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. 2021 Sep 13;33(8):860–868. doi: 10.1016/j.sdentj.2021.09.013

Comparison of oropharyngeal airway dimensional changes in patients with skeletal Class II and Class III malocclusions after orthognathic surgery and functional appliance treatment: A systematic review

Feras AlQahtani a, Jeny Mary George b,⁎, Khaled Bishawi c, Sam Thomas Kuriadom b
PMCID: PMC8665181  PMID: 34938026

Abstract

Objective

To compare the dimensional changes in the oropharyngeal airway in patients with skeletal Class II and Class III malocclusion before and after orthognathic surgery and treatment with a functional appliance.

Methods

The protocol was developed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and was registered to the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42020170901. Furthermore, the reporting of the present SR was performed based on the PRISMA checklist.

Results

The use of removable functional appliances increased the volume of the oropharyngeal airway in patients with skeletal Class II malocclusion. Furthermore, the increase in the volume of the oropharyngeal airway following the removable functional appliance treatment was more than that observed after fixed functional appliance treatment in growing patients. For patients with skeletal Class III malocclusion, who underwent the bimaxillary orthognathic surgery, resulted in no change in the dimensions of the oropharyngeal airway.

Conclusion

Growing patients who receive removable functional appliance treatment have a more favorable long-term prognosis with regard to the oropharyngeal airway when compared with those who receive fixed functional appliance. Alternatively, in patients aged from (18–22) years with skeletal class III malocclusion Bimaxillary orthognathic surgery was found to be the recomended and superior method of treatment.

Keyword: Airway dimension, Class II skeletal malocclusion, Class III skeletal malocclusion, Functional appliance, Orthognathic surgery, Bimaxillary surgery

1. Introduction

Dimensional changes in the oropharyngeal airway are a contentious issue examined by orthodontists, oral and maxillofacial surgeons, otolaryngologists, and others who are interested in the influence of the upper airway on growth and lifestyle. The morphometries of the upper airway vary in patients with different skeletal characteristics; in addition, an association between the airway space and skeletal growth pattern has been reported (Claudino et al., 2013, Pirilä-Parkkinen et al., 2011, Park et al., 2010).

Patients with retrognathic mandibles in Class II occlusion have the lowest oropharyngeal dimensions, whereas those with prognathic mandibles in Class III occlusion have the highest dimensions. Furthermore, a difference in the airway orientation in these skeletal deformities has been observed (Grauer et al., 2009). Patients with Class III skeletal issues have a vertical orientation, as opposed to the forward orientation in patients with Class II skeletal defects. The differences in these airway dimensions, among other related structural problems, could subsequently play a role in the development of breathing problems in these patients. Therefore, such patients require appropriate interception and early intervention.

However, multiple treatment modalities, including functional appliances, orthognathic surgery, or a combination of the two, are considered for patients with skeletal discrepancies, depending on the age and skeletal maturation. Currently, no study has compared the dimensional change in the oropharyngeal airway following these treatment modalities. Although, functional treatment might occasionally eliminate the need for surgery, whether the treatment outcome is equivalent to that obtained following orthognathic surgery remains unclear.

Therefore, the objective of this study was to compare the dimensional changes in the oropharyngeal airway in patients with skeletal Class II and Class III malocclusion before and after orthognathic surgery and functional appliance treatment.

2. Materials and Methods

2.1. Protocol and registration

The protocol was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols (PRISMA-P) and was registered to the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42020170901. Furthermore, the reporting of the present SR was performed based on the PRISMA checklist.

2.2. Search strategy

The databases investigated were: PubMed/MEDLINE, Scopus, Google Scholar, and Web of Science. Additionally, the respective reference list of the journals included in the acquired research studies were hand searched. The terms in the Medical Subject Headings selected for this search included “Orthognathic Surgery,” “Functional Appliance,” “Class II, Class III,” and/or “Skeletal Relationship.” Based on the PICO framework, the current systematic review involved the Patient Population (males, females), Intervention (orthognathic surgery or functional appliances), Comparison (pharyngeal airway dimension), and Outcome (oropharynx dimension following orthognathic surgery and functional appliances). Studies that met our inclusion criteria were selected for analysis, However as the outcome variables were not homogenous, cumulative analysis could not be performed.

2.3. Eligibility criteria

The eligibility criteria used to acquire the data that were related directly to the core of this study were as follows: Published articles, articles available as full-text and not in the abstarct form; have a systematic review or systematic review and meta-analysis design; and have a prospective or retrospective design that focuses on all age groups. From each of the studies included, a data collection form was used to collect data regarding the surgical or functional appliance used, Class II or III skeletal relationship, study interval, number of patients, aim of the study, quality assessment, and conclusion of the study. The exclusion criteria were as follows: non-English language studies, those involving Class II or Class III dental relationship, and those aimed to assess any other airways apart from the oropharynx.

