1093/ejo/cjm076
Advance Access publication 28 September 2007
© The Author 2007. Published by Oxford University Press on behalf of the European Orthodontic Society.
All rights reserved. For permissions, please email: journals.permissions@oxfordjournals.org.
Effects on the sagittal pharyngeal dimensions of protraction and
rapid palatal expansion in Class III malocclusion subjects
Ali Serdar Kilinç*, Seher Gündüz Arslan**, Jalen Deveciog˘ lu Kama**, Törün Özer**
and Osman Dari***
*Private Practice, Gaziantep, **Department of Orthodontics, Faculty of Dentistry, University of Dicle, Diyarbakır
and ***Private Practice, Antalya, Turkey.
This study examined the effects of rapid palatal expansion (RPE) and maxillary protraction
headgear therapy in 18 patients with a skeletal Class III malocclusion (11 girls and seven boys; mean
age 10.9 years) on upper airway dimensions compared with an untreated control group (nine girls and
eight boys; mean age 10.9 years). Pre- and post-treatment cephalometric radiographs were traced and
analysed at similar time intervals. The average treatment time was 6.94 ± 0.56 months. Wilcoxon’s test
was used for intragroup comparisons and the Mann–Whitney U-test for intergroup comparisons.
A significant increase occurred in the maxillary forward position. Mandibular forward movement
and downward and backward rotation were inhibited. In addition, the upper incisors were proclined
(P < 0.001), and the lower incisors were significantly retroclined (P < 0.05). When the treatment and
control groups were compared, the upper airway linear measurements (pns-ad1, pns-ad2, APW-PPW,
APW’-PPW’) and the nasopharyngeal area had increased in the treatment group.
These results demonstrated that maxillary expansion together with protraction of the maxilla improved
naso- and oropharyngeal airway dimensions in the short term.
SUMMARY
Class III malocclusions are considered to be among the
most challenging malocclusions to treat. Studies on the
multifactorial aetiology of Class III malocclusions have
shown that true maxillary skeletal retrusion is as frequent
as mandibular prognathism and that 32–63 per cent of
patients with a skeletal Class III malocclusion have a
retruded maxilla or a combination of a retruded maxilla
and excessive mandibular growth (Sanborn, 1955;
Jacobson et al., 1974; Ellis and McNamara, 1984; Guyer
et al., 1986; Williams and Andersen, 1986). Enlow (1982)
described the typical Class III individual as having a
middle cranial fossa that is aligned in a backward and
upward manner, resulting in the nasomaxillary complex
being in a more retrusive position. The ramus is often
rotated forward with upward and backward displacement
of the middle cranial fossa and a vertically short nasal
region (Sanborn, 1955; Jacobson et al., 1974; Enlow,
1982; Ellis and McNamara, 1984; Guyer et al., 1986;
Williams and Andersen, 1986).
It has been almost 100 years since Class III malocclusions
characterized by maxillary retrusion were being treated with
protraction headgear (Postpeschnigg, 1875) that applies
continuous and directional anterior force. A number of
animal studies have shown that continuous protraction force
causes significant anterior displacement concurrently with
histological changes in the maxillary and circummaxillary
sutures (Kambara, 1971; Jackson et al., 1979).
Maxillary displacement can be easily achieved using
rapid palatal expansion (RPE). Using both appliances
(RPE + protraction headgear) combined can weaken the
sutural junctions of the maxilla with the other nine bones
of the craniofacial structure and allows the protraction
force to work effectively (Haas, 1970; Bell, 1982). Palatal
expansion with protraction headgear is an accepted and
routine part of the treatment of Class III malocclusions
(Turley, 2002).
The changes in the upper airway dimensions and
craniofacial structures related to RPE and maxillary
protraction protocols have not been compared with an
untreated Class III control group, although the severe
maxillary hypoplasia seen in craniofacial anomalies is
thought to constrict the upper airway, including the nasal
cavity and velopharynx (Handler, 1985; Hui et al., 1998). A
positive effect of midface distraction on alleviating upper
airway obstruction in the midface hypoplasia seen with
achondroplasia was recently reported (Elwood et al., 2003),
and the change in respiratory function induced by RPE has
also been documented (Basciftci et al., 2002; Doruk et al.,
2004). A maxillary protraction appliance used in combination
with a chin cap alters the upper airway dimensions during
maxillary protraction (Hiyama et al., 2002). Thus, the aim
of this study was to determine the effects of RPE and
maxillary protraction headgear on the upper airway
dimensions (naso- and oropharyngeal airway) compared
with an untreated control group.
