ORIGINAL ARTICLE

Evaluation of pharyngeal space and its

correlation with mandible and hyoid
bone in patients with different skeletal
classes and facial types
Yuri Nejaim,a Johan K. M. Aps,b Francisco Carlos Groppo,c and Francisco Haiter Netoa
Piracicaba, S~ao Paulo, Brazil, and Seattle, Wash

Introduction: The purpose of this article was to evaluate the pharyngeal space volume, and the size and shape
of the mandible and the hyoid bone, as well as their relationships, in patients with different facial types and skel-
etal classes. Furthermore, we estimated the volume of the pharyngeal space with a formula using only linear
measurements. Methods: A total of 161 i-CAT Next Generation (Imaging Sciences International, Hatfield,
Pa) cone-beam computed tomography images (80 men, 81 women; ages, 21-58 years; mean age, 27 years)
were retrospectively studied. Skeletal class and facial type were determined for each patient from multiplanar
reconstructions using the NemoCeph software (Nemotec, Madrid, Spain). Linear and angular measurements
were performed using 3D imaging software (version 3.4.3; Carestream Health, Rochester, NY), and
volumetric analysis of the pharyngeal space was carried out with ITK-SNAP (version 2.4.0; Cognitica,
Philadelphia, Pa) segmentation software. For the statistics, analysis of variance and the Tukey test with a
significance level of 0.05, Pearson correlation, and linear regression were used. Results: The pharyngeal space
volume, when correlated with mandible and hyoid bone linear and angular measurements, showed significant
correlations with skeletal class or facial type. The linear regression performed to estimate the volume of the
pharyngeal space showed an R of 0.92 and an adjusted R2 of 0.8362. Conclusions: There were significant cor-
relations between pharyngeal space volume, and the mandible and hyoid bone measurements, suggesting that
the stomatognathic system should be evaluated in an integral and nonindividualized way. Furthermore, it was
possible to develop a linear regression model, resulting in a useful formula for estimating the volume of the
pharyngeal space. (Am J Orthod Dentofacial Orthop 2018;153:825-33)

C
raniofacial growth and occlusion are influenced,
among other things, by the respiratory function.1
An impaired nasal respiratory function is associ-
ated with airway inadequacy that can result in the habit
of mouth breathing.2 This change in breathing pattern
leads to lowering of the mandible and the tongue, and
an extended head posture.3 Changes in normal airway
function during the active facial growth period can
a
Department of Oral Diagnosis, Piracicaba Dental School, State University of
Campinas, Piracicaba, S~ao Paulo, Brazil.
b
Department of Pediatric Dentistry, University of Washington, Seattle, Wash.
c
Department of Physiological Sciences, Piracicaba Dental School, State University
of Campinas, Piracicaba, S~ao Paulo, Brazil.
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conflicts of Interest, and none were reported.
Address correspondence to: Yuri Nejaim, Av. Limeira, 901, Arei~ao, Piracicaba, SP,
Brazil, 13414-903; e-mail, ynejaim@hotmail.com.
Submitted, January 2017; revised and accepted, September 2017.
0889-5406/$36.00
Ó 2018 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2017.09.018
have a profound influence on facial development by
the time a patient comes for orthodontic treatment.4,5
Combined orthodontic and orthognathic surgical
treatment has become a common modality for the
correction of facial deformities. An important aspect of
orthognathic surgery is the effect of skeletal movements
in the surrounding structures.6 Maxillomandibular
advancement leads to anterior movements of the soft
palate, base of the tongue, hyoid bone, and anterior
pharyngeal tissues, resulting in increases in the volumes
of the nasopharynx, oropharynx, and hypopharynx, and
therefore increasing the posterior airway space.7
Mandibular setback surgery can cause relative narrowing
of the pharyngeal airway and a significant posterior
movement of the hyoid bone.8,9
The hyoid bone is connected to the pharynx,
mandible, and cranium by muscles and ligaments. The
hyoid bone and its connecting muscles are also part of
the oropharyngeal complex. Without the hyoid bone,
our facility for maintaining an airway, swallowing,
825
826 Nejaim et al