2.4. Quality of the studies

Two independent authors (FQ and KB), assessed the quality of the included studies. The weighted kappa statistic value between author agreements was 91%. The authors independently extracted the data and entered them into a prespecified data sheet in Microsoft Excel after confirming the quality of each study. From each eligible study the variables extracted included the name of the first author, year of publication, duration of the study, location of the study, design of the study, median follow-up time, data source, and size of the sample. The recommended checklist used was of STrengthening the Reporting of Observational Studies in Epidemiology (STROBE) (Rizk et al., 2016) to assess the risk of bias in all the full text articles that were identified and collected, which had the following characteristics: (a) clear definition of the source of participant selection; (b) clear definition of the eligibility criteria; (c) explanation about the method used to measure the exposure; (d) explanation about the method used to measure the outcomes; (e) appropriate information about the follow-up; (f) definition of the sample sizes; and (g) clearly defined aims and objectives. All studies were reported to have a low risk of bias.

3. Results

Examination of five databases, along with additional hand searching, was performed, resulting in the extraction of 58 articles; 57 articles were screened following the removal of duplicates. Among them, 23 were excluded as they did not satisfy our inclusion criteria and the remaining 34 articles were assessed for eligibility. Subsequently, 13 studies were excluded as they were not relevant to our search question, and a total of 21 articles were finally used for quality assessment. All 21 articles published from 2007 to 2018 presented with a low risk of bias (Fig. 1).

Fig. 1.

Fig. 1

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Prisma chart.

A total of 806 patients with skeletal Class II and Class III malocclusion were included in the analysis. Among them, 472 received functional appliance therapy, whereas 334 underwent orthognathic surgery (Table 1, Table 2).

  • a.

    Outcome of oropharyngeal airway following orthognathic surgery in patients with Class II skeletal malocclusion

Table 1.

Summary of Patients with Class II and Class III Malocclusion Treated Surgically.

Author/Year Number of Patients Mean Age Skeletal Relationship Treatment Outcome
Panouet al., 2013 17 Patients 22.59 Years Class III Bi-maxillary orthognathic surgery Decrease in the lower pharyngeal airway – 4196.27 mm3
Decrease in total pharyngeal airway volumes – 3375.53 mm3
Hartet al., 2015 71 Patients 18.8 Years Class II and Class III Bi-maxillary orthognathic surgery Class II – increase in oropharyngeal volume 383.9 ± 127.9 mm3
Class III – decrease in oropharyngeal volume – 648.2 ± 270.4 mm3
Aydemir et al., 2012 48 patients * Class III 1.Mandibular setback
2.Maxillary advancement and bi-maxillary surgery		 Oropharyngeal area was decreased following mandibular setback only and exhibited no change after bi-maxillary or maxillary advancement procedures
Maxillary advancement
Posterior Phayrngeal Space – increased by 5.3 mm
Middle Pharyngeal Space – increased by 0.9 mm
Mandibular setback
Posterior Phayrngeal Space – increased by 0.6 mm
Middle Pharyngeal Space – decreased by 1.8 mm
Bi-maxillary surgery
Posterior Phayrngeal Space – increased by 2.2 mm
Middle Pharyngeal Space – decreased by 0.8 mm
Chen et al., 2007 66 Patients * Class III Mandibular setback surgery and bi-maxillary surgery Airway was constricted after mandibular setback
T1 – T2 = 4.26 mm
T1 – T3 = 2.85 mm
(T1 = 13.01 ± 3.71
T2 = 8.75 ± 2.17
T3 = 10.16 ± 3.51)
No change in airway after bi-maxillary surgery
T1 – T2 = 2.95 mm
T1 – T3 = 1.5 mm
(T1 = 14.46 ± 4.19
T2 = 11.51 ± 3.58
T3 = 12.96 ± 3.51)
Torre et al., 2017 20 Patients * Class II Mandibular advancement Increase in airway
= 4.2235 cm2
Jiang et al., 2017 50 Patients 21 Years Class II Mandibular advancement alone or mandibular advancement with maxillary setback Increase in oropharyngeal airway
Mandibular advancement
T2 – T1 = 839 ± 168.2 mm2
T3 – T1 = 80.44 ± 249.5 mm2
Mandibular advancement + Maxillary setback
T2 – T1 = 694.1 ± 170.4 mm2
T3 – T1 = 859 ± 222.9 mm2
Efendiyeva R., et al., 2014 26 Patients 21.88 Years Class III Bi-maxillary surgery Posterior Pharyngeal Space – increased by 2.2 mm
Middle Pharyngeal Space – decreased by 0.8 mm
Park et al., 2012 36 Patients 22 Years Class III Mandibular setback and bi-maxillary surgery Decreased oropharyngeal airway
Anteroposterior length decreased:
Mandibular setback
T1 – T0 = 1.61 mm
T2 – T0 = 3.13 mm
(T0 = 18.15 ± 5.26
T1 = 16.54 ± 5.67
T2 = 15.02 ± 2.82
Maxillary advancement + Mandibular setback
T1 – T0 = 2.59 mm
T2 – T0 = 2.44 mm
(T0 = 18.56 ± 4.38
T1 = 15.97 ± 4.42
T2 = 16.12 ± 4.56
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* = Data Not Available.

