The hyoid triangle

R. E. Bibby, B.M.Sc.(Hons.), B.D.S., M.M.Sc.(Dundee), and

C. B. Preston, B.D.S., ffl.Dent.(Rand)
(‘upmwt~, Sorrth A,fi-ku Dr BIbby

I
n general considerations of the cervicofacial skeleton, the hyoid bone tends to
be overlooked or given scant attention. However, it is a unique structure in man in that,
unlike all other bones of the head and neck, it has no bony articulations. There are two
major groups of muscles-the suprahyoid and the infrahyoid-attaching to this bone.
These muscles rely on the hyoid bone for their actions and have certain very important
functions. The digastric muscles increase the anteroposterior dimension and the
oropharynx during deglutition, while the posterior belly of the digastric and the stylohyoid
muscle act to prevent regurgitation of food after swallowing. ’
The suprahyoid muscles depress the mandible by contracting against a fixed hyoid
platform, the absence of which may seriously impair mandibular opening.

From the University of Western Cape Faculty of Dentistry

92 0002.9~16/81/070092+06$00.6010 0 1981 The C V Mosby Co

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Hyoid triangle 93
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Brodie2pointsout that as man assumedan upright posturethe headhad to be balanced

on the vertebralcolumn. This is attainedby equal anteriorand posteriormuscletension
relative to the occipital condyles.In the accomplishmentof this delicatecranial balance
and posture,the hyoid bone plays an important and active part.
According to Gray’the omohyoid musclesare concerned,“especially in prolonged
inspiratory efforts, since by tensing the lower part of the cervical fascia it lessensthe
inward suctionof the soft partswhich would otherwisecompressthe greatvesselsandthe
lung apices.’’
The importanceof the hyoid boneshouldnow be self-evident.Without it, our facility
of maintainingan airway, swallowing and preventingregurgitation,and maintainingthe
upright posturalposition of the headcould not be as well controlled.
Review of the literature
Precisemeasurement of hyoid position by cephalometricmeansis considereddifficult.
Graber3states that slight variations in head position in the cephalostat,the postural
position of the spine, and the state of function all affect the position of the hyoid bone.
However, he points out that within theselimitations definite conclusionsconcerningthe
normal hyoid position may be made. Stepovich4reportsthat when roentgenograms of the
same person were taken at different time intervals the hyoid bone was found to be
positioned differently in each film. Ingervall and associates5believe that Stepovich
exaggeratesthe lack of precision in recordingthe hyoid bone position, although they
admit that the hyoid position will vary even under standardconditions.King6 notesthat
changesin head position lead to changesin the position of the hyoid bone in the same
person.If the headis extendedback, then the hyoid bonemovesback; if the headis tipped
forward, then the hyoid bone moves forward. This confirmedthe postulateof Negus.’
Wood8found the hyoid bone to elevatewhen the head was in dorsiflexionand to move
down when the headwas in ventriflexion.Ingerval15 found a positivecorrelation(although
not always significant)betweenthe anteroposteriordistancebetweenretrudedcontactand
intercuspalpositionsof the mandible and the vertical movementof the hyoid bone be-
tween thesepositions. In anotherstudy, Ingervallgcomparedthe hyoid bone positions
when the mandibleis in intercuspalposition and when it is in posturalposition. He found
that the hyoid bone was higher in postural position than in intercuspal position.
Thompsonlo wrote that in mouth opening, since the mandible moves downward, one
might expectthe hyoid bone to do the same.He found that this did not occurand that the
hyoid bonetendsto remainat a constantlevel, moving slightly backward.Brodie2brought
attentionto the suprahyoidmuscleswhich suspendthe hyoid bone, the larynx, the phar-
ynx, and the tongue. Since thesemusclesare attachedat or near the symphysisof the
mandible, it follows that, shouldthe hyoid bone passivelyfollow the courseof the chin,
all of the abovestructureswould fall back and thus tend to shut off the airway.* This is
preventedby shorteningof the suprahyoidmuscles.Grant1Lstudied the position of the
hyoid bonein ClassI, II, andIII malocclusions.He concludesthat the hyoid boneposition
is constantin all threeclassesandthat the position of the hyoid bone is determinedby the
musculatureand not by the occlusionof the teeth.
Durzo and Brodie’* show that the relationshipbetweenthe hyoid bone and the mandi-
ble is maintainedfrom the age of 3 years.The sameauthorswrite that the hyoid bone is
positionedat a level oppositethe lower portion of the third cervical vertebraeand the
upper portion of the fourth cervical vertebrae. Its anteroposterior position, they state. is
dependent on the relative lengths of the muscles running to it and also on gravity acting on
the larynx. Bench’:’ studied a sample of persons from 2 to 45 years of age. He found that
