Original Article

Three-dimensional evaluation of maxillary dentoalveolar changes and

airway space after distalization in adults
Jae Hyun Parka,b; Sungkon Kimc; Yoon-Jin Leed; Mohamed Bayomee,f; Yoon-Ah Kookg;
Mihee Hongh; Yoonji Kimi

ABSTRACT
Objectives: To evaluate the changes in position of the maxillary dentition and the airway space
after distalization using a modified C-palatal plate (MCPP) in adult patients through CBCT images
and to analyze the relationship between the amount of distalization and the changes in the airway
space.
Materials and Methods: CBCT images of 33 adult Class II patients (22.2 6 4.0 years old; 27
women and 6 men) treated by total maxillary arch distalization using the MCPP were evaluated
before and after distalization. The patients were divided into nonextraction and extraction groups.
The changes in the airway space as well as the changes in the positions of the maxillary dentition
were evaluated. The distalization effects were calculated and assessed using paired t-tests.
Results: After distalization, the first molar showed significant distalization and intrusion (P , .001)
with no significant rotation of the crown and no significant buccal displacement of its root in the
transverse dimension. There were no significant changes in the airway volume or the minimum
cross-sectional area of the oropharynx.
Conclusions: The application of the MCPP resulted in significant total arch distalization without a
significant effect on the transverse dimensions or changes in the oropharynx airway space. The
MCPP can be considered a viable treatment option for patients with Class II malocclusion. (Angle
Orthod. 2018;88:187–194.)
KEY WORDS: Distalization; Modified C-palatal plate; Airway space; CBCT

INTRODUCTION treatment effects, as reported by the same research

Distalization of the maxillary dentition has become
an important treatment modality for Class II and Class I
malocclusion with bimaxillary dentoalveolar protrusion
patients, especially when extraction treatment is not
accepted by patients.1,2 Recently, the modified C-
palatal plate (MCPP) has been reported to achieve
efficient and effective total arch distalization.3 Its
a
Professor and Chair, Postgraduate Orthodontic Program,
Arizona School of Dentistry & Oral Health, A.T. Still University,
Mesa, Arizona, USA.
b
International Scholar, Graduate School of Dentistry, Kyung
Hee University, Seoul, Korea.
c
Former Resident, Department of Orthodontics, Seoul St.
Mary’s Hospital, The Catholic University of Korea, Seoul, Korea.
d
Resident, Department of Orthodontics, Seoul St. Mary’s
Hospital, The Catholic University of Korea, Seoul, Korea.
e
Research Assistant Professor, College of Medicine, The
Catholic University of Korea, Seoul, Korea.
f
Visiting Professor, Department of Postgraduate Studies,
Universidad Autonóma del Paraguay, Asunción, Paraguay.
g
Professor, Department of Orthodontics, Seoul St. Mary’s
Hospital, The Catholic University of Korea, Seoul, Korea.
group, showed significant amounts of distalization and
intrusion with minimal distal tipping of the first molar.4,5
However, accurate evaluation of the root position is
very difficult to perform on two-dimensional (2D) lateral
cephalograms because of superimposition and projec-
tion factors.
Recently, airway analysis and the effect of different
treatment modalities on the airway space have gained
increased interest from researchers and have had
conflicting results in the literature. Several studies
h
Assistant Professor, Department of Orthodontics, School of
Dentistry, Kyungpook National University, Daegu, Korea.
i
Associate Professor, Department of Orthodontics, Seoul St.
Mary’s Hospital, The Catholic University of Korea, Seoul, Korea.
Corresponding author: Yoonji Kim, Department of Orthodon-
tics, Seoul St. Mary’s Hospital, The Catholic University of Korea,
505 Banpo-Dong, Seocho-Gu, Seoul, 137-701, Korea
(e-mail: juice@catholic.ac.kr)
Accepted: November 2017. Submitted: December 2016.
Published Online: January 16, 2018
Ó 2018 by The EH Angle Education and Research Foundation,
Inc.

