CRANIO®

The Journal of Craniomandibular & Sleep Practice

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Change of hyoid bone position in patients treated

for and resolved of myofascial pain

Nathan J. Pettit DMD, MSD & Ronald C. Auvenshine DDS, PhD

To cite this article: Nathan J. Pettit DMD, MSD & Ronald C. Auvenshine DDS, PhD (2018):
Change of hyoid bone position in patients treated for and resolved of myofascial pain, CRANIO®,
DOI: 10.1080/08869634.2018.1493178

To link to this article: https://doi.org/10.1080/08869634.2018.1493178

Published online: 31 Jul 2018.

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 ®
CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2018.1493178

RADIOLOGY

Change of hyoid bone position in patients treated for and resolved of

myofascial pain
Nathan J. Pettit DMD, MSDa,b and Ronald C. Auvenshine DDS, PhDa,b,c,d
a
MedCenter TMJ, PC, Houston, TX, USA; bTMD/Orofacial Pain Clinic, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA;
c
University of Texas Health Science Center, School of Dentistry, Houston, TX, USA; dLouisiana State University, School of Dentistry, New
Orleans, LA, USA

ABSTRACT KEYWORDS
Objective: The purpose of this study was to investigate change in hyoid bone position for Hyoid bone; myofascial pain;
patients suffering from myofascial pain and to evaluate the modified hyoid triangle as a three- hyoid triangle;
dimensional cephalometric modality for measuring hyoid position. cephalometric; airway;
Methods: Pre- and post-treatment CBCT scans for 30 female patients resolved of myofascial pain hyoid; cone beam computed
tomography; posture
were reviewed by a blinded investigator using the modified hyoid triangle. Changes in dimen-
sions of the hyoid triangle were analyzed with the t-test for paired comparisons.
Results: Statistical analysis showed a drawing nearer of the chin to the third cervical vertebra
(–2.0 mm, p = 0.026) and a release of the hyoid bone away from the floor of the mouth
(1.5 mm, p = 0.011).
Discussion: These findings suggest resolution of myofascial pain may correlate with decreased
forward head posture and relaxation of suprahyoid musculature. The potential for change in
oropharyngeal dimension and airway is evident.

Introduction is dynamic and may reflect the health of the head and
neck musculature, whether peaceful and coordinated or
The hyoid bone is a frequently overlooked structure in
disturbed [1,6,8,18,24,42,44–48]. The hyoid is key in pre-
the field of dentistry [1]. Its unique relationship to
servation of oropharyngeal function, and a change in its
other structures gives it a pivotal role in cranioman-
position may relate to changes in oropharyngeal dimen-
dibular functions [2]. It floats at the anterior portion of
sion [4,5,6,8,17,20,21,22,40 [5–49],] (Figure 1).
the neck between the mandible and thyroid cartilage at
Hyoid position has been measured with a variety of
about the level of the third cervical vertebra (C3) [3–7].
methods using two-dimensional lateral cephalograms
The hyoid bone has no bony articulations, making its
[1,15,23,40,47,48,50]. The advent of cone beam com-
movement and posture dependent on the attachments
puted tomography (CBCT) has introduced capabilities
of ligaments, fascia, and muscles [1,2,4–6,8,9]. Hyoid
of 3D cephalometric analysis, precise anatomic land-
posture is critical for maintenance of the airway, pho-
mark identification, measurement of volumes in both
nation, mastication, intraoral transport, swallowing,
hard and soft tissue, morphologic studies, and other
breathing, esophageal sphincter opening, tongue pos-
previously unappreciated observations in the head and
ture, craniocervical posture, mandibular posture, and
neck [10,51–66]. No standard for measurement of
shoulder girdle posture [1,4–34].
hyoid bone position has been established for CBCT
Hyoid bone posturing and position have been related
[57,64,67–69]. This study evaluated a method for mea-
to obstructive sleep apnea (OSA), vertical jaw dysplasia,
suring hyoid bone position termed the modified hyoid
malocclusion, temporomandibular dysfunction, atypical
triangle [70].
deglutition, inadequate upper esophageal sphincter open-
The aim of this study was to (1) determine if
ing, muscle tension dysphonia, dysphagia, and cervical
there is a change in hyoid bone position in adult
disorders [7,17,18,22,23,25,26,31,35–42]. Few studies
female patients treated for and resolved of myofas-
have investigated the relationship between hyoid position
cial pain symptoms as compared to pre-treatment;
and myofascial pain disorders [43]. Due to its suspensory
(2) evaluate practical use and precision of the
relationship with circumjacent structures, hyoid posture

