J Orofac Orthop
DOI 10.1007/s00056-016-0062-0
ORIGINAL ARTICLE
Upper airway changes following single-step or stepwise
advancement using the Functional Mandibular Advancer
Veränderungen im Bereich der oberen Luftwege nach einzeitiger
bzw. schrittweiser Vorverlagerung mit dem Functional
Mandibular Advancer
Isil Aras1 • Aylin Pasaoglu2 • Sultan Olmez3 • Idil Unal4 • Aynur Aras1
Received: 12 May 2016 / Accepted: 11 August 2016
Ó Springer-Verlag Berlin Heidelberg 2016
Abstract
Objectives Purpose of the present study was to determine
and compare possible changes in the dimensions of the
pharyngeal airway, morphology of the soft palate, and
position of the tongue and hyoid bone after single-step or
stepwise mandibular advancement using the Functional
Mandibular Advancer (FMA).
Patients and methods The sample included 51 peak-pu-
bertal Class II subjects. In all, 34 patients were allocated to
two groups using matched randomization: a single-step
mandibular advancement group (SSG) and a stepwise
mandibular advancement group (SWG). Both groups were
treated with FMA followed by fixed appliance therapy; the
remaining 17 subjects who underwent only fixed appliance
therapy constituted the control group (CG). The study was
conducted using pre- and posttreatment lateral cephalomet-
ric radiographs. Data were analyzed by paired t test, one-way
analysis of variance, and Pearson’s correlation coefficient.
Result In the SWG and SSG, although increases in
nasopharyngeal airway dimensions were not significant
compared with those in the CG, enlargements in the
Isil Aras: Dr.
& Isil Aras
isilaras@gmail.com
Aynur Aras
aynuraras@yahoo.com
1
Department of Orthodontics, Faculty of Dentistry, Ege
University, 35080Bornova, Izmir, Turkey
2
Cihangir Mah. Kaptan Sokak Avcılar, Istanbul, Turkey
3
Dentege ADSM, Sair Esref Bulvarı No:90, Alsancak, Izmir,
Turkey
4
Dent Ekol ADSM, Mavisehir, Cigli, Izmir, Turkey
oropharyngeal airway dimensions at the level of the soft
palate tip and behind the tongue, and decreases in soft
palate angulation, were significant. Tongue height
increased significantly only in the SWG. Compared with
the CG, while forward movement of the hyoid was more
prominent in SSG and SWG, the change in the vertical
movement of the hyoid was not significant. No significant
difference between SWG and SSG was observed in pha-
ryngeal airway, soft palate, tongue or hyoid measurements.
Conclusions The mode of mandibular advancement in
FMA treatment did not significantly affect changes in the
pharyngeal airway, soft palate, tongue, and hyoid bone.
Keywords Mandibular advancement
Functional
orthodontic appliance
Pharynx
Cephalometry
Zusammenfassung
Zielsetzung Ziel der Arbeit war die Überprüfung mögli-
cher Veränderungen hinsichtlich der Dimensionen der
pharyngealen Luftwege, der Morphologie des weichen
Gaumens sowie der Position von Zunge und Os hyoideum
nach einzeitiger bzw. mehrschrittiger Unterkiefervorver-
lagerung mittels Functional Mandibular Advancer (FMA).
Patienten und Methoden Das Studienkollektiv bestand aus
51 Klasse-II-Patienten im pubertären Wachstumsmaxi-
mum. Insgesamt 34 Patienten wurden mittels gematchter
Randomisierung 2 Gruppen zugeteilt: Gruppe 1 mit ein-
schrittiger (‘‘single-step mandibular advancement group’’,
SSG) und Gruppe 2 mit schrittweiser Unterkiefervorver-
lagerung (‘‘stepwise mandibular advancement group’’,
SWG). In beiden Gruppen wurde mit FMA und ansch-
ließender festsitzender Apparatur behandelt. Die 17 Pati-
enten, die nur mit einer festsitzenden Apparatur behandelt
wurden, dienten als Kontrollgruppe (‘‘control group’’, CG).
Untersucht wurden Fernröntgenseitenbilder vor und nach
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Behandlung; die Evaluierung der Daten erfolgte mit
gepaartem t-Test, einfaktorieller Varianzanalyse und dem
Korrelationskoeffizienten nach Pearson.
Ergebnisse Die Erweiterungen im Bereich des Nasopha-
ryngealraums waren nach SWG und SSG im Vergleich zu
CG nicht signifikant. Vergrößerungen des oropharyngealen
Luftwegs auf Höhe der Spitze des weichen Gaumens und
hinter der Zunge sowie die Verringerungen der Angulie-
rung des weichen Gaumens erwiesen sich als signifikant.
Nur in der SWG-Gruppe änderte sich die Höhe der Zunge
signifikant. Während die Bewegung des Os hyoideum nach
anterior im Vergleich zur CG in den Gruppen SSG und
SWG deutlicher war, erwies sich die Änderung in der
vertikalen Bewegung des Os hyoideus als nicht signifikant.
Zwischen den Gruppen SWG und SSG wurden keine
signifikanten Unterschiede im Hinblick auf den pharynge-