DOI: 10.2319/121116-889.1 187 Angle Orthodontist, Vol 88, No 2, 2018

188
showed a decrease in the pharyngeal airway size with
extraction treatment.6–8 Guilleminault et al.9 suggested
that extraction treatment may predispose patients to
obstructive sleep apnea (OSA). On the other hand,
Larsen et al.10 demonstrated strong evidence using a
large sample matched for age range, gender, and body
mass index that there was no relationship between
premolar extraction treatment and OSA. However, the
effect of distalization of the maxillary dentition in
nonextraction Class II patients on the airway has not
been evaluated. Also, the three-dimensional (3D)
evaluation of the position of the maxillary roots after
distalization, especially changes in the transverse
dimension and buccolingual axial inclinations, have
not been assessed. The evaluation of changes in root
position is essential for the prediction of the stability of
the treatment outcome.
Therefore, the purposes of this study were to
evaluate the changes in position of the maxillary
dentition and the airway space after distalization using
a MCPP in adult patients using cone-beam computed
tomography (CBCT) images and to analyze the
relationship between the amount of distalization and
the changes in airway space.
MATERIALS AND METHODS
This study analyzed CBCT images of 33 consecu-
tively treated Class II adult patients (27 women and 6
men), with an average age of 22.18 6 3.99 years, who
underwent bilateral total arch distalization of the
maxillary dentition at the Department of Orthodontics
Seoul St. Mary’s Hospital, The Catholic University of
Korea, Seoul, Korea. The inclusion criteria in this
retrospective study were (1) dental Class II relation-
ship, (2) 3D CBCT images taken immediately before
(T1) and after (T2) distalization, (3) age was older than
18 years. Approval was obtained from the institutional
review board of the Catholic University of Korea
(KC11RASI0790), and informed consent was provided
according to the Declaration of Helsinki.
The sample was divided into extraction and non-
extraction groups. The extraction group (n ¼ 16; 22.9
years old) consisted of those who were treated by
premolar extraction and retraction of the anterior
segment; they then received the MCPP for additional
maxillary total arch distalization after extraction space
closure. The nonextraction group (n ¼ 17; 21.5 years
old) was treated using MCPP appliances for distaliza-
tion of the maxillary dentition (Figure 1). Table 1 shows
the distribution of the severity of the Class II molar
relationship in the extraction and nonextraction groups.
All patients were treated by the same operator (Y-A
K). The installation method of the MCPP appliance has
been previously described.11 The MCPP was fitted on
Angle Orthodontist, Vol 88, No 2, 2018
PARK, KIM, LEE, BAYOME, KOOK, HONG, KIM
Table 1. Distribution of the Severity of Class II Molar Relationship in
Extraction and Nonextraction Groups
Severity of Class II Extraction Nonextraction Total
Quarter cusp 21 18 39
Half cusp 6 9 15
Three-quarters cusp 0 1 1
Full cusp 5 6 11
v2 test: P ¼ .601.
the palatal surface of the dental cast with its arms
extended between the first molar and second premolar,
leaving 2 mm between the arms and the palatal slopes.
A jig was used to transfer the MCPP to the patient’s
mouth. It was then installed by three 8-mm length/2.0-
mm diameter miniscrews (Jeil Corporation, Seoul,
Korea). A palatal bar with two hooks was extended
along the gingival margins of the teeth and banded to
the maxillary first molars. Immediately after placement,
distalization was initiated by connecting elastics or
nickel-titanium closed coil springs, applying approxi-
mately 300 g of force per side between the MCPP arms
and the palatal bar hooks. Along with the MCPP
appliance, 0.022-inch slot (Tomy Inc., Tokyo, Japan)
brackets and bands were placed on the maxillary and
mandibular teeth, including the second molars.
CBCT images (at T1 and T2) were taken using an
iCAT scanner (Imaging Science International, Hatfield,
Pa). The scanning parameters were 120 kV, 47.7 mAs,
20 seconds per revolution, a 170 3 130 mm field of
view, and a voxel size of 0.4 mm. The head position
was oriented so that the Frankfort plane was parallel to
the floor in a seated position, and the images were
taken at the intercuspal position.
The CBCT data were exported in a digital imaging
and communications in medicine multifile format and
imported into InVivo 5.2 software (Anatomage Inc, San
Jose, Calif) for 3D volume rendering. Reorientation of
the head position of each scan was performed as
follows: the horizontal plane was defined through the
right and left orbitales and the left porion, whereas the
midsagittal plane was defined as the perpendicular
plane passing through nasion and the anterior nasal
spine. The vertical plane was perpendicular to both the
horizontal and midsagittal planes. The CBCT images
were digitized, and the software calculated 24 linear
and angular measures between certain landmarks
(Figure 2).
Assessment of the Airway Space
The airway measurements of the pre- and postdis-
talization CBCT images were done by the same
researcher using In vivo 5.2 software (Anatomage
Inc). The oropharynx was divided into the following two
areas: velopharynx and glossopharynx. The velophar-
UPPER DENTITION & AIRWAY SPACE AFTER DISTALIZATION 189

