# X-Ray Cephalometric Analysis of the Effects of Angle Class II and III Malocclusion on the Upper Airway Width and Hyoid Position between Parents and Children of Uygur Nationality

Authors: Lijun Cheng; Yuxin Jiang; Shasha Man; Yanan Wang; Yan Yang; Mi Zhou
Journal: Computational and Mathematical Methods in Medicine
 (2022)

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## Abstract

Objective. The objective of this paper is to analyze the effect of angle class II and III malocclusion on the sagittal diameter of the upper airway between parents and children of Uygur nationality and to compare the degree of influence. Methods. 29 Uygur adolescents with malocclusion and their fathers (mothers) were selected as our subjects via X-ray cephalometric radiograph to analyze the difference between the upper airway sagittal dimension and normal occlusion and compare the influence of malocclusion on the upper airway between parents and children. Results. Compared with normal group, the vertical distance from the hyoid point to orbital-ear plane (H-FH) and vertical distance from hyoid point to the mandibular plane (H-MP) in angle class II malocclusion elevated signally, while the vertical distance from hyoid point to anterior cervical plane (H-VL), PNS-UPW, H-FH, and H-MP decreased significantly; compared with normal group: the distance between the posterior nasal spine and the upper pharynx wall (PNS-UPW), H-FH, and H-MP in angle class III malocclusion visually reduced, while PAS, and horizontal distance from the hyoid point and center point of sella turcica to orbital-ear foot (H-S), increased markedly. The impact of class II malocclusion on parents’ U-MPM was greater than their children. Conclusion. The oropharyngeal space of upper airway becomes smaller and hyoid shifts downwards due to class II malocclusion. Class III malocclusion results in decreased nasopharyngeal gap with hyoid to shift upward. The influence of class II malocclusion on the upper pharyngeal tract of parents was greater than their children.


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## Body

## 1. Introduction

Obstructive sleep apnea-hypopnea syndrome (OSAHS) is a clinically universal and potentially fatal disease [1–3]. Its main manifestations are collapsed or partial obstruction of the upper airway during sleep, resulting in increased resistance during breathing, poor ventilation, and even apnea. At the same time, the patient is also accompanied by snoring, decreased blood oxygen saturation, increased nocturia, hypercapnia, and metabolic disorders. The disease can lead to cardiovascular and cerebrovascular complications and even multiorgan damage, which seriously threatens human health. Weight control, body position therapy, smoking and drinking, oral appliances, surgery, and continuous positive airway pressure (CPAP) are the commonly used methods for treating OSAHS. Studies have shown that morphological abnormalities in the upper airway and its surrounding tissues are one of the causes of OSAHS [4–6]. At present, relevant studies have shown that this abnormal morphological structure of the upper airway is related to the sagittal surface type. Abnormal development of craniofacial bones is available to result in changes in upper airway morphology, while its abnormal morphological structure and function will also affect craniomaxillofacial growth and development [7–9]. OSAHS often occurs in populations with class II sagittal facial type and high mandibular plane angle [10–13]. Severe OSAHS patients are often accompanied by mandibular retrusion and thus have a higher apnea index [14, 15]. There is a clear correlation between airway morphology abnormalities and malocclusion deformity, and differences in airway morphology in patients with different ecchal deformities are also significantly correlated [16]. This study compared the effect of angel class II and class III malocclusion on the upper airway and hyoid position, as well as the degree of their influence on the upper airway between Uyghur parents and their children, to put forward a theoretical basis for early treatment malocclusion.


## 2. Subjects and Methods

### 2.1. Subjects

The study involved 29 Uyghur adolescents and their parents subjected to orthodontics in the Department of Stomatology of Bazhou People’s Hospital in Xinjiang from January 2018 to January 2020, including 13 men and 16 women, with an average age of 12.6 years. At least one of the selected parents and the patients were infected with the same type of malocclusion. None of the subjects with no systemic diseases did not experience major accidents, orthodontics, and upper respiratory tract diseases. Angle class II malocclusion inclusion criteria [17, 18]: ANB is greater than 5°, with deep overjet and molar distal relationship; angle class III malocclusion inclusion criteria: ANB is less than 0°, with bone anterior teeth inversion with molar proximal relationship [19, 20].Normal group data: 83 cases with normal occlusion received a medical examination, 36 in adult group, with an average age of 37.2 years, and 47 in the youth group, with an average age of 11.7 years. Inclusion criteria: Uyghur nationality,0°<ANB<5°, average angle, normal overbite, first moral with neutral relationship, no history of orthodontic treatment, no tonsils and adenoid hypertrophy, and normal body mass index (BMI).Exclusion criteria: patients with abnormal facial appearance, asthma, pneumonia, and other diseases, and patients with a history of respiratory surgery in the past.