CONTACT Nathan J. Pettit office@medcentertmj.com MedCenter TMJ, PC, 7505 S. Main St., Ste. 210, Houston, TX 77030, USA
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ycra.
© 2018 Taylor & Francis
2 N. J. PETTIT AND R. C. AUVENSHINE
Figure 1. Hyoid bone muscle attachments.
modified hyoid triangle for tracking hyoid bone
position in CBCT scans.
Materials and methods
Thirty female patients consecutively treated for
myofascial pain were selected according to inclusion
and exclusion criteria for retrospective analysis.
Patients were selected from a pool of patients trea-
ted by a credentialed practitioner who limits his
practice to the treatment of craniomandibular dis-
orders. The study was limited to a review of female
subjects in order to eliminate potential variables
related to sexual dimorphism of hyoid bone posi-
tion or response to treatment. An effort to limit
influence of disorders other than myofascial pain
was also made to strengthen the study design.
Inclusion and exclusion criteria for the analysis
were as follows:
Inclusion criteria: Female gender, 20–70 years of age,
diagnosed with myofascial pain, treated to resolution of
myofascial pain symptoms, pre – and post-treatment
CBCT scans available, with patient in occlusion.
Exclusion criteria: Bone pain, disk degradation,
internal derangement, popping of the temporomandib-
ular joint, and other disorders affecting the temporo-
mandibular joint internally.
Patients had received a CBCT scan for diagnostic
review prior to initiation of treatment in all cases.
Following treatment and resolution of myofascial pain
symptoms, patients received a post-treatment CBCT
scan in the same manner as the initial pre-treatment
scan. Time interval between scans depended on treat-
ment duration, which usually occurred over a period of
6 months.
All CBCT scans were made with an i-CAT Next
Generation CT Scanner (Hatfield, PA). Radiograph
parameters were 120kV and 5mA with an effective
dose of 74 μSv. Patients were positioned within the
scanner sitting upright and instructed to hold still with
their teeth together while staring at a distant fixed point.
A rotating source/detector captured the volumetric
image of the patient’s head in an 8.9-s scan. Each scan
consisted of 300 primary images stored as digital ima-
ging and communications in medicine (DICOM) data
files. Data collection occurred in two phases. One
blinded investigator performed all measurements.
Phase 1
Each DICOM file (both a pre- and post-treatment scan for
each subject) was assigned three random numbers using a
random number generator. Scans were randomized by
ranking the random numbers into a sequence; each scan
was represented three times within the sequence. Each
scan was then de-identified and viewed in sequence by
an investigator blinded as to whether the scan was a pre- or
post-treatment scan. CBCT data from each scan was ana-
lyzed using InVivoDental 5.2.2 (Anatomage Inc., San Jose,
CA, USA) on one of two 24-in. monitors (U2410 Dell Inc.,
Round Rock, TX, USA and VE248H ASUSTek Computer
Inc., Beitou District, Taipei, Taiwan). Position of the hyoid
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CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 3

bone in relation to the third cervical vertebra and genial
tubercles of the mandible was measured using the mod-
ified hyoid triangle.
Modified hyoid triangle reference points were
selected based on manipulation of the volume rendered
scan in three dimensions and defined as follows:
C3: The most anterior inferior angle of the body of
the third cervical vertebra at its approximate midline.
H: The most anterior superior point of the body of
the hyoid bone at its approximate midline.
GT: An identifiable prominence in the region of the
genial tubercles at the approximate midline of the
mandible.
The dimensions of the modified hyoid triangle were
measured and defined as follows:
C3-H: The distance in millimeters from selected
point C3 to selected point H.
H-GT: The distance in millimeters from selected
point H to selected point GT.
C3-GT: The distance in millimeters from selected
point C3 to selected point GT.
H-1: The closest distance from selected point H to a
line connecting selected point C3 to selected point GT.
Each modified hyoid triangle dimension was recorded
in a spreadsheet and later decoded for statistical analysis.
The average of three measurements of each dimension,
from each patient scan, was calculated and appears in
Table 1.
Phase 2
The DICOM data for each patient (both pre- and post-
treatment scans) were measured side by side using two
separate computer monitors in one room. One com-
puter monitor had the de-identified pre-treatment
CBCT scan of a patient open for analysis, while the
other monitor had the post-treatment CBCT scan of
the same patient open for analysis. The pre- and post-
treatment scans of the same patient were randomized
as to which monitor would display which scan, blind-
ing the investigator as to treatment status. CBCT data
from each scan were analyzed using the same software
and hardware as was utilized in Phase 1.
Position of the hyoid bone was measured as
described in Phase 1 of data collection, but with the
following modifications:
● Measurements were made on the pre- and post-
treatment scans simultaneously.

Table 1. Averages of modified hyoid triangle measurements, Phase I (mm).

