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LONG TERM STABILITY OF POSTERIOR PHARYNGEAL WALL THICKNESS

AND PHARYNGEAL AIRWAY PASSAGE DIMENSION CHANGES FOLLOWING


TWIN-BLOCK THERAPY
Submitted in partial fulfillment of the requirements
for the degree of
Master of Dental Surgery (MDS)
of the Postgraduate Institute of Medical Education and Research,
Chandigarh, India
By
Dr. Sreeram Nayak Malavathu
Junior Resident
Unit of Orthodontics, Oral Health Sciences Centre,
Postgraduate Institute of Medical Education & Research, Chandigarh.
Chief Guide
Dr. Satinder Pal Singh, MDS, DIBO
Professor & Head, Unit of Orthodontics,
Oral Health Sciences Centre,
Postgraduate Institute of Medical Education & Research, Chandigarh.

Co-Guide

Co-Guide

Dr. Krishan Gauba

Dr. Ashok Kumar Jena

Professor & Head

MDS (AIIMS), PGDHM, MAMS, DIBO, FPFA,


FIMSA

Unit of Pedodontics & Preventive dentistry

Associate Professor

Oral Health Sciences centre

Department of Dental surgery

PGIMER, Chandigarh

AIIMS, Sijua, Bhubaneswar, Odisha

AIM AND OBJECTIVES


Aim
Evaluation of long term stability of changes in the posterior pharyngeal wall thickness and
pharyngeal airway passage dimensions following advancement of mandible by twin block
appliance among Class II malocclusion subjects with retrognathic mandibles.
Objectives
1. To evaluate the immediate changes in posterior pharyngeal wall thickness following twin block
appliance therapy among Class II malocclusion subjects with retrognathic mandible.

2. To evaluate the immediate changes in pharyngeal airway passage dimensions following twin
block appliance therapy among Class II malocclusion subjects with retrognathic mandible.

3. To evaluate the long-term stability in the posterior pharyngeal wall and pharyngeal airway
passage dimensions changes following twin block appliance therapy.
4. To compare the longterm stability of posterior pharyngeal wall and pharyngeal airway
passage dimensions changes following twin block appliance therapy with age matched control
group in the age range of 9-15 years with Class II malocclusion subjects with mandibular
deficiency.

MATERIALS AND METHODS


A sample of 60 subjects in the age range of 9-15 years with Class II malocclusion associated
with mandibular deficiency who reported to the Unit of Orthodontics, OHSC, PGIMER were
included in this study. Total sample was divided into two groups of each containing 30
subjects. Group 1 (Study group) consisted of subjects who were given a benefit of twin-block
therapy followed by comprehensive orthodontic treatment. Serial lateral cephalograms before
twin-block therapy (T0), at the end of active twin block therapy (T 1) and at least 2-years after
the twin-block appliance therapy (T2) were analysed for the assessment of long-term stability
of posterior pharyngeal wall thickness and pharyngeal airway passage dimension changes.
Group 2 consisted of control subjects in whom no intervention was given and lateral
cephalograms were recorded prior to follow-up and at the end of 2-years of follow-up.
The following inclusion and exclusion criteria were followed for including the subjects for
the study.
Inclusion criteria:
1. Age range of 9-15 years
2. Class II malocclusion subjects with normal maxilla (angle SNA 79 0-840) and retrognathic
mandible (angle SNB 760).
3. Average maxillo-mandibular growth pattern with Frankfort mandibular plane angle (FMA) in
the range of 180-280.
4. Full cusp Class II (Angles) molar relationship bilaterally.
5. Overjet of 5 mm.
6. Presence of good quality lateral cephalograms before twin block therapy (To), at the end of
active functional appliance therapy (T1) and after a follow-up period of at least 2-years (T2).
Exclusion criteria:
1. Subjects with previous history of any kind of orthodontic treatment.
2. Subjects with anterior openbite.