Table 2.

Summary of Patients with Class II Malocclusion Treated with Functional Appliances.

Author/year Number of patients Skeletal relationship Mean Age Type of Treatment Results
Isidor et al., 2018 20 patients Class II 11 Years Functional appliance Oropharyngeal airway was increased by 1167 mm3
Rizk et al., 2016 20 patients Class II 11 Years Mandibular Anterior Repositioning Appliance (MARA) followed by fixed appliances Oropharyngeal airway increased by 5537.4 mm3
Ozdemir et al., 2014 23 patients Class II 17 Years Fixed functional appliance No statistically significant change in the oropharyngeal area – 0.16 mm2
Restrepo et al., 2011 50 Patients
(19 Bionator Appliance)
(31 Klammt Appliance)		 Class II 6–8 Years Bionator Appliance
Klammt Appliance		 Significant increase in airway dimensions
Bionator by 2.06 mm
Klammt activator by 1.31 mm
Yassaei et al., 2012 23 patients Class II 13 Years Headgear activator and fixed orthodontic treatment Increase in oropharyngeal airway by 2 mm
Ghodke et al., 2014 20 patients Class II 8–14 Years Twin block appliance Depth of the oropharynx was increased significantly by 1.54 mm
Jena et al., 2013 83 patients Class II 8–14 Years Mandibular Protraction Appliance (MPA-IV) & twin block appliance Mandibular Protraction Appliance (MPA– IV)
Increase in oropharyngeal airway by 0.85 mm
Twin block increased
oropharyngeal airway by 2.12 mm
Han et al., 2014 48 patients Class II 11.5 Years Functional appliance
 Increase in pharyngeal airway dimensions by
T1-T0 – 105.9 mm2
T2-T0 – 142.9 mm2
Maspero et al., 2015 40 patients Class II 9–14 Years Activator Increase in oropharyngeal airway by 2.43 mm
Ulusoy et al., 2014 37 patients Class II 11 Years Activator Oropharyngeal area increased
T2-T1
Superior Pharyngeal Space – 0.47 mm
Middle Pharyngeal Space – −0.56 mm
Inferior Pharnygeal Space – −0.34 mm
T3-T1
Superior Pharnygeal Space – 1.34 mm
Middle Pharyngeal Space – 0.65 mm
Inferior Pharyngeal Space – 1.62 mm
Elfeky and Fayed, 2015 36 patients Class II 8–12 Years Twin block Oropharyngeal airway increased by 3052.45 mm3
Iwasaki et al., 2014 44 patients Class II 11.5 Years Herbst
 Increased oropharyngeal airway depth by 4.16 mm
Increase in oropharyngeal airway width by 7.72 mm
Increase in oropharyngeal airway volume by 5000.2 mm
Yassaei et al., 2007 28 patients Class II 10–14 Years Functional appliance Oropharyngeal airway increased by 1.49 mm
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* = Data Not Available.

The total number of patients with skeletal Class II malocclusion who had undergone orthognathic surgery was 141; 106 of them received mandibular advancement surgery, and 35 patients underwent bi-maxillary orthognathic surgery (Table 1).

Mandibular advancement surgery alone exhibited an increase in the volume of the oropharyngeal airway. Likewise, skeletal Class II patients who underwent bi-maxillary surgery exhibited an increase in the volume of the oropharyngeal airway; however, the amount of increase was less than that observed in patients who underwent the mandibular advancement procedure (Table 1).

  • b.

    Outcome of the oropharyngeal airway following fixed and removable functional appliance therapy in patients with Class II skeletal malocclusion

A total of 472 patients used orthodontic functional appliances to correct Class II skeletal malocclusion. Different functional appliances were used, such as Mandibular Anterior Repositioning Appliance (MARA), headgear, twin block, cervical headgear, Mandibular Protraction Appliance (MPA-IV), Anderson appliance, Activator, and Herbst appliances (Table 2).

The use of removable functional appliances increased the volume of the oropharyngeal airway in patients with skeletal Class II malocclusion. Furthermore, the increase in the volume of the oropharyngeal airway following the removable functional appliance treatment was more than that observed after fixed functional appliance treatment (Table 2).

Among the functional appliances used, the Mandibular Anterior Repositioning Appliance (MARA) appliance presented with the highest amount of increase in the oropharyngeal airway volume, followed by the twin block and Herbst appliances (Table 2).

  • c.

    Outcome of oropharyngeal airway following orthognathic surgery in patients with Class III skeletal malocclusion

A total of 417 patients had skeletal Class III malocclusion and underwent surgical correction via bi-maxillary surgery and mandibular setback. None of them received functional appliance therapy to correct the malocclusion. The mandibular setback procedure resulted in a marked decrease in the volume of the oropharyngeal airway, whereas no change was observed following the bi-maxillary surgery (Table 1).