alen Raum, den weichen Gaumen, die Zunge oder das
Hyoid beobachtet.
Schlussfolgerung Die Art der Unterkiefervorverlagerung
mit der FMA-Apparatur hatte keinen signifikanten Effekt
in Hinblick auf den pharyngealen Luftweg, weichen
Gaumen, Zunge und Os hyoideum.
Schlüsselwörter Unterkiefervorverlagerung
Funktionelle
kieferorthopädische Apparatur
Pharynx
Kephalometrie
Introduction
Any change in the oral cavity alters airway morphology
due to the adaptation capacity of the pharyngeal struc-
tures [3, 8]. Accordingly, the effects of mandibular
advancement on pharyngeal dimensions have been
reported in different stages of life, ranging from child-
hood to adulthood [6, 13, 15, 16, 21, 30, 31, 33, 36].
Moreover, early treatment using functional appliances
resulting in mandibular advancement may prevent future
airway problems [14, 33, 37]. Indeed, the effects of
treatment with functional appliances were mainly den-
toalveolar with small changes in the position of the
mandible. In an effort to obtain the more forward posi-
tioning of the mandible, the following have been pro-
posed: using rigid fixed functional appliances, timing
treatment so that it coincides with the pubertal growth
spurt, and using stepwise mandibular advancement rather
than single-step protrusion [5, 11].
The Functional Mandibular Advancer (FMA), a type
of rigid fixed functional appliance, became available in
2002 [20]. A stepwise advancement protocol can be
performed using the FMA by moving the protrusive
guide pins to a more anterior position via the mounting
plate with threaded inserts. However, no study has
investigated the difference between stepwise and single-
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I. Aras et al.
step functional advancement in terms of the effects on
pharyngeal airway parameters. As the size of the pha-
ryngeal airway is affected by both dental and skeletal
sagittal movements, we considered whether the effects of
stepwise advancement would surpass maximum bite
jumping on pharyngeal airways.
The aim of the current study was to determine and
compare changes in the pharyngeal airway and soft palate
dimensions, as well as the position of the tongue and hyoid
bone following single-step or stepwise mandibular
advancement using a FMA.
Materials and methods
The study protocol was approved by the Ethics Committee
of the School of Medicine, Ege University, and written
consent was obtained from all patients. This study was a
continuation of a previous randomized, parallel-arm, clin-
ical study [1]. According to the patient recruitment proto-
col of the preceding study, 36 patients (18 females and 18
males) with the following characteristics were recruited:
(1) Angle Class II, Division 1 malocclusion in the perma-
nent dentition with an overjet larger than 6 mm and full
cusp Cl II molar relationship; (2) ANB greater than 4o due
to mandibular retrognathism; (3) no or mild space dis-
crepancy that does not require extractions; (4) growth
period just before or at the peak stage of the pubertal
growth phase (evaluated by hand–wrist radiographs) [12];
(5) mandibular plane angle (SNGoGn) of 30°–36°; and (6)
no medical history of respiratory problems. Subjects were
divided into 18 pairs using matched randomization [35]
based on sex and a similar degree of malocclusion (con-
sidering SNB, ANB, SNGoGn, and overjet). One patient of
each pair, selected at random by tossing a coin, was treated
with FMA utilizing stepwise advancement, while the
mandible of the other patient was progressed in a single
step. Thus, subjects were divided into two groups based on
the mode of mandibular advancement: a single-step
advancement group (SSG) and a stepwise advancement
group (SWG). The FMA consisted of cast stainless steel
crowns with welded mounting plates, and a transpalatal and
lingual arch (Fig. 1). While the mandible was advanced to
a super class I molar relation in the SSG, the SWG had an
initial bite advancement of 4 mm, followed by 2 mm
advancements in every two months via the threaded insert
supports until the overjet was eliminated. The patients were
treated by four experienced clinicians working in the
orthodontic clinic of the same university using a stan-
dardized protocol. All patients received FMA therapy fol-
lowed by multibracket appliance treatment. The functional
phase lasted for 10 months. In the second treatment phase
(multibracket appliance), Class II elastics were worn (at
Airway changes following single-step or stepwise advancement