### 2.2. Research Methods

A total of 58 subjects and 83 in the control group received the lateral cephalogram via the Finnish-produced X-ray camera for skull positioning by a full-time personnel. Patients were required to sit straight with eyes looking straight ahead, their orbital-ear planes parallel to the ground level, and mandibles in the median occlusion. The shooting was done at the end of patients’ exhalation. One person did the measurement: the conventional lateral cephalogram was sketched and measured via tracing method on sulfuric acid paper. Each data measurement was done 2 times to calculate the average, accurate to 0.01 mm.


### 2.3. Measurement Items

Totaling 8 measurements of the upper airway and hyoid, each with 4 measured items (see Figures1 and 2).Figure 1
(1) PNS-UPW: the distance between the posterior nasal spine and the upper pharynx wall, representing the nasopharyngeal airway gap; (2) U-MPW: the distance between the soft palate and the middle and posterior pharynx wall, representing the upper oropharyngeal airway gap; (3) PAS: the space extends through nasal passages to the posterior pharynx and beyond the base of the tongue, lower oropharyngeal airway gap/airway gap behind the root of tongue; and (4) V-LPW: the distance between the vallecula epiglottica point and the posterior pharyngeal wall point, representing the laryngopharyngeal airway gap.Figure 2
(1) H-FH: vertical distance from the hyoid point to orbital-ear plane; (2) H-MP: vertical distance from the hyoid point to mandibular plane; (3) H-S: horizontal distance from the hyoid point and center point of sella turcica to orbital-ear foot, representing the front and rear position of hyoid relative to butterfly saddle point; and (4) H-VL: vertical distance from the hyoid point to the anterior cervical plane.


### 2.4. Statistical Analysis

Statistical analysis is done via SPSS 19.0 statistical software, and the measurement data were detailed inmean±standarddeviation (SD). The normal distribution data were detected via t-test, whereas the abnormal distribution data received nonparametric tests. The differences in the measured indexes of patients with different malocclusions in youth and adult groups were compared with the normal occlusion; the differences in the measured values of angle class II and class III patients and in the changes in the mean of normal occlusion between youth and adult groups were compared, respectively. p<0.05 was considered statistically significant.


## 2.1. Subjects

The study involved 29 Uyghur adolescents and their parents subjected to orthodontics in the Department of Stomatology of Bazhou People’s Hospital in Xinjiang from January 2018 to January 2020, including 13 men and 16 women, with an average age of 12.6 years. At least one of the selected parents and the patients were infected with the same type of malocclusion. None of the subjects with no systemic diseases did not experience major accidents, orthodontics, and upper respiratory tract diseases. Angle class II malocclusion inclusion criteria [17, 18]: ANB is greater than 5°, with deep overjet and molar distal relationship; angle class III malocclusion inclusion criteria: ANB is less than 0°, with bone anterior teeth inversion with molar proximal relationship [19, 20].Normal group data: 83 cases with normal occlusion received a medical examination, 36 in adult group, with an average age of 37.2 years, and 47 in the youth group, with an average age of 11.7 years. Inclusion criteria: Uyghur nationality,0°<ANB<5°, average angle, normal overbite, first moral with neutral relationship, no history of orthodontic treatment, no tonsils and adenoid hypertrophy, and normal body mass index (BMI).Exclusion criteria: patients with abnormal facial appearance, asthma, pneumonia, and other diseases, and patients with a history of respiratory surgery in the past.


## 2.2. Research Methods

A total of 58 subjects and 83 in the control group received the lateral cephalogram via the Finnish-produced X-ray camera for skull positioning by a full-time personnel. Patients were required to sit straight with eyes looking straight ahead, their orbital-ear planes parallel to the ground level, and mandibles in the median occlusion. The shooting was done at the end of patients’ exhalation. One person did the measurement: the conventional lateral cephalogram was sketched and measured via tracing method on sulfuric acid paper. Each data measurement was done 2 times to calculate the average, accurate to 0.01 mm.


