ORIGINAL ARTICLE

Effects of maxillary protraction therapy on the

pharyngeal airway in patients with repaired
unilateral cleft lip and palate: A 3-dimensional
computed tomographic study
Zhen Fu,a Yifan Lin,b Lian Ma,c and Weiran Lid
Beijing, China

Introduction: The purposes of this study were to assess the effects of maxillary protraction therapy on the
pharyngeal airways in patients with repaired unilateral cleft lip and palate (UCLP) 3 dimensionally.
Methods: Eighteen patients with repaired UCLP and anterior crossbite (ages, 10.4 6 1.3 years) were enrolled
in the study group. Hyrax appliances and reverse headgears were used. Cone-beam computed tomography
volume scans were taken before and immediately after treatment. Fourteen patients (ages, 9.6 6 1.7 years)
with UCLP who did not receive orthopedic treatment served as the control group. The volumes of the
pharyngeal airways, cross-sectional areas, sagittal diameters, and transversal diameters of 3 levels of
airway cross-section were measured. Results: After protraction, the volumes of the pharyngeal airway
increased significantly. Cross-sectional area, sagittal diameter, and transversal diameter of the upper and
lower pharyngeal airways also had significant increases. These changes were significant when compared
with the untreated subjects except for the transversal diameter of the lower pharyngeal airway. Dimensions of
the middle pharyngeal airway remained unchanged. Conclusions: Maxillary protraction therapy significantly af-
fects airway dimensions in patients with repaired UCLP 3 dimensionally. (Am J Orthod Dentofacial Orthop
2016;149:673-82)

P
atients with cleft lip and palate (CLP) are usually mastication.4 Since improvements of the soft tissue pro-
characterized by maxillary retrusion and anterior file and the sagittal jaw relationship in early childhood
crossbite after cleft repair. Midface retrusion in are obviously important, maxillary protraction has
patients with CLP often results in personal, social, and been recommended.1,8,9
psychological problems, along with functional diffi- Pharyngeal size plays an important role in speech and
culties.1 Maxillary protraction is an effective way to respiratory function. It is well known that many patients
relieve mild to moderate anterior crossbite for preadoles- with CLP still have speech problems even after palato-
cents, and it will lead to skeletal changes as well as plasty surgery. In addition, it was reported that patients
improvements in the lateral profile.1-8 Normalization with CLP had an increased risk of obstructive sleep ap-
of the sagittal jaw relationship and elimination of the nea.10-13 The pharynx is close behind the maxilla and
dysfunction will result in normal function and the mandible. Movement of the jaws may have an
effect on the dimensions of the pharyngeal airway.
From the School and Hospital of Stomatology, Peking University, Beijing, China.
a
PhD student, Department of Orthodontics. Several studies have reported the skeletal response of
b
Postgraduate student, Department of Orthodontics. maxillary protraction in patients with CLP.2-8 However,
c
Professor, Department of Oral and Maxillofacial Surgery. only a limited number of reports have explored the
d
Professor and chair, Department of Orthodontics.
All authors have completed and submitted the ICMJE Form for Disclosure of effects of maxillary protraction on the pharynx, and
Potential Conflicts of Interest, and none were reported. most focused on noncleft patients.8,14-21 Moreover,
Supported by National Clinical Key Specialty Construction Projects. those studies were all based on cephalograms; thus,
Address correspondence to: Weiran Li, Department of Orthodontics, Peking
University School and Hospital of Stomatology, 22 Zhongguancun Nandajie, only sagittal depth of the pharyngeal airway was assessed.
Haidian District, Beijing 100081, P.R. China; e-mail, weiranli2003@163.com. Therefore, the aim of this study was to assess the ef-
Submitted, February 2015; revised and accepted, October 2015. fects of maxillary protraction therapy on the pharyngeal
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. airway in patients with repaired unilateral CLP (UCLP) 3
http://dx.doi.org/10.1016/j.ajodo.2015.10.024 dimensionally.
673
674 Fu et al