Figure 1. Pre- and posttreatment intraoral photos and lateral cephalometric tracing superimpositions. (A) Example from the extraction group. (B)
Example from the nonextraction group. Black, pretreatment; blue, progress; red, posttreatment.

Angle Orthodontist, Vol 88, No 2, 2018

190
Figure 2. Landmarks on 3D CBCT render view. N indicates nasion;
Po, porion; Or, orbitale; ANS, anterior nasal spine; A, A point; B, B
point; Pg, pogonion; U1A, upper central incisor apex; U1C, upper
central incisor crown; U3A, upper canine apex; U3C, upper canine
crown; U6A, upper first molar palatal root apex; U6CM, upper first
molar crown mesial; and U6CD, upper first molar crown distal.
ynx was defined from the horizontal level of the palatal
plane to the horizontal level of the end of the uvula,
whereas the glossopharynx was defined from the
horizontal level of the end of the uvula to the horizontal
level of the C3 (the most anterior and inferior point of
the third cervical vertebra).12 The volume of the airway
space and the minimum cross-sectional area (MCA)
were computed automatically by the software (Figures
3 and 4). The amounts of change between pre- and
postdistalization variables were calculated.
Figure 3. Sagittal view of airway space measurements. (A) Upper airway. (B) Lower airway.
Angle Orthodontist, Vol 88, No 2, 2018
PARK, KIM, LEE, BAYOME, KOOK, HONG, KIM
Ten randomly selected cases were reprocessed 4
weeks later to evaluate intraoperator reliability. Intra-
Class correlation coefficient using a two-factor, mixed-
effects model and type consistency showed that the
measurements were reliable (intraClass correlation
coefficient for all variables ranged between 0.90 and
0.99). It was not possible to blind the groups and the
time point of each CBCT image.
Statistical Analysis
Statistical evaluation was performed using SPSS
16.0 (SPSS Inc, Chicago, Ill). Normal distribution of the
parameters was assessed by the Shapiro-Wilk test.
The chi-square test was used to compare the
distribution of the severity of Class II between the
extraction and nonextraction groups. Changes that
occurred from T1 to T2 were evaluated by paired t-test.
Differences between the extraction and nonextraction
groups were assessed by independent sample t-test.
Correlations between the amount of distalization and
the changes in the total airway volume and the MCA in
both groups were evaluated using Pearson correlation.
The statistical significance was determined at a ¼ 0.05.
Bonferroni correction for multiple comparisons was
applied.
RESULTS
There was no significant difference in the distribution
of the severity of Class II relationships between the
groups (P ¼ .601; Table 1). Tables 2 and 3
demonstrate the before and after distalization compar-
isons between the extraction and nonextraction
groups.
After distalization, in the nonextraction group, the
crown of the first molar showed 3.24 mm of distaliza-
tion (P , .001). The palatal root had a nonsignificant
UPPER DENTITION & AIRWAY SPACE AFTER DISTALIZATION 191