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Introduction
62
A. S. KILINÇ ET AL.
Materials and methods
Cephalometric analysis
Cephalometric radiographs were obtained in the natural
head position (NHP; Solow and Tallgren, 1971) at a filmfocus distance of 155 cm with a midsagittal plane-to-film
Table 1 Chronological age distribution (years).
Treatment
Control
Minimum
Maximum
Mean
SD
9.3
9.9
11.9
11.8
10.5
10.9
0.93
0.82
SD, standard deviation.
Statistical analysis and method error
Statistical analysis was undertaken using version 6 of the
Statistical Package for Social Sciences (SPSS Inc., Chicago,
Illinois, USA). Wilcoxon’s test was used to evaluate the
treatment effects and changes during the observation period
Figure 1 Reference points and angular measurements. Reference points
(Linder-Aronson, 1970): Hyoid (hy), the most postero-superior point on
the body of the second cervical vertebra (cv2); cv2tg, the most posteroinferior point on the body of cv2; cv2ip, the most postero-inferior point on
the body of cv2; cv4ip, the most antero-inferior point on the body of the
fourth cervical vertebra (cv4ia); ad2, the intersection between a line from
posterior nasal spine (pns) to the midpoint of a line joining basion (ba) and
sella (s) and the posterior contour of the adenoid soft tissue shadow; ad1,
the intersection between a line from pns to ba and the posterior contour of
the adenoid soft tissue shadow; APW, the anterior pharyngeal wall along
the line intersecting cv2ia and hy; PPW, the posterior pharyngeal wall
along the line intersecting cv2ia and hy; APW′, the
anterior pharyngeal wall along the line intersecting cv4ia and hy; PPW′,
the posterior pharyngeal wall along the line intersecting cv4ia and hy.
Angular measurements: 1-SNA, 2-SNB, 3-ANB, 4-U1 to NSL, 5-L1 to
ML, 6-NSL/ML, 7-NSL/CVT; NSL, nasion sella line; ML, mandibular
plane; NSL-CVT, the angle between line NSL and the line from cv4ip to
cv2ip (cervical vertebra tangent).
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Lateral cephalometric radiographs of 18 patients (11 girls,
seven boys) treated at the Department of Orthodontics,
Faculty of Dentistry, Dicle University, Diyarbakir, Turkey,
and 17 untreated control subjects (nine girls and eight boys)
were examined. The first radiograph (T1) was taken before
appliance therapy and the second (T2) after achieving a
positive overjet but before a second phase of fixed appliance
treatment. The records included in the treatment group were
selected retrospectively. The criteria used were the presence
of a skeletal Class III malocclusion with maxillary skeletal
retrusion, the absence of other congenital anomalies, an
anterior crossbite with a Class III molar relationship, and no
mandibular displacement.
The control subjects, selected from the clinic archive, had
been used in two previous studies (Kama et al., 2006;
Özbaş, 2006). The control subjects were matched according
to the skeletal maturation stage and chronological age and
had a Class III skeletal malocclusion with maxillary skeletal
retrusion. The control period was 9.82 ± 0.48 months [mean
± standard deviation (SD)]. The mean ages at T1 for the
treatment and control groups are shown in Table 1. To
evaluate the maturation stage, hand–wrist radiographs were
used. All the treatment and control subjects were between
PP2 and MP3cap developmental stages at T1.
The treatment groups were treated successfully with
protraction headgear and RPE. Expansion was achieved
using a banded Hyrax expansion appliance. The first
permanent molars and first premolars or the first primary
molars were banded. After obtaining alginate impressions, a
Hyrax screw was soldered to the bands on the models in
an antero-posterior direction. Following cementation, an
orthodontist first activated the appliance; the patients were
then asked to activate the screw twice a day for 7 days. At
the end of day 7, protraction therapy commenced. A Petittype facemask was used with 600–700 g of force applied
bilaterally. The direction of the elastics was approximately
20 degrees below the occlusal plane. The patients were
instructed to wear the appliance for at least 18 hours a day.
