Original Article

Changes in the oropharyngeal airway of Class II patients treated with

the mandibular anterior repositioning appliance
Susan Rizka; Valmy Pangrazio Kulbershb; Riyad Al-Qawasmic
ABSTRACT
Objective: To evaluate the effects of functional appliance treatment on the oropharyngeal airway
volume, airway dimensions, and anteroposterior hyoid bone position of growing Class II patients.
Materials and Methods: Twenty Class II white patients (mean age, 11.7 6 1.75 years) treated
with the MARA followed by fixed appliances were matched to an untreated control sample by
cervical vertebrae maturation stage at pretreatment (T1) and posttreatment (T2) time points. Cone
beam computed tomography scans were taken at T1 and T2. Dolphin3D imaging software was
used to determine oropharyngeal airway volume, dimensions, and anteroposterior hyoid bone
position.
Results: Multivariate ANOVA was used to evaluate changes between T1 and T2. Oropharyngeal
airway volume, airway dimensions, and A-P position of the hyoid bone increased significantly with
functional appliance treatment. SNA and ANB decreased significantly in the experimental group (P
# .05). Changes in SNB and Sn-GoGn failed to reach statistical significance.
Conclusions: Functional appliance therapy increases oropharyngeal airway volume, airway
dimensions, and anteroposterior hyoid bone position in growing patients. (Angle Orthod.
2016;86:955961.)
KEY WORDS: Class II; Airway; Obstructive sleep apnea; Functional appliance; MARA

modality to improve the mandibular position relative to

the maxilla while simultaneously improving the profile.3
The incidence of sleep-disordered breathing (SDB)
in adolescents has been estimated at 6%, with
sufferers being twice as likely as their peers to have
excessive daytime sleepiness, poorer grade point
average, and attention-deficit/hyperactivity disorder.4
A number of predisposing factors, including asthma,
adenotonsillar hypertrophy, allergies, obesity, and
craniofacial abnormalities, such as mandibular retrognathism, have been identified for SDB.5 Previous
studies have demonstrated the association between
mandibular position in relation to the cranial base and
oropharyngeal airway (OA) volume.6,7 Specifically,
mandibular retrognathia has been associated with
a decreased OA volume, which may be due to
posterior positioning of the tongue or a posterior
position of the hyoid bone.8,9
It has been postulated that advancement of the
mandible using anterior posturing appliances immediately enlarges the airway. Such appliances are used
for adults with obstructive sleep apnea to prevent
upper airway collapse during sleep.10 However, conflicting data exist regarding the long-term effects of
functional appliances on oropharyngeal volume, airway dimensions, and hyoid bone position in growing

INTRODUCTION
The majority of Class II malocclusions can be
attributed to mandibular retrognathia rather than
maxillary prognathism.1,2 For the growing skeletal
Class II patient with mandibular retrognathia, treatment
modalities to correct the malocclusion include functional appliances, orthognathic surgery when growth
has ceased, and extraction or distalization of maxillary
teeth, which may have deleterious effects on the soft
tissue profile. Functional appliances, such as the
mandibular anterior repositioning appliance (MARA;
Ormco, Orange, Calif), are an accepted treatment

Private Practice, Lathrup Village, Mich.

Professor, Department of Orthodontics, University of Detroit
Mercy, Detroit, Mich.
c
Associate Professor, Department of Orthodontics, University
of Detroit Mercy, Detroit, Mich.
Corresponding author: Dr Valmy Pangrazio Kulbersh, Professor, Department of Orthdontics, University of Detroit Mercy,
2700 Martin Luther King Jr Blvd, Detroit, MI 48208
(e-mail: vkulbersh@aol.com)
a
b

Accepted: November 2015. Submitted: April 2015.

Published Online: December 9, 2015
G 2016 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/042915-295.1

955

Angle Orthodontist, Vol 86, No 6, 2016

956
patients, which may be due to the difficulties in
assessing these variables with 2-D analyses.11
The aim of the present study was to evaluate
changes in hyoid bone position, oropharyngeal volume, and dimensions in the transverse and sagittal
planes after treatment of skeletal Class II patients with
functional appliances followed by edgewise treatment.
This study utilized cone beam computed tomography
(CBCT) imaging, which has been shown to be an
adequate method for airway analysis.12,13
Null Hypothesis: There is no significant change in
antero-posterior (A-P) hyoid bone position, or oropharyngeal volume and dimensions after functional appliance treatment.
MATERIALS AND METHODS
This retrospective study was approved by the
institutional review board (Protocol 1314-64)