MATERIAL AND METHODS

A longitudinal study was carried out according to the
Declaration of Helsinki guidelines and approved by the
ethics committee of Peking University in Beijing, China.
All patients in the study group and their parents were
informed of the purpose of this study and signed an
informed consent form.
The study group was selected according to the
following screening criteria: (1) operated nonsyndromic
UCLP, (2) concave profile with overjet between –4 and
0 mm, (3) palatoplasty surgery before 3 years old, (4)
no pharyngeal flap surgery, and (5) growth of body
height had not accelerated. Patients who met the
screening criteria were asked to have a cone-beam
computed tomography (CBCT) scan. Also, from the
CBCT synthetic cephalograms, patients whose cervical
vertebral maturation stage was 1 or 2 and whose ANB
angle was between
4 and 0 were included.22
Patients in the study group were treated by an author
(W.L.). Hyrax appliances with bands on the first molars
Fig 1. Hyrax appliance (upper) and bite-block (lower).
and premolars (or deciduous molars) were used. The hy-
rax appliance incorporated the maxillary left and right
first molars and premolars (or deciduous molars); this
made a firm anchorage to transfer the orthopedic force
effectively to the maxilla through the teeth during pro-
traction. Two hooks were soldered and extended from
the permanent first molars to the region of the decidu-
ous molars or premolars. The transverse dimensions of
the maxillary dental arches were sufficient in all patients;
thus, maxillary expansion was not conducted. Bite-block
appliances in the mandibular arch were used to eliminate
incisor interference (Fig 1). The patients were instructed
to wear facemasks (Tiantian Dental Equipment, Hunan,
China; Fig 2) for at least 12 hours per day. The protrac-
tion force was 450 to 500 g equally on both sides and
directed 20 to 30 downward and forward in relation
to the occlusal plane. Maxillary protraction was stopped
after achieving about 2 mm of positive overjet,
occluding the posterior teeth, and after at least 8 months
of treatment.
CBCT volume scans were taken before (T0) and
immediately after treatment (T1) using a dental- Fig 2. Facemask.
imaging system (DCT Pro; VATECH, Gyeonggi-do,
Korea). All CBCT scans were taken with the following derived from the computed tomography database of
conditions: sitting position, natural head position, inter- Peking University's CLP treatment center, served as the
cuspal occlusion, tongue in a relaxed position, and nat- control group. The data sets were acquired using a
ural breath. The imaging protocol used a 20 3 19-cm high-resolution multidetector computed tomography
field of view to include the entire craniofacial anatomy. (MDCT) device (BrightSpeed Edge; General Electric, Fair-
The voxel resolution was 0.4 mm. The CBCT data sets field, Conn). MDCT volume scans were taken with the
were exported in DICOM file format. following conditions: supine position, Frankfort hori-
For ethical reasons, we did not include a prospective zontal plane perpendicular to the floor, intercuspal oc-
control group. Instead, retrospective longitudinal data, clusion, tongue in a relaxed position, and natural