Table I. Measurements
Measurement Description Reconstruction Figure
Pharyngeal space dimensions:
Anterior nasal spine-posterior nasal Line from the most anterior to the most posterior point of hard palate Sagittal 1A
spine distance
Shortest distance Horizontal line on the greatest constriction of pharyngeal space Sagittal 1B
C1- latero-lateral distance Horizontal line on the greatest latero-lateral dimension of pharyngeal space Axial 2A
oriented at the level of the most inferior point of C1
C1-anteroposterior distance Vertical line on the greatest anterior-posterior dimension of pharyngeal Axial 2A
space oriented at the level of the most inferior point of C1
C2-latero-lateral distance Horizontal line on the greatest latero-lateral dimension of pharyngeal space Axial 2B
oriented at the level of the most inferior point of C2
C2-anteroposterior distance Vertical line on the greatest anteroposterior dimension of pharyngeal space Axial 2B
oriented at the level of the most inferior point of C2
C3-latero-lateral distance Horizontal line on the greatest latero-lateral dimension of pharyngeal space Axial 2C
oriented at the level of the most inferior point of C3
C3-anteroposterior distance Vertical line on the greatest anteroposterior dimension of pharyngeal space Axial 2C
oriented at the level of the most inferior point of C3
Epiglottis-latero-lateral distance Horizontal line on the greatest latero-lateral dimension of pharyngeal space Axial 2D
oriented at the level of the most concave point of epiglottis base
Epiglottis-anteroposterior distance Vertical line on the greatest anteroposterior dimension of pharyngeal space Axial 2D
oriented at the level of the most concave point of epiglottis base
Mandible dimensions:
Anterior-posterior angle of mandible Angle between the most posterior point of the mandibular condyle, the Sagittal (MIP) 1C
gonion point and the most inferior border of the mandible body
Transverse angle of mandible Angle between the most anterior point of the mandibular symphysis and the Axial 3A
gonion point on right and left sides of the mandible
Latero-lateral distance of mandible Line between the right and left gonion points Axial 3B
Anteroposterior distance of mandible Perpendicular line from the most anterior point on the lingual surface of the Axial 3C
symphysis to a line between the right and left gonion points
Hyoid bone dimensions:
Transverse angle of hyoid bone Angle between the projections of the lines crossing the lesser and greater Axial 4A
horns of right and left sides of hyoid bone
Latero-lateral distance of hyoid bone Line between the right and left greater horns Axial 4B
Anteroposterior distance of hyoid bone Perpendicular line from the most anterior point in the concavity of the body Axial 4C
of the hyoid bone to a line between the right and left greater horns

preventing regurgitation, and maintaining the upright
postural position of the head could not be controlled
as carefully.10
The use of 3-dimensional (3D) imaging in dentistry,
more specifically cone-beam computed tomography
(CBCT), has increased considerably in the last years,
making possible the evaluation of anatomic structures
and analysis of pharyngeal space morphology.11 Because
of its high spatial resolution, adequate contrast between
the soft tissues and empty space, and the relatively low
radiation dose compared with multislice computed to-
mography, CBCT is an important tool in the study of
craniofacial development.12,13
Due to the close relationship between the pharynx,
mandible, and hyoid bone and the fact that orthodontic
or orthognathic interventions may affect the pharyngeal
space,14 information regarding the influence of skeletal
classes and facial types on these structures would improve
the diagnosis and treatment of orthodontic patients.
The aim of this study was to correlate the volume of
the pharyngeal space, the size and shape of mandible
and the hyoid bone in patients with different facial types
and skeletal classes. Furthermore, we estimated the vol-
ume of the pharyngeal space with a formula using only
linear measurements.
MATERIAL AND METHODS
This study was approved by the research ethics com-
mittee of Piracicaba Dental School, State University of
Campinas, in Brazil with protocol number 092/2014.
This retrospective study was performed on a batch of
previously taken CBCT volumes (i-CAT Next Generation;
Imaging Sciences International, Hatfield, Pa) at 120 kV,
5 mA, 23 3 17-cm field of view, 0.4-mm voxel, and 40-
second scanning time, with indication for orthodontic
treatment or orthognathic surgery planning. The CBCT
examinations were made with each subject sitting up-
right, and with the Frankfort horizontal plane parallel