Table 2. Comparison of Predistalization Measurements Between Table 3. Comparison of Postdistalization Measurements Between
Extraction and Nonextraction Groups Extraction and Nonextraction Groups
Extraction Nonextraction Extraction Non-extraction
Variable Mean SD Mean SD P Value Variable Mean SD Mean SD P Value
A point to frontal, mm 1.74 2.69 0.49 3.25 .040 A point to frontal, mm 0.24 2.67 1.53 3.27 .100
B point to frontal, mm 7.78 5.98 7.06 6.80 .753 B point to frontal, mm 9.13 5.45 7.63 6.69 .486
Pog to frontal, mm 10.03 6.48 6.42 7.96 .164 Pog to frontal, mm 11.13 6.34 6.91 7.91 .102
A point to FH, mm 30.23 3.00 30.69 3.25 .677 A point to FH, mm 29.60 2.16 30.79 2.76 .181
B point to FH, mm 71.67 2.84 69.77 6.11 .261 B point to FH, mm 71.85 3.63 68.84 5.17 .067
Pog to FH, mm 86.94 3.24 83.94 7.48 .145 Pog to FH, mm 87.55 3.60 82.81 5.79 .009
CU6 to FH, mm 46.64 4.32 46.44 3.79 .845 CU6 to FH, mm 45.62 3.28 45.03 4.57 .553
RU6 to FH, mm 30.75 3.27 30.23 3.55 .542 RU6 to FH, mm 29.68 3.58 28.98 3.87 .449
CU6 to frontal, mm 17.01 3.99 21.26 4.08 ,.001 CU6 to frontal, mm 20.42 3.95 24.50 4.46 ,.001
RU6 to frontal, mm 24.08 4.02 27.88 3.75 ,.001 RU6 to frontal, mm 26.08 3.93 30.31 4.40 ,.001
RU6 to midsagitta, mm 17.88 2.60 18.26 3.22 .601 RU6 to midsagittal, mm 18.48 2.96 19.10 2.60 .367
U6 axis – FH, 8 66.96 5.97 67.46 6.74 .754 U6 axis – FH,8 70.64 6.14 70.54 8.39 .956
CU6 MD axis – 8.98 5.80 9.97 5.93 .500 CU6 MD axis – 8.32 5.28 11.15 6.35 .062
midsagittal, 8 midsagittal,8
CU1 to FH, mm 56.04 3.07 54.73 4.08 .147 CU1 to FH, mm 56.10 2.67 55.32 3.86 .350
RU1 to FH, mm 35.20 2.87 34.42 3.63 .339 RU1 to FH, mm 34.62 2.64 34.82 3.58 .799
CU1 to frontal, mm 5.06 4.71 4.12 6.00 .482 CU1 to frontal, mm 1.80 4.23 2.71 5.05 .434
RU1 to fronta, mm 1.27 3.70 4.20 3.20 .001 RU1 to frontal, mm 1.65 3.52 3.96 3.72 .012
RU1 to midsagittal, mm 3.55 1.95 3.52 2.42 .964 RU1 to midsagittal, mm 3.94 2.17 3.26 1.54 .142
U1 axis – FH, 8 73.03 7.83 67.80 10.44 .024 U1 axis – FH,8 80.48 7.72 72.23 8.45 ,.001
RU3 to FH, mm 58.78 3.55 57.15 5.85 .181 RU3 to FH, mm 59.30 3.72 57.16 6.07 .090
RU3 to midsagittal, mm 15.74 2.47 14.38 2.89 .046 RU3 to midsagittal, mm 16.99 2.53 15.20 2.02 .003
RU3 to frontal, mm 0.36 8.77 0.16 10.48 .831 RU3 to frontal, mm 0.02 9.39 0.07 10.43 .970
U3 axis – FH, 8 78.12 8.00 72.50 8.18 .007 U3 axis – FH,8 84.27 5.23 77.90 7.79 ,.001
U3 axis – midsagittal, 8 10.91 5.99 10.73 5.81 .903 U3 axis – midsagittal,8 8.24 4.61 8.98 4.05 .494
SD indicates standard deviation; Pog, pogonion; FH, Frankfort SD indicates standard deviation; Pog, pogonion; FH, Frankfort
horizontal; C, crown; R, root; U, upper; 1, central incisor; 3, canine; 6, horizontal; C, crown; R, root; U, upper; 1, central incisor; 3, canine; 6,
first molar; and MD, mesiodistal. first molar; and MD, mesiodistal.