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Fu et al 675

breath. The slice thickness was 1.25 mm. The inclusion

Table I. Landmarks
criteria were the same as for the study group. Two sets
of MDCT images at a time interval of 6 to 24 months Landmark Definition
were required. The patients did not receive orthopedic S Sella, center of sella turcica
treatment because maxillary protraction was not offered N Nasion, most anterior point of the frontonasal suture in
the median plane
when they were treated. They also did not receive phar-
Ba Basion, most anterior point of the foramen magnum
yngoplasty surgery, tonsillectomy, or adenoidectomy Po Porion, most superior point of each external acoustic
during the observation period. Fourteen patients (9 meatus
boys, 5 girls) were included in the control group. The Or Orbitale, most inferior point of each infraorbital rim
mean age of the patients at the first observation (T0) PM Posterior maxilla, most posterior point of the hard palate
on the noncleft side
was 9.6 6 1.7 years (range, 6.9-12.8 years). The MDCT
U Tip of the uvula
data sets were also exported in DICOM file format. A Point of maximum concavity in the alveolar process of
When calculating the sample size needed in the study the maxilla
group, both the treatment effect and the variance of the B Point of maximum concavity in the alveolar process of
difference were set at 1.5 mm according to the results of the mandible
Go Gonion, point of maximum convexity at the mandibular
a previous study.23 The power was set at 0.75, and the
angle on each side
significance level was set at 0.05. Then the sample size Me Menton, most inferior point of the chin on the outline of
was calculated using PASS software (version 11.0; the mandibular symphysis
NCSS, Silver Spring, Md). The minimum size needed EP Tip of the epiglottis
was 16 in the treated group. To allow for losses, 20 pa-
tients who met the criteria were asked to participate the
study. However, 2 refused to participate because of the tip of the epiglottis. The posterior limit was delimited
remoteness of their home. Thus, 18 children (13 boys, by the posterior pharyngeal wall, and the anterior limit
5 girls) were included in the study group. Their mean was delimited by the anterior wall of the pharynx, soft
age at T0 was 10.4 6 1.3 years (range, 7.6-12.4 years). palate, and tongue. After the boundary was confirmed,
Using software (version 11.7; Dolphin Imaging & a seed point was added in the airway cavity. The detec-
Management Solutions, Chatsworth, Calif), sagittal, tion sensitivity of the airway space was set individually.
axial, and coronal slices as well as the 3-dimensional The seed point extended to the area that had a similar
(3D) reconstructions of the images were created. Land- gray scale according to the detection sensitivity. Then
marks used for setting reference planes and measure- the airway volume was calculated automatically
ment planes are illustrated in Table I. The 3D reference (Fig 3). Areas, sagittal diameters, and transversal diam-
system was constructed as follows: basion was selected eters of the 3 levels of airway cross-sections were
as the origin of coordinates. The horizontal plane was measured. The most superior and inferior cross-
parallel to the Frankfort horizontal plane, which was sectional planes of the pharyngeal airway were defined
constructed on the bilateral porions and the noncleft as the upper pharyngeal airway (UPA) and the lower
side of orbitale. The midsagittal plane was drawn pharyngeal airway (LPA). The cross-sectional plane
perpendicular to the horizontal plane, passing through passing through the tip of the uvula and parallel to
sella and basion. The coronal plane was at right angles the Frankfort horizontal plane was defined as the middle
to the horizontal plane and the midsagittal plane, pass- pharyngeal airway (MPA). The images of UPA, LPA and
ing through basion. MPA were exported in JPEG file format. Dimensions of
The spatial positions of each landmark were repre- the 3 planes were measured using Photoshop (version
sented as numeric values on each axis. The coordinates 12.0; Adobe Systems, San Jose, Calif) image processing
of all landmarks were then exported to an Excel spread- software (Fig 4).
sheet (version 15.0; Microsoft, Redmond, Wash). Mea-
surements of the dentofacial morphology were Statistical analysis
calculated based on the coordinates of the related land- Paired t tests were used to assess the changes during
marks. the treatment or the observation period in the 2 groups.
The volume of the pharyngeal airway was calculated An independent-sample t test was carried out to
using the sinus/airway module of the Dolphin Imaging compare the T0 and T1 measurements and the T1 to
software. The superior limit of the pharyngeal airway T0 changes between the groups. The data were analyzed
was taken as a line connecting the posterior maxilla with software (version 11.0; SPSS, Chicago, Ill). Statisti-
and basion. The inferior limit was taken as a line parallel cal significance was tested at P \0.001, P \0.01, and
to the Frankfort horizontal plane, passing through the P \0.05.

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676 Fu et al

Fig 3. Volumetric quantification of the pharyngeal airway. Superior limit, a line connecting the posterior
maxilla and basion. Inferior limit, a line parallel to the Frankfort horizontal plane, passing through the tip
of the epiglottis. Posterior limit, the posterior pharyngeal wall. Anterior limit, the anterior wall of the phar-
ynx, soft palate, and tongue.

Fig 4. Three specific cross-sections of the pharyngeal airway and qualitative assessment of A, Cross-
sectional area, S, sagittal diameter, and T, transversal diameter of the pharyngeal airway. See Table I
for definitions of the abbreviations.