## 2.3. Measurement Items

Totaling 8 measurements of the upper airway and hyoid, each with 4 measured items (see Figures1 and 2).Figure 1
(1) PNS-UPW: the distance between the posterior nasal spine and the upper pharynx wall, representing the nasopharyngeal airway gap; (2) U-MPW: the distance between the soft palate and the middle and posterior pharynx wall, representing the upper oropharyngeal airway gap; (3) PAS: the space extends through nasal passages to the posterior pharynx and beyond the base of the tongue, lower oropharyngeal airway gap/airway gap behind the root of tongue; and (4) V-LPW: the distance between the vallecula epiglottica point and the posterior pharyngeal wall point, representing the laryngopharyngeal airway gap.Figure 2
(1) H-FH: vertical distance from the hyoid point to orbital-ear plane; (2) H-MP: vertical distance from the hyoid point to mandibular plane; (3) H-S: horizontal distance from the hyoid point and center point of sella turcica to orbital-ear foot, representing the front and rear position of hyoid relative to butterfly saddle point; and (4) H-VL: vertical distance from the hyoid point to the anterior cervical plane.


## 2.4. Statistical Analysis

Statistical analysis is done via SPSS 19.0 statistical software, and the measurement data were detailed inmean±standarddeviation (SD). The normal distribution data were detected via t-test, whereas the abnormal distribution data received nonparametric tests. The differences in the measured indexes of patients with different malocclusions in youth and adult groups were compared with the normal occlusion; the differences in the measured values of angle class II and class III patients and in the changes in the mean of normal occlusion between youth and adult groups were compared, respectively. p<0.05 was considered statistically significant.


## 3. Result

### 3.1. Compared with the Normal Group

Angle class II: H-FH and H-MP signally increased; U-MPW, PAS, and H-VL significantly reduced, indicating that the oropharyngeal gap diminished, and the hyoid shifted downward (Table1).Table 1
Measurement for the upper airway and hyoid in angle class II malocclusion.
ChildrenParentsMeasured itemsNormal occlusionAngel class IIpNormal occlusionAngel class IIpIn the upper airwayPNS-UPW (mm)25.23±1.4725.47±1.450.8127.48±3.1727.18±3.580.766U-MPW (mm)12.37±1.7410.28±1.430.045∗12.56±3.029.46±3.730.012∗PAS (mm)12.22±2.0110.18±1.820.043∗14.34±2.9312.14±3.030.036∗V-LPW (mm)14.70±2.0414.21±2.010.62823.19±3.7622.99±4.260.843In the hyoidH-FH (mm)83.15±3.7491.45±3.840.000∗95.04±3.24102.44±4.140.000∗H-MP (mm)12.01±1.7515.22±1.370.003∗12.87±5.0314.65±4.560.010∗H-VL (mm)35.26±2.3832.55±2.380.005∗42.37±3.1440.16±2.840.035∗H-S (mm)13.81±4.3411.25±5.210.13016.06±4.4214.84±3.220.095∗p<0.05.


### 3.2. Angle Class III

PNS-UPW, H-FH, and H-MP significantly reduced; PAS, and H-S significantly increased, indicating a decrease in nasopharyngeal gap, and the hyoid shifted forward (Table2).Table 2
Measurement for the upper airway and hyoid in angle class III malocclusion.
ChildrenParentsMeasured itemsNormal occlusionAngle class IIIpNormal occlusionAngle class IIIpIn the upper airwayPNS-UPW (mm)25.23±1.4723.15±1.640.047∗27.48±3.1725.48±3.230.055∗U-MPW (mm)12.37±1.7412.88±1.460.61412.56±3.0212.86±2.740.767PAS (mm)12.22±2.0113.72±2.820.042∗14.34±2.9316.04±1.980.031∗V-LPW (mm)14.70±2.0414.11±2.730.56023.19±3.7623.89±2.640.490In the hyoidH-FH (mm)83.15±3.7481.15±4.840.045∗95.04±3.2492.84±4.740.036∗H-MP (mm)12.01±1.7510.82±3.370.024∗12.87±5.0310.65±3.430.035∗H-VL (mm)35.26±2.3836.25±3.380.33042.37±3.1443.66±2.730.208H-S (mm)13.81±4.3415.15±3.210.035∗16.06±4.4217.64±5.420.027∗∗p<0.05.