3. Subjects with known history of any systemic disease affecting the normal growth and
development.
After selecting the subjects for the study, data collected from the Unit of Orthodontics,
Oral Health Sciences Centre (OHSC), Postgraduate Institute of Medical Educational
Research, Chandigarh. The before twin block therapy (To), at the end of active Twin block
therapy (T1) and at-least 2-years the twin-block appliance follow up (T2) lateral
cephalogram and A control group (9-15) with Class II with mandibular deficiency at
T2 time interval, traced manually for the evaluation of long-term stability of skeletal and
dentoalveolar effects, posterior pharyngeal wall and pharyngeal airway passage dimension
changes following twin-block appliance therapy.
After selecting a subject for the study a written consent form was obtained from patient
and their parents. The study was approved by Institute Review Board (IRB) (PUT IRB
NUMBER The sign and symptoms of any airway obstruction were evaluated by medical
history, clinical examination and written questionnaire (Annexure I). A physical examination
was performed to evaluate Class II malocclusion, mandibular hypoplasia and mouth breathing.
The parents of the subjects were interviewed to complete a written questionnaire regarding
symptoms of airway obstruction (Annexure II).
Study group:
All the subjects in study group (Group I) were treated by standard twin-block appliance
or with some modification followed by comprehensive orthodontic treatment. Serial lateral
cephalogram recorded before twin-block therapy (T0), at the end of active twin-block therapy
(T1) and at least 2-years after the twin-block appliance therapy (T 2) were evaluated for the
stability of posterior pharyngeal wall and pharyngeal airway passage dimension.

Control group:Subjects with Class II malocclusion who undergone other than twin-block appliance
therapy were included in the study.
In all the subjects, changes in the skeletal and dentoalveolar, posterior pharyngeal wall and
pharyngeal airway passage dimensions were evaluated from lateral cephalograms. The

allocation of all subjects to various groups, their treatment and follow-up are described in
figure-1.

Figure-1: Diagrammatic representation of total sample


EVALUATION OF SKELETAL, DENTO-ALVEOLAR, POSTERIOR PHARYNGEAL
WALL THICKNESS AND POSTERIOR PHARYNGEAL AIRWAY PASSAGE
DIMENSIONS
A) Evaluation of skeletal and Dento-alveolar effects:For the evaluation of immediate and long-term stability of skeletal and dentoalveolar changes
following twin-block appliance therapy, following cephalometric landmarks were identified.
1.

ANS (Anterior Nasal Spine): It is the anterior tip of the sharp bony process of the maxilla at
the lower margin of the anterior nasal opening.22

2.

PNS (Posterior Nasal Spine): It is the posterior spine of the palatine bone constituting the hard
palate.22

3.

Ba (Basion): It is the lowest point on the anterior rim of the foramen magnum.22

4.

Cd (Condylion): It is the most superior point on the head of the condyle.22


5

5.

Go (Gonion): A constructed point and the intersection of the line tangent to the posterior
margin of the ascending ramus and mandibular base.22

6.

Gn (Gnathion): It is a point located by taking the midpoint between the anterior (pogonion) and
inferior (menton) points of the bony chin.22

7.

Me (Menton): It is the most caudal point in the outline of the symphysis.22

8.

N (Nasion): The most anterior point of the nasofrontal suture in the median plane22

9.

Or (Orbitale): The lowest point on the inferior rim of the orbit.22

10. Pog (Pogonion): It is the most anterior point on the chin.22


11. Po (Porion): The most superiorly positioned point of the external auditory meatus.22
12. Point A: The deepest mid line point in the curved bony outline from base to the alveolar
process of the maxilla.22
13. Point B: It is the most posterior point in the outer contour of the mandibular alveolar process.22
14. Ptm (Pterygomaxillare): It is the lowest point of the opening of the pterygomaxillary fissure.22
15. S (Sella): The geometric centre of the pituitary fossa located by visual inspection.22