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Fu et al 677

For the error measurements, 5 randomly selected

Table II. Mean differences and intraclass correlation
pairs of MDCT and CBCT data sets were measured twice
coefficient (ICC) values between double measurements
by Z.F., at an interval of 2 weeks. Correlations and mean
differences between the double measurements were Measured variable Mean difference (SD) ICC
then analyzed. Dentofacial morphology
SNA0 ( )* 0.11 (0.63) 0.99
SNB0 ( )* 0.05 (0.49) 0.99
RESULTS
ANB0 ( )* 0.01 (0.37) 0.98
The intraclass correlation coefficients between the MP0 /SN ( )y 0.08 (1.11) 0.98
double measurements were all over 0.9, indicating Volume (mm3) 278.5 (568.22) 1.00
Upper pharyngeal airway
high reliability. Mean differences between the double
Area (mm2) 16.99 (32.19) 0.97
measures and the intraclass correlation coefficient Sagittal diameter (mm) 0.60 (1.75) 0.97
values are shown in Table II. Transversal diameter (mm) 0.46 (0.49) 0.99
All 18 patients in the study group were successfully Middle pharyngeal airway
treated. Age distribution, treatment or observation dura- Area (mm2) 5.16 (10.17) 1.00
Sagittal diameter (mm) 0.02 (0.68) 0.98
tion, and sex distribution showed no significant differ-
Transversal diameter (mm) 0.35 (0.59) 0.99
ences between the groups, as illustrated in Tables III Lower pharyngeal airway
and IV. Area (mm2) 2.26 (15.62) 0.97
After treatment with maxillary protraction, the projec- Sagittal diameter (mm) 0.12 (0.44) 0.98
tion of the SNA angle on the midsagittal plane (SNA0 ) Transversal diameter (mm) 0.42 (0.76) 0.98
increased by 1.75 6 1.83 (P \0.001), the projection *SNA0 , SNB0 , and ANB0 are the projections of the SNA, SNB, and ANB
of the SNB angle on the midsagittal plane (SNB0 ) angles on the midsagittal plane, respectively; yMP0 is the projection
decreased by 1.81 6 1.43 (P \0.001), the projection of the mandibular plane (constructed on menton and the midpoint
of the ANB angle on the midsagittal plane (ANB0 ) of right and left gonions) on the midsagittal plane.
increased by 3.56 6 1.71 (P\0.001), and the projection
of the mandibular plane on the midsagittal plane (MP0 / congenital deformity. Rose et al24 and Oosterkamp
SN) increased by 2.22 6 1.93 (P \0.001; Table V). et al25 found that the pharyngeal morphology of CLP
The differences in these changes were significant when and obstructive sleep apnea patients demonstrated sub-
compared with the untreated subjects (P\0.05; Table V). stantial similarities. Pharyngeal size plays an important
The volume of the pharyngeal airway increased by role in speech and respiratory function. The skeletal
3001.89 6 4127.96 mm3 (P \0.01; Table V) in the response of maxillary protraction in both children without
treated group, whereas the increment was not signifi- clefts26-29 and those with CLP2-8 have been studied.
cant in the control group. The exploratory analysis of However, only a few studies have evaluated the effect
differences in the changes from T0 to T1 between the of maxillary protraction on pharyngeal structure, and all
treated patients and the untreated subjects showed of these studies were based on cephalograms.14-21
that the mean group differences were significant Although lateral cephalometric measurements are useful
(P \0.05; Table V). for measuring sagittal depth of the airway, they cannot
Cross-sectional area, sagittal diameter, and trans- depict the 3D airway anatomy. We evaluated changes
versal diameter of the UPA and LPA also showed signif- of the pharyngeal airway during protraction using CBCT
icant increases (P \0.05; Table V) in the treated group; and MDCT. Compared with conventional cephalogram,
however, the changes were not significant in the control computed tomography has the distinct advantage of
group, except for the transversal diameter of the LPA. viewing anatomic structures 3 dimensionally. Therefore,
Differences of the changes were significant between not only sagittal depth, but also transverse diameter,
the 2 groups (P \0.05; Table V), except for the trans- area, and volume of the pharyngeal airway were
versal diameter of the LPA. analyzed in this study.
All measurements of the MPA remained unchanged Early treatment of Class III malocclusion has been
in both groups (P .0.05; Table V). Independent t tests advocated for a long time. In a meta-analysis, Kim
also showed no significance in the mean group differ- et al30 reported that the younger group had greater
ences for the dimensions of the MPA (P .0.05; Table V). treatment changes during protraction facemask therapy.
The ages of the treated subjects in this study (mean age,
DISCUSSION 10.4 6 1.3 years; range, 7.6-12.4 years) seemed too old
The pharyngeal structure of patients with CLP is for ordinary Class III patients to receive maxillary pro-
different from the noncleft population because of the traction. However, it was reported that the growth curves

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678 Fu et al

Table III. Comparisons of ages and treatment and observation durations between the groups
Treated patients Untreated patients