The treatment time was 6.94 ± 0.56 months (mean ± SD).
distance of 12.5 cm. NHP was achieved by having the
subjects look into their own eyes in a mirror while
standing in the orthoposition defined by Mølhave (1958).
The cephalometric radiographs were traced and the
reference points (Linder-Aronson, 1970; Figure 1) were
marked on the two films for each subject simultaneously
by one author (JDK) to obtain maximum agreement when
marking.
Area measurements: the total, nasopharyngeal (NA), and
oropharyngeal areas (Figure 2) were measured using Image
tool 3.0 software (UTHSCSA, University of Texas Health
Science Center at San Antonio, Texas, USA).
63
PHARYNGEAL SAGITTAL DIMENSIONS IN CLASS III SUBJECTS
Table 2 The reliability coefficient for the cephalometric
measurements.
Reproducibility coefficient
SNA (º)
SNB (º)
ANB (º)
U1 to NSL (º)
L1 to ML (º)
NSL/ML (º)
NSL/CVT (º)
pns-ad1 (mm)
pns-ad2 (mm)
APW-PPW (mm)
APW′-PPW′ (mm)
NA (mm2)
OA (mm2)
TA (mm2)
0.9979
0.9964
0.9833
0.9829
0.9947
0.9913
0.9984
0.9768
0.9721
0.9956
0.9802
0.9816
0.9801
0.9804
Table 3 Descriptive variables and comparison of the changes in
the treatment group (n = 18) at the start (T1) and end (T2) of rapid
palatal expansion.
Figure 2 Upper airway distance measurements. pns-ad1, the distance
from posterior nasal spine (pns) to the posterior pharyngeal wall (ad1) along
the line from pns to basion (ba); pns-ad2, the distance from pns to the
adenoid tissue (ad2) along the line from pns to the midpoint of a line joining
ba and the centre of sella turcica (s); APW-PPW, pharyngeal depth, the
linear distance on the line connecting points hy and cv2ia, between the
intersection point on the anterior and posterior pharyngeal walls; APW′PPW′, pharyngeal depth, the linear distance on the line connecting points
hy and cv4ip, between the intersection point on the anterior and posterior
pharyngeal walls. Upper airway area measurements: the total area of the
upper airway was divided into two parts; nasopharyngeal area (NA) and
oropharyngeal area (OA) by an extension of the palatal plane (NL). The
line from hy point to cv3ia point, which intersects the anterior and posterior
pharyngeal walls, was accepted as the lower border of oropharyngeal area.
in each group, and the differences between the groups were
determined using a Mann–Whitney U-test.
To evaluate the error in cephalometric tracing, 10 randomly
selected radiographs were retraced and re-evaluated by the
same author aftter a 3-week interval. The reliability
coefficients for the measurements due to cephalometric
errors are given in Table 2.
Results
The changes that occurred during RPE and facemask
therapy are presented in Table 3. The parameters
pertaining to the sagittal maxillary position (SNA)
demonstrated that point A moved anteriorly. The decrease
in SNB angle demonstrated counterclockwise rotation
parallel with clockwise rotation of the mandible. The
vertical parameter, NSL/ML, increased significantly. The
upper incisors tipped labially and the lower incisors
lingually.
SNA (º)
SNB (º)
ANB (º)
U1 to NSL (º)
L1 to ML (º)
NSL/ML (º)
NSL/CVT (º)
pns-ad1 (mm)
pns-ad2 (mm)
APW-PPW (mm)
APW′-PPW′ (mm)
NA (mm2)
OA (mm2)
TA (mm2)
Mean, T1
SD
Mean, T2
SD
P
75.23
78.03
−1.80
99.46
86.06
34.13
108.93
13.73
18.00
11.73
14.60
213.99
827.59
1041.58
2.21
2.30
1.96
3.39
9.42
5.02
11.00
6.94
6.27
3.88
4.86
40.05
270.42
340.38
77.13
76.50
1.63
106.73
82.66
36.66
111.57
18.36
23.60
13.20
18.73
287.29
938.75
1226.04
2.58
2.17
1.74
4.35
10.21
5.23
7.95
5.14
4.23
3.80
4.77
23.80
306.23
375.17
***
***
***
***
*
**
*
**
*
**
*
**
NS
NS
SD, standard deviation; P, probability.