Figure 2: Cephalometric landmarks for the evaluation of skeletal changes and dental
changes: N, Nasion; S, Sella; Or, Orbitale; Ptm, Pterygomaxillary fissure; Co- Condylion;
Ba, Basion; ANS, Anterior Nasal Spine; PNS, Posterior Nasal Spine; A, Point A; B, Point
B; Pog, pogonion; Gn, Gnathion; Me, Menton; Go, Gonion
Cephalometric Reference planes:
The following reference planes were drawn on the lateral cephalogram for the evaluation of
immediate and long-term stability of the skeletal and dento-alveolar changes following twinblock appliance therapy.22
1. SN-plane: It is the plane connecting S and N.22
2. Long axis of upper incisor (UI): The line passing through the incisal edge and the apex of the
root of the maxillary central incisor.22
3. FH-plane: The line joining Po and Or.22
4. Long axis of lower incisor (LI): The line passing through the incisal edge and the apex of the
root of the mandibular central incisor.22
5. Mandibular plane: It is the plane joining Gn and Me.22

Figure 2: Various cephalometric reference planes for the evaluation of skeletal and dental
changes; SN plane, line joining S and N; FH plane, line joining Po and Or;
Mandibular plane (MP), line joining Me and Go; Long axis of upper central incisor
(U1), line passing through the incisal edge and apex of root of maxillary central incisor

and Long axis of lower central incisor (L1), line passing through the incisal edge of and
apex of the root of the mandibular central incisor.
Linear parameters:
The following linear parameters were measured on the lateral cephalograms for the
evaluation of immediate and long-term stability of the skeletal and dento-alveolar changes
following twin-block appliance therapy (Figure 3).
1. ANS-PNS (Maxillary length): It is the linear measurement from ANS to

PNS. 23

2. Co-A(Effective maxillary length): It is the linear measurement of Co to point A.22


3. Go-Pog perpendicular MP (Mandibular length): It is the linear distance from Go to the
perpendicular drawn from Pog on the mandibular plane joining the Gn and Me.22
4. Co-Gn (Effective mandibular length): It is the linear distance from Co to
Anatomic Gn.22
5. U1 to NA distance: It is the shortest distance from incisal edge of the most prominent maxillary
central incisor to N-A plane.22
6. L1 to NB distance: It is the shortest distance from incisal edge of the most prominent
mandibular central incisor to N-B plane.22

Figure 3: various linear parameters for the evaluation of the skeletal and dental changes;
1.ANS-PNS, maxillary length; 2. Co-A, Effective mandibular length; 3. Go- Pog per MP,

Mandibular length; 4. Co- Gn, Effective mandibular length; 5. Upper incisor to NA and 6.
Lower incisor to NB

Angular parameters:
The following angular parameters were measured on the lateral cephalograms for the
evaluation of immediate and long-term stability of the skeletal and dento-alveolar changes
following twin-block appliance therapy (Figure 4).
1.

SNA: It is the angle between sella- nasion point A which represents thhe antero posterior
position of the maxillary base in relation to the anterior cranial base.22

2.

SNB: It is the angle between sella- nasion point B that represents the antero posterior
position of the mandible in relation to the anterior cranial base.22

3.

ANB: It is the angle between point A nasion point B and it represents the anteroposterior
position of the jaws in relation to each other.22

4.

FMA: It is the angle between FH plane and mandibular plane (Go- Me).22

5.

SN-GoGn: It is angle formed by mandibular plane drawn between gonion and Gnathion to S-N
plane.22

6.

Y-axis: The acute angle formed by the intersection of a line from the sella tursica to gnathion
with Frankfort horizontal plane.22

7.

Upper incisor to NA: It is the angle between the long axis of maxillary central incisor (U1) and
line from N to point A.22

8.

Upper incisor to SN: It is the angle between the long axis of maxillary central incisor (U1) and
SN plane.22

9.