Pre-treatment scan Post-treatment scan
Subject C3-GT C3-H H-GT H-1 C3-GT C3-H H-GT H-1
1 77.10 33.04 44.15 1.81 69.31 28.71 40.95 3.22
2 65.86 25.22 40.91 2.91 58.38 26.99 34.54 9.64
3 60.64 30.17 33.53 9.73 60.79 30.15 33.46 9.33
4 62.98 33.16 30.53 4.70 63.15 32.11 31.88 5.07
5 59.39 32.54 34.36 15.39 62.69 31.27 37.30 13.91
6 60.55 34.66 26.44 4.05 60.54 34.43 26.76 4.42
7 63.63 31.39 32.27 0.75 65.90 31.45 34.53 1.66
8 52.56 22.79 29.90 1.87 49.28 21.92 27.76 3.09
9 N/A N/A N/A N/A N/A N/A N/A N/A
10 63.00 33.75 31.00 7.46 60.78 33.41 28.83 6.64
11 62.34 31.66 30.67 4.21 60.97 33.40 30.69 9.86
12 64.67 29.80 36.88 8.08 62.98 29.74 34.07 5.14
13 54.55 29.08 29.01 9.97 54.32 28.54 28.50 8.65
14 56.61 36.82 28.92 16.53 58.48 35.60 31.07 15.95
15 60.96 29.19 34.47 9.13 61.12 29.08 35.11 9.75
16 69.59 35.32 35.08 5.35 68.32 35.63 33.91 6.45
17 57.78 29.29 30.14 6.96 56.27 30.39 29.68 10.50
18 76.17 35.63 41.25 5.23 67.01 33.68 38.93 13.93
19 62.94 26.97 36.12 2.12 57.85 25.23 33.51 5.05
20 71.18 34.21 37.20 2.62 72.49 34.27 38.36 2.23
21 70.09 37.17 34.82 8.18 70.66 33.71 38.47 7.41
22 66.42 34.91 34.48 10.03 73.86 34.49 42.99 11.73
23 60.74 30.85 30.33 3.26 59.68 29.68 31.45 6.53
24 66.16 33.22 35.97 10.13 67.26 34.05 34.55 6.75
25 65.15 29.64 35.54 0.86 58.86 29.41 29.95 3.77
26 69.51 33.01 36.67 2.40 69.34 32.48 37.42 4.21
27 64.60 28.62 37.63 7.27 62.63 30.00 35.01 8.68
28 60.49 27.79 34.58 7.57 57.78 28.71 31.99 9.27
29 77.79 38.66 39.15 0.92 62.70 33.86 29.46 4.35
30 71.55 33.04 39.11 4.64 66.27 34.39 33.84 8.11
N/A: not applicable; subject 9 was excluded from analysis due to CBCT scan showing patient not in occlusion.
C3-GT: distance from point C3 (third cervical vertebra) to point GT (genial tubercle) in mm; C3-H: distance from point C3 (third cervical vertebra) to point H (hyoid bone)
in mm; H-GT: distance from point H (hyoid bone) to point GT (genial tubercle) in mm; H-1: distance from point H (hyoid bone) to line C3-GT in mm.
4 N. J. PETTIT AND R. C. AUVENSHINE

● The investigator was able to switch back and forth
between monitors, manipulating the volume ren-
dered scans in various views to confirm that the
same precise anatomic landmark was selected for
both scans.
● The reference point GT was selected by locating
either an identifiable prominence or depression
within the genial tubercle region. This choice
was dependent on available landmark anatomy
of the patient for both scans.
● Each pair of modified hyoid triangle measure-
ments was recorded in a spreadsheet and later
decoded to pre- or post-treatment status for sta-
tistical analysis. The data for each subject appears
in Table 2.
Statistical analysis
Statistical analysis was performed using a commercially
available statistical software program (SPSS 20.0, IBM,
Armonk, NY, USA). Agreement of the two data sets
(Phase 1 and Phase 2) were evaluated by calculating the
intraclass correlation coefficient for each variable.
Subject 9 was excluded from analysis, due to the
CBCT scan showing the patient was not in occlusion
during the post-treatment scan, thus not meeting
inclusion criteria.
Data from Phase 2 was then analyzed for normality
by looking at skewness and kurtosis values. A paired
comparison t-test was performed for each dimension of
the hyoid triangle to test the null hypothesis that no
change occurred in any dimension of the modified
hyoid triangle from pre-treatment to post-treatment.
Distance between H and GT manifested a somewhat
non-normal distribution, indicating performance of an
additional Wilcoxon signed rank test of the null
hypothesis. The level of significance was set at p ≤ 0.05.
Results
Regarding the agreement between the modified hyoid
triangle dimensions measured in Phase 1 and Phase 2,
each variable showed very good agreement, as deter-
mined by the intraclass correlation coefficient (≥0.8).
These values are represented in Table 3.
Results of the paired comparisons t-test are shown
in Table 4. There was a statistically significant change
in the modified hyoid triangle dimensions of C3 to GT
(p = 0.026) and H-1 (p = 0.011). The mean dimensional

Table 2. Modified hyoid triangle measurements, Phase II (mm).