### 3.3. Comparison of the Changes in Normal Occlusion between Parents and Children

(a)
Angle Class II: The changes in U-MPW of parents were significantly greater than those of children (Table3)(b)
Angle Class III (Table4)Table 3
The changes in the mean between the parent-child groups with angle class II and normal group.
Measured itemsChildrenParentspPNS-UPW (mm)———U-MPW (mm)2.09±1.383.27±3.210.015PAS (mm)2.04±2.371.86±1.330.305V-LPW (mm)———H-FH (mm)8.30±3.186.87±4.150.062H-MP (mm)3.03±3.372.78±2.380.787H-VL (mm)3.01±2.182.52±3.340.214H-S (mm)———Table 4
The changes in the mean between the parent-child groups with angle class III and normal group.
Measured itemsChildrenParentspPNS-UPW (mm)2.08±2.752.23±3.430.973U-MPW (mm)———PAS (mm)1.4±1.871.1±2.130.834V-LPW (mm)———H-FH (mm)2.15±2.642.2±2.230.912H-MP (mm)1.19±3.252.22±3.580.071H-VL (mm)———H-S (mm)1.14±1.921.38±2.930.827


## 3.1. Compared with the Normal Group

Angle class II: H-FH and H-MP signally increased; U-MPW, PAS, and H-VL significantly reduced, indicating that the oropharyngeal gap diminished, and the hyoid shifted downward (Table1).Table 1
Measurement for the upper airway and hyoid in angle class II malocclusion.
ChildrenParentsMeasured itemsNormal occlusionAngel class IIpNormal occlusionAngel class IIpIn the upper airwayPNS-UPW (mm)25.23±1.4725.47±1.450.8127.48±3.1727.18±3.580.766U-MPW (mm)12.37±1.7410.28±1.430.045∗12.56±3.029.46±3.730.012∗PAS (mm)12.22±2.0110.18±1.820.043∗14.34±2.9312.14±3.030.036∗V-LPW (mm)14.70±2.0414.21±2.010.62823.19±3.7622.99±4.260.843In the hyoidH-FH (mm)83.15±3.7491.45±3.840.000∗95.04±3.24102.44±4.140.000∗H-MP (mm)12.01±1.7515.22±1.370.003∗12.87±5.0314.65±4.560.010∗H-VL (mm)35.26±2.3832.55±2.380.005∗42.37±3.1440.16±2.840.035∗H-S (mm)13.81±4.3411.25±5.210.13016.06±4.4214.84±3.220.095∗p<0.05.


## 3.2. Angle Class III

PNS-UPW, H-FH, and H-MP significantly reduced; PAS, and H-S significantly increased, indicating a decrease in nasopharyngeal gap, and the hyoid shifted forward (Table2).Table 2
Measurement for the upper airway and hyoid in angle class III malocclusion.
ChildrenParentsMeasured itemsNormal occlusionAngle class IIIpNormal occlusionAngle class IIIpIn the upper airwayPNS-UPW (mm)25.23±1.4723.15±1.640.047∗27.48±3.1725.48±3.230.055∗U-MPW (mm)12.37±1.7412.88±1.460.61412.56±3.0212.86±2.740.767PAS (mm)12.22±2.0113.72±2.820.042∗14.34±2.9316.04±1.980.031∗V-LPW (mm)14.70±2.0414.11±2.730.56023.19±3.7623.89±2.640.490In the hyoidH-FH (mm)83.15±3.7481.15±4.840.045∗95.04±3.2492.84±4.740.036∗H-MP (mm)12.01±1.7510.82±3.370.024∗12.87±5.0310.65±3.430.035∗H-VL (mm)35.26±2.3836.25±3.380.33042.37±3.1443.66±2.730.208H-S (mm)13.81±4.3415.15±3.210.035∗16.06±4.4217.64±5.420.027∗∗p<0.05.