0.84-mm buccal movement, but significant 1.26-mm

Figure 4. Cross-sectional view showing the measurement of the
minimum cross-sectional area of the oropharyngeal airway.
intrusion and 2.43-mm distalization (P , .001). The
angulation of the long axis showed a nonsignificant
3.078 of distal tipping. The crown showed no significant
rotation in the transverse plane (P ¼ .387).
The root of the central incisor showed no significant
changes, whereas the crown showed a significant
retraction of 1.41 mm (P ¼ .001), and a lingual
inclination of 4.448 (P ¼ .001). Also, the root of the
canine demonstrated no significant changes, with a
significant lingual crown tipping of 5.558 (Table 3).
In the extraction group, the first molar showed 3.41
mm of distalization at the crown level (P , .001). The
root demonstrated 2.00 mm of distalization (P , .001),
1.07 mm of intrusion (P ¼ .001), and a nonsignificant
buccal movement of 0.41 mm. The inclination of the first
molar had 3.688 of distal tipping (P , .001). Also, there
was no significant rotation of the crown (P ¼ .472).
The root of the central incisor in the extraction group
showed no significant changes, whereas the crown
showed a significant retraction of 3.26 mm (P , .001),
and a lingual inclination of 7.468 (P , .001). The root of
the canine showed a facial movement of 1.25 mm in
the transverse plane (P ¼ .001), with lingual crown
tipping of 6.158. There were no significant differences

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192 PARK, KIM, LEE, BAYOME, KOOK, HONG, KIM

Table 4. Comparison of Distalization Effect Measurements Between Extraction and Nonextraction Groups
Extraction Nonextraction
Variable Mean SD P Value Mean SD P Value P Value
A point to frontal, mm 1.50 0.93 ,.001 1.04 0.84 ,.001 .148
B point to frontal, mm 1.36 2.11 .021 0.56 1.73 .197 .245
Pog to frontal, mm 1.10 1.95 .040 0.49 1.77 .269 .359
A point to FH, mm 0.28 1.13 .179 0.09 1.05 .721 .346
B point to FH, mm 0.18 1.78 .695 0.16 1.21 .597 .531
Pog to FH, mm 0.61 1.57 .140 0.08 1.03 .753 .150
CU6 to FH, mm 1.02 1.67 .002 1.41 2.07 ,.001 .403
RU6 to FH, mm 1.07 1.72 .001 1.26 1.51 ,.001 .646
CU6 to frontal, mm 3.41 1.25 ,.001 3.24 1.79 ,.001 .656
RU6 to frontal, mm 2.00 1.50 ,.001 2.43 1.97 ,.001 .327
RU6 to midsagittal, mm 0.41 1.38 .058 0.84 2.46 .055 .390
U6 axis  FH,8 3.68 4.97 ,.001 3.07 6.77 .012 .687
CU6 MD axis  midsagittal,8 0.51 3.74 .472 1.18 7.85 .387 .294
CU1 to FH, mm 0.06 1.57 .839 0.59 1.05 .002 .106
RU1 to FH, mm 0.57 1.36 .023 0.40 1.50 .127 .007
CU1 to frontal, mm 3.26 2.75 ,.001 1.41 2.23 .001 .004
RU1 to frontal, mm 0.39 2.15 .320 0.23 1.52 .375 .185
RU1 to midsagittal, mm 0.40 1.80 .224 0.27 2.34 .511 .204
U1 axis  FH,8 7.46 6.52 ,.001 4.44 7.19 .001 .079
RU3 to FH, mm 0.52 1.67 .091 -0.04 2.01 .919 .232
RU3 to midsagittal, mm 1.25 1.83 .001 0.92 2.07 .016 .502
RU3 to frontal, mm 0.34 2.30 .414 0.23 1.49 .378 .828
U3 axis  FH,8 6.15 6.54 ,.001 5.55 4.23 ,.001 .666
U3 axis  midsagittal,8 2.34 4.70 .011 2.03 5.07 .033 .808
SD indicates standard deviation; Pog, pogonion; FH, Frankfort horizontal; C, crown; R, root; U, upper; 1, central incisor; 3, canine; 6, first molar;
and MD, mesiodistal.

in the distalization effect between the nonextraction
and extraction groups (Table 4).
Regarding the airway space analysis, the nonex-
traction group showed a nonsignificant decrease of
0.92 cm3 in airway volume. Also, the MCA of the
oropharynx was decreased by 7.82 mm2, which was
not statistically significant. Similarly, the extraction
group demonstrated no significant changes in the
airway volume or the MCA. There were no significant
differences in the airway variables between the two
groups (Table 5).
When the correlation between the amount of
distalization and airway space parameters were
evaluated, the nonextraction group showed no signif-
icant correlation between the amount of distalization
and the changes in the total volume or the MCA.
However, in the extraction group, there were significant
inverse moderate correlations (r ¼ 0.58, P ¼ .025; r ¼
0.53, P ¼ .040, respectively).
DISCUSSION
The CBCT images allowed the clinicians to accu-
rately evaluate the root position before and after