Fig. 1 Application of Functional Mandibular Advancer

Abb. 1 Anwendung des Functional Mandibular Advancers

night only) to maintain the occlusal relationship until

maximum intercuspation was achieved. The overall treat-
ment duration in the SSG and SWG was 20.48 ± 2.15 and
19.16 ± 2.67 months, respectively.
Patients in the control group (CG), who were matched
for gender and pubertal development period, had Class II
malocclusion and were selected from the archives of the
Orthodontics Department of the Faculty of Dentistry, Ege
University. CG subjects were treated using a multibonded
appliance; no Class II mechanics, such as headgear or
functional appliances, were used and no extractions were
carried out. The mean treatment duration in the CG was
18.9 ± 3.8 months.
The study material comprised lateral cephalograms
which were obtained prior to FMA placement (T1) and
immediately after termination of fixed appliance therapy
(subsequent to functional treatment in the SWG and SSG).
In the CG, lateral cephalograms were obtained before (T1)
and after (T2) fixed appliance treatment. All cephalometric
radiographs were obtained using the same cephalostat. The
head was oriented using the Frankfort Horizontal Plane
parallel to the floor in accordance with standard cephalo-
metric procedures. All tracings and measurements on lat-
eral cephalograms were carried out by the same person Fig. 2 Landmarks and reference lines constructed and angular and
using ImageJ open-source image analysis software (ver. linear measurement used in cephalometric analysis. For definitions,
see Table 1
1.46r, National Institutes of Health, Bethesda, MD, USA). Abb. 2 In der kephalometrischen Analyse verwendeten Landmarken
Cephalometric measurements were performed in a blinded und Referenzlinien sowie lineare und Winkelmessungen. Definitionen
manner, i.e., the examiner (A.P.) was unaware of the group s. Tab. 1
assignment. Linear measurements were corrected for
magnification using the scale on the films. Lines parallel to
Statistical analysis of the cephalometric data was carried
the reference plane (constructed by drawing a second line
out using SPSS for Windows software (ver. 17.0; SPSS Inc.,
with a -7° difference from the SN plane) were used to
Chicago, IL, USA). Data were tested for normality using the
determine the counterpart landmarks for PW2, PW3, and
Shapiro–Wilk test. Since the data were normally distributed,
PW4 on the posterior pharyngeal wall (Fig. 2; Table 1).
parametric tests were used. A paired t test was used to assess
the significance of mean changes within groups; comparisons
Statistical analysis
of mean changes between groups and the homogeneity of the
groups at T1 were evaluated by one-way analysis of variance
According to a power analysis, with 80 % power at the
and Tukey’s test. To evaluate whether there was a consistent
0.05 level (based on a standard deviation of 1.56 and a
relationship between the measured parameters, Pearson’s
1.5 mm detectable difference in oropharyngeal airway
correlation analysis was performed. Statistical significance
space distance) [16], the minimum sample size for each
was determined at p \ 0.05.
group was 16.84.