## 3.3. Comparison of the Changes in Normal Occlusion between Parents and Children

(a)
Angle Class II: The changes in U-MPW of parents were significantly greater than those of children (Table3)(b)
Angle Class III (Table4)Table 3
The changes in the mean between the parent-child groups with angle class II and normal group.
Measured itemsChildrenParentspPNS-UPW (mm)———U-MPW (mm)2.09±1.383.27±3.210.015PAS (mm)2.04±2.371.86±1.330.305V-LPW (mm)———H-FH (mm)8.30±3.186.87±4.150.062H-MP (mm)3.03±3.372.78±2.380.787H-VL (mm)3.01±2.182.52±3.340.214H-S (mm)———Table 4
The changes in the mean between the parent-child groups with angle class III and normal group.
Measured itemsChildrenParentspPNS-UPW (mm)2.08±2.752.23±3.430.973U-MPW (mm)———PAS (mm)1.4±1.871.1±2.130.834V-LPW (mm)———H-FH (mm)2.15±2.642.2±2.230.912H-MP (mm)1.19±3.252.22±3.580.071H-VL (mm)———H-S (mm)1.14±1.921.38±2.930.827


## 4. Discussion

### 4.1. The Effects of Age, Genetic Factors, and Race on the Upper Airway

Age also has an effect on upper airway volume, LaBanc et al. found that the size of the pharyngeal cavity is relatively fixed in early infancy and does not change with age through long-term surveys of children aged 3-16 years [13]. Some scholars also believe that the size of the nasopharyngeal cavity will change with age [21, 22]. Guo et al. and Li et al. found that the upper airway narrows with physiological changes such as age and fat deposition, while the flat and wide airways of the nasopharynx can resist this unfavorable physiological change and keep the airway functioning normally [23, 24]. With the development of growth, the upper airway at various levels tends to be sagittal to a different degree [25, 26]. But with adduction of the anterior teeth and oral volume reduction, the tongue has a postshift, which imposes pressure on the soft palate to backward and upward shift. So some adolescents’ nasopharyngeal parts compared to adults’ are still small [27]. Genetic factors affect bones and dentitions all the way through adulthood, at least in the early stages of permanent teeth, after which they may be less affected by soft tissues and more significantly influenced by the environment [28]. Samman et al. found that airway measurement findings in healthy Chinese in Hong Kong were different from Caucasians, but similar to those in southern China (Shanghai) [29]. The objects included in our study were Uyghur patients; their measurement findings of the upper airway were similar to those of Han nationality, and the impacts of various malocclusion on the upper airway were also consistent with that on those of Han nationality.


### 4.2. Effect of Angle Class II Malocclusion on the Upper Airway

This study found that compared with normal mandibular, the changes in airways of parents and children with angle class II are consistent, and the hyoid position is posterior. The distance from the hyoid bone to the orbital ear and the mandibular plane was increased, but the distance to the anterior plane of the neck was decreased, which may be caused by angular type II malocclusion with short and small mandibular retraction of the posterior mandible. Nasopharyngeal airways and upper pharynx airways are signally reduced than those with normal mandible, possibly due to changes in sagittal position, which changes the position of hyoid and tongue via the muscle [26, 30]. The abnormal retractation of mandibular position, forcing the tongue and soft palate back to the pharynx, results in occupation. The airway position and morphological changes reduces the cross-sectional area of the narrow region [31]. With the reduction of oral cavity, the sagittal areas of the soft palate and tongue accounting for the cross-sectional area of the oropharyngeal cavity increased, prone to occur obstruction in the upper airway and secondary OSAHS [32].


### 4.3. Effect of Angle Class III Malocclusion on the Upper Airway

The study found that compared with those in normal group, the nasopharyngeal gap in the parents and children groups was significantly reduced, the PAS was signally increased, the H-FH decreased, and the H-S was larger than that of normal mandible, indicating that the hyoid was more anterior. Nasopharyngeal gap is related to the protrusion and length of the upper mandible. Angle class III malocclusion exists short length of the upper mandible backward, which greatly affects the nasopharyngeal gap [33]. The space of the inferior oropharyngeal airway is affected by the mandible and hyoid bone and is therefore significantly increased in angle class III malocclusion.