4. Discussion

The oropharyngeal airway has been an area of interest for otolaryngologists and orthodontists ever since craniofacial growth and development were known to be affected by respiratory functions (Claudino et al., 2013, Sheng et al., 2009, Oh et al., 2011). A particular concern would be a decrease in the airway dimension that can lead to obstructive sleep apnea or snoring. What would be important is that the treatment of these skeletal malocclusion can affect the size of the airway and thereby change the quality of life of the individual. Most of these functional problems are seen in skeletal Class II malocclusions.

In growing children with skeletal Class II malocclusion, functional appliances are used primarily to cause a change in the position of the mandible (Isidor et al., 2018, Rizk et al., 2016 Ghodke et al., 2014, Jena et al., 2013, Han et al., 2014, Maspero et al., 2015, Ulusoy et al., 2014, Elfeky and Fayed, 2015, Iwasaki et al., 2014, Yassaei et al., 2007). Whereas, in adult patients, a skeletal Class II or Class III malocclusion is corrected by orthognathic surgery that may involve one or both jaws (Gokce et al., 2012, Tepecik et al., 2018). In a skeletal Class II malocclusion, an anterior repositioning of the mandible can increase the volume of the posterior airway. In patients with skeletal Class III malocclusion and a prognathic mandible, mandibular setback alone decreases the volume of the posterior pharyngeal space; however, the dimensions may remain the same or increase when bi-maxillary surgery is performed (Aydemir et al., 2012, Efendiyeva et al., 2014). Therefore, we wanted to analyse if functional treatment would eliminate the need for surgery or whether the treatment outcome is equivalent to that obtained following orthognathic surgery or otherwise.

4.1. Effect of removable and fixed functional appliance

Our observation showed that the outcomes of functional appliance treatment with regard to changes in the dimension of the oropharyngeal airway are inconsistent (de Almeida et al., 2006, Battagel et al., 1999) and this may be due to the position of the tongue following the treatment wherein the length, height, and position of the tongue were changed following treatment with a functional appliance (Ulusoy et al., 2014, de Almeida et al., 2006). Likewise, another study demonstrated changes in the position of the tongue following functional appliance correction (Battagel et al., 1999).

However, in the current study, most of the growing patients with Class II malocclusion underwent functional appliance treatment to correct the malocclusion, with a resultant increase in the dimensions of the oropharyngeal airway (Isidor et al., 2018, Rizk et al., 2016, Ozdemir et al., 2014, Restrepo et al., 2011, Yassaei et al., 2012, Ghodke et al., 2014, Jena et al., 2013, Han et al., 2014, Maspero et al., 2015, Ulusoy et al., 2014, Elfeky and Fayed, 2015, Iwasaki et al., 2014, Yassaei et al., 2007). This finding is not in accordance with those reported by Zymperdikas et al. and Kevin O’Brien et al. wherein functional appliances did not appear to have a important influence on the skeletal position (Zymperdikas et al., 2016, O’Brien et al., 2003).

The use of the twin block appliance resulted in an increase in the oropharyngeal airway size in the current study. This finding is in line with those reported by Ghodke et al., Jena et al., and Elfeky et al., but contrary to that reported by O’Brien et al. (Isidor et al., 2018, Rizk et al., 2016, Ozdemir et al., 2014, Restrepo et al., 2011, Yassaei et al., 2012, Ghodke et al., 2014, Jena et al., 2013, Han et al., 2014, Maspero et al., 2015, Ulusoy et al., 2014, Elfeky and Fayed, 2015, Iwasaki et al., 2014, Yassaei et al., 2007). Aksu et al. concluded that the activator appliance increased the oropharyngeal airway dimension at the level of the middle pharyngeal space only (Aksu et al., 2017). Contrarily, Ozbek et al. recorded a total increase in all dimensions of the oropharyngeal airway following treatment with the activator appliance (Ozbek et al., 1998), as observed in two studies in the current systematic review. Alternatively, Ulusoy et al. reported no significant enhancement in the oropharyngeal airway dimension following treatment with activator appliance (Ulusoy et al., 2014).

In the present study, the removable functional appliance had the most reliable outcome on the oropharyngeal airway when compared with fixed functional appliances in growing patients (6–17 years). Removable functional appliances have been shown to increase the volume of the airway to a greater extent when compared with fixed functional appliances (Rizk et al., 2016, Jena et al., 2013, Elfeky and Fayed, 2015, Ghodke et al., 2014).

4.2. Effect of orthognathic surgery

Bi-maxillary surgery and mandibular advancement procedures have resulted in significant increase in the dimension of the oropharyngeal airway (Hart et al., 2015, Torre et al., 2017, Jiang et al., 2017). The findings of our study corresponded to those reported by Joao Roberto (Goncalves et al., 2004) and Jakobsone et al. wherein a considerable increase in the volume of the oropharyngeal airway was observed following bi-maxillary surgery (Jakobsone et al., 2010).