Lower incisor to NB: It is the angle between the long axis of mandibular central incisor (L1)
and the line from N to point B.22

10. IMPA: It is the angle formed by the intersection of the mandibular plane (Go-Me) with a line
passing through the incisal edge and the apex of the root of the mandibular central incisor.22

Figure 4; various cephalometric angular parameters for the evaluation of skeletal and dental
changes 1. SNA; 2. SNB; 3.ANB; 4. FMA; 5. SN- Go-Gn; 6. Y-axis; 7. Upper incisor to NA 8.
Upper incisor to SN; 9. Lower incisor to NB and 10. IMPA

B) Evaluation of posterior pharyngeal airway passage dimension


The immediate and long-term stability of the changes in the dimensions of pharyngeal
airway passage following twin-block appliance therapy were evaluated by the method as
described by Jena et al. (2010).24 The following cephalometric landmarks, reference planes
and linear and angular parameters were measured for the evaluation of immediate and longterm stability of the changes in the dimensions of posterior pharyngeal airway passage
following twin-block appliance therapy.
Cephalometric landmarks:
1. N (Nasion): The most anterior point of the nasofrontal suture in the median plane.24
2. Po (Porion): The most superiorly positioned point of the external auditory meatus. 24
3. Or (Orbitale): The lowest point on the inferior rim of the orbit.24
4.

Ptm (Pterygomaxillare): It is the lowest point of the opening of the pterygomaxillary fissure. 24

5. Ba (Basion): It is the lowset point on the anterior rim of the foramen Magnum.24

10

6. PNS (Posterior Nasal Spine): It is the posterior spine of the palatine bone constituting the hard
palate.24
7. Point V (Vallecula): It is the intersection of the epiglottis and the base of the tongue.24
8. Point U (Tip of Uvula): It is the most posteroinferior point of the uvula representing tip of the
uvula.24
9. UPW (Upper Pharyngeal Wall): It is the intersection of line joining Ptm to Ba and posterior
pharyngeal wall.24
10. MPW (Middle Pharyngeal Wall): It is the intersection of perpendicular line on Ptm
perpendicular from U with posterior pharyngeal wall.24
11. LPW (Lower Pharyngeal Wall): It is the intersection of perpendicular line on Ptm
perpendicular from V with posterior pharyngeal wall.24

Figure 5: Various cephalometric landmarks for the evaluation of pharyngeal airway


pharyngeal airway passage dimensions

Cephalometric reference planes


1. FH plane: It is the line joining Po and Or.24
2. Ptm perpendicular (Ptm per): It is the perpendicular plane drawn on FH plane at
Ptm.24
3. Ba- N Plane: It is the line joining Ba and N.24
11

Cephalometric linear parameters


1. DNP (Depth of nasopharynx): It is the linear distance between Ptm and UPW.24
2. HNP (Height of nasopharynx): It is the shortest linear distance from PNS to Ba-N
plane. 24
3. DOP (Depth of oropharynx): It is the linear distance between U and MPW.24
4. DHP (Depth of hypopharynx): It is the linear distance from V to LPW.24
5. SPL (Soft palate length): It is the linear distance between U and PNS.24
6. SPT (Soft palate thickness): It is the maximum thickness of the soft palate.24

Cephalometric angular parameters:


SPI (Soft palate inclination): It is the angle between Ptm perpendicular and soft
palate.

Figure 6:- Various cephalometric reference planes and linear and angular parameters
for the evaluation of pharyngeal airway passage dimensions.

C) Evaluation of posterior pharyngeal wall thickness


The immediate changes and long-term stability of the changes in the dimensions of posterior
pharyngeal wall following the twin-block appliance therapy were determined according to the
method described by Joseph et al. (1998). 25 The following cephalometric landmarks,
reference planes and linear parameters were used for the evaluation of immediate and long-

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term stability of the changes in the dimensions of posterior pharyngeal wall following the
twin-block appliance therapy.
Cephalometric landmarks
1. ANS (Anterior Nasal Spine): It is the anterior tip of the sharp bony process of the maxilla at
the lower margin of the anterior nasal opening.21
2. PNS (Posterior Nasal Spine): It is the posterior spine of the palatine bone constituting the hard
palate.21
3. Go (Gonion): A constructed point and the intersection of the line tangent to the posterior
margin of the ascending ramus and mandibular base.21
4. Me (Menton): It is the most caudal point in the outline of the symphysis.21
5. U (tip of the soft palate): It is the most posterioinferior point of the uvula representing tip of the
uvula.21
6. MSP (mid- point of soft palate): The midpoint is established by bisecting the line PNSU a
maximum thickness of soft palate.21
7. SC3 (superior- anterior point of C3): It is the most superior point on the anterior border of C 3
vertebra.21
8. IC3 (inferior anterior point of C3vertebrae): It is the most inferior point on the anterior border
of C3 vertebra.21
Cephalometric reference planes:
1. Palatal plane (ANS-PNS): It is the line joining the Anterior nasal spine (ANS) and Posterior
nasal Spine (PNS).21
2. Mandibular plane (MP): It is the plane joining to Gonion to the Menton (Me)
3. Anterior tangent to C2 vertebra: It is tangent drawn along the anterior border of second cervical
vertebra C2. 21
4. Long axis of soft palate (PNS-U): It is the line joining posterior nasal spine (PNS) to tip of the
soft palate(U).21