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 I. Aras et al.

Tab 1 Cephalometric landmarks and reference planes, and cephalometric measurements

Tab. 1 Kephalometrische Landmarken und Referenzebenen sowie kephalometrische Messungen
ANS Anterior nasal spine
PNS Posterior nasal spine (the intersection of a continuation of the anterior wall of the pterygopalatine fossa and the floor of the nose,
marking the dorsal limit of the maxilla)
u Most inferior point of the soft palate (uvula)
eb Base of epiglottis
tt Tongue tip
tb Tongue base
pw1 Intersection point of posterior pharyngeal wall and a line passing through palatal plane (ANS-PNS) parallel to THL
pw2 Intersection point of posterior pharyngeal wall and a line drawn from ‘‘u’’ parallel to the THL
pw3 Intersection point of posterior pharyngeal wall and a line drawn from ‘‘tb’’ parallel to the THL
pw4 Intersection point of posterior pharyngeal wall and a line drawn from ‘‘eb’’ parallel to the THL
AH Most superior and anterior point of the hyoid bone
THL Line though Sella having a 7° of difference with the SN plane
TVL Line through Sella perpendicular to the THL
(1) NPA Nasopharyngeal airway dimension (linear distance between PNS and pw1)
(2) OPA Oropharyngeal airway dimension (linear distance between u and pw2)
(3) RGA Retroglossal airway dimension, which is the narrowest depth of the oropharynx behind the tongue (smallest distance between tb
and pw3)
(4) HPA Hypopharyngeal airway dimension (linear distance between eb and pw4)
(5) TH Tongue height (maximum height of the tongue measured vertical to the line between tt and eb)
(6) SPL Length of the soft palate (linear distance between PNS-u)
(7) SPT Soft palate thickness (maximum distance of the soft palate measured vertical to the line between PNS and u)
(8) SPA Angle of the soft palate (formed by a line passing through palatal plane and intersecting with the SPL)
(9) AHFHP Sagittal position of the hyoid bone (linear distance from AH to TVL)
(10) AHFH Vertical position of the hyoid bone (linear distance from AH to THL)

For assessment of the method error, 20 randomly
selected cephalograms were retraced and remeasured at a
2-week interval, and intraclass correlation coefficients were
calculated.
Results
Because a male patient in the SSG discontinued treatment,
the corresponding patient in the other group was excluded
from the final analysis to maintain a 1:1 intergroup ratio.
Data for 34 subjects were collected. Nine female and eight
male patients (mean age of 13.48 ± 0.88 years) comprised
the SWG, while the SSG consisted of nine female and eight
male patients (mean age of 13.15 ± 0.77 years). The mean
age of subjects in the CG (nine female, eight male) was
13.76 ± 0.62 years. High intraclass correlation coefficients
were obtained for the angular and linear measurements
([0.94 and [0.92, respectively).
SNB differed significantly between groups at T1, with
the CG showing lower values due to the appliance-dictated
subject selection. In contrast, the SWG and SSG were
comparable in terms of pretreatment cephalometric vari-
ables. The cephalometric measurements for the SSG,
SWG, and CG at T1 and T2 are shown in Table 2. The
changes in cephalometric parameters, and the significance
thereof, in each group are described in Table 3, and the
intergroup comparisons are presented in Table 4.
In the CG, there was no significant change in the posi-
tion of the maxilla or mandible (p [ 0.05). Airway
dimensions remained unchanged (p [ 0.05), with the
exception of an increase in nasopharyngeal size (p \ 0.05).
The position of the hyoid bone was significantly lower
(p \ 0.05), but the anterior relocation of hyoid bone was
not (p [ 0.05). Also, tongue height did not show a sig-
nificant change (p [ 0.05).
NPA increased significantly in the SSG and SWG
(p \ 0.05); however, these increases were not significant
compared to those in the CG (p [ 0.05). While the
oropharyngeal airway dimensions (OPA) and minimal
distance between the base of the tongue and the posterior
pharyngeal wall (PASmin) in the SWG and SSG increased