Mean (range) SD Mean (range) SD P

T0 (y) 10.37 (7.58-12.42) 1.31 9.62 (6.92-12.83) 1.74 0.173
T1 (y) 11.81 (9.08-14.58) 1.52 10.96 (8.75-13.83) 1.72 0.153
Duration (mo) 17.17 (8.00-26.00) 5.43 16.14 (8.00-24.00) 5.88 0.613

volume of the pharyngeal airway was enlarged during

Table IV. Sex distributions in the groups
protraction.
P (Fisher To further investigate the effects of protraction on
Male Female Total exact test) the different levels of the pharyngeal airway, 3 specific
Treated patients 13 5 18 0.712 airway cross-sections were analyzed. These cross-
Untreated patients 9 5 14
Total 22 10 32
sections used in this study were mainly derived from pre-
vious studies.15-19,34,35 A modified point, posterior
maxilla, which represents the most posterior point of
of patients with CLP were different from those of the the palatal bone on the noncleft side, was used instead
noncleft standard samples, and the pubertal growth of posterior nasal spine since it does not form in
maximum occurred later in patients with CLP.31 Accord- patients with palatal clefts.
ing to Sun and Li,32 more than 75% of the patients be- Compared with the untreated control group, sagittal
tween 11 and 12 years of age were at cervical vertebral depth of the UPA increased from T0 to T1 in the study
maturation stage 1 or 2, considered the prepubertal group. This finding agreed with that of Tindlund
stages. Suda et al33 reported that the forward movement et al.8 Since the sagittal position of the maxilla moved
of the maxilla and the increase in palatal length showed forward (SNA0 increased), the soft tissue boundary of
significant inverse correlations with bone age but not the UPA was enlarged. The transversal dimension of
with chronologic age. In our study, although the pa- the UPA in the treated group also increased. Since maxil-
tients' chronologic ages seemed too old, the cervical lary expansion was not used in any patient, enlargement
vertebral maturation stages were carefully evaluated of the transverse diameter should also be attributed to
from computed tomography synthetic cephalograms, the effect of protraction treatment. Fairburn et al36 as-
and only patients at stages 1 and 2 were enrolled. sessed 3D changes in the upper airways of patients
Thus, all 18 patients in the study group were successfully with obstructive sleep apnea after maxillomandibular
treated. advancement and also reported that the transversal
Dentofacial morphology was evaluated first to diameter of the upper airway increased after surgery.
determine the skeletal response of protraction treat- The explanation of this phenomenon may relate to
ment. In our 3D analysis, several projections such as neuromuscular adaptation. However, the exact mecha-
SNA0 , SNB0 , and ANB0 were used instead of direct mea- nism cannot be answered in our study.
surements because in cleft patients, Points A and B Sagittal diameter and area of the LPA increased
were not always on the midsagittal plane. Geometri- significantly when compared with the untreated con-
cally, the SNA, SNB, and ANB angles would be influ- trols. One possible explanation for this finding is that
enced by deviations of the landmarks from the MSP the oral cavity was enlarged with the advancement of
and therefore could not represent the sagittal skeletal maxilla. Then the tongue tended to move forward, and
relationship precisely. Using projections of the land- eventually the space of the LPA increased. The LPA is
marks on the MSP can eliminate the influence of devi- close behind the mandible. Forward or backward move-
ations from the MSP. The variable MP0 /SN was created ment of the mandible can also affect the size of the LPA.
for a similar reason. These results agreed with the find- However, the main effect of protraction on the mandible
ings of previous studies that reported maxillary was clockwise rotation. Geometrically, rotation caused
advancement and mandibular clockwise rotation during more displacement on the anterior part but less displace-
protraction.2-8 ment on the posterior part of the mandible. Thus, the ef-
To date, no authors have evaluated the effect of fect of mandibular rotation on the size of the LPA was
maxillary protraction on volumetric changes of pharyn- slight. This finding agrees with that of Kilinc et al,15
geal airways, especially in patients with CLP. Our results who reported that maxillary protraction significantly
showed that with advancement of the maxilla, the increased the sagittal oropharyngeal airway dimensions.