Pre-treatment scan Post-treatment scan
Subject C3-GT C3-H H-GT H-1 C3-GT C3-H H-GT H-1
1 77.77 33.16 44.65 1.12 69.33 27.52 41.98 2.34
2 66.58 22.83 43.84 1.65 58.22 24.07 36.74 8.58
3 60.16 30.03 33.10 9.56 61.21 30.46 33.46 9.19
4 62.76 31.91 31.06 2.49 62.72 31.23 31.71 2.57
5 60.43 32.73 36.09 16.44 63.61 31.44 39.27 15.33
6 60.21 34.12 26.41 3.05 60.35 34.14 26.50 2.95
7 63.41 29.23 34.39 2.54 65.65 29.35 36.46 2.30
8 54.40 26.00 30.46 7.53 50.53 25.85 25.55 4.72
9 N/A N/A N/A N/A N/A N/A N/A N/A
10 67.61 36.29 31.59 3.06 63.57 34.53 29.36 3.17
11 66.56 32.48 35.19 6.10 65.85 33.98 35.36 10.87
12 66.06 30.25 37.70 7.90 64.45 29.93 35.17 4.60
13 57.10 28.81 32.16 10.66 56.44 27.92 31.30 8.95
14 58.68 36.39 32.36 17.87 60.62 35.36 34.00 16.84
15 63.85 28.58 38.95 10.84 64.41 28.74 39.88 11.66
16 69.33 35.20 35.02 5.57 68.04 35.22 33.99 6.31
17 60.83 28.96 33.53 7.13 59.47 29.69 33.51 10.68
18 78.45 36.22 42.57 3.60 69.54 33.35 40.13 11.80
19 66.13 26.73 39.50 1.72 60.35 24.18 37.12 5.22
20 73.25 34.20 39.86 5.45 74.55 33.34 42.25 6.23
21 72.94 34.60 39.56 6.68 72.42 33.55 40.33 7.28
22 67.11 34.44 35.68 10.15 75.80 33.99 45.47 11.78
23 63.71 30.53 33.87 4.70 62.66 28.66 35.90 7.72
24 68.71 32.61 39.27 10.49 69.28 34.04 36.92 7.65
25 66.44 29.70 36.75 0.50 60.18 28.63 32.26 4.61
26 71.65 33.51 38.92 5.28 71.62 33.12 39.95 7.21
27 66.61 28.41 40.29 8.27 65.29 30.04 38.13 9.73
28 60.22 27.93 34.46 8.11 57.43 28.83 32.12 10.18
29 80.37 37.84 42.65 2.26 65.57 34.18 32.66 10.49
30 71.39 32.65 39.35 4.70 66.11 34.30 33.77 8.10
N/A: Not applicable; subject 9 was excluded from analysis due to CBCT scan showing patient not in occlusion.
C3-GT: distance from point C3 (third cervical vertebra) to point GT (genial tubercle) in mm; C3-H: distance from point C3 (third cervical vertebra) to point H
(hyoid bone) in mm; H-GT: distance from point H (hyoid bone) to point GT (genial tubercle) in mm; H-1: distance from point H (hyoid bone) to line C3-GT
in mm.
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CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5

Table 3. Intraclass correlation coefficients of modified hyoid
triangle measurements between Phase 1 and Phase 2.
Modified hyoid triangle
dimension Scan
C3-GT Pre-treatment
C3-GT Post-treatment
C3-H Pre-treatment
C3-H Post-treatment
H-GT Pre-treatment
H-GT Post-treatment
H-1 Pre-treatment
H-1 Post-treatment
C3-GT: distance from point C3 (third cervical vertebra) to point GT (genial
tubercle) in mm; C3-H: distance from point C3 (third cervical vertebra) to
point H (hyoid bone) in mm; H-GT: distance from point H (hyoid bone) to
point GT (genial tubercle) in mm; H-1: distance from point H (hyoid bone)
to line C3-GT in mm.
change of C3 to GT was a decrease of 1.98 mm, repre-
senting a 3.0% decrease in dimension, as compared to
the pre-treatment distance. The mean dimensional
change of H-1 was an increase of 1.50 mm, which
represents a 23.5% increase in dimension, as compared
to its pre-treatment length. Analysis also showed a
trend for decrease in distance between C3 to H
approaching statistical significance (p = 0.072). A simi-
lar trend for decrease in distance between H and GT
was also noted (p = 0.165).
Discussion
The modified hyoid triangle for CBCT
This is the first study to evaluate the agreement and
reproducibility of measurements obtained from CBCT
cephalometric analysis of hyoid position using the
modified hyoid triangle. The original hyoid triangle
was introduced by Dr. Ronald E. Bibby for use in 2D
lateral cephalograms [70]. Bibby and Preston point out
that previously utilized cranial reference points were
distant from the hyoid bone and as such, were poor
references due to introduction of exaggerated measure-
ments [1]. The hyoid triangle attempts to minimize the
overlapping effects of head and hyoid posturing by
selecting points that are relatively consistent among
varying head postures [1].
In this study, analogous points to the original hyoid
triangle are utilized on the third cervical vertebra, the
Intraclass hyoid bone, and the lingual surface of the mandible
correlation
0.944
near its symphysis (Figure 2).
0.934 The hyoid bone appears to maintain a relatively con-
0.947 sistent distance to the third cervical vertebra during flex-
0.938
0.842 ion and extension of the neck, making it a desirable
0.839 reference point for tracking hyoid movement [7]. The
0.903
0.868 hyoid bone also follows a similar trajectory to the mand-
ible in flexion and extension of the cervical vertebrae,
suggesting the mandible as a good reference point for
tracking hyoid position, as well [7].
Identification of anatomical landmarks in three dimen-
sions is not simple [64]. Even with the improved detail of an
image rendered in three dimensions, it remains difficult to
define an anatomic point precisely enough for it to be
consistently selected across multiple scans, given the vary-
ing anatomy between humans. For instance, defining the
reference point for the genial tubercle (GT) was difficult,
due to variation exhibited in the anatomy between subjects
(Figure 3). The region of the genial tubercles showed a
variety of morphology, including prominent genial tuber-
cles, either symmetrically or asymmetrically placed, a single
broadly raised tubercle, a depression, groove, or pit
between genial protuberances, etc. The hyoid structure
itself has demonstrated much anatomic variation
(Figure 4) [10]. The presence of a lingula in some hyoid
bones and not in others made selection of consistent ana-
tomic points difficult. Sometimes the lingula made an
excellent reference point for use in the hyoid triangle, but
other times it was totally absent in the morphology of the
bone (Figure 5).
Additionally, the lack of depth perception in CBCT
is noted as a limitation to the selection of precise
anatomic points [64]. The authors tried to overcome
this limitation of non-stereoscopic imaging by manip-
ulating the volume rendering into various orientations
for multiple views of the same anatomic landmark,
allowing several perspectives to confirm selection of
the desired point (Figures 6, 7, 8).
One aim of this study was to assess practicality and
reproducibility of measurements made using the