Minh Nguyen reported that mandibular advancement surgery improved the dimensions of the oropharyngeal airway, whereas bi-maxillary surgery decreased the dimensions of the airway (Nguyen et al., 2014). These findings were similar to that of another study where bi-maxillary surgery resulted in a decrease in the oropharyngeal airway (Mattos et al., 2011).

In skeletal Class III patients, mandibular setback surgery has been shown to decrease the dimensions of the oropharyngeal airway (Aydemir et al., 2012; Park et al., 2012). Liukkonen et al. reported a decrease in the volume of the oropharyngeal airway in patients with Class III skeletal relations, following mandibular setback surgery. This may be due to the counterclockwise rotation of the mandible during the setback surgery, which results in a reduction in the volume of the oropharyngeal airway, (de Haan et al., 2013, Liukkonen et al., 2002), or due to the posterior and inferior displacement of the hyoid bone, which results in the obstruction of the airway (Kawamata et al., 2000).

Maxillary advancement surgeries in the current study were found to have no effect on the dimensions of the oropharyngeal airway on grown patients. This may be due to the integration of the soft palate to maintain the velopharyngeal seal prior to maxillary advancement (Schendel et al., 1976, Aydemir et al., 2012). This finding was not in accordance with those of several other studies that recorded a decrease in the oropharyngeal airway dimension following the advancement surgery (Degerliyurt et al., 2008, Mehra et al., 2001, Samman et al., 2002).

In grown patients aged (18–22) years with skeletal class III malocclusion, bimaxillary orthognathic surgery was found to be the recommended and superior method of treatment due to its effect of reducing relapse in the oropharyngeal airway, its ability to correct and prevent obstructive sleep apnea in skeletal class III patients (Gokce et al., 2012, Tepecik et al., 2018) and due to a resultant increase in the airway space as reported by Santagata (Santagata et al., 2015). It is also observed that bimaxillary surgery can decrease the magnitude of the reduction of the airway space caused by mandibular setback (Lye, 2008).

5. Conclusion

The limitations of this study include the presence of incomplete records, missing patient information, inadequate documentation and the limited amount of studies with non-homogeneous variables among the included articles cumulative analysis could not be performed.

In patients with skeletal Class II malocclusion, removable functional appliances appear to increase the dimensions of the oropharyngeal airway to a greater extent when compared with the fixed functional appliances in growing patients (6–17) years. Therefore, patients who receive removable functional appliance treatment have a more favorable long-term prognosis with regard to the oropharyngeal airway when compared with those who receive fixed functional appliance. Alternatively, in patients aged from (18–22) years with skeletal class III malocclusion bimaxillary orthognathic surgery was found to be the recommended and superior method of treatment due to its effect of reducing relapse in the oropharyngeal airway and its ability to correct and prevent obstructive sleep apnea in skeletal class III patients.

CRediT authorship contribution statement

Feras Al Qahtani: Conceptualization, data curation, formal analysis, methodology, writing original draft. Khalid Bishawi: Conceptualization, data curation, formal analysis, methodology, writing original draft. Jeny Mary George: Conceptualization, methodology, project administration, supervision, writing - review and editing. Sam Thomas: Methodology, validation, Writing - review and editing.

Declaration of Competing Interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Footnotes

Peer review under responsibility of King Saud University.