Table 5. Comparison of Airway Space Between Pre- and Postdistalization Measurements in Extraction and Nonextraction Groups
Extraction Nonextraction P P P
Value Value Value
Predist. Postdist. Diff. Predist. Postdist. Diff.
P P of of of
Variable Mean SD Mean SD Mean SD Value Mean SD Mean SD Mean SD Value Predist Postdist Distdiff
U airway vol., 8.24 4.98 8.31 3.42 0.49 2.68 .937 10.66 3.03 9.21 3.60 1.45 2.23 .016 .098 .465 .277
cm3
U airway MCA, 191.48 116.58 186.33 87.66 18.91 85.50 .838 249.71 96.27 230.19 117.47 19.51 60.55 .203 .127 .236 .982
mm2
L airway vol., 4.91 2.26 4.68 1.70 0.25 1.71 .584 6.54 3.03 6.39 3.06 0.15 2.42 .798 .097 .057 .901
cm3
L airway MCA, 130.82 61.24 124.81 56.80 6.99 50.67 .602 185.80 71.93 178.19 85.70 7.61 51.35 .550 .028 .044 .973
mm2
Total vol., cm3 14.42 6.23 13.83 5.05 0.53 4.08 .625 16.25 5.28 15.32 6.13 0.92 4.14 .371 .376 .452 .786
MCA, mm2 131.47 62.38 120.80 52.41 12.45 39.87 .246 189.91 71.11 182.09 89.80 7.82 56.31 .575 .02 .023 .793
Predist. indicates predistalization; Postdist., postdistalization; Diff., difference; SD, standard deviation; Distdiff, distalization difference; U,
upper; L, lower; vol., volume; and MCA, minimum cross-sectional area.