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 American Journal of Orthodontics and Dentofacial Orthopedics

Fu et al
Table V. Changes from T0 to T1 in the treated patients and untreated subjects and comparisons between the 2 groups
Control group Treated group Differences between groups

T0 T1 Change T0 T1 Change T0 T1 Change

Dentofacial morphology
SNA0 ( )* 76.31 6 2.80 75.10 6 2.51
1.21 6 0.91{ 75.02 6 3.66 76.77 6 3.95 1.75 6 1.83{
1.29 6 1.18 1.67 6 1.21 2.97 6 0.53§
NS NS
SNB0 ( )* 77.64 6 3.09 78.56 6 4.13 0.92 6 2.57 77.14 6 4.05 75.33 6 4.59
1.81 6 1.43{
0.51 6 1.31
3.23 6 1.57z
2.73 6 0.71§
NS NS
ANB0 ( )*
1.34 6 3.64
3.47 6 4.46
2.13 6 2.25§
2.12 6 1.79 1.44 6 2.32 3.56 6 1.71{
0.78 6 0.98 4.91 6 1.22{ 5.69 6 0.70§
NS
MP0 /SN ( )y 37.50 6 5.05 37.08 6 4.40
0.42 6 3.21 37.77 6 5.17 39.99 6 5.91 2.22 6 1.93{ 0.27 6 1.82 2.92 6 1.89 2.64 6 0.91§
NS NS NS
Pharyngeal airway
Total volume 9162.9 6 2226.4 9248.1 6 3236.5 85.3 6 3490.1 9915.7 6 3748.7 12917.6 6 5192.8 3001.9 6 4128.0§ 752.8 6 1133.1 3669.4 6 1586.4z 2916.6 6 1377.1z
(mm3) NS NS
Upper pharyngeal airway
Area (mm2) 287.52 6 72.74 268.38 6 43.98
19.14 6 62.67 419.78 6 106.55 483.09 6 117.66 63.30 6 87.33§ 132.26 6 33.29{ 214.70 6 33.20{ 82.44 6 27.66§
NS
Sagittal 20.62 6 3.94 19.94 6 2.54
0.69 6 2.67 24.49 6 5.78 26.82 6 5.21 2.32 6 4.46z 3.87 6 1.81z 6.88 6 1.52{ 3.01 6 1.35z
diameter (mm) NS
Transversal 24.74 6 3.50 23.79 6 2.30
0.94 6 3.40 29.53 6 3.13 30.84 6 3.42 1.31 6 2.18z 4.80 6 1.17{ 7.05 6 1.06{ 2.25 6 0.99z
diameter (mm) NS
Middle pharyngeal airway
Area (mm2) 151.06 6 73.10 146.39 6 56.45
4.68 6 86.19 223.82 6 81.77 246.78 6 98.77 22.97 6 85.87 72.75 6 27.84z 100.39 6 29.62§ 27.64 6 30.65
NS NS NS
Sagittal diameter 11.65 6 2.94 11.00 6 2.68
0.65 6 3.25 14.85 6 3.05 14.92 6 3.16 0.07 6 2.89 3.20 6 1.07§ 3.92 6 1.06{ 0.72 6 1.09
(mm) NS NS NS
Transversal 18.19 6 5.96 19.16 6 4.20 0.96 6 5.47 23.02 6 4.62 24.43 6 5.35 1.41 6 4.53 4.83 6 1.87z 5.27 6 1.74§ 0.44 6 1.77
diameter (mm) NS NS NS
Lower pharyngeal airway
May 2016  Vol 149  Issue 5

Area (mm2) 154.31 6 48.25 160.92 6 53.53 6.60 6 57.71 162.54 6 60.19 213.42 6 70.71 50.88 6 61.44§ 8.23 6 19.72 52.51 6 22.75z 44.28 6 21.33z
NS NS
Sagittal 8.39 6 3.76 7.38 6 3.24
1.01 6 2.64 9.31 6 2.39 10.94 6 2.77 1.63 6 1.86§ 0.92 6 1.09 3.57 6 1.06§ 2.65 6 0.80§
diameter (mm) NS NS
Transversal 18.53 6 5.54 21.10 6 5.77 2.57 6 3.98z 25.06 6 2.40 28.22 6 3.13 3.16 6 3.12{ 6.53 6 1.45{ 7.12 6 1.59{ 0.59 6 1.26
diameter (mm) NS

NS, Not significant.