Table 4. Paired comparisons t-test for change in modified hyoid triangle dimensions.
Paired differences
95% Confidence interval of the difference
Hyoid triangle dimension Mean Standard deviation Standard error mean Lower Upper t df Sig. (2-tailed)
C3-GT −1.98103 4.5250 0.84027 −3.7023 −0.25981 −2.36 28 0.026
C3-H −0.57586 1.6599 0.30824 −1.2073 0.05554 −1.87 28 0.072
H-GT −0.96483 3.6453 0.67692 −2.3514 0.42178 −1.43 28 0.165
H-1 1.50483 2.9957 0.55628 0.3653 2.64432 2.71 28 0.011
C3-GT: distance from point C3 (third cervical vertebra) to point GT (genial tubercle) in mm; C3-H: distance from point C3 (third cervical vertebra) to point H
(hyoid bone) in mm; H-GT: distance from point H (hyoid bone) to point GT (genial tubercle) in mm; H-1: distance from point H (hyoid bone) to line C3-GT in
mm; df: degrees of freedom; Sig: significance p-value for paired comparisons t-test.
6 N. J. PETTIT AND R. C. AUVENSHINE

Figure 2. The modified hyoid triangle. Representative images of hyoid triangle selection in one subject. Note change in
craniovertebral angle and inferior movement of hyoid bone in the post-treatment scan. Green: C3, Red: H, Yellow: GT. Above:
Pre-treatment. Below: Post-treatment.

modified hyoid triangle with its defined landmarks.
Two phases of data collection transpired. The first
phase involved analysis of one scan at a time, rando-
mized in order, with each scan appearing three separate
times, dispersed in random sequence. Later, the
repeated measurements of the same scans were aver-
aged against themselves. The variance exhibited by
Phase 1 measurements for the most part was very
small, approaching 0.00 in many cases (Table 5).
Several scans demonstrated a wider variance, suggest-
ing less consistent selection of anatomic landmarks in
these scans. This confirms the limitation of selecting
anatomic points by definition alone. Anatomic varia-
tion makes precise description of 3D landmarks
difficult. The intention of measuring each scan three
times and calculating the average was to increase inter-
nal validity and limit potential for error.
Phase 2 data collection was performed with two
volumetric renderings side by side, allowing the inves-
tigator to manipulate in three dimensions his view of
the anatomy, whether the hyoid bone, the cervical
vertebrae, or the lingual surface of the mandible. The
investigator was blinded as to which scan was pre-
treatment and which scan was post-treatment, prevent-
ing the potential for bias. In making the side by side
measurements, selected points were adjusted from var-
ious perspectives until they correlated well from scan to
scan when viewed from the same directions (Figure 6,
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CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 7

Figure 3. Variation in genial tubercle region anatomy. Representative images of volume rendered genial tubercle region of the
mandible from some of the subjects studied. Note the wide variation in anatomy.

7, 8). This is the preferred method of the authors,
providing greater confidence that the same anatomic
points were selected in the pre-treatment scan as were
selected in the post-treatment scan.
To test the agreement between Phase 1 data and
Phase 2 data, intraclass correlation coefficients were
calculated for each variable. Medical statistics standards
show that any intraclass correlation coefficient above
0.80 is considered very good agreement [71]. Intraclass
correlation coefficients can be viewed in Table 3. Each
variable showed a correlation over 0.80, suggesting
either set of data could be used for statistical analysis.
The high intraclass correlation coefficients between
Phase 1 and Phase 2 data suggest the reference points
defined in this paper are ample in depth and clarity to
provide consistent and reproducible measurements for the
hyoid bone in CBCT imaging. In effect, it mattered not
whether the average of three measurements was used or if
the scan was measured once with its counterpart. These
findings support previous literature reporting increased
accuracy and precision of measurements using CBCT
[53,57,59,60,72]. It shows that CBCT really does allow
reproducible measurements in three dimensions and that
precision of measurements was good. These findings
8 N. J. PETTIT AND R. C. AUVENSHINE

Figure 4. Variation in hyoid anatomy. Representative images of volume rendered hyoid bones from some of the subjects studied.
Note the wide variation in hyoid bone anatomy and the presence or absence of lingula.

Figure 5. Lingula of the hyoid bone. Representative images of a hyoid bone in one subject with lingula. Left: view from patient’s
right. Middle: superior view. Right: frontal view. See also Figure 4 for additional examples of the hyoid lingula.

support the hyoid triangle, as modified in this study, as
candidate for a new standard for hyoid position analysis.
Due to the excellent agreement of data collected by
Phase 1 with Phase 2 methods, Phase 2 data were
selected for further statistical analysis. It is the opinion
of the authors that Phase 2 data most closely represents
a true comparison between pre- and post-treatment
CBCT scans, due to the ability to confirm selection of
the same anatomic points between pre- and post-treat-
ment scans. Statistically significant changes in the
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CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 9

Figure 6. Selection of modified hyoid triangle Point H. Representative images of volume rendered hyoid bones from one subject,
showing various views to facilitate location and selection of precise anatomic landmark (red dot). Left: pre-treatment scan. Right:
post-treatment scan.