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UPPER DENTITION & AIRWAY SPACE AFTER DISTALIZATION
treatment in this study. The analysis of changes in root
position is crucial for the confirmation of achieving
proper root movement to enhance the stability of
treatment results after debonding. This study attempt-
ed to assess the positional changes in the maxillary
dentition and the dimensional alterations in the airway
after distalization using MCPP using 3D CBCT images.
A study recently evaluated the 3D changes in the
maxillary tuberosity after distalization using MCPP in
adults. A small amount of increase in the bone size
was reported at the distal end of the tuberosity.12
However, there was no assessment of the 3D changes
in the molar root positions. Only a few studies
evaluated the transverse changes after distalization.
Fuziy et al.13 reported approximately 1.5 mm of buccal
movement of the molars after distalization using the
pendulum appliance. Varlik and Iscan14 showed an
increase of about 1.0 mm in the intercanine width and
1.6 mm in the intermolar width after distalization using
cervical headgear. In the current study, the roots of the
canine and molar showed nonsignificant displacement
(0.4 and 0.8 mm, respectively) in the buccal direction.
Another study evaluating the transverse effect of
distalization demonstrated that the Frog appliance
resulted in distobuccal rotation of the first molar,
whereas ‘‘Karad’s integrated distalizing system’’ result-
ed in greater rotation but in the distopalatal direction
with greater expansion.15 Kang et al.16 reported, in a
finite element study, a mesial-in rotation with distaliza-
tion using MCPP that was decreased with the eruption
of the second molar. The pendulum appliance also
showed mesial-in rotation, whereas the headgear
showed distal-in rotation. In the current study, the
MCPP resulted in significant distalization and intrusion
of the first molar with no significant rotation of the
crown and no significant buccal displacement of its root
in the transverse dimension. Therefore, the palatal
approach method might be superior to the buccal
approach in controlling the resultant tooth movements.
Sagitally, a recent study showed 4.2 mm of molar
distalization and 3.28 of distal tipping accompanied by
0.3 mm of extrusion using a distal screw appliance
placed on the palate.17 Another study reported 3.1 mm
of molar distalization with 1.58 of distal tipping and 1.7
mm of extrusion using the MCPP.4 However, in the
current study, the molars were distalized 3.2 mm with
3.18 of distal tipping and 1.3 mm of intrusion. These
differences might be because the previous studies
were performed on adolescents using a 2D evaluation
method.
Regarding the airway analysis, Hsieh et al. 18
reported an approximately 3-cm3 decrease in the
airway volume after mandibular and maxillary set-back
surgery. Wang et al.6 reported a decrease of 1 to 1.5
mm in the oropharyngeal airway anteroposterior width
193
with extraction treatment. However, the decrease in the
oropharyngeal airway anteroposterior width was 2.1
mm and 3.8 mm in patients treated with extraction and
maximum anchorage in the study of Germec-Caken et
al.8 Chen et al.7 demonstrated a 21.0% and 25.2%
decrease in the cross-sectional areas of the palato-
pharynx and glossopharynx, respectively, after four
first premolar extraction treatments. However, no
previous study has evaluated the changes that may
occur in the airway space after distalization of the
maxillary dentition. In the current study, there was an
approximately 0.5 to 1.5 cm3 decrease in the volume
and about an 8% to 10% decrease in the MCA of the
upper oropharynx; however, these decreases were not
statistically significant.
In the extraction group, the amount of distalization
had a significant inverse moderate correlation with the
changes in airway volume and MCA. This suggests
that an increase in distalization would cause some
decrease in the airway volume. However, this was not
found in the nonextraction group. This might be
because the amount of incisor retraction was greater
in the extraction group (3.26 mm) than in the
nonextraction group (1.41 mm; P ¼ .004), causing
some decrease in the tongue space, and in turn
decreasing the airway volume to a level that would
cause further distalization to have an inverse correla-
tion with the airway volume.
Several studies reported a relationship between the
MCA of the oropharynx and the occurrence and
severity of OSA.19–21 Lowe et al.21 showed that the
mean airway volume in OSA patients was 13.9 cm3. In
the current study, the mean airway volume was 16.3
cm3 in the nonextraction group and 14.4 cm3 in the
extraction group. After distalization, the volumes
decreased to 15.3 cm3 and 13.8 cm3, respectively.
However, these changes were not statistically signifi-
cant.
There were no significant changes in the airway
volume or the MCA of the oropharynx. However,
because the patients in the current study were adults,
the amount of distalization (mean 3.3 mm) might not be
large enough to induce changes on the airway space.
Therefore, future studies evaluating the airway chang-
es in adolescent patients treated by MCPP with large
amounts of distalization might be recommended.
In this study, the space of the nasopharynx was not
evaluated because the treatment effect was related to
the oral cavity and its effect on the airway space would
be on the oropharynx and not the nasopharynx.
Therefore, adding the nasopharynx space may have
resulted in an increase of confounding factors. In