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Airway changes following single-step or stepwise advancement

Tab 2 Pre-(T1) and posttreatment (T2) cephalometric measurements of the groups

Tab. 2 Prä-(T1) und posttherapeutische (T2) kephalometrischen Messungen der Gruppen
Single step group Stepwise group Control group
T1 mean ± SD T2 mean ± SD T1 mean ± SD T2 mean ± SD T1 mean ± SD T2 mean ± SD

NPA 21.91 ± 2.62 23.30 ± 2.54 22.49 ± 2.17 23.84 ± 2.28 22.16 ± 2.31 23.18 ± 2.41
OPA 10.01 ± 2.39 11.60 ± 2.03 10.46 ± 2.90 12.15 ± 2.52 10.86 ± 3.11 10.43 ± 3.05
HPA 12.46 ± 1.78 13.51 ± 2.02 12.28 ± 2.35 13.26 ± 2.96 12.14 ± 3.06 13.04 ± 3.75
PASmin 9.77 ± 2.89 10.70 ± 2.44 9.42 ± 1.92 10.60 ± 2.64 9.95 ± 2.05 9.73 ± 3.75
TH 29.44 ± 3.54 30.22 ± 3.60 31.65 ± 4.41 32.91 ± 4.57 33.47 ± 4.11 33.84 ± 3.17
SPL 32.93 ± 2.61 32.85 ± 2.25 32.37 ± 3.10 32.23 ± 4.57 35.11 ± 3.23 35.20 ± 3.03
SPT 5.91 ± 0.86 6.02 ± 0.80 6.57 ± 1.16 6.74 ± 0.94 7.18 ± 1.09 7.40 ± 0.96
SPA 137.76 ± 6.36 136.31 ± 6.70 136.81 ± 5.05 134.77 ± 4.93 134.43 ± 5.20 134.49 ± 5.32
Hyoid horizontal 17.98 ± 2.47 19.36 ± 3.14 19.68 ± 3.33 21.45 ± 3.22 20.05 ± 3.66 20.41 ± 3.42
Hyoid vertical 83.62 ± 7.86 85.27 ± 7.89 87.37 ± 9.76 88.43 ± 9.44 85.05 ± 8.01 85.93 ± 7.47
SNA 81.33 ± 1.29 81.63 ± 1.04 80.81 ± 1.36 81.10 ± 1.26 82.10 ± 1.80 82.51 ± 1.51
SNB 75.78 ± 1.67 77.54 ± 1.33 75.40 ± 1.31 77.88 ± 0.95 77.13 ± 1.56 77.24 ± 1.88
ANB 5.55 ± 0.90 4.09 ± 0.73 5.41 ± 0.98 3.22 ± 0.85 4.97 ± 0.83 5.27 ± 1.44
SNGoGn 33.56 ± 2.85 34.48 ± 2.17 31.40 ± 3.76 32.29 ± 2.77 31.78 ± 2.44 32.07 ± 1.12
SD standard deviation