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Nejaim et al
Fig 1. A, Distance ANS-PNS; B, shortest distance; C, AP angle of mandible.
to the ground and the patient's teeth occluding in
maximum intercuspation.
A total of 161 CBCT volumes from 80 men and 81
women, aged between 21 and 58 years (mean age,
27 years), were included in this study. Patients younger
than 21 years (due to incomplete development of their
craniofacial structures), patients who had orthognathic
surgery, and those with pathologies in the region of the
head and neck or syndromes were excluded from the study.
Skeletal class (Classes I, II, and III) and facial type
(brachycephalic, mesocephalic, and dolichocephalic)
were determined by an orthodontist with 13 years of
experience for each patient from multiplanar recon-
structions (lateral cephalometric) derived from the
CBCT images with the NemoCeph software (Nemotec,
Madrid, Spain).
To determine the skeletal classes, classified as Class I,
Class II, or Class III, we used the SNA, SNB, and ANB angle
measures from the cephalometric analysis of Steiner.15 All
patients selected as Class II had a greater value of SNA
angle (accentuated development of the maxilla), whereas
all Class III patients had an increased SNB angle (accentu-
ated development of the mandible). The measurement of
Jarabak and Fizzell16 for line connecting point A to the
occlusal plane and line connecting point B to the occlusal
plane was used to confirm the skeletal class classification.
With regard to facial type, differentiation into vertical
groups (brachyfacial, mesofacial, dolichofacial) was
determined by the VERT index (arithmetic average of 5
cephalometric measurements, angle of the facial axis,
facial depth, mandibular plane angle, lower facial
height, and mandibular arch) as calculated in the ceph-
alometric analysis of Ricketts.17 With regard to the VERT
index, a negative value corresponded to a dolichofacial
type and a positive value to a brachyfacial type; if the
value was zero, the patient was classified as mesofacial.
American Journal of Orthodontics and Dentofacial Orthopedics
827
Linear and angular measurements were performed
using the CS 3D Imaging software (version 3.4.3; Care-
stream Health, Rochester, NY). The linear ones were
anterior nasal spine-posterior nasal spine distance
(ANS-PNS distance), shortest distance of the pharyngeal
space (shortest distance), anteroposterior distance of the
pharyngeal space-C1 (APC1), latero-lateral distance of
the pharyngeal space-C1 (LLC1), anteroposterior dis-
tance of the pharyngeal space-C2 (APC2), latero-lateral
distance of the pharyngeal space-C2 (LLC2), anteropos-
terior distance of the pharyngeal space-C3 (APC3),
latero-lateral distance of the pharyngeal space-C3
(LLC3), anteroposterior distance of the pharyngeal
space-base of epiglottis (AP epiglottis), latero-lateral
distance of the pharyngeal space-base of epiglottis (LL
epiglottis), latero-lateral distance of mandible (LL
mandible), anteroposterior distance of mandible (AP
mandible), latero-lateral distance of hyoid bone (LL hy-
oid bone), and anteroposterior distance of hyoid bone
(AP hyoid bone). The angular measurements were ante-
roposterior angle of mandible (AP angle of mandible),
transverse angle of mandible (TA mandible), and trans-
verse angle of hyoid bone (TA hyoid bone). The measure-
ments are listed in Table I and Figures 1-4.
To perform the linear measurements, all CBCT exam-
inations were oriented according to the structures to be
measured. For pharyngeal space, the vertical reference
line was positioned in the median sagittal plane, and
the horizontal line was positioned from the anterior
nasal spine to the posterior nasal spine in the axial and
sagittal reconstructions. For the mandible, the horizon-
tal line was tangentially positioned on the lower edge of
the mandible in the sagittal reconstruction and then
moved superiorly to the genial tubercle. For the hyoid
bone, the software orientation line was positioned, in
the sagittal reconstruction, on the long axis of this bone.
June 2018  Vol 153  Issue 6
828 Nejaim et al

Fig 2. A, LLC1 and APC1; B, LLC2 and APC2; C, LLC3 and APC3; D, LL epiglottis and AP epiglottis.

The analysis of the pharyngeal space volume (PS vol-
ume) was carried out from the 3D model. The recon-
struction of the 3D model was established with the
semiautomatic segmentation mode of the software
Insight ITK-SNAP (version 2.4.0; Cognitica, Philadel-
phia, Pa), which measured the volume of the structure
in cubic millimeters. The volume measured in this study
corresponded to the union between oropharynx and hy-
popharynx. For this, we followed the anatomic delimita-
tions described by Park et al18 establishing a superior
reference line traced from the posterior nasal spine to
the lowest point of the first cervical vertebra, and an
inferior reference line traced on the most inferior point
of the fourth cervical vertebra perpendicular to the
medial sagittal plane (Fig 5).
One calibrated examiner (Y.N.) performed all soft-
ware operations and measurements in a subdued and
quiet room. The examiner executed all 18 measures 10
times, with a 1-day interval, to assess the reproducibility
of the method. The intraclass correlation coefficient was
determined to assess the investigator's reproducibility on
the measurements.