*P < 0.05; **P < 0.01; ***P < 0.001; NS, not significant.
The changes that occurred during the follow-up period in
the control group are presented in Table 4. Significant
increases were found for SNA, SNB, and the oropharyngeal
dimensions (APW-PPW, APW′-PPW′) with growth and
development.
The changes in each group differed with treatment (Table
3) or natural growth (Table 4). Comparison of the control
and treated groups showed the ‘real’ effects of treatment
(Table 5). The increase in SNA and decrease in SNB
demonstrated that counterclockwise maxillary rotation
occurred in parallel with clockwise rotation of the
mandible. The vertical parameter NSL/ML increased
significantly. The upper incisors tipped labially and the
lower incisors lingually. With RPE and maxillary protraction,
significant increases were observed in the nasopharyngeal
and oropharyngeal dimensions. The head was in a more
extended position relative to the cervical vertebrae, as
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Parameters
64
A. S. KILINÇ ET AL.
Table 4 Descriptive variables and comparison of the changes
with growth in the control group, n = 17 at the start (C1) and end
(C2) of the observation period.
SD
Mean, C2
SD
P
74.80
77.66
−2.86
100.93
84.13
35.43
107.63
14.53
20.03
14.30
13.73
212.30
818.65
1030.96
4.00
3.87
1.32
6.47
5.40
4.23
8.32
2.61
3.78
5.14
3.28
39.34
189.39
189.42
75.90
79.06
−3.16
101.86
84.30
34.06
107.16
15.10
20.00
14.50
14.60
226.26
766.29
992.56
3.19
3.42
1.93
6.16
5.33
4.37
6.28
2.87
3.89
4.39
2.97
60.27
132.25
119.55
*
*
NS
NS
NS
NS
NS
NS
NS
*
*
NS
NS
NS
SD, standard deviation; P, probability.
*P < 0.05; **P < 0.01; ***P < 0.001; NS, not significant.
Table 5 Statistical comparison of the changes between the
treated (n = 18) and control (n = 17) groups at the start (T1/C1) and
end (T2/C2) of treatment/observation.
SNA (º)
SNB (º)
ANB (º)
U1 to NSL (º)
L1 to ML (º)
NSL/ML (º)
NSL/CVT (º)
pns-ad1 (mm)
pns-ad2 (mm)
APW-PPW (mm)
APW′-PPW′ (mm)
NA (mm2)
OA (mm2)
TA (mm2)
Differences
(T2−T1)
SD
Differences
(C2−C1)
SD
P
1.90
−1.53
3.43
7.27
−3.40
2.53
2.64
4.63
5.60
1.47
4.13
73.30
111.16
184.46
0.96
0.87
0.90
3.84
4.13
4.38
2.26
5.32
1.84
4.35
7.07
25.17
373.65
427.21
1.10
1.37
−0.30
0.93
0.17
−1.37
−0.47
0.57
−0.03
0.20
−0.87
13.96
−52.36
−38.40
1.94
1.98
1.76
4.01
2.04
0.97
1.90
0.76
1.36
1.26
5.73
37.22
151.84
143.56
*
***
***
***
*
**
**
***
*
**
***
*
NS
NS
SD, standard deviation; P, probability.
*P < 0.05; **P < 0.01; ***P < 0.001; NS, not significant.
confirmed by the 2.64 degree increase in NSL/CVT. The
mean increases for the nasopharyngeal airway measurements
(pns-ad1, pns-ad2) were 4.63 and 5.60 mm, respectively, and
those for the oropharyngeal airway measurements (APWPPW, APW′-PPW′) 1.47 and 4.13 mm, respectively. A 73.3mm2 increase was observed in the NA (Tables 3 and 5).