addition, the CBCT images were acquired with the
patient in a seated position, which resulted in different
airway measurements than those taken in a supine
Angle Orthodontist, Vol 88, No 2, 2018
194
position. Therefore, the dimensions of the airway
space in this study should be interpreted with caution.
Moreover, the body mass index was not reported and
the mode of respiration was not controlled. Also, the
shape of the palate was not included in the current
study; therefore, an assessment of the relationship
between palatal dimensions and the changes in root
positions might be warranted.
CONCLUSIONS
 The use of the MCPP resulted in significant total arch
distalization without significant displacement of the
teeth in the transverse dimension or changes in the
oropharynx airway space.
 There was a statistically significant moderate inverse
correlation between the amount of distalization and
the amount of change in the airway volume in the
extraction group only.
 Based on the results observed, no patients in this
study developed a significant risk of OSA after
distalization of the maxillary dentition.
ACKNOWLEDGMENTS
This study was partly supported by funds of the Department of
Dentistry and Graduate School of Clinical Dental Science,
Catholic University of Korea.
REFERENCES
1. Kook YA, Park JH, Kim Y, Ahn CS, Bayome M. Sagittal
correction of adolescent patients with modified palatal
anchorage plate appliances. Am J Orthod Dentofacial
Orthop. 2015;148:674–684.
2. Kook YA, Park JH, Kim Y, Ahn CS, Bayome M. Orthodontic
treatment of skeletal Class ii adolescent with anterior open
bite using mini-screws and modified palatal anchorage plate.
J Clin Pediatr Dent. 2015;39:187–192.
3. Kook YA, Park JH, Bayome M, Sa’aed NL. Correction of
severe bimaxillary protrusion with first premolar extractions
and total arch distalization with palatal anchorage plates. Am
J Orthod Dentofacial Orthop. 2015;148:310–320.
4. Sa’aed NL, Park CO, Bayome M, Park JH, Kim Y, Kook YA.
Skeletal and dental effects of molar distalization using a
modified palatal anchorage plate in adolescents. Angle
Orthod. 2015;85:657–664.
5. Kook YA, Bayome M, Trang VT, et al. Treatment effects of a
modified palatal anchorage plate for distalization evaluated
with cone-beam computed tomography. Am J Orthod
Dentofacial Orthop. 2014;146:47–54.
6. Wang Q, Jia P, Anderson NK, Wang L, Lin J. Changes of
pharyngeal airway size and hyoid bone position following
orthodontic treatment of Class I bimaxillary protrusion. Angle
Orthod. 2012;82:115–121.
Angle Orthodontist, Vol 88, No 2, 2018
PARK, KIM, LEE, BAYOME, KOOK, HONG, KIM
7. Chen Y, Hong L, Wang CL, et al. Effect of large incisor
retraction on upper airway morphology in adult bimaxillary
protrusion patients. Angle Orthod. 2012;82:964–970.
8. Germec-Cakan D, Taner T, Akan S. Uvulo-glossopharyn-
geal dimensions in non-extraction, extraction with minimum
anchorage, and extraction with maximum anchorage. Eur J
Orthod. 2011;33:515–520.
9. Guilleminault C, Abad VC, Chiu HY, Peters B, Quo S.
Missing teeth and pediatric obstructive sleep apnea. Sleep
Breath. 2016;20:561–568.
10. Larsen AJ, Rindal DB, Hatch JP, et al. Evidence supports no
relationship between obstructive sleep apnea and premolar
extraction: an electronic health records review. J Clin Sleep
Med. 2015;11:1443–1448.
11. Kook YA, Lee DH, Kim SH, Chung KR. Design improve-
ments in the modified C-palatal plate for molar distalization. J
Clin Orthod. 2013;47:241–248; quiz 267–248.
12. Chen Y, Hong L, Wang CL, et al. Effect of large incisor
retraction on upper airway morphology in adult bimaxillary
protrusion patients. Three-dimensional multislice computed
tomography registration evaluation. Angle Orthod.
2012;82:964–970.
13. Fuziy A, Rodrigues de Almeida R, Janson G, Angelieri F,
Pinzan A. Sagittal, vertical, and transverse changes conse-
quent to maxillary molar distalization with the pendulum
appliance. Am J Orthod Dentofacial Orthop. 2006;130:502–
510.
14. Varlik SK, Iscan HN. The effects of cervical headgear with
an expanded inner bow in the permanent dentition. Eur J
Orthod. 2008;30:425–430.
15. Uzuner FD, Kaygisiz E, Unver F, Tortop T. Comparison of
transverse dental changes induced by the palatally applied
Frog appliance and buccally applied Karad’s integrated
distalizing system. Korean J Orthod. 2016;46:96–103.
16. Kang JM, Park JH, Bayome M, et al. A three-dimensional
finite element analysis of molar distalization with a palatal
plate, pendulum, and headgear according to molar eruption
stage. Korean J Orthod. 2016;46:290–300.
17. Caprioglio A, Cafagna A, Fontana M, Cozzani M. Compara-
tive evaluation of molar distalization therapy using pendulum
and distal screw appliances. Korean J Orthod. 2015;45:171–
179.
18. Hsieh YJ, Chen YC, Chen YA, Liao YF, Chen YR. Effect of
bimaxillary rotational setback surgery on upper airway
structure in skeletal Class III deformities. Plast Reconstr
Surg. 2015;135:361e–369e.
19. Li HY, Chen NH, Wang CR, Shu YH, Wang PC. Use of 3-
dimensional computed tomography scan to evaluate
upper airway patency for patients undergoing sleep-
disordered breathing surgery. Otolaryngol Head Neck
Surg. 2003;129:336–342.
20. Ogawa T, Enciso R, Shintaku WH, Clark GT. Evaluation of
cross-section airway configuration of obstructive sleep
apnea. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
2007;103:102–108.
21. Lowe AA, Gionhaku N, Takeuchi K, Fleetham JA. Three-
dimensional CT reconstructions of tongue and airway in
adult subjects with obstructive sleep apnea. Am J Orthod
Dentofacial Orthop. 1986;90:364–374.