modified hyoid triangle dimensions were discovered

for C3-GT and H-1.
Change in head posture
The decrease in distance from the point GT to the
point C3 suggests a drawing nearer of the chin to the
cervical vertebrae. As a consequence of the dentition in
occlusion for each scan, the decreased distance does
not imply a change in mandibular positioning as much
as it implies a change in craniocervical posture.
Patients suffering from chronic pain disorders will fre-
quently manifest a forward head posture [42,73].
Myofascial pain can contribute to a forward head pos-
ture because of the intimate connection between oro-
facial and upper cervical dysfunction [42]. Patients
with a forward head posture usually present with a
projected chin and a hyperextended craniocervical
junction [42]. Forward head posture can result from
either forward flexion, anterior translation, or a com-
bination of both [74].
Posturing of the head requires balancing forces of
gravity and functional movements with the tonus of
the muscles of the head, neck, and shoulder girdle [32].
The hyoid bone, attaching to each of these structures, is
intimately involved in posturing the head, neck, and
shoulder girdle [32]. The supra and infrahyoid muscles
depend on the hyoid bone to determine the curvature
of the cervical spine and balance the craniovertebral
joints [6]. The mechanical advantage of the hyoid bone
lies in its anterior placement to the cervical spine [7].
This allows significant flexor moment arms to act on
the upper cervical spine by the hyoid muscles [34].
Hyoid kinematics has been related to diagnosis and
treatment of neck disorders [7]. Any change in an
10 N. J. PETTIT AND R. C. AUVENSHINE

Figure 7. Selection of modified triangle Point GT. Representative images of volume rendered mandible from one subject, showing
various views to facilitate location and selection of precise anatomic landmark. Left: pre-treatment scan. Right: post-treatment scan.

anatomic component, such as a spasm of a cervical
muscle, may lead to change in head posture [33,47].
It has been suggested that body posture substan-
tially affects the upper airway dimension and muscle
activity [6,17]. Extension of the head changes cranio-
cervical inclination. Change in this inclination corre-
lates with pharyngeal airway space and the position of
the hyoid bone [75]. Head extension appears to
increase pharyngeal airway space, especially when the
extension is at the uppermost cervical spine [75]. An
increase of 10 mm in the distance between anatomic
points C3 and menton has been shown to increase the
pharyngeal airway space by about 4 mm [75].
Forward head posture has also been implicated in
improved respiratory strength [76]. Forward head pos-
ture may be an adaptive response in an attempt to
improve weakened respiratory function [76]. It is pos-
sible the reduction in forward head posture implied by
this study reflects an improvement in the airway of
subjects resolved of myofascial pain. Perhaps as mus-
cles in the throat relax, head posture corrects itself
because it no longer must compensate for a reduced

CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Figure 8. Selection of third cervical vertebra Point C3. Representative images of volume rendered cervical vertebrae from one
subject, showing various views to facilitate location and selection of a precise anatomic landmark.
airway. The coincident finding of an inferiorly dis-
placed hyoid bone may also have implications of an
improved airway by change in oropharyngeal dimen-
sion and hyoid posture.
The decrease of 1.98 mm from the point C3 to GT,
although calculated to be statistically significant, may
not represent clinical significance, in that the relative
change in dimension is only about 3.0%. Head posture
appears to change over time [77]. The modified hyoid
triangle is not designed to evaluate head or neck pos-
ture, but to relate hyoid position to these circumjacent
structures. The findings of this study do not directly
show a decreased forward head posture. The potential
for a decreased forward head posture, however, is pre-
sent. Future studies of craniocervical posture may be
enhanced with use of hyoid measurements to establish
correlation between the modified hyoid triangle
dimensions and forward head posture.
Inferior movement of the hyoid
Perhaps of greater significance is the increase in
dimension of H-1. The hyoid moved away from the
line connecting C3 to GT by 1.50 mm, suggesting an
inferior movement or release of the hyoid bone away
®
11
from the floor of the mouth. This change in hyoid
position suggests a relaxation of suprahyoid muscula-
ture, tongue position, and coincident change in oro-
pharyngeal and airway dimensions [22,25]. Position of
the tongue has been suggested as more important in
airway size than the size of the soft palate [17].
The resting position of the hyoid is dependent on
the tensional balance between the suprahyoid and
infrahyoid muscles [48]. Any change in this balance
is likely to affect hyoid position [48]. The mylohyoid
and geniohyoid muscles appear to be the main
suprahyoid muscles involved in elevation of the
hyoid bone [8,78]. These muscles can require varying
workloads, depending on patient positioning and
posture [17].
The statistically significant increase in dimension of
H-1 represents a 23.5% increase in the overall dimension
of H-1, carrying more weight in regard to clinical signifi-
cance. One of the authors’ interests for future investigation
is the effect this change in resting hyoid position may have
on the airway dimension. The hyoid bone and its posture
have been related to the stabilization and maintenance of
the airway [5,9,22,23]. The airway is dependent upon soft-
tissue volumes and the bony confinements that determine
its dimensions [21]. The hyoid serves as a prop to maintain
12 N. J. PETTIT AND R. C. AUVENSHINE