the hyoid bone gradually descends from a position opposite the lower half of the third and
the upper half of the fourth cervical vertebrae at the age of 3 years to a position opposite
the fourth cervical vertebrae in adulthood. King” states that the distance between the hyoid
bone and the cervical vertebrae is constant until puberty, when the hyoid bone moves
slightly forward.
The possibility of some tie-up between hyoid bone position and mandibular mor-
phology led to a consideration of skeletal types which, according to Graber,:’ gives
disparate results, since some of the investigations find positive correlations between hyoid
bone position and skeletal type while others find no correlation at all. ‘I’ ‘I ~’i
Previous investigations have found that the hyoid bone has a highly variable position,
not only from person to person but also from minute to minute in the same person.:i, ’
Since most analyses have employed cranial structures to define the plane from which
the hyoid bone position is measured, it is not surprising that such variation has been
found.
Cranial points are relatively far removed from the hyoid bone. Thus, a small variation
in the position of the reference plane would result in a much greater apparent variation of
the hyoid bone, whether the hyoid bone position changed or not.
The object of this article is to introduce an analysis of hyoid bone position which
minimizes the effect of head posture, thus ensuring a more correct determination. The
analysis is known as the hyoid triangle.”
Hyoid bone position is a reflection of the relative tensions of the muscles, ligaments,
and fascia attached to it. Thus, the hyoid triangle, which allows the assessment of hyoid
bone posture in three directions, may be used to assess normal physiologic position and
functions of the surrounding anatomy in this area, which may be important in orthodontic
and surgical relapse.
If the hyoid bone is in the same position before and after orthodontic treatment, the
soft tissue must still be in the same balance, thus possibly reducing the chance of relapse
from these soft-tissue forces. If the hyoid position is altered, a longer retention period than
normal may be indicated. Any alteration in hyoid position following mandibular surgery
may be an indication for the balancing of muscle forces to be made more favorable by
myectomy or myotomy to reduce surgical relapse.
The hyoid triangle employs planes between the cervical vertebrae and the mandibular
symphysis which markedly reduce the effect of changes in head posture and eliminate the
variation of the cranial reference planes.
The triangle is formed by joining the cephalometric points, retrognathion (the most
inferior, posterior point on the mandibular symphysis), hyoidale (the most superior,
anterior point on the body of the hyoid bone), and C3 (the most inferior, anterior position
on the third cervical vertebrae) (Fig. 1).
Anteroposterior position of the hyoid bone is determined from H-RGn and H-C3 in
anterior and posterior directions.
Vertical position of the hyoid bone is determined by dropping a perpendicular from the
plane C3-RGn to hyoidale (H-H’).
The angular position of the hyoid bone which incorporates the greater horns is given
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Hyoid triangle 95

Fig. 1. Hyoid traingle.

by the angle that the hyoid axis makes with the plane C3-RGn. This dimension is known
as the hyoid plane angle.
Thus, using this analysis, the position of the hyoid bone can easily be fixed in space in
three directions without the use of cranial reference planes.

Definitions of cephalometric points and planes

CS-The point at the most inferior anterior position on the third cervical vertebrae.
RGn (retrognathion)-The most inferior posterior point on the mandibular sym-
physis.
H (hyaidulej-The most superior, anterior point on the body of the hyoid bone.
Hyoid plane-The plane from H along the long axis of the greater horns of the hyoid
bone.
Hyoidplane angle--The most superior posterior angle made by the intersection of the
hyoid plane with C3-RGn.
AA-The most anterior point on the body of the atlas vertebrae seen on the lateral
cephalometric radiograph.
PNS (posterior nasal spine)-The tip of the posterior nasal spine seen on the lateral
cephalometric radiograph.
Materials and methods
This analysis was tested by taking pretreatment lateral cephalometric radiographs of
fifty-four patients from the files of the Orthodontic Department of the School of Dentistry
at the University of the Witwatersrand. This sample consisted of twenty-eight males and
twenty-six females. The mean age of the boys was 12.5 years (standard deviation, 1.9
years) and of the girls, 13 years (standard deviation, 2.4 years). This sample was limited
to Class I malocclusion with no significant abnormalities in the vertical dimension. All
radiographs were taken by the same radiographers, using the same equipment and
technique.
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96 Bibby und Preston Jul\ 1981