13

Figure 9: Various cephalometric landmarks for the evaluation of posterior pharyngeal wall
thickness
Linear parameters:1. PPW1 (Posterior pharyngeal wall 1): It is the distance from the intersection point
of palatal plane and posterior pharyngeal wall to the intersection point of palatal
plane and anterior tangent of 2nd cervical vertebra.21
2.

PPW 2 (Posterior pharyngeal wall 2): It is the distance from the intersection point of line
parallel to the palatal plane passing through mid- point of the soft palate (MSP) and the
posterior pharyngeal wall to the intersection point of same line extended posteriorly and
anterior tangent of 2nd cervical vertebra.21 The mid- point of the soft palate is the intersection of
long axis of soft palate (PNS-U) and a line representing the maximum thickness of soft palate.

3.

PPW 3 (Posterior pharyngeal wall 3): It is the distance from the intersection point of line
parallel to palatal plane passing through the tip of uvula (U) and the posterior pharyngeal wall
to the intersection point of same line extended posteriorly and anterior tangent of 2 nd cervical
vertebra.21

4.

PPW 4 (Posterior pharyngeal wall 4): It is the distance from the intersection point of the
mandibular plane and posterior pharyngeal wall to the intersection point of the mandibular
plane and anterior tangent of 2nd cervical vertebra.21

5.

PPW 5 (Posterior pharyngeal wall 5): It is the distance from the intersection point of line
parallel to the mandibular plane passing through the superio-anterior point of 3 rd cervical
vertebra to superior-anterior point of 3rd cervical vertebra.21
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6.

PPW 6 (Posterior pharyngeal wall 6): It is the distance from the intersection point of line
parallel to mandibular plane passing through the inferior-anterior point of 3 rd cervical vertebra
to inferior-anterior point of 3rd cervical vertebra.21

Figure 8 Various cephalometric reference planes for the evaluation of Posterior


pharyngeal wall thickness.
MEASUREMENT OF CEPHALOMETRIC ERRORS
1.

Error due to fatigue


Ten cephalograms were analysed on an average in a day to eliminate the error due to

fatigue of the investigator.


2. Intra-Observational error
The assessment of reliability and reproducibility of various land marks location and
measurement errors were analysed by retracing the 10 % randomly selected
cephalograms after a gap of 15 days. The method error was calculated according to
Dahlbergs formula. (Put reference) The reliability of measurements are described in
table-1

= E d 2/2 n

= Method error
d= difference between single measurement and mean of the single measurement
n= no of measurements

15

To judge the reliability of the repeated tracing of chosen cephalometric landmarks, the
method error was put in relation to biological variance
Reliability = 1-2 / S2
2 = Method error
S2v = Total variance of measurement
Statistical analysis (I have not checked as you write according after putting the
statistics)
The mean value of each of the respective individual measurement for the digital
lateral cephalogram tracings were subjected to statistical analysis. The data was
analysed in SPSS software (Version-16). All data was subjected to descriptive statistics
to determine mean, standard deviation (SD), range, coefficient of variance (CV) ect.
The statistical significance value was determined by Repetitive ANNOVA test. The pvalue of 0.05 was considered as level of significance.
Table -1:- The reliability for various cephalometric variables measurements.
Parameter