References

  1. Aksu M., Gorucu-Coskuner H., Taner T. Assessment of upper airway size after orthopedic treatment for maxillary protrusion or mandibular retrusion. Am. J. Orthod. Dentofacial Orthop. 2017;152(3):364–370. doi: 10.1016/j.ajodo.2016.12.027. [DOI] [PubMed] [Google Scholar]
  2. de Almeida F.R., Lowe A.A., Sung J.O., Tsuiki S., Otsuka R. Long-term sequellae of oral appliance therapy in obstructive sleep apnea patients: Part 1. Cephalometric analysis. Am. J. Orthod. Dentofac. Orthop. 2006;129(2):195–204. doi: 10.1016/j.ajodo.2005.10.001. [DOI] [PubMed] [Google Scholar]
  3. Aydemir H., Memikoğlu U., Karasu H. Pharyngeal airway space, hyoid bone position and head posture after orthognathic surgery in Class III patients. Angle Orthod. 2012;82(6):993–1000. doi: 10.2319/091911-597.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Battagel J.M., Johal A., L’Estrange P.R., Croft C.B., Kotecha B. Changes in airway and hyoid position in response to mandibular protrusion in subjects with obstructive sleep apnoea (OSA) Eur. J. Orthod. 1999;21:363–376. doi: 10.1093/ejo/21.4.363. [DOI] [PubMed] [Google Scholar]
  5. Chen F., Terada K., Hua Y., Saito I. Effects of bimaxillary surgery and mandibular setback surgery on pharyngeal airway measurements in patients with Class III skeletal deformities. Am. J. Orthod. Dentofacial Orthop. 2007;131(3):372–377. doi: 10.1016/j.ajodo.2005.06.028. [DOI] [PubMed] [Google Scholar]
  6. Claudino L.V., Mattos C.T., Ruellas A.C.d.O., Sant' Anna E.F. Pharyngeal airway characterization in adolescents related to facial skeletal pattern: a preliminary study. Am. J. Orthod. Dentofacial Orthop. 2013;143(6):799–809. doi: 10.1016/j.ajodo.2013.01.015. [DOI] [PubMed] [Google Scholar]
  7. Degerliyurt K., Ueki K., Hashiba Y., Marukawa K., Nakagawa K., Yamamoto E. A comparative CT evaluation of pharyngeal airway changes in class III patients receiving bimaxillary surgery or mandibular setback surgery. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2008;105(4):495–502. doi: 10.1016/j.tripleo.2007.11.012. [DOI] [PubMed] [Google Scholar]
  8. de Haan I.F., Ciesielski R., Nitsche T., Koos B. Evaluation of relapse after orthodontic therapy combined with orthognathic surgery in the treatment of skeletal class III. J. Orofac. Orthop. 2013;74:362–369. doi: 10.1007/s00056-013-0161-0. [DOI] [PubMed] [Google Scholar]
  9. Efendiyeva R., Aydemir H., Karasu H., Toygar-Memikoğlu U. Pharyngeal airway space, hyoid bone position, and head posture after bimaxillary orthognathic surgery in Class III patients: long-term evaluation. Angle Orthod. 2014;84:773–781. doi: 10.2319/072213-534.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Elfeky H.y., Fayed M.M.S. Three-dimensional effects of twin block therapy on pharyngeal airway parameters in Class II malocclusion patients. J. World Fed. Orthod. 2015;4(3):114–119. [Google Scholar]
  11. Ghodke S., Utreja A.K., Singh S.P., Jena A.K. Effects of twin-block appliance on the anatomy of pharyngeal airway passage (PAP) in class II malocclusion subjects. Prog. Orthod. 2014;15:68. doi: 10.1186/s40510-014-0068-3. [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Gokce S.M., Gorgulu S., Gokce H.S., Bengi O., Sabuncuoglu F., Ozgen F., Bilgic H. Changes in posterior airway space, pulmonary function and sleep quality, following bimaxillary orthognathic surgery. Int. J. Oral Maxillofacial Surg. 2012;41(7):820–829. doi: 10.1016/j.ijom.2012.01.003. [DOI] [PubMed] [Google Scholar]
  13. Goncalves J.R., Wolford L., Bushang P., Goncalves D. The postsurgical stability of oropharyngeal airway changes following maxillomandibular advancement surgery. J. Oral Maxillofac. Surg. 2004;62:53–54. doi: 10.1016/j.joms.2005.11.046. [DOI] [PubMed] [Google Scholar]
  14. Grauer D., Cevidanes L.S.H., Styner M.A., Ackerman J.L., Proffit W.R. Pharyngeal airway volume from cone-beam computed tomography: relationship to facial morphology. Am J Orthod Dentofacial Orthop. 2009;136(6):805–814. doi: 10.1016/j.ajodo.2008.01.020. [DOI] [PMC free article] [PubMed] [Google Scholar]
  15. Han S., Choi Y.J., Chung C.J., Kim J.Y., Kim K.-H. Long-term pharyngeal airway changes after bionator treatment in adolescents with skeletal Class II malocclusions. Korean J. Orthod. 2014;44(1):13. doi: 10.4041/kjod.2014.44.1.13. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Hart P.S., McIntyre B.P., Kadioglu O., Currier G.F., Sullivan S.M., Li J.i., Shay C. Postsurgical volumetric airway changes in 2-jaw orthognathic surgery patients. AJO-DO. Am J Orthod Dentofacial Orthop. 2015;147(5):536–546. doi: 10.1016/j.ajodo.2014.12.023. [DOI] [PubMed] [Google Scholar]