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Nejaim et al 829

Fig 3. A, Transverse angle of hyoid bone; B, LL hyoid bone; C, AP hyoid bone.

Fig 4. A, Transverse angle of mandible; B, LL mandible; C, AP mandible.

Fig 5. A, Segmentation of the pharyngeal space using the reference points described in the text (red);
B, 3D volume of the union between oropharynx and hypopharynx.

American Journal of Orthodontics and Dentofacial Orthopedics June 2018  Vol 153  Issue 6
830 Nejaim et al

APC1, and LL epiglottis, although only in few subgroups

Table II. Distribution of patients according to skeletal
classes and facial types
Female Male Total
(n 5 81) (n 5 80) (N 5 161)
Class I 37 (45.7%) 23 (28.8%) 60 (37.3%)
Class II 31 (38.3%) 29 (36.2%) 60 (37.3%)
Class III 13 (16.0%) 28 (35.0%) 41 (25.4%)
Brachycephalic 35 (43.2%) 35 (43.8%) 70 (43.5%)
Dolichocephalic 17 (21.0%) 21 (26.2%) 38 (23.6%)
Mesocephalic 29 (35.8%) 24 (30.0%) 53 (32.9%)
Statistical analysis
Data normality and homoscedasticity of variances
were accessed by Shapiro-Wilk and Levene tests, respec-
tively. Data analysis was carried out using statistical soft-
ware (version 15.8; MedCalc Software, Ostend,
Belgium). Analysis of variance and Tukey tests with a
significance level of 0.05 (alpha, 5%) were used to
compare the groups (facial type and skeletal class), and
the Pearson correlation test was used to identify correla-
tions between the volume of the pharyngeal space and
the other variables analyzed. A linear regression was per-
formed to create a formula for estimating the volume of
the pharyngeal space.
RESULTS
The intraclass correlation coefficients were 0.988 for
the linear measurements and 0.99 for the angular mea-
surements.
The distributions of skeletal class and facial type are
shown in Table II. There were no statistically significant
differences between sexes for facial type or skeletal class.
With regard to skeletal class, transverse angle of
mandible, AP mandible, LL mandible, APC2, LL
epiglottis, shortest distance, and PS volume showed sta-
tistically significant differences (Table III).
In relation to the different facial types, LL hyoid bone,
transverse angle of mandible, AP angle of mandible,
APC2, AP epiglottis, and shortest distance showed statis-
tically significant differences (Table IV).
A significant correlation was found between the PS
volume and the measurements performed, except for
the transverse angle of hyoid bone, LL hyoid bone, trans-
verse angle of mandible, AP angle of mandible, and
ANS-PNS distance. There were significant correlations
in all subgroups in the following measurements: APC2,
APC3, AP epiglottis, LLC1, LLC2, LLC3, and shortest dis-
tance, when the sample was divided into skeletal classes
and facial types. Furthermore, there was a significant
correlation between the PS volume and the measure-
ments of AP hyoid bone, AP mandible, LL mandible,
(Table V).
The linear regression model led to the formula: PS
volume 5 2533.1 1 (27.1 3 LLC2) 1 (52 3 shortest
distance) 1 (46.3 3 APC3) 1 (11.2 3 LL mandible) 1
(13.3 3 LLC1) 1 (23.1 3 AP hyoid bone) 1 (15.8 3 LL
epiglottis) 1 (25.1 3 APC1) (11.3 3 ANS-PNS
distance) 1 (11.9 3 LLC3). The inclusion of other vari-
ables, such as age, sex, skeletal class, or facial type, did
not improve the model (Table VI). Analysis of variance
showed that the model is valid (P \0.01). The R was
0.92, and the adjusted R2 was 0.8362, showing that
the model can be useful to estimate the PS volume.
DISCUSSION
The pharyngeal space is a region that allows the pas-
sage of the inspired air from the nasal cavity to the
glottis, and the expired air from glottis to the nasal cav-
ity. It is formed by the union between 3 anatomic areas:
nasopharynx, oropharynx, and hypopharynx.19 In this
study, only the volume corresponding to the union be-
tween the oropharynx and the hypopharynx was evalu-
ated, since these 2 areas are connected by muscles and
ligaments to the hyoid bone and the mandible.
Some authors have stated that variations in the
pharyngeal space may be associated with conditions
such as functional anterior shifting head posture, skel-
etal classes, and facial types.19-21 Therefore, we believe
that this study can improve understanding about the
morphology and relationship of structures in the head
and neck regions, assisting in orthodontic diagnosis
and treatment planning.
Some authors have evaluated the volume of the
pharyngeal space in different skeletal classes; however,
the results are controversial. Some authors have not
found a statistically significant difference between the
classes,22,23 whereas others have reported that Class II
subjects showed lower volumes when compared with
Class I and Class III subjects, with statistically significant
differences.24,25 Furthermore, another study comparing
male and female Class I and Class III subjects showed a
statistically significant difference in pharyngeal volumes
only among the female subjects.4 In our research, a statis-
tically significant difference was found between Class I
and Class III subjects, with higher volume values in Class
III subjects. In relation to the facial types, it was reported
that there are no statistically significant differences in the
volumes of pharyngeal spaces between them.22,23 In our
research, a statistically significant difference was found
only in the brachyfacial subjects. We believe that these
variations between the study results may be related to
the different methodologies, including different sample