*SNA0 , SNB0 , and ANB0 are the projections of the SNA, SNB, and ANB angles on the midsagittal plane, respectively; yMP0 is the projection of the mandibular plane (constructed on menton and the
midpoint of right and left gonions) on the midsagittal plane; zP \0.05; §P \0.01; {P \0.001.

679
680 Fu et al

Oktay and Ulukaya,19 Kaygısız et al,16 and Lee et al18 accurate with both CBCT and MDCT.41 One major differ-
also reported increases in lower pharyngeal depth after ence between the CBCT and MDCT devices used in this
protraction, although the changes were insignificant. study was that patients were examined in supine posi-
The transversal diameter of the LPA increased as well tion with the MDCT and in upright position with the
in the study group; however, when compared with the CBCT. Gravity can produce movements in pharyngeal
controls, it was not significant. So, it can be concluded structures in response to postural changes between the
that the increase of transversal diameter of the LPA upright and supine positions.42 In this study, all pharyn-
was partly caused by growth of the pharynx. geal measurements in the treated group were greater
It is interesting that the dimensions of both the UPA than those in the control group at T0, and most of these
and the LPA increased, but the size of the MPA remained differences were significant. Since age and sex distribu-
unchanged. Several studies regarding velopharyngeal tions were balanced, and dentofacial morphologies were
changes reported that after distraction osteogenesis similar between the 2 groups at T0, these differences
treatment, the velar angle (angle between the soft palate should mainly be attributed to the influence of gravity.
and the palatal plane) of patients with CLP increased.37,38 In supine position, gravity makes the tongue and soft
Geometrically, when the velar angle increases, the palate closer to the pharyngeal wall and narrows the di-
distance between the tip of the soft palate and the mensions of the airway. The different imaging modal-
pharyngeal wall would decrease. Therefore, the increase ities and body positions were major limitations of our
in sagittal depth of the pharyngeal airway caused by study because they could affect the differences of
distraction osteogenesis was compensated. pharyngeal changes between the 2 groups. However,
Compensation in the velopharyngeal mechanism might the trend of the influence of growth should not be
also be assumed to explain the results in this study. altered, whether the patients were examined in supine
Since the changes caused by maxillary protraction were or upright position. In the control group, although there
more gradual than by maxillary distraction, the patients was no significance, most measurements showed nega-
had more chance to adapt themselves to the tive changes. In this way, growth may decrease, or at
velopharyngeal changes. Thus, the increases in the least should not increase, the airway dimensions in the
dimensions of the MPA were not significant. treated group. Therefore, although exact changes
Another interesting finding of this study was that age caused by treatment cannot be calculated, it can still
did not change the airway size in the control group. be concluded that maxillary protraction treatment can
Sheng et al39 reported that the pharyngeal airway depth increase the pharyngeal airway dimensions.
increased from the mixed dentition stage to the perma- Another limitation of our study was that only a short-
nent dentition stage. Schendel et al40 also reported a term evaluation was conducted. Since long-term stabil-
consistent increase in the airway volume from ages 6 to ity is a major concern when treating Class III patients,
20 years. Our results were inconsistent with the previous posttreatment follow up is required in future studies.
studies.39,40 The inconsistency may have 2 sources. First, Speech and respiratory functions are of the utmost
the time interval was relatively short (16.1 months) when importance in the treatment of patients with CLP. As-
compared with previous studies (3-4 years). Second, the sessments of morphologic changes of the pharyngeal
populations studied were different in this study and airway are indispensable when assessing speech and res-
previous studies. Airway sizes are expected to change piratory functions. Future studies could provide more in-
with growth of the maxillofacial skeleton. Since formation by including additional assessments such as
maxillary growth was restricted in patients with CLP, polysomnography and nasoendoscopy examinations.
changes of airway size may also be reduced.
For ethical reasons, we did not include a prospective CONCLUSIONS
control group. Instead, a retrospective longitudinal The dimensions of the pharyngeal airway as well as
MDCT data set was the control group. In the CLP treat- the jaw relationship were affected by maxillary protrac-
ment center of our university, the MDCT scans tion therapy. Maxillary protraction treatment could not
were usually taken before and 1 to 2 years after alveolar only relieve mild to moderate anterior crossbite, but
bone graft surgery as the preoperative examination and also potentially improve respiratory functions for pread-
the postoperative evaluation, respectively. In this study, olescent patients with CLP.
those MDCT data sets were used as the control group to
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