  17. Isidor S., Di Carlo G., Cornelis M.A., Isidor F., Cattaneo P.M. Three-dimensional evaluation of changes in upper airway volume in growing skeletal Class II patients following mandibular advancement treatment with functional orthopedic appliances. Angle Orthod. 2018;88:552–559. doi: 10.2319/083117-587.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Iwasaki T., Takemoto Y., Inada E., Sato H., Saitoh I., Kakuno E., Kanomi R., Yamasaki Y. Three-dimensional cone-beam computed tomography analysis of enlargement of the pharyngeal airway by the herbst appliance. Am. J. Orthod. Dentofacial Orthop. 2014;146(6):776–785. doi: 10.1016/j.ajodo.2014.08.017. [DOI] [PubMed] [Google Scholar]
  19. Jakobsone G., Neimane L., Krumina G. Two- and three-dimensional evaluation of the upper airway after bimaxillary correction of Class III malocclusion. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2010;110(2):234–242. doi: 10.1016/j.tripleo.2010.03.026. [DOI] [PubMed] [Google Scholar]
  20. Jena A.K., Singh S.P., Utreja A.K. Effectiveness of twin-block and mandibular protraction appliance-IV in the improvement of pharyngeal airway passage dimensions in Class II malocclusion subjects with a retrognathic mandible. Angle Orthod. 2013;83:728–734. doi: 10.2319/083112-702.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Jiang C., Yi Y., Jiang C., Fang S., Wang J. Pharyngeal airway space and hyoid bone positioning after different orthognathic surgeries in skeletal class II patients. J. Oral Maxillofac. Surg. 2017;75(7):1482–1490. doi: 10.1016/j.joms.2017.02.021. [DOI] [PubMed] [Google Scholar]
  22. Kawamata A., Fujishita M., Ariji Y., Ariji E. Three-dimensional computed tomographic evaluation of morphologic airway changes after mandibular setback osteotomy for prognathism. Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 2000;89(3):278–287. doi: 10.1016/s1079-2104(00)70089-8. [DOI] [PubMed] [Google Scholar]
  23. Liukkonen M., Vähätalo K., Peltomäki T., Tiekso J., Happonen R.P. Effect of mandibular setback surgery on the posterior airway size. Int. J. Adult Orthodon. Orthognath. Surg. 2002;17:41–46. [PubMed] [Google Scholar]
  24. Lye K.W. Effect of orthognathic surgery on posterior airway space (PAS) Ann Acad Med Singapore. 2008;2008(37):677–682. [PubMed] [Google Scholar]
  25. Maspero C., Giannini L., Galbiati G., Kairyte L., Farronato G. Upper airway obstuction in class II patients. Effects of Andresen activator on the anatomy of pharingeal airway passage. Cone beam evalution. Stomatologija. 2015;17:124–130. [PubMed] [Google Scholar]
  26. Mattos C.T., Vilani G.N.L., Sant’Anna E.F., Ruellas A.C.O., Maia L.C. Effects of orthognathic surgery on oropharyngeal airway: a meta-analysis. Int. J. Oral Maxillofac. Surg. 2011;40(12):1347–1356. doi: 10.1016/j.ijom.2011.06.020. [DOI] [PubMed] [Google Scholar]
  27. Mehra P., Downie M., Pita M.C., Wolford L.M. Pharyngeal airway space changes after counterclockwise rotation of the maxillomandibular complex. Am. J. Orthod. Dentofacial Orthop. 2001;120(2):154–159. doi: 10.1067/mod.2001.114647. [DOI] [PubMed] [Google Scholar]
  28. Nguyen M.T., Visuttiwattanakorn S., Truong D.M., Wongsirichat N. Effects of orthognathic surgery on pharyngeal airway space: A literature review. Mahidol Dent. J. 2014;34:165–173. [Google Scholar]
  29. O’Brien K., Wright J., Conboy F., Sanjie Y., Mandall N., Chadwick S., Connolly I., Cook P., Birnie D., Hammond M., Harradine N., Lewis D., McDade C., Mitchell L., Murray A., O’Neill J., Read M., Robinson S., Roberts-Harry D., Sandler J., Shaw I. Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, randomized, controlled trial. Part 1: Dental and skeletal effects Am. J. Orthod. Dentofacial Orthop. 2003;124:234–243. doi: 10.1016/S0889540603003524. quiz 339. [DOI] [PubMed] [Google Scholar]
  30. Oh K.-M., Hong J.-S., Kim Y.-J., Cevidanes L.S.H., Park Y.-H. Three-dimensional analysis of pharyngeal airway form in children with anteroposterior facial patterns. Angle Orthod. 2011;81(6):1075–1082. doi: 10.2319/010711-8.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Ozbek M.M., Memikoglu T.U., Gögen H., Lowe A.A., Baspinar E. Oropharyngeal airway dimensions and functional orthopedic treatment in skeletal class 2 cases. Angle Orthod. 1998;68:327–336. doi: 10.1043/0003-3219(1998)068<0327:OADAFO>2.3.CO;2. [DOI] [PubMed] [Google Scholar]