Table 5. Variance of three measurements for modified hyoid The subjects observed in this study began treatment
triangle dimensions. with symptoms of myofascial pain and a superiorly
Subject # Treatment status C3-GT C3-H H-GT H-1 placed hyoid bone position, as compared to post-treat-
1 Pre 0.06 0.03 0.11 0.53
Post 0.02 0.60 0.40 0.19
ment. Upward positioning of the hyoid bone has been
2 Pre 0.01 0.10 0.08 0.05 related to a significant reduction in posterior lingual
Post 0.03 0.04 0.02 0.37 airway space [49]. Surgeries to relocate the hyoid infer-
3 Pre 0.11 0.07 0.00 0.03
Post 0.03 0.02 0.00 0.01 iorly and anteriorly attempt to widen the posterior
4 Pre 0.04 0.08 0.08 0.35 airway space and minimize tongue base obstruction
Post 0.32 0.16 0.12 1.24
5 Pre 0.03 0.11 0.00 0.03 [79]. The possibility of a relaxed suprahyoid complex
Post 0.01 0.18 0.01 0.38 in the resolved myofascial pain patient and affiliated
6 Pre 0.09 0.03 0.02 0.04
Post 0.01 0.03 0.01 0.21 opening of the airway space is evident.
7 Pre 0.03 0.13 0.15 0.23 There also appears to be a decrease in movement of
Post 0.04 0.05 0.02 0.03
8 Pre 0.06 0.21 0.07 0.00
the hyoid in patients suffering from OSA [17]. This
Post 0.07 0.17 0.06 0.02 decreased movement may be a result of chronic mal-
9 Pre 0.01 0.00 0.00 0.07 posturing or muscles holding taut the oropharyngeal
Post 0.05 0.03 0.02 0.15
10 Pre 0.10 0.00 0.10 0.00 complex. Sleep apnea disorders have been linked with
Post 0.24 0.42 0.03 0.09 characteristic voice features, suggesting a complex
11 Pre 0.06 0.05 0.24 1.04
Post 0.01 0.00 0.01 0.02 interrelation between airway and oropharyngeal func-
12 Pre 0.02 0.01 0.06 0.03 tions [80]. Patients with OSA present with inflamma-
Post 0.07 0.08 0.01 0.05
13 Pre 3.10 0.03 5.45 0.69 tory and denervation changes in the muscles of the
Post 2.86 0.10 4.15 1.56 upper airway [81]. These may be related to neuromus-
14 Pre 0.17 0.02 1.20 0.46
Post 0.17 0.04 1.24 0.48
cular weakness and contribute to the pathophysiology
15 Pre 0.05 0.02 0.01 0.00 of OSA [81]. Denervation and inflammatory cell infil-
Post 0.05 0.01 0.03 0.07 trate may lead to muscle weakness and may, in a
16 Pre 0.05 0.03 0.00 0.00
Post 0.04 0.06 0.01 0.01 similar way, be contributory to myofascial pain symp-
17 Pre 0.04 0.04 0.02 0.23 toms. Hyoid mobility was not assessed in this study.
Post 0.03 0.01 0.18 0.08
18 Pre 0.25 0.04 0.12 0.01 However, the change in hyoid position observed could
Post 0.24 0.02 0.09 0.15 feasibly reflect a restored mobility of the hyoid in the
19 Pre 0.04 0.06 0.00 0.25
Post 0.03 0.00 0.00 0.01 resolved myofascial pain patient.
20 Pre 1.89 0.01 1.07 2.23 On the other hand, an inferiorly positioned hyoid
Post 1.19 0.04 0.66 0.69
21 Pre 0.01 0.03 0.01 0.22
bone has been implicated with decreased respiratory
Post 0.05 0.29 0.09 0.57 function because it is a common finding in patients
22 Pre 0.01 0.25 0.08 0.50 suffering from OSA [36–40]. However, the inferior
Post 0.26 0.03 0.53 0.32
23 Pre 0.95 0.13 1.36 2.96 movement of the hyoid bone manifest in these patients
Post 0.87 0.06 1.73 2.03 may represent a compensating response in an attempt
24 Pre 0.01 0.03 0.02 0.04
Post 0.13 0.00 0.14 0.02 by the body to increase the posterior airway dimension.
25 Pre 0.32 0.05 0.21 0.11 It should also be noted that the hyoid was measured
Post 0.34 0.04 0.65 1.10
26 Pre 0.02 0.06 0.09 0.03 with the patient upright and not in a supine position,
Post 0.03 0.10 0.20 2.27 as would occur during most sleep apnea events. Being
27 Pre 0.07 0.00 0.08 0.11
Post 0.03 0.03 0.07 0.00
in the supine position can require increased activity
28 Pre 0.02 0.01 0.00 0.07 and contraction of the suprahyoid muscles to keep
Post 0.13 0.13 0.08 0.22 the airway open [17].
29 Pre 0.11 0.13 0.11 0.06
Post 0.01 0.08 0.02 0.28 One important consideration when assessing the
30 Pre 0.03 0.01 0.04 0.01 clinical significance of the inferiorly positioned hyoid
Post 0.01 0.01 0.03 0.13
is the naturally occurring inferior migration of the
C3-GT: distance from point C3 (third cervical vertebra) to point GT (genial
tubercle) in mm; C3-H: distance from point C3 (third cervical vertebra) to hyoid that occurs with aging [20]. The degree of infer-
point H (hyoid bone) in mm; H-GT: distance from point H (hyoid bone) to ior movement in this study, however, suggests a far
point GT (genial tubercle) in mm; H-1: distance from point H (hyoid bone) to
line C3-GT in mm. greater dimensional change (23.5%) than would occur
in a normal physiologic migration over a 6-month
a patent airway, providing attachment for the muscles of period. The migration of the hyoid due to aging is
the anterior neck [4]. Hyoid bone position has also been thus unlikely to confound the significance of the cur-
related to OSA [36–38]. rent findings.