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Nejaim et al 831

Table III. All the measures according to the skeletal class

Mean (6SEM)

Class I (n 5 60) Class II (n 5 60) Class III (n 5 41)

Transverse angle of hyoid bone 41.7 (61.26) 43.5 (61.38) 41 (61.38)
AP hyoid bone 23.2 (60.55) 23.5 (60.43) 25 (60.72)
LL hyoid bone 36 (60.6) b 38.5 (60.65) a 37.5 (60.84) ab
Transverse angle of mandible 62.5 (60.44) a 63.3 (60.5) a 60.4 (60.72) b
AP mandible 56.4 (60.66) b 57.8 (60.73) b 62.8 (61.09) a
LL mandible 80.5 (60.66) b 83.9 (60.71) a 85.5 (60.9) a
AP angle of mandible 132 (119) 131 (118.5) 129 (12.5)
APC1 13.1 (10.1) 15 (11.15) 13.4 (4.65)
APC2 10.5 (60.4) b 9.5 (60.45) c 12.3 (60.67) a
APC3 11.7 (60.45) 11.1 (60.59) 13.1 (60.65)
AP epiglottis 14.9 (60.31) 14.4 (60.39) 15.3 (60.49)
LLC1 29.2 (60.85) 30.7 (60.92) 31.2 (61.14)
LLC2 24.6 (60.74) 26.2 (60.93) 27.5 (61.3)
LLC3 29.6 (60.54) 29.9 (60.69) 30.9 (60.72)
LL epiglottis 34.2 (60.56) b 36.2 (60.49) a 36.3 (60.68) a
ANS-PNS distance 54.1 (60.6) 54.9 (60.54) 54.5 (60.59)
Shortest distance 7.8 (60.35) ab 6.9 (60.45) b 8.8 (60.43) a
PS volume 14560.2 (6660.32) b 16110.8 (6910.7) ab 18840.8 (6970.38) a
All measurements in millimeters.
Different letters indicate statistically significant difference between the indicated groups (P .0.05) by analysis of variance.
SEM, Standard error of mean.

Table IV. All the measures according to the facial types

Mean (6SEM)

Brachyfacial (n 5 70) Mesofacial (n 5 53) Dolichofacial (n 5 38)

Transverse angle of hyoid bone 42.2 (61.24) 41.6 (61.24) 43.1 (61.69)
AP hyoid bone 24.2 (60.5) 23.4 (60.56) 23.5 (60.64)
LL hyoid bone 37.4 (60.65) ab 36.1 (60.65) b 38.8 (60.72) a
Transverse angle of mandible 61.9 (60.5) b 61.5 (60.5) b 64 (60.62) a
AP mandible 58.9 (60.85) 58.2 (60.76) 58.5 (60.96)
LL mandible 83.8 (60.73) 81.5 (60.74) 83.8 (60.86)
AP angle of mandible 124.4 (60.83) c 127.8 (60.7) b 132.3 (61.12) a
APC1 13.2 (60.47) 12.8 (60.51) 11.7 (60.5)
APC2 11.7 (60.5) a 9.9 (60.42) b 9.4 (60.49) b
APC3 12.5 (60.5) 11.3 (60.6) 11.4 (60.6)
AP epiglottis 15.6 (60.37) a 13.8 (60.34) b 14.9 (60.4) ab
LLC1 29.5 (60.75) 29.7 (61) 32.5 (61.21)
LLC2 26.3 (60.9) 25 (60.96) 26.4 (61.04)
LLC3 30.2 (60.65) 29.3 (60.57) 31 (60.64)
LL epiglottis 35.4 (60.56) 34.9 (60.47) 36.4 (60.7)
ANS-PNS distance 55.2 (60.48) 53.9 (60.53) 53.9 (60.8)
Shortest distance 8.4 (60.39) a 7.3 (60.39) b 7 (60.48) b
PS volume 17370.9 (6810.77) a 15080 (6752.22) b 15720.9 (61050.9) b
All measurements in millimeters.
Different letters indicate statistically significant difference between the indicated groups (P .0.05) by analysis of variance.
SEM, Standard error of mean.