Table I. T values for males versus females

C3-RGn 1.8
C3-H 0.58
H-R& 2.0
H-H’ 0.90
Hyoid planeangle 0.04
AA-PNS 0.7

Table II. Standard

valuesfor hyoid tirangle
Mean S.D.

C3-RGn 67.2 6.6

C3-H 31.76 2.9
H-RGn 36.83 5.83
H-H’ 4.80 4.64
Hyoid plane angle 25.63 10.59
AA-PNS 32.91 3.66

The equipmentconsistedof a Wehmercephalostatto hold the headof the patient, an

anodepositionedat a standard60 inchesfrom the patients’midsagittalplane, and a film
cassettefitted with intensifyingscreens.The patientswereinstructedto closetheir lips and
teeth lightly togetherduring film exposure.All patientswere requiredto standwhile the
films wereexposed.The radiographswere tracedby handover an illuminated viewer onto
acetatepaper. All tracingswere made by the sameperson.
To limit the degreeof error, all tracingswererepeatedafter an interval of someweeks.
Measurementswere taken to the nearest0.5 mm. and 0.5 degree.
The samplewas divided into malesandfemalesto test for sexualdimorphismandthen
to provide meansand standarddeviationsfor the dimensionof the hyoid triangle.
The dimensionAA-PNS (that is, the bony anteroposterior dimensionof the pharynxat
the level of C 1) was measuredto compareit to the bony dimensionC3-H .
Recrulta and discussion
The vertical, horizontal, and angularanatomicrelationshipsof the hyoid bone were
computedusing the hyoid triangle and the hyoid plane angle.
The sample was tested for sexual dimorphism in hyoid bone position, and no sig-
nificant differenceswere found. The sexeswere then pooled and normal standardswere
derivedfor hyoid bone position on the hyoid triangle, as shown in the results.
Measurementsof the angular and vertical positions of the hyoid bone, however,
appearedto have greaterrangesthan the horizontaldimensions.A correlationwas found
betweenthe angularand vertical measurements (hyoid planeangle, H-H’, respectively).
The correlationcoefficient (r = 0.73) was statistically significant and indicatedthat the
hyoid bone may see-sawaboutan axis through its greaterhorns(TableI). The anteropos-
terior position of the hyoid relativeto the cervicalvertebraewas very constantwith a mean
value of 31.76 mm. and a standarddeviation of 2.9 (Table II). The anteroposterior
dimensionof the upperbony airway (AA-PNS) was also constant,with a meanvalue of
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Number 1

32.91 mm. and a standard deviation of 3.66. Previous research indicates that the dimen-
sion AA-PNS is determined at an early age. 8, 25 The correlation coefficient between the
two anteroposterior dimensions (AA-PNS and C3-H) was 0.98. This finding indicates that
the hyoid bone represents the anterior bone boundary of the pharynx at a lower level than
PNS . There is no difference between the anteroposterior dimension of the upper and lower
pharynx of males and females of comparable age in this sample.
Further studies will be undertaken to enlarge the sample size as well as to study the
effect of age, race, and posture on the position of the hyoid bone.

Conclusions
1. The hyoid triangle allows determination of hyoid bone position in three directions
and, since it is not dependent on a cranial reference plane, and incorrectness that may stem
from changes in head posture is minimized. Thus, the possible functional importance of
changes in hyoid position can be assessed.
2. No sexual dimorphism in hyoid bone position was found in this sample.
3. The bony pharynx at the level of PNS and hyoidale was found to have the same
anteroposterior dimensions.
4. Standard values are given for the dimensions of the hyoid triangle.

REFERENCES
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