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Changes in Hyoid Bone Position Following Rapid Maxillary Expansion

Changes in Hyoid Bone Position Following Rapid Maxillary Expansion

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12/04/2012

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Original Article 
Changes in hyoid bone position following rapid maxillary expansionin adolescents
Austin Phoenix
a
; Manish Valiathan
b
; Suchitra Nelson
c
; Kingman P. Strohl
d
; Mark Hans
e
ABSTRACTObjective:
To examine changes in hyoid to mandibular plane distance (H-MP) and tongue length(TL) between children who had orthodontic treatment with and without rapid maxillary expansion(RME).
Materials and Methods:
Lateral and frontal cephalograms of 138 patients treated with RME and148 controls treated without RME were used to measure pretreatment (T
1
) and posttreatment (T
2
)intermolar (IM) distance, lateronasal width (LNW), H-MP, and TL. Medical histories were used tocollect demographic information, history of mouth breathing, difficulty breathing through the nose,and previous adenotonsillectomy. Groups were group-matched for age and gender. Descriptivestatistics were calculated. Group means were compared using
-tests and chi-square statistics.Reliability was estimated using intraclass correlations and kappa statistics. Statistical significancewas set at
,
.05.
Results:
At T
1
, the RME group showed smaller LNW (24.83
6
1.99 vs 26.18
6
2.05) and IM(50.17
6
2.3 vs 51.58
6
2.83). The distance from H-MP was longer in the RME group (15.69
6
3.95 vs 13.86
6
3.4). Mean changes (T
2
2
T
1
) in the RME group were increased LNW (
+
2.48
6
1.38 vs
+
0.94
6
1.11 for the non-RME group) and IM (
+
3.21
6
1.72 vs
+
0.98
6
1.67). The meanchange (T
2
2
T
1
) in H-MP for the RME group was
2
0.68
6
3.67 compared with
+
1.1
6
2.96 for thenon-RME group. Mean changes for TL were not statistically significant. No significant differenceswere noted at T
2
between groups for LNW, H-MP, or TL.
Conclusions:
In this sample, RME produced significant changes in H-MP, and TL was unaffected.(
Angle Orthod.
2011;81:632–638.)
KEY WORDS:
Rapid maxillary expansion; Airway; Hyoid bone
INTRODUCTION
Orthodontic treatment provides many benefits topatients. Improved esthetics and masticatory functionare the best known. Recent evidence suggests thatdevices designed to protrude the mandible may beeffective for the treatment of breathing problems andsnoring.
1
The goal of such therapy is to modify theposition of upper airway structures in efforts to enlargethe airway and reduce its collapsibility.Another way to reduce upper airway collapsibility isto reduce the resistance to airflow within the airwaypassage. Maxillary transverse deficiency reduces thecross-sectional area of the airway, leading to in-creased nasal resistance. Previous studies havedemonstrated a reduction in nasal resistance followingrapid maxillary expansion (RME) with banded orbonded appliances.
2–4
Evidence suggests that RMEmay reduce the apnea hypopnea index in children withsleep apnea.
5–7
Improved nasal airflow and resolutionof obstructive sleep-disordered breathing have beenreported in adults undergoing surgically assistedRME.
8
RME treatment improves nasal breathing bysignificantly increasing total minimum cross-sectionalarea and total nasal volume.
9
a
Private practice, Portland, Ore.
b
Assistant Professor, Department of Orthodontics, CaseWestern Reserve University, Cleveland, Ohio.
c
Associate Professor, Department of Community Dentistry,Case Western Reserve University, Cleveland, Ohio.
d
Professor of Medicine, Anatomy, and Orthodontics; Director,Center for Sleep Disorders Research, Louis Stokes DVA MedicalCenter, Case Western Reserve University, Cleveland, Ohio.
e
Professor and Chairman, Department of Orthodontics, CaseWestern Reserve University, Cleveland, Ohio.Corresponding author: Dr Manish Valiathan, Assistant Pro-fessor, Department of Orthodontics, School of Dental Medicine,Case Western Reserve University, 10900 Euclid Ave, Cleveland,OH 44106(e-mail: mxv13@case.edu).Accepted: October 2010. Submitted: June 2010.Published Online: February 9, 2011
G
2011 by The EH Angle Education and Research Foundation,Inc.
DOI:
10.2319/060710-313.1632
Angle Orthodontist, Vol 81, No 4, 2011
 