RIZK, KULBERSH, AL-QAWASMI

Oropharyngeal Airway Analysis

Dolphin3D (Dolphin Imaging and Management
Solutions, Chatsworth, Calif) was used for all data
collection by one investigator (S.R.). The A-P and
transverse dimensions of the oropharynx were measured at the level of its narrowest A-P dimension in the
midsagittal plane (Figure 1).
A volumetric analysis was performed using Dolphins Airway Module. The oropharyngeal airway (OA)
space was defined by two horizontal planes paralleling
Frankfort horizontal (FH). The superior limit was the
horizontal line connecting the posterior nasal spine
and the posterior wall of the pharynx. The inferior limit
was that spanning the A-P dimension of the airway,
passing through the tip of the epiglottis (Figure 2). The
airway sensitivity setting, which controls the programs
ability to find differences in gray-scale resolution, was
standardized at 45 to best recognize the airway and
calculate the volume in mm3.

Sample Description
The experimental group consisted of 20 Class II
white patients13 females and 7 males (mean age,
11.7 6 1.75 years), treated with the MARA followed by
fixed appliances. CBCT scans, using the i-CAT Cone
Beam 3D Imaging System (Imaging Sciences International, Hatfield, Pa), were taken prior to the
placement of any appliances (T1) and immediately
after removal of the fixed edgewise appliances (T2).
Scans were done with the patients in centric occlusion
with the following radiographic parameters: 120 kVp,
18.54 mAs, 8.9-second scan time, and 0.3-mm voxel
dimension. Subjects were seated in a chair and asked
to hold their breath and refrain from swallowing while
the scans were taken in the natural head position.
The control group consisted of 73 untreated skeletal
Class II white subjects, who had CBCT scans taken with
the same parameters as did the experimental group.
Controls were selected with the inclusion criteria of SNGoGn $ 27 and # 37, SNB # 77, and ANB $ 4.5, as well
as cervical vertebrae maturation stage (CVMS), as
described by Baccetti,14 to match the experimental group.
Exclusion Criteria
All subjects were nonsyndromal. Patients with
a CVMS of 5 or greater at the pretreatment time point
were excluded due to a lack of remaining growth.14
Subjects were excluded if, upon visual inspection of
the CBCT scan, they were found to be swallowing or
having a hyperextended head position while the scan
was taken. All subjects who were found to have
a nonconcentric condylar position upon visualization of
the CBCT-formatted TMJ tomograms were also
excluded from the sample.
Angle Orthodontist, Vol 86, No 6, 2016

Cephalometric Analysis
The CBCT scans were formatted to produce lateral
cephalograms oriented according to FH without magnification, digitized, and traced. A custom analysis was
created to determine SNA, SNB, ANB, SN-GoGn, and
a linear measurement of the A-P position of the hyoid
bone. Hyoid bone position was defined by the line from
the anterior aspect of the hyoid bone to the posterior
pharyngeal wall, paralleling FH, as seen in Figure 3.
Statistical Analysis
All variables were remeasured for five randomly
selected patients. The intraclass correlation coefficient
was calculated for all measurements and repeated
measurements to determine the accuracy of data
collection. The accuracy of measurements was calculated as 99.9% for airway volume, 97.2% for hyoid
bone position, 90.4% and 99.7% for A-P and transverse airway dimensions (respectively), 97.4% for
SNA, 99.6% for SNB, 99.4% for ANB, and 99.5% for
SN-GoGn, indicating a high level of agreement.
Power calculations were done for this study using
the following parameters: the level of significance was
a 5.05 and the power of the test was 80%. It was
found that a sample of 11 individuals was need to
detect a difference of at least 1400 mm3 with standard
deviation of 1650 mm3 as found by our preliminary
studies (unpublished data). Multivariate ANOVA was
used to evaluate the effect of functional appliances on
the experimental variables when controlling for CVMS
as previously described. Comparison of the starting
forms for the experimental and control groups was also
done.

AIRWAY CHANGES AFTER TREATMENT WITH THE MARA

957

Figure 1. Measurement of OA A-P and transverse dimensions.

Figure 2. Measurement of OA volume.

Angle Orthodontist, Vol 86, No 6, 2016

958

RIZK, KULBERSH, AL-QAWASMI

Figure 3. Hyoid-posterior pharyngeal wall measurement.