sizes, ethnicities, examination modalities (2-dimensional
or 3D), and software programs used.
Linear and angular measurements have been per-
formed in the mandible, hyoid bone, and pharyngeal
space to classify different degrees of obstructive sleep
apnea in previous studies. These have found that the
smaller the measurement, the more severe the obstruc-
tive sleep apnea.24-26 In our study, we measured the
distance of greatest constriction in the pharyngeal
space. The results showed that these measurements

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832 Nejaim et al

Table V. Correlations (Pearson, rP) between PS volume and all other variables, segmented in groups (facial types or
occlusal classes) or not (total)
PS volume Total Brachyfacial Dolichofacial Mesofacial Class I Class II Class III
Transverse angle of 0.1604 0.1872 0.1962 0.0921 0.0746 0.2432 0.1051
hyoid bone (P 5 0.0421) (P 5 0.1207) (P 5 0.2378) (P 5 0.5121) (P 5 0.571) (P 5 0.0612) (P 5 0.5133)
AP hyoid bone 0.3229 0.3755 0.2397 0.2754 0.2097 0.2804 0.4316
(P \0.0001)* (P 5 0.0014)* (P 5 0.1472) (P 5 0.0459) (P 5 0.1079) (P 5 0.03)* (P 5 0.0048)*
LL hyoid bone 0.0369 0.1221 0.0422 0.0945 0.0834 0.0615 0.0451
(P 5 0.6419) (P 5 0.3138) (P 5 0.8012) (P 5 0.5011) (P 5 0.5264) (P 5 0.6406) (P 5 0.7796)
Transverse angle of 0.1398 0.1894 0.2298 0.0262 0.024 0.2253 0.013
mandible (P 5 0.077) (P 5 0.1163) (P 5 0.1652) (P 5 0.8522) (P 5 0.8556) (P 5 0.0835) (P 5 0.9355)
AP mandible 0.2907 0.339 0.3534 0.1191 0.0124 0.4292 0.0979
(P 5 0.0002)* (P 5 0.0041)* (P 5 0.0295)* (P 5 0.3955) (P 5 0.9252) (P 5 0.0006)* (P 5 0.5425)
LL mandible 0.2594 0.3328 0.0652 0.2274 0.217 0.2288 0.1102
(P 5 0.0009)* (P 5 0.0049)* (P 5 0.6974) (P 5 0.1016) (P 5 0.0958) (P 5 0.0787) (P 5 0.4926)
AP angle of mandible 0.0868 0.1177 0.0059 0.0771 0.1524 0.0687 0.1736
(P 5 0.2736) (P 5 0.332) (P 5 0.972) (P 5 0.5832) (P 5 0.245) (P 5 0.6019) (P 5 0.2776)
APC1 0.3404 0.2557 0.4575 0.3892 0.4055 0.3496 0.1686
(P \0.0001)* (P 5 0.0326) (P 5 0.0039)* (P 5 0.004)* (P 5 0.0013)* (P 5 0.0062)* (P 5 0.292)
APC2 0.6123 0.6222 0.624 0.5574 0.6357 0.722 0.4405
(P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P 5 0.0039)*
APC3 0.6696 0.7733 0.5362 0.5971 0.612 0.7019 0.6708
(P \0.0001)* (P \0.0001)* (P 5 0.0005)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)*
AP epiglottis 0.5244 0.6182 0.3946 0.3808 0.4381 0.6279 0.467
(P \0.0001)* (P \0.0001)* (P 5 0.0142)* (P 5 0.0049)* (P 5 0.0005)* (P \0.0001)* (P 5 0.0021)*
LLC1 0.5641 0.6274 0.5416 0.604 0.5547 0.6069 0.495
(P \0.0001)* (P \0.0001)* (P 5 0.0004)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P 5 0.001)*
LLC2 0.6727 0.7286 0.5015 0.72 0.6201 0.6589 0.7177
(P \0.0001)* (P \0.0001)* (P 5 0.0013)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)*
LLC3 0.5747 0.6066 0.5235 0.5777 0.4022 0.6273 0.6467
(P \0.0001)* (P \0.0001)* (P 5 0.0007)* (P \0.0001)* (P 5 0.0014)* (P \0.0001)* (P \0.0001)*
LL epiglottis 0.3004 0.2929 0.295 0.3377 0.2034 0.2854 0.3394
(P 5 0.0001)* (P 5 0.0139)* (P 5 0.0722) (P 5 0.0134)* (P 5 0.119) (P 5 0.0271)* (P 5 0.0299)*
ANS PNS distance 0.128 0.1585 0.1553 0.0349 0.1964 0.0167 0.2208
(P 5 0.1056) (P 5 0.1899) (P 5 0.3518) (P 5 0.8042) (P 5 0.1327) (P 5 0.8992) (P 5 0.1654)
Shortest distance 0.6615 0.6358 0.6746 0.6727 0.7258 0.7632 0.4089
(P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P \0.0001)* (P 5 0.0079)*