Discussion
This investigation compared the pure effects of maxillary
protraction treatment protocols and evaluated the differences
in the skeletal and upper airway dimensions after treatment.
There are studies in the literature where Class I control
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SNA (º)
SNB (º)
ANB (º)
U1 to NSL (º)
L1 to ML (º)
NSL/ML (º)
NSL/CVT (º)
pns-ad1 (mm)
pns-ad2 (mm)
APW-PPW (mm)
APW′-PPW′ (mm)
NA (mm2)
OA (mm2)
TA (mm2)
Mean, C1
groups have been used; however, the dentoalveolar and
skeletal growth trends in subjects with a Class III
malocclusion may differ from those of ‘normal’ subjects.
The need to use a Class III adequately matched control
sample to make valid comparisons is therefore essential.
Furthermore, there are examples which show that Class I
control groups are not suitable for comparison with Class
III treatment groups (Tindlund, 1989; Takada et al., 1993;
Shanker et al., 1996) Therefore, to explain the basic effects
of the protocol, the treatment group was compared with
untreated Class III patients as a control group. For this
purpose, radiographs were chosen from similar age groups
and treatment/control durations.
The mean ages of the control and treatment groups were
10.9 and 10.5 years, respectively. Clinical studies have used
maxillary protraction in the late-mixed to early permanent
dentition stages of development in order to take maximum
advantage of growth (Irie and Nakamura, 1975; Ishii et al.,
1987; Takada et al., 1993).
In this study, an increase in SNA and a decrease in SNB
were observed in the treatment group. In fact, the decrease
in SNB was not related to the inhibition of mandibular
growth but occurred as a result of clockwise rotation of the
mandible. In the vertical plane, a significant increase in
NSL/ML was observed, indicating clockwise rotation of the
mandible (mean = 2.53 degrees) as an effect of combined
RPE and facemask therapy. In contrast, NSL/ML decreased
in the control group, although not significantly. This clearly
indicates that posterior rotation of the mandible occurred as
an effect of the facemask therapy.
In maxillary protraction studies, the maxilla moves
anteriorly (Björk, 1966; Iseri and Solow, 1990), increasing
SNA (Turley, 1988; Shanker et al., 1996; Nartallo-Turley
and Turley, 1998), and the maxilla often rotates in a
counterclockwise direction, with posterior nasal spine
moving inferiorly more than anterior nasal spine. This
vertical movement of the maxilla is accompanied by
clockwise rotation of the mandible, causing the chin to
move downward and backward. Lower anterior face
height increases, while overbite decreases (Irie and
Nakamura, 1975; Nanda, 1980; Nanda and Hicory, 1984;
Ishii et al., 1987; Mermigos et al., 1990; McNamara and
Brudon, 1993; Takada et al., 1993; Turley, 1996). The
results of the present study are compatible with these
findings.
It has also been reported that the treatment effects of
maxillary protraction include retroclination of the lower
incisors and proclination of the maxillary incisors
(McNamara and Brudon, 1993; Kim et al., 1999).
Treatment increased U1 to NSL by 7.27 degrees. The mean
change in L1 to ML decreased significantly for the
treatment group compared with the controls. There is a
certain relationship between craniocervical angle and
craniofacial morphology (Solow and Sandham, 2002).
After treatment, the head was in a more extended position
65
PHARYNGEAL SAGITTAL DIMENSIONS IN CLASS III SUBJECTS
Conclusions
This findings of the study demonstrated that RPE together
with protraction of the maxilla improved the naso- and
oropharyngeal airway dimensions in the short term.
The present and previous studies concerning airway
dimensions were based on two-dimensional cephalometric
measurements and thus have limitations. An examination of
the changes that any treatment produces in the upper airway
should include three-dimensional measurements using
different imaging systems. Moreover, future research on
this topic should monitor respiratory function.
Address for correspondence
Seher Gündüz Arslan
Dicle University
Dental Faculty
Department of Orthodontics
Diyarbakır
Turkey
E-mail: agseher@hotmail.com
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expected from growth and development regardless of
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66
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