RESULTS
The mean length of functional appliance treatment
was 10.6 months. The average length of time from
functional appliance removal to debond was 16.8
months.
Descriptive statistics for the experimental group at
T1 and T2 are listed in Table 1. Table 2 shows the
descriptive statistics for the control groups at each
CVMS. Comparison of mean changes from T1T2 for
experimental and control samples is shown in Table 3.
When the MARA and control groups were evaluated
at T1 (comparison of starting forms), no statistically
significant differences were found between the experimental and control groups in OA volume, transverse
airway dimension, SNA, SNB, ANB, or SN-GoGn.
There was a significant difference, however, in the
narrowest A-P airway dimension, whereby this variable

was significantly smaller initially in the experimental

group than in the control group (P 5.023).
Statistical analysis showed that the airway volume,
A-P hyoid bone position, and A-P and transverse airway
dimensions were significantly increased in the experimental group compared with the control group (P 5
.005, .000, .000, .000, respectively). SNA and ANB
decreased significantly in the experimental group
compared with controls (P 5 .000 and .026). Although
SNB increased in the experimental group from T1 to T2,
this change did not reach statistical significance (P 5
.063). There was no significant change in SN-GoGn (P
5 .43). Upon visual inspection of TMJ tomograms at T2,
we found no patients with condylar distraction.
On average, the experimental group had a 5537.4mm3 increase in OA volume from T1 to T2 in contrast to
the 2220.5-mm3 increase exhibited by controls attributable to growth. Functional appliance usage explains

Table 1. Descriptive Statistical Values, Experimental Sample

T1, Pretreatment
Variable
Age (y)
Airway volume (mm3)
A-P hyoid bone position (mm)
Airway A-P dimension (mm)
Airway transverse dimension (mm)
SNA (u)
SNB (u)
ANB (u)
SN-GoGn (u)

Angle Orthodontist, Vol 86, No 6, 2016

T2, Posttreatment

Mean

SD

Mean

SD

11.7
9081.90
25.4
7.24
21.19
80.38
74.79
5.59
31.68

1.75
3406.15
2.93
2.21
4.15
2.73
2.95
1.53
5.03

14.5
14619.27
29.7
9.08
25.99
79.67
75.08
4.57
32.2

1.2
5534.69
3.58
2.52
4.21
2.93
3.16
1.29
5.49

959

2.38

1.79

2.18

1
1
0.9
2.75

27.13

6.45

22.95

81.38
75.9
5.48
33.5
2.35
2.06
1.55
2.41
80.58
74.71
5.84
31.58
2.56
2.36
1.67
2.15
80.48
74.21
6.28
32.98
1.96
1.37
1.2
2.24
80.93
74.89
6.06
32.64
2.48
1.69
1.22
3.05
1.3
0.6
0.99
2.25
80.26
73.99
6.28
33.33

80.41
74.57
5.85
31.6

8.31
21.7
6.1
22.09
4.98
21.67
6.04
5.71
21.83

20.2

2.12
8.05
1.93
8.13
2.38
7.53
2.65
2.32
8.66

8.59

2.79
26.73
2.62
27.56
3.05
26.3
2.56
26.09
2.44
24.07

1080.03
11649.7
2361.54

Variable

approximately 39.1% of airway A-P dimensional

changes in our sample, 30.3% of A-P hyoid bone
positional changes, 28.5% of SNA changes, 27.7% of
airway transverse dimensional changes, 18.7% of
airway volume changes, and 12.3% of the change in
ANB.
DISCUSSION

Airway volume
(mm3)
A-P hyoid bone
position (mm)
Airway A-P
dimension (mm)
Airway transverse
dimension (mm)
SNA (u)
SNB (u)
ANB (u)
SN-GoGn (u)

7884.2

7973.98

3033.98

8704.6

3127.1

9638.87

3681.73

10603.99

4563.69

SD
Mean
SD
Mean
Mean
SD
Mean
SD
Mean
SD
Mean

4, (n 5 12)
CVMS
3 (n 5 20)
2 (n 5 15)
1 (n 5 8)

Table 2. Descriptive Statistical Values, Control Sample Grouped by Cervical Vertebrae Maturation Stage (CVMS)

SD

5, (n 5 10)

6, (n 5 8)