Tab 3 Means of pre- and

Single Step Group Stepwise Group Control Group
posttreatment differences,
related standard deviations Mean SD p Mean SD p Mean SD p
(SD), and p values
Tab. 3 Durchschnitte der prä- NPA 1.39 2.31 0.025* 1.35 2.51 0.041* 1.02 1.95 0.047*
und posttherapeutischen OPA 1.59 2.01 0.005* 1.69 2.08 0.004* -0.43 1.75 0.326
Unterschiede, entsprechende
HPA 1.05 2.24 0.071 0.98 2.04 0.065 0.90 2.01 0.083
Standardabweichungen (SD)
und p-Werte PASmin 0.93 1.13 0.004* 1.18 1.09 \0.001 -0.22 1.08 0.413
TH 0.78 1.56 0.056 1.26 1.13 \0.001 0.37 1.03 0.158
SPL -0.08 1.21 0.789 -0.14 0.98 0.564 0.09 0.83 0.661
SPT 0.11 0.32 0.176 0.17 0.64 0.290 0.22 0.59 0.144
SPA -1.45 1.72 0.003* -2.04 1.08 \0.001 0.06 1.09 0.823
Hyoid horizontal 1.38 1.28 \0.001 1.77 1.33 \0.001 0.36 0.97 0.145
Hyoid vertical 1.65 2.67 0.021* 1.06 2.08 0.052 0.88 1.15 0.006*
SNA 0.30 0.64 0.071 0.29 0.69 0.102 0.41 1.01 0.114
SNB 1.76 0.82 \0.001 2.48 0.88 \0.001 0.11 1.07 0.677
ANB 1.46 0.71 \0.001 2.19 0.63 \0.001 0.30 0.99 0.229
SNGoGn 0.92 1.04 0.002* 0.89 1.24 0.009* 0.29 0.88 0.193
* p \ 0.05

significantly (p \ 0.05), changes in the hypopharyngeal
airway dimensions were not significant (p [ 0.05). In the
SSG and SWG, while there were no significant changes in
soft palate length or thickness (p [ 0.05), the decrease in
soft palate angle was significant (p \ 0.05). Although the
tongue height increased significantly in the SWG
(p \ 0.05), the increase in tongue height in the SSG was
not significant (p [ 0.05). Forward movement of the
hyoid bone was more prominent in the SSG and SWG
than in the CG (p \ 0.05). Downward movement of the
hyoid bone was significant in the SSG (p \ 0.05), but the
increase in the vertical movement of the hyoid bone was
not significant when compared with that of the CG
(p [ 0.05). Furthermore, in the SSG and SWG, SNB
increased and ANB improved significantly (p \ 0.05),
while the change in SNGoGn was not significant
(p [ 0.05). SNB and ANB measurements differed sig-
nificantly between the SWG and SSG (p \ 0.05); how-
ever, the differences between these groups regarding the
pharyngeal airway, soft palate, tongue, and hyoid bone

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 I. Aras et al.

Tab 4 Statistical comparison of

Single step/control Stepwise/control Single step/stepwise
groups
p value p value p value
Tab. 4 Statistische
Gruppenvergleiche NPA 0.806 0.851 1.000
OPA 0.016* 0.012* 0.973
HPA 0.925 0.998 1.000
PASmin 0.017* 0.011* 0.733
TH 0.486 0.046 0.423
SPL 1.000 0.530 0.972
SPT 0.567 0.891 0.798
SPA 0.015* 0.001* 0.340
Hyoid horizontal 0.044* 0.021 0.539
Hyoid vertical 0.498 0.817 0.616
SNA 0.803 0.781 1.000
SNB \0.001 \0.001 0.036*
ANB \0.001 \0.001 0.013*
SNGoGn 0.152 0.246 1.000
* p \ 0.05