  32. Ozdemir F., Ulkur F., Nalbantgil D. Effects of fixed functional therapy on tongue and hyoid positions and posterior airway. Angle Orthod. 2014;84:260–264. doi: 10.2319/042513-319.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Panou E., Motro M., Ateş M., Acar A., Erverdi N. Dimensional changes of maxillary sinuses and pharyngeal airway in Class III patients undergoing bimaxillary orthognathic surgery. Angle Orthod. 2013;83:824–831. doi: 10.2319/100212-777.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Park J.-W., Kim N.-K., Kim J.-W., Kim M.-J., Chang Y.-I. Volumetric, planar, and linear analyses of pharyngeal airway change on computed tomography and cephalometry after mandibular setback surgery. Am. J. Orthod. Dentofacial Orthop. 2010;138(3):292–299. doi: 10.1016/j.ajodo.2009.10.036. [DOI] [PubMed] [Google Scholar]
  35. Park S.-B., Kim Y.-I., Son W.-S., Hwang D.-S., Cho B.-H. Cone-beam computed tomography evaluation of short- and long-term airway change and stability after orthognathic surgery in patients with Class III skeletal deformities: bi-maxillary surgery and mandibular setback surgery. Int. J. Oral Maxillofac. Surg. 2012;41(1):87–93. doi: 10.1016/j.ijom.2011.09.008. [DOI] [PubMed] [Google Scholar]
  36. Pirilä-Parkkinen K., Löppönen H., Nieminen P., Tolonen U., Pääkkö E., Pirttiniemi P. Validity of upper airway assessment in children A clinical, cephalometric, and MRI study. Angle Orthod. 2011;81(3):433–439. doi: 10.2319/063010-362.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Restrepo C., Santamaría A., Peláez S., Tapias A. Oropharyngeal airway dimensions after treatment with functional appliances in class II retrognathic children. J. Oral Rehabilit. 2011;38:588–594. doi: 10.1111/j.1365-2842.2011.02199.x. [DOI] [PubMed] [Google Scholar]
  38. Rizk S., Kulbersh V.P., Al-Qawasmi R. Changes in the oropharyngeal airway of Class II patients treated with the mandibular anterior repositioning appliance. Angle Orthod. 2016;86:955–961. doi: 10.2319/042915-295.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Samman N., Tan S.S., Xia J. Cephalometric study of the upper airway in surgically corrected class III. skeletal deformity. Int. J. Adult Orthod. Orthognath. Surg. 2002;17:180–190. [PubMed] [Google Scholar]
  40. Santagata M., Tozzi U., Lamart E., Tartaro G. Effect of orthognathic surgery on the posterior airway space in patients affected by skeletal class III malocclusion. J. Maxillofac. Oral Surg. 2015;14(3):682–686. doi: 10.1007/s12663-014-0687-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Schendel S.A., Eisenfeld J., Bell W.H., Epker B.N., Mishelevich D.J. The Long face syndrome: vertical maxillary excess. Am. J. Orthod. 1976;70(4):398–408. doi: 10.1016/0002-9416(76)90112-3. [DOI] [PubMed] [Google Scholar]
  42. Sheng C.M., Lin L.H., Su Y., Tsai H.H. Developmental changes in pharyngeal airway depth and hyoid bone position from childhood to young adulthood. Angle Orthod. 2009;79:484–490. doi: 10.2319/062308-328.1. [DOI] [PubMed] [Google Scholar]
  43. Tepecik T., Ertaş Ü., Akgün M. Effects of bimaxillary orthognathic surgery on pharyngeal airway and respiratory function at sleep in patients with class III skeletal relationship. J. Craniomaxillofac Surg. 2018;46(4):645–653. doi: 10.1016/j.jcms.2018.01.009. [DOI] [PubMed] [Google Scholar]
  44. Torre D., Burtscher D., Widmann G., Rasse M., Puelacher T., Puelacher W. Long-term influence of mandibular advancement on the volume of the posterior airway in skeletal Class II-patients: a retrospective analysis. Br. J. Oral Maxillofac Surg. 2017;55(8):780–786. doi: 10.1016/j.bjoms.2017.06.005. [DOI] [PubMed] [Google Scholar]
  45. Ulusoy C., Canigur Bavbek N., Tuncer B.B., Tuncer C., Turkoz C., Gencturk Z. Evaluation of airway dimensions and changes in hyoid bone position following class II functional therapy with activator. Acta Odontol. Scand. 2014;72(8):917–925. doi: 10.3109/00016357.2014.923109. [DOI] [PubMed] [Google Scholar]
  46. Yassaei S., Bahrololoomi Z., Sorush M. Changes of tongue position and oropharynx following treatment with functional appliance. J. Clin. Pediatr. Dent. 2007;31:287–290. doi: 10.17796/jcpd.31.4.lp479v346345460g. [DOI] [PubMed] [Google Scholar]
  47. Yassaei S., Tabatabaei Z., Ghafurifard R. Stability of pharyngeal airway dimensions, tongue and hyoid changes after treatment with a functional appliance. Int. J. Orthod. 2012;23:9–15. [PubMed] [Google Scholar]
  48. Zymperdikas V.F., Koretsi V., Papageorgiou S.N., Papadopoulos M.A. Treatment effects of fixed functional appliances in patients with Class II malocclusion: a systematic review and meta-analysis. Eur. J. Orthod. 2016;38(2):113–126. doi: 10.1093/ejo/cjv034. [DOI] [PMC free article] [PubMed] [Google Scholar]

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