AIRWAY CHANGES AFTER TREATMENT WITH THE MARA

Functional appliances such as the MARA are used

in the orthopedic treatment of skeletal Class II patients
to place the mandible in a more favorable A-P position.
It is expected that this anterior posturing increases the
OA volume and A-P airway dimensions during
functional jaw orthopedic treatment and thereafter.
Similar to the findings of the present study, Iwasaki et
al. found a 5000.2-mm3 increase in OA volume after
treatment with the Herbst appliance compared with
a 2451.6-mm3 increase in skeletal Class I controls.15
Statistically significant decreases in SNA (P 5 .000)
and ANB (P 5 .026) were found in the experimental
group, possibly due to restriction of maxillary growth
found by other investigators.16 This headgear effect
could have been a limiting factor in the amount of
forward mandibular growth. Thus, the significant
increase in airway volume, dimensions, and hyoid
bone position cannot be attributed solely to mandibular
anterior positioning relative to the cranial base.
Rather, the statistical analyses in this study indicated that forward positioning of the mandible with
functional appliances influences oropharyngeal
changes through alterations in the airway morphology
and A-P hyoid bone position. These findings confirm
the results of other studies using the Twin-block,17,18
acrylic-splint Herbst,19 and activator.20 Mean A-P
airway dimension decreased from T1 to T2 in controls
and was accompanied by a small increase in transverse dimension. Although the experimental group had
a significantly narrower A-P dimension than did
controls at T1, functional appliance treatment resulted
in significant widening of the airway in the transverse
and A-P dimensions. Hence, the oropharynx became
wider in the transverse dimension from T1 to T2 and
more elliptical in shape, as described by Abramsom et
al.21
The present study demonstrated an anterior change
in A-P hyoid bone position in the experimental group
that was three times that of controls. This may indicate
an alteration in tongue posture with functional appliance treatment. The hyoid bone, which is suspended
by muscles and ligaments without bony articulations,
plays an important role in maintaining airway dimensions and has been found to vary in position according
to the position of the mandible. It is more posteriorly
positioned in skeletal Class II patients than in Class I or
Angle Orthodontist, Vol 86, No 6, 2016

960

RIZK, KULBERSH, AL-QAWASMI

Table 3. Comparison of Mean Changes From T1T2 for Experimental and Control Samples
Experimental

D
D
D
D
D
D
D
D

Airway volume (mm3)

A-P Hyoid bone position (mm)
Airway A-P dimension (mm)
Airway transverse dimension (mm)
SNA (u)
SNB (u)
ANB (u)
SN-GoGn (u)

Control

Mean

SD

Mean

SD

P value

R2

5537.38
4.3020
1.835
4.795
20.705
0.2900
21.03
0.52

4849.72815
2.68789
2.52634
4.55568
1.36708
1.23668
1.25241
2.27

2220.4770
1.5041
21.1043
0.8063
0.5357
0.8893
-0.3643
0.17

1310.07942
1.50570
0.83776
1.03516
0.40873
0.65754
0.3011
0.96

0.005*
0.000*
0.000*
0.000*
0.000*
0.063
0.026*
0.43

0.187
0.303
0.391
0.277
0.285
0.088
0.123
0.016

* P # .05.

III.2224 A posteriorly displaced hyoid bone has been

correlated with severity of the obstructive sleep apnea
syndrome and has been found to improve with
mandibular advancement surgery.25 Similarly, functional appliances advance the position of the mandible
and tongue, resulting in an anterior pull on the hyoid
bone by the connecting musculature and ligaments
and improving airway morphology, as supported by the
findings of our study. Although the change in mandibular position did not reach statistical significance, it
could have been of clinical significance, whereby the
concomitant advancement of the tongue could have
influenced the change in airway volume and dimensions.26,27
Although the sample was relatively small, a power
analysis was used for study design to determine the
minimum sample size.28 The minimum sample size
was determined to be 11 subjects to be able to
correctly reject the null hypothesis. Due to limitations in
the number of controls satisfying the inclusion criteria,
the present study did not control for gender. Past
research on the influence of gender has produced
conflicting results. Abramson et al. reported no effect
of gender on measured airway parameters,21 whereas
Tan et al. found larger oropharyngeal airway volumes
in males.29 Hence, there is a need for future studies
with more untreated subjects to account for gender as
a potential confounding factor.
Another factor requiring investigation is the effect of
palatal expansion on the oropharyngeal airway, which
is unclear. The treated group included patients who
had palatal expanders as a component of the MARA.
While the effect of expansion was not accounted for in
the present study, it may not have a significant
influence. Several studies have used CBCT scans to
evaluate airway changes following palatal expansion,
finding no statistically significant effect on OA volume,3034 although significant effects have been demonstrated in the nasopharyngeal airway.35
Lastly, CBCT scans were obtained in the current
study with subjects in a seated position. It has been
established that gravitational pull of soft tissues while
Angle Orthodontist, Vol 86, No 6, 2016