were not significant. According to a correlation analysis,
there was only a weak correlation between the changes in
the horizontal position of the hyoid bone and SNB in the
SWG (r = 0.38; p \ 0.05).
Discussion
Severe skeletal retrognathia could increase the risk of
sleep-disordered breathing in the future [18]. Airway
problems do not usually self-correct but instead deteriorate
with age [17, 25, 26, 32]. In contrast, early improvements
in the pharyngeal airway are maintained in the long term
after functional treatment [13, 14, 39]. Hence, mandibular
advancement has been recommended to overcome current
pharyngeal deficiencies and decrease the risk of developing
obstructive sleep apnea in adulthood [33].
Favorable effects of functional appliances—such as the
bionator [21], twin-block [16, 21], activator [14, 26],
Herbst appliance [15], mandibular anterior repositioning
appliance [31], and Forsus Fatigue Resistant Device [2]—
have been reported; however, other studies reported no
effect [19, 22, 27]. Kinzinger et al. [19] reported that
treatment with an FMA or Herbst appliance did not cause
any significant changes in the airway of patients of a wide
range of ages (12–25 years for FMA and 9–16 years for
Herbst), likely due to marked interindividual differences.
These results are not in accordance with the outcomes of
the present study and that by Schutz et al. [33] who
reported an increase in airway space and improved respi-
ration following treatment of adolescents at their pubertal
growth peak with the Herbst appliance. The present study
showed that prominent forward positioning of the mandible
with FMA affected the oropharynx, soft palate, tongue, and
hyoid bone. However, despite the more-forward position-
ing of the mandible in the SWG, the changes in the
aforementioned parameters induced by stepwise mandibu-
lar advancement were not greater than those in subjects in
whom the mandible was protruded in a single step.
The increases in NPA in the SWG and SSG at T2 were
comparable to those in the CG. The dimensions of the NPA
are influenced mainly by the size of the adenoids and may
also be affected by headgear use [10] (but not by functional
appliances) [13, 16]. However, oropharyngeal airway depth
measured at the tip of the soft palate increased significantly
in the SWG and SSG, as has been reported previously
[2, 9, 16, 33]. These changes were similar in both groups.
Jena et al. [16] also reported no significant difference
between subjects treated with the twin-block or Mandibular
Protraction Appliance IV, despite the more-forward posi-
tion of the mandible in the twin-block group. This was
explained in terms of relief of pressure on the uvula exerted
by the backwardly positioned tongue, which forced the soft
palate towards the dorsal wall of the pharynx. The dimin-
ished force on the uvula has been proposed to be a result of
advancement of the tongue via forward movement of the
mandible or mesialization of the mandibular dentition. This
decrease in pressure forcing the uvula backwards has also
been proposed to decrease the angle between the soft palate
and hard palate, shorten the uvula and increase its thick-
ness. In the current study, no significant change in the
thickness or length of the soft palate was observed, whereas
the decrease in its inclination was similar between the two
groups. Also, Jena et al. [16] reported a comparable
decrease in soft palate inclination in subjects treated using
the twin-block or Mandibular Protraction Appliance IV.

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Airway changes following single-step or stepwise advancement