*Statistically significant difference (P\0.05).

Table VI. The best (analysis of variance, F 5 82.7; P \0.0001) linear regression (stepwise) model for PS volume
Nonstandardized coefficient (B) SD Standardized coefficient (beta) t Significance VIF
Constant 2533.1 371.2 6.8 \0.0001
LLC2 27.1 4.1 0.30 6.6 \0.0001 2.0043
Shortest distance 52 9.8 0.25 5.3 \0.0001 2.1900
APC3 46.3 6.9 0.30 6.7 \0.0001 1.9403
LL mandible 11.2 4.2 0.10 2.7 0.0088 1.4238
LLC1 13.3 4.1 0.15 3.3 0.0013 1.9209
AP hyoid bone 23.1 5.8 0.15 4 0.0001 1.3197
LL epiglottis 15.8 5.9 0.10 2.7 0.0083 1.4981
APC1 25.1 7.3 0.15 3.4 0.0008 1.7510
ANS-PNS distance 11.3 5.6 0.08 2 0.0428 1.3168
LLC3 11.9 5.9 0.09 2 0.0436 1.8444

B, Nonstandardized coefficient; VIF, variance inflation factor.

June 2018  Vol 153  Issue 6 American Journal of Orthodontics and Dentofacial Orthopedics
Nejaim et al
were smaller in Class II mesofacial and dolichofacial
patients.
To provide the assessment of pharyngeal space vol-
ume by professionals who do not have access to or expe-
rience in segmentation software programs, we have
created a formula through linear regression analysis us-
ing only linear measurements. This formula showed that
our model can be useful to estimate the volume of the
pharyngeal space. As far as we know, no other studies
in the literature have developed a formula with this goal.
CONCLUSIONS
It was concluded that there are significant correla-
tions between the volume of pharyngeal space and the
mandible and hyoid bone measurements, suggesting
that the stomatognathic system should be evaluated in
an integral and nonindividualized way. Furthermore, it
was possible to develop a linear regression model with
precision, resulting in a useful formula for estimating
the volume of the pharyngeal space.
REFERENCES
1. Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D.
Comparison of airway space with conventional lateral headfilms
and 3-dimensional reconstruction from cone-beam computed to-
mography. Am J Orthod Dentofacial Orthop 2009;135:468-79.
2. de Freitas MR, Alcazar NM, Janson G, de Freitas KM, Henriques JF.
Upper and lower pharyngeal airways in subjects with Class I and
Class II malocclusions and different growth patterns. Am J Orthod
Dentofacial Orthop 2006;130:742-5.
3. Solow B, Siersbaek-Nielsen S, Greve E. Airway adequacy, head
posture, and craniofacial morphology. Am J Orthod 1984;86:214-23.
4. Hong JS, Oh KM, Kim BR, Kim YJ, Park YH. Three-dimensional anal-
ysis of pharyngeal airway volume in adults with anterior position of
the mandible. Am J Orthod Dentofacial Orthop 2011;140:e161-9.
5. El H, Palomo JM. Airway volume for different dentofacial skeletal
patterns. Am J Orthod Dentofacial Orthop 2011;139:e511-21.
6. Efendiyeva R, Aydemir H, Karasu H, Toygar-Memikoglu U. Pharyn-
geal airway space, hyoid bone position, and head posture after bi-
maxillary orthognathic surgery in Class III patients: long-term
evaluation. Angle Orthod 2014;84:773-81.
7. El AS, El H, Palomo JM, Baur DA. A 3-dimensional airway analysis
of an obstructive sleep apnea surgical correction with cone beam
computed tomography. J Oral Maxillofac Surg 2011;69:2424-36.
8. Jiang YY, Xu X, Su HL, Liu DX. Gender-related difference in
the upper airway dimensions and hyoid bone position in Chi-
nese Han children and adolescents aged 6-18 years using cone