Method
Error

SNA (deg)
Maxillary length (ANA-PNS) (mm)
Effective maxillary length (Co- A) (mm)
SNB (deg)
Mandibular length (Go- Pog per MP) (mm)
Effective mandi. length (Co- Gn) (mm)
ANB (deg)
Maxillo-mandibular difference (mm)
FMA (deg)
SN- Go Gn deg
Y- Axis (deg)
Upper incisor to NA (mm)
Upper incisor to NA (mm)
Lower incisor to NB (mm)
Lower incisor to NB (deg)
IMPA (deg.)
Depth of Nasopharynx (DON) (mm)
Height of Nasopharynx (HON) (mm)
Depth of oropharynx (DOO) (mm)
Depth of hypopharynx (DOH) (mm)
Soft palate length (SPL) (mm)
Soft palate thickness (SPT) (mm)
Soft palate inclination (SPI) (deg)
PPWT1 at nasopharyngeal space 1 (mm)
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Mode of
variance

Reliability

PPWT 2 at nasopharyngeal space 2 (mm)


PPWT 3 at oropharyngeal space 1 (mm)
PPWT 4 at oropharyngeal space 2 (mm)
PPWT 5 at Hypopharynx space 1 (mm)
PPWT 6 at Hypopharynx space (2 mm)
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(ANNEXURE-I)
Ethical Justification
The study was undertaken after the ethical clearance from the institutes ethical committee.
All the patients will give their consent for functional appliance therapy followed by
comprehensive Orthodontic treatment to the doctors of Unit of Orthodontics, Oral Health
Sciences Centre, Postgraduate Institute of Medical Education & Research, Chandigarh.
They informed that they have been fully explained about the treatment procedures. They were
also explained that the end results of treatment will be an improvement in present situation
and not perfection.
They gave consent for use/evaluation of technique based on sound scientific principles.
The study has utilized the existing resources without additional expenditure from hospital or
patient. No invasive procedure or special intervention were needed for the purpose of the
study

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PATIENT INFORMATION SHEET


Proforma for Stability of Posterior pharyngeal wall and pharyngeal airway passage
following Twin block therapy

1. S. No

2. Name:

3. Age:

4. Sex 1. Male
2. Female

5. Date of Birth

6. Ortho. No
7. C.R.No

8. Guardian Name
21

9. Contact

number:

Phone number

Land line number

10. Address:

11. CEPHALOMETRIC EVALUATION:- (You must refer Dr. Swapnils thesis)


S.
N
o

Skeletal & Dental


parameters

SNA (deg.)

MAXILLARY LENGTH
(ANS-PNS)
EFFECTIVE
MAXILLARY LENGTH
(Co-A)
SNB (deg.)

4
5

7
8

PRE
TREATMEN
T

MANDIBULAR
LENGTH(Go-Pog per
MP)
EFFECTTIVE
MANDIBULAR
LENGTH (Co-Gn)
ANB (deg.)

MAXILLOMANDIBULA
R DIFFERENTIAL in mm
FMA (deg.)

10

SN- Go GN

22

POST
FUNCTIONA
L

POST
TREATMEN
T

AGE
MATCHE
D
CONTRO
L GROUP

11

Y AXIS (deg.)

12

UPPER INCISOR TO NA
(in mm)
UPPER INCISOR TO NA
(deg.)
UPPER INCISOR TO SN
(deg.)
LOWER INCISOR TO
NB (in mm)
LOWER INCISOR TO
NB(deg.)
IMPA

13
14
15
16
17

PAP Dimension
18

Depth of nasopharynx

19

Height of nasopharynx

20

Depth of oropharynx

21

Depth of hypopharynx

22

Soft palate length (SPL)

23

Soft palate thickness


(SPT)
Soft palate inclination
(SPI)

24

PP W THICKNESS
25

26

27
28

29

PPWT 1 at
nasopharyngeal space
1(mm)
PPWT 2 at
nasopharyngeal space 2
(mm)
PPWT 3 at oropharyngeal
space 1 (mm)
PPWT 4 at
oropharyngeal space 2
(mm)
PPWT 5 at
hypopharyngeal space 1
(mm)
23

30

PPWT 6 at
hypopharyngeal space 2
(mm)

24

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