Since oxygen saturation and airflow competency are as The anteroposterior position of the hyoid bone was
sufficient as permitted by the narrowest part of the airway, positively correlated with oropharyngeal airway dimen-
irrespective of the degree of enlargement of other parts of sions at the level of the soft palate or second cervical
the pharynx, PASmin is important as it is the most con- vertebra [2, 36]. In addition, a negative correlation was
stricted area of the airway and the most susceptible to reported between airway dimensions at the CV2 level and
changes induced by orthodontic treatment [29, 34]. In the the vertical position of the hyoid bone [2]. In the present
current study, both groups showed significant improve- study, only the anterior movement of the hyoid was weakly
ments in PASmin, consistent with previous reports correlated with the change in SNB in the SWG. This is in
[2, 14, 31]; ventral movement of the anterior border of the accordance with the finding of Eggensperger et al. [6] and
oral cavity caused by mandibular advancement increased Chung et al. [4] who reported a significant correlation
the available space for the tongue and shifted the tongue in between horizontal change in the hyoid bone position and
an anterior direction. The improvement in PASmin was B point following surgical mandibular advancement. Pre-
more noticeable in the SWG; however, no significant vious studies, as well as the present study, suggest that the
intergroup difference was detected. In a previous study [14] effect of functional therapy on the above parameters cannot
and in the present study, the expected significant correla- be explained simply by the established changes, and the
tion between changes in the PASmin and SNB was not underlying mechanism is more complex.
found.
Although a significant enhancement in tongue height was
found in the SWG, the difference between the two treatment
Limitations
groups was not significant. Schutz et al. [33] reported that
increases in tongue height following maxillary expansion
According to the Safety and Efficacy of a New and
and mandibular advancement using an acrylic splint Herbst
Emerging Dental X-ray Modality (SEDENTEXCT)
appliance may reduce the hypotonia of the tongue. We
guidelines, cone-beam computerized tomography (CBCT)
speculate that gradual sagittal advancement of the mandible
use is not warranted for screening purposes only, but is
favors correct tongue function, as indicated by the aug-
valid for procedures such as orthognathic surgery or for
mentation of tongue height. The underlying mechanism may
determination of alveolar bone graft volume. However,
be the enhanced neuromuscular adaptation of the muscles in
strong correlations were reported between pharyngeal
the SWG. Gradual advancement of the mandible could have
measurements obtained using lateral cephalometric head-
reduced stretching of the genioglossus and geniohyoid
films and three-dimensional (3D) magnetic resonance
muscles, leading to improved tongue tonus.
images [28] and CBCT [7, 38] with very high repro-
Several studies have reported coherent relocation of the
ducibility and accuracy [24]. Hence, conventional lateral
hyoid bone in response to mandibular sagittal changes
cephalograms are reliable for sagittal airway measurement
[2, 21, 22, 31, 33, 36], as the hyoid bone is attached to the
for diagnostic and therapeutic purposes, as they are con-
mandible via the geniohyoid, anterior digastric and mylohyoid
venient, inexpensive, and involve minimal exposure to
muscles. The position of the hyoid bone is linked to tongue
radiation, but do not provide a 3D image of the airway.
posture and function. This is due to the geniohyoid muscle
(which originates on the inside surface of the mandible on
mental tubercles, inserting along the entire length of the tongue
Conclusion
and ending on the body of the hyoid) influencing the position,
shape, and size of the tongue [23]. In this respect, the significant
At the pubertal peak growth stage, treatment with FMA can
anterior movement of the hyoid bone in both groups can be
increase the oropharyngeal airway dimensions at the level
interpreted as a natural outcome of mandibular and tongue
of the soft palate tip and the shortest distance behind the
advancement, as suggested previously [9, 31]. In our study, the
tongue, as well as decreasing soft palate angulation and
movement in an inferior direction of the hyoid bone was slightly
anterior repositioning of the hyoid bone. In stepwise
greater in the SSG than in the CG. However, no significant
mandibular advancement, there was a tendency towards a
difference was found when compared with the CG. In the SWG,
higher tongue posture. Significant anterior development of
no significant change in the vertical position of the hyoid bone
the mandible occurred in SSG and SWG. More-forward
was found. Furthermore, the changes in the horizontal and
positioning of the mandible with stepwise mandibular
vertical positions of the hyoid bone were comparable between
advancement did not exert a greater effect on the dimen-
the SWG and SSG. Our findings are consistent with previous
sions of the pharyngeal airway or soft palate, nor on the
reports of a relatively stable vertical position [21, 22] after
position of the tongue and hyoid bone.
functional treatment.

123

Compliance with ethical guidelines
Conflict of interest I Aras, A. Pasaoglu, S. Olmez, I. Unal, and A.
Aras declare that there are no competing interests. All procedures
performed in studies involving human participants were in accor-
dance with the ethical standards of the institutional and/or national
research committee and with the 1964 Helsinki declaration and its
later amendments or comparable ethical standards. Informed consent
was obtained from all individual participants included in the study.
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