## 4.1. The Effects of Age, Genetic Factors, and Race on the Upper Airway

Age also has an effect on upper airway volume, LaBanc et al. found that the size of the pharyngeal cavity is relatively fixed in early infancy and does not change with age through long-term surveys of children aged 3-16 years [13]. Some scholars also believe that the size of the nasopharyngeal cavity will change with age [21, 22]. Guo et al. and Li et al. found that the upper airway narrows with physiological changes such as age and fat deposition, while the flat and wide airways of the nasopharynx can resist this unfavorable physiological change and keep the airway functioning normally [23, 24]. With the development of growth, the upper airway at various levels tends to be sagittal to a different degree [25, 26]. But with adduction of the anterior teeth and oral volume reduction, the tongue has a postshift, which imposes pressure on the soft palate to backward and upward shift. So some adolescents’ nasopharyngeal parts compared to adults’ are still small [27]. Genetic factors affect bones and dentitions all the way through adulthood, at least in the early stages of permanent teeth, after which they may be less affected by soft tissues and more significantly influenced by the environment [28]. Samman et al. found that airway measurement findings in healthy Chinese in Hong Kong were different from Caucasians, but similar to those in southern China (Shanghai) [29]. The objects included in our study were Uyghur patients; their measurement findings of the upper airway were similar to those of Han nationality, and the impacts of various malocclusion on the upper airway were also consistent with that on those of Han nationality.


## 4.2. Effect of Angle Class II Malocclusion on the Upper Airway

This study found that compared with normal mandibular, the changes in airways of parents and children with angle class II are consistent, and the hyoid position is posterior. The distance from the hyoid bone to the orbital ear and the mandibular plane was increased, but the distance to the anterior plane of the neck was decreased, which may be caused by angular type II malocclusion with short and small mandibular retraction of the posterior mandible. Nasopharyngeal airways and upper pharynx airways are signally reduced than those with normal mandible, possibly due to changes in sagittal position, which changes the position of hyoid and tongue via the muscle [26, 30]. The abnormal retractation of mandibular position, forcing the tongue and soft palate back to the pharynx, results in occupation. The airway position and morphological changes reduces the cross-sectional area of the narrow region [31]. With the reduction of oral cavity, the sagittal areas of the soft palate and tongue accounting for the cross-sectional area of the oropharyngeal cavity increased, prone to occur obstruction in the upper airway and secondary OSAHS [32].


## 4.3. Effect of Angle Class III Malocclusion on the Upper Airway

The study found that compared with those in normal group, the nasopharyngeal gap in the parents and children groups was significantly reduced, the PAS was signally increased, the H-FH decreased, and the H-S was larger than that of normal mandible, indicating that the hyoid was more anterior. Nasopharyngeal gap is related to the protrusion and length of the upper mandible. Angle class III malocclusion exists short length of the upper mandible backward, which greatly affects the nasopharyngeal gap [33]. The space of the inferior oropharyngeal airway is affected by the mandible and hyoid bone and is therefore significantly increased in angle class III malocclusion.


## 5. Differences in the Effect on the Upper Airway between Parents and Children

The present study found that angle class II malocclusion had a greater impact on the nasopharyngeal space in parents compared with the mean of the normal mandible, and the reduction of the nasopharyngeal space was more pronounced than that of the normal mandible in children. Angle class II malocclusion is mainly manifested in short and small mandible with shrinkage, which results in more posterior hyoid and later in reduced oropharyngeal airway gap, especially the PAS. Many studies have concluded that patients with upper airway stenosis are consistent with the craniofacial features of the shrunk mandible in angle class II malocclusion [29]. Therefore, early treatment of childhood angle II malocclusion with mandibular reduction should be performed promptly. Structural stenosis of the upper airway caused by OSAHS should be prevented as soon as possible when the mandible is moved forward under guidance when the anterior teeth are retracted.There are also some shortcomings in this study: the patients in this study are all from the same hospital, which results in unrepresentative results and are prone to bias; we will also collect patients from different hospitals in the next study for further study. In addition, the sample size of this study is small, which will lead to the emergence of negative results.


## 6. Conclusion

OSAHS in children can be given as early orthodontics, so as to promote normal development of mandibular bone and change the features of the craniofacial soft tissue that induces OSAHS.



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