CRANIO : THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Other attempts to change hyoid position
Change in hyoid position and airway dimension can be
attempted surgically or through appliance therapy
[21,48,82–90]. Surgical attempts occasionally result in
partial relapse with time, perhaps due to the resulting
force vectors adjusting and compensating over time
[87]. Certain appliances, such as mandibular advance-
ment splints, tend to have some adverse effects, at least
initially, on patients suffering from muscular and tem-
poromandibular joint discomfort [91]. Additionally,
patients treated with these appliances tend to “drop
out” of persistent use over time, even though respira-
tory response remains improved for those who con-
tinue using the appliances [89].
The findings of this study indicate that a plastic
physiologic change in hyoid posture may be possible
in some cases without the need of invasive surgery or
the use of mandibular advancement devices.
Future studies
The present study reviewed the data of only 30 female
patients treated for myofascial pain. It is unclear why
(or even if) women face temporomandibular disorders
more frequently than men. Genetics, behavior, and
biology have been suggested as potential contributors
to the perceived higher incidence in females [92].
Males were excluded from the study to remove poten-
tial variables related to sexual dimorphism of hyoid
bone position or response to treatment [7,19]. Future
studies should investigate the hyoid position of males
in relation to myofascial pain to see if the findings in
this study hold true across genders.
In addition, radiographic position of the hyoid bone
may relate to airway space and merits further investiga-
tion [22]. The current findings suggest a change in oro-
pharyngeal dimension has occurred. CBCT has been
shown to reliably measure airway volume [93]. Three-
dimensional imaging is suggested as the method of
choice for measurement and evaluation of the upper
airway [55]. Information collected by a CBCT scan can
be used to calculate the volume of spaces, such as airway
passages and sinus spaces, which could be applied in a
similar study design as this study [66]. Imaging of the
upper airway may lead to better predictability of airway
response to therapy and increased understanding of
potential benefits from resolving myofascial pain [88].
Many aspects of hyoid posturing remain unclear
[9]. For example, the extent to which hyoid position
is determined by a passive equilibrium or by active
positioning mediated by sensory feedback to moto-
neurons is not fully understood [9]. However, this
®
13
study supports a hyoid function reflecting the inter-
dependence of the head, neck, and shoulder muscu-
lature [1,6]. Hyoid position appears to be an indicator
of the well-being of the musculoskeletal system of the
head and neck.
Summary
This retrospective analysis investigated the change in
hyoid bone position for patients suffering from myo-
fascial pain and evaluated the modified hyoid triangle
as a 3D cephalometric modality for measuring hyoid
position. Pre- and post-treatment CBCT scans for 30
female patients treated for and resolved of myofascial
pain were reviewed by a blinded investigator using the
modified hyoid triangle. Phase 1 and 2 measurements
were assessed for agreement with the intraclass correla-
tion coefficient, and changes in any dimension of the
hyoid triangle from pre- to post-treatment were ana-
lyzed with the t-test for paired comparisons. Good
agreement with the intraclass correlation coefficient
suggested reproducibility of measurements using
volume rendered CBCT images. The modified hyoid
triangle is supported as a cephalometric modality for
hyoid bone position analysis. Statistically significant
changes in hyoid position were manifest as a drawing
nearer of the chin to the third cervical vertebra (-
2.0 mm, p = 0.026) and a release of the hyoid bone
away from the floor of the mouth (1.5 mm, p = 0.011).
These findings suggest that resolution of myofascial
pain may correlate with decreased forward head pos-
ture and relaxation of suprahyoid musculature. The
potential for change in oropharyngeal dimension and
airway is evident.
Conclusion
The purpose of this research was to contribute to the
understanding of hyoid bone biomechanics and inves-
tigate its potential relationship to posturing, chronic
pain, and neuromuscular disorders. The modified
hyoid triangle was also evaluated for precision and
practical use in CBCT hyoid position analysis. Within
the limitations of this retrospective analysis, the follow-
ing conclusions were made:
(1) Adult female patients treated for and resolved of
myofascial pain show a statistically significant
change in dimension of the modified hyoid tri-
angle when pre- and post-treatment CBCT
scans are compared.
14 N. J. PETTIT AND R. C. AUVENSHINE
(2) Resolution of myofascial pain symptoms is coin-
cident with an inferiorly positioned hyoid bone
(p = 0.011).
(3) Resolution of myofascial pain symptoms is coin-
cident with a drawing nearer of the chin to the
cervical vertebrae (p = 0.026).
(4) The modified hyoid triangle, as defined in this
study, provides a reliable method of tracking
hyoid bone position in CBCT with precision.
Phase 1 and Phase 2 methods showed good agree-
ment, indicating either method may be employed.
(5) The indication of change in oropharyngeal
dimension is evident, with potential implica-
tions for airway dimension, tongue posturing,
swallowing, mastication, cranial posturing, and
other oropharyngeal functions.
Disclosure of interest
The authors report no conflicts of interest.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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