beam computed tomography. Acta Odontol Scand 2015;73:
391-400.
9. Park JW, Kim NK, Kim JW, Kim MJ, Chang YI. Volumetric, planar,
and linear analyses of pharyngeal airway change on computed
American Journal of Orthodontics and Dentofacial Orthopedics
833
tomography and cephalometry after mandibular setback surgery.
Am J Orthod Dentofacial Orthop 2010;138:292-9.
10. Sheng CM, Lin LH, Su Y, Tsai HH. Developmental changes in
pharyngeal airway depth and hyoid bone position from childhood
to young adulthood. Angle Orthod 2009;79:484-90.
11. Di Carlo G, Polimeni A, Melsen B, Cattaneo PM. The relationship
between upper airways and craniofacial morphology studied in
3D. A CBCT study. Orthod Craniofac Res 2015;18:1-11.
12. Chen H, Aarab G, Parsa A, De Lange J, Van Der Stelt PF,
Lobbezoo F. Reliability of three-dimensional measurements
of the upper airway on cone beam computed tomography im-
ages. Oral Surg Oral Med Oral Pathol Oral Radiol 2016;122:
104-10.
13. Abramson ZR, Susarla S, Tagoni JR, Kaban L. Three-dimensional
computed tomographic analysis of airway anatomy. J Oral Maxil-
lofac Surg 2010;68:363-71.
14. Yang Q, Wang CH, Fan C, Chen J. A changes in hyoid bone position
after orthodontic treatment of patients with mandibular deviation.
West Indian Med J 2013;62:239-43.
15. Steiner CC. Cephalometrics for you and me. Am J Orthod 1953;39:
729-55.
16. Jarabak JR, Fizzell JA. Technique and treatment with light-wire
edgewise appliances. 2nd ed. St Louis: Mosby; 1972.
17. Ricketts RM. A foundation for cephalometric communication. Am
J Orthod 1960;46:330-57.
18. Park SB, Kim YI, Son WS, Hwang DS, Cho BH. Cone-beam
computed tomography evaluation of short- and long-term airway
change and stability after orthognathic surgery in patients with
Class III skeletal deformities: bimaxillary surgery and mandibular
setback surgery. Int J Oral Maxillofac Surg 2012;41:87-93.
19. Bhat M, Enlow DH. Facial variations related to headform type.
Angle Orthod 1985;55:269-80.
20. Ceylan I, Oktay H. A study on the pharyngeal size in different skel-
etal patterns. Am J Orthod Dentofacial Orthop 1995;108:69-75.
21. Memon S, Fida M, Shaikh A. Comparison of different craniofacial
patterns with pharyngeal widths. J Coll Physicians Surg Pak 2012;
22:302-6.
22. Brasil DM, Kurita LM, Groppo FC, Haiter-Neto F. Relationship of
craniofacial morphology in 3-dimensional analysis of the pharynx.
Am J Orthod Dentofacial Orthop 2016;149:683-91.
23. Grauer D, Cevidanes LS, Styner MA, Ackerman JL, Proffit WR.
Pharyngeal airway volume and shape from cone-beam computed
tomography: relationship to facial morphology. Am J Orthod Den-
tofacial Orthop 2009;136:805-14.
24. Ha JG, Min HJ, Ahn SH, Kim CH, Yoon JM, Lee JG, et al.
The dimension of hyoid bone is independently associated
with the severity of obstructive sleep apnea. PLoS One
2013;8:e81590.
25. Ito K, Ando S, Akiba N, Watanabe Y, Okuyama Y, Moriguchi H,
et al. Morphological study of the human hyoid bone with three-
dimensional CT images—gender difference and age-related
changes. Okajimas Folia Anat Jpn 2012;89:83-92.
26. Saigusa H, Suzuki M, Higurashi N, Kodera K. Three-dimensional
morphological analyses of positional dependence in patients
with obstructive sleep apnea syndrome. Anesthesiology 2009;
110:885-90.
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