Evidence indicates that hyoid bone position may beaffected by upper airway resistance. Verin et al.
10
found that transpalatal resistance was correlated withgreater hyoid to mandibular plane distance. It has alsobeen shown that the hyoid bone becomes progres-sively lower as airway resistance increases.
11
Hyoidbone position changes with age. According toTourne,
12
the hyoid bone descends during growthand maintains its position between C3 and C4. Taylor
13
also demonstrated a steady descent of the hyoid boneduring adolescent growth. Nelson et al.
14
found thatalthough snoring subjects had lower hyoid boneposition at all ages, the hyoid position became lowerwith increasing age, regardless of snoring status.Because increased nasal resistance is associatedwith maxillary transverse deficiency, and becauseRME decreases nasal resistance, it is possible thatRME affects hyoid bone position. In addition, in-creased tongue length (TL) has been associated withobstructive sleep apnea,
15
and RME has been recom-mended for treatment of obstructive sleep apneasyndrome (OSAS). The purpose of this study was toexamine differences in hyoid to mandibular planedistance (H-MP) and TL between children who hadorthodontic treatment with and without RME.
MATERIALS AND METHODS
The treatment records of 630 children, who wereactivepatientsbetween2001and2005atanestablishedorthodontic graduate clinic in the Midwest, were exam-ined. Patients in the surgical, adult, and craniofacialanomalies specialty clinics were excluded. Of theremaining 556 charts, 156 patients whose treatmentplan included RME (Hyrax, Haas, or bonded expandersactivated at least every other day) followed by fixedappliances,madeuptheexperimentalgroup.Thecontrolgroup (165 patients), consisting of patients treated withbraces alone, was randomly chosen from the remainingcharts and was group-matched by age and gender.Inclusion criteria for both groups were as follows: (1)patients younger than age 18 at pretreatment, (2)patients who completed medical history forms, and (3)patients with complete pretreatment and posttreatmentradiographic records. Patients who had not completedtheir treatment, who underwent tonsillectomy/adenoid-ectomy or any other surgical procedures during thecourse of the orthodontic treatment, or who appearedto have atypical posture on the lateral radiograph (eg,teeth not together, swallowing as evidenced by themorphology of the soft palate on the radiograph) wereexcluded. On the basis of these criteria, 53 patientswere excluded.Confirmation of group-matching by age and genderwas supported by the absence of statistical differencesin these assessments. The sample treated with RMEconsisted of 138 individuals (55 boys and 83 girls).Average age at the start of treatment (T
1
) was 13 years2 months
6
1 year 6 months. Average age at the endof treatment (T
2
) was 15 years 8 months
6
1 year6 months. The sample treated without RME consistedof 148 children (53 boys and 95 girls). Average age atT
1
was 13 years 6 months
6
1 year 6 months. Averageage at T
2
was 15 years 10 months
6
1 year 7 months.The duration of orthodontic treatment in both groupswas approximately 2 years 5 months.The patient medical history and the treatment recordwere used to collect the following information:
N
Patient’s age at the time of initial and final records
N
Gender
N
Race
N
Mouth breathing at T
1
N
Difficulty breathing through the nose
N
Adenoids/Tonsils removed before treatment.All lateral and frontal cephalograms at T
1
and T
2
were adjusted for magnification. Average magnifica-tion for lateral and frontal radiographs was 14% and8%, respectively. Magnification was calculated bymeasuring the actual and perceived dimensions ofthe nasion piece and the ear piece. Tracings of initialand final frontal and lateral radiographs were used tocollect the following cephalometric measurements witha digital caliper:
N
Pretreatment and posttreatment shortest perpendic-ular distance from the most anterior-superior point ofthe hyoid bone to the mandibular plane (Figure 1)
N
Pretreatment and posttreatment TL measured fromthe base of the epiglottis to the tip of the tonguebehind the lower incisors (Figure 1)
N
Pretreatment and posttreatment intermolar (IM)width (the most prominent lateral point on the buccalsurface of the upper first molar) measured from thefrontal cephalogram (Figure 2)
N
Pretreatment and posttreatment lateronasal width(LNW) measured as the distance between the mostlateral points of the nasal cavity (Figure 3).All measurements were completed by a singleoperator. Ten percent of the sample was randomlyidentified, and cephalometric measurements wererepeated at a 2-week interval. Categorical data werereentered for the same 10% of the sample. Paired
-tests used to compare continuous variables revealedno statistical difference (
,
.05). Intraclass correla-tion coefficients for all continuous variables wereabove 0.91. The kappa statistic was used to compareagreement of the categorical variables. All categorical
CHANGES IN HYOID BONE POSITION FOLLOWING RME
633
Angle Orthodontist, Vol 81, No 4, 2011
 
variables had perfect agreement (coefficient of 1),except race, which had a coefficient of 0.71.
Statistical Analysis
Histograms of continuous variables showed thatthey were normally distributed. Descriptive statisticswere obtained for cephalometric measurements at T
1
and T
2
. Independent sample
-tests for comparisons ofmeans between groups were used to evaluate thechanges, and paired
-tests were used to examinechanges within groups. Chi-square statistics wasperformed for categorical variables. Computer soft-ware (Statistical Package for the Social Sciences[SPSS], version 10, SPSS Inc., Chicago, Ill) was usedto complete statistical computations.
RESULTS
Age, gender, and race distributions for the two groupsare given in Table 1. At T
1
, statistical differences wereobserved between RME and non-RME groups (Ta-ble 2).TheRMEgroupshowedadeficiencyinLNWandin IM distance when compared with controls. Thedistance from H-MP was also longer in the RME group.Unlike the cephalometric variables, none of the cate-gorical variables (tonsils and adenoids removed, mouthbreathing,anddifficultybreathingthroughnose)showedsignificant differences at T
1
(Table 3).RME induced significant changes in the transversedimension (Tables 4 and 5). The RME group similarlydemonstrated (T
2
2
T
1
) a greater increase in LNW andin IM width. The H-MP distance decreased in the RMEgroup and increased in the non-RME group.At T
2
, no statistical difference was noted in LNWbetween the groups (Table 6), and IM was greater inthe RME group. The between-group difference inhyoid bone position observed at T
1
was indistinguish-
Figure 1.
Tongue length measured from the base of the epiglottis tothe tip of the tongue behind the lower incisors. Hyoid distancemeasured from the most anterior-superior point of the hyoid to themandibular plane.
Figure 2.
Intermolar distance measured between the most promi-nent lateral surfaces of the maxillary first molars.
Figure3.
Lateronasal width measured from the most lateral points ofthe nasal cavity.
634
PHOENIX, VALIATHAN, NELSON, STROHL, HANS
Angle Orthodontist, Vol 81, No 4, 2011

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