in the supine position may cause airway collapse. A

36.5% decrease in oropharyngeal area has been
previously reported in obstructive sleep apnea patients
with a positional change from upright (standing) to
supine.36 Although supine CBCT scans would have
ideally been utilized, it would be unethical to expose
growing patients to the radiation of multiple scans.
Since a 30% variation in airway volume has been
demonstrated with positional change,37 our findings
can be extrapolated.
CONCLUSIONS
N Functional appliance therapy with the MARA increases oropharyngeal airway volume, airway dimensions, and A-P hyoid bone position in growing
patients. Therefore, the null hypothesis was rejected.
N Future studies are necessary to clarify the relationship
between the symptoms of sleep-disordered breathing
and the effects of functional jaw orthopedics.
REFERENCES
1. Moyers R, Riolo M, Guire K, Wainwright R, Bookstein F.
Differential diagnosis of Class II Malocclusion. Am J Orthod
Dentofacial Orthop. 1980;78:477494.
2. McNamara JA. Components of Class II malocclusion in
children 810 years of age. Angle Orthod. 1981;51:
177202.
3. Quintao C. Soft tissue facial profile changes following
functional appliance therapy. Eur J Orthod. 2005;28:3541.
4. Johnson E, Roth T. (2006) An epidemiologic study of sleepdisordered breathing symptoms among adolescents.
SLEEP. 2006;29:11351142.
5. Kandasamy S, Goonewardene M. Class II Malocclusion and
sleep-disordered breathing. Semin Orthod. 2014;20:
316323.
6. El H, Palomo J. An airway study of different maxillary and
mandibular sagittal positions. Eur J Orthod. 2013;35:
262270.
7. Abdelkarim A. A cone beam CT evaluation of oropharyngeal
airway space and its relationship to mandibular position and
dentocraniofacial morphology. J World Fed Orthod. 2012;1:
E55E59.
8. El H, Palomo J. Airway volume for different dentofacial
skeletal patterns. Am J Orthod Dentofacial Orthop. 2011;
139:E511E521.

961

AIRWAY CHANGES AFTER TREATMENT WITH THE MARA

9. Muto T, Yamazaki A, Takeda S. A cephalometric evaluation

of the pharyngeal airway space in patients with mandibular
retrognathia and prognathia, and normal subjects. Int J Oral
Maxillofac Surg. 2008;37:228231.
10. Ogutcen-Toller M, Sarac Y, Cakr-Ozkan N, Sarac D, Sakan
B. Computerized tomographic evaluation of effects of
mandibular anterior repositioning on the upper airway: a pilot
study. J Prosthet Dent. 2004;92:184189.
11. Lin Y, Lin H, Tsai H. Changes in the pharyngeal airway and
position of the hyoid bone after treatment with a modified
bionator in growing patients with retrognathia. Journal of
Experimental & Clinical Medicine. 2011;3:9398.
12. Ghoneima A, Kula K. Accuracy and reliability of cone-beam
computed tomography for airway volume analysis.
Eur J Orthod. 2013;35:256261.
13. Aboudara C, Nielsen I, Huang J, Maki K, Miller A, & Hatcher,
D. Comparison of airway space with conventional lateral
headfilms and 3-dimensional reconstruction from conebeam computed tomography. Am J Orthod Dentofacial
Orthop. 2009;135:468479.
14. Franchi L, Baccetti T, McNamara JA. Mandibular growth as
related to cervical vertebrae maturation and body height.
Am J Orthod Dentofacial Orthop. 2000;118:335340.
15. Iwasaki T, Takemoto Y, Inada E, Sato H, Saitoh I, Kakuno
E, 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;146:776785.
16. Pangrazio M, Pangrazio-Kulbersh V, Berger J, Bayirli B,
Movahhedian A. Treatment effects of the mandibular
anterior repositioning appliance in patients with Class II
skeletal malocclusions. Angle Orthod. 2012;82:971977.
17. Li L, Liu H, Cheng H, Han Y, Wang C, Chen Y, Song J, Liu
D. CBCT evaluation of the upper airway morphological
changes in growing patients of Class II division 1 malocclusion with mandibular retrusion using Twin-block appliance:
a comparative research. PLoS One. 2014;9:e94378.
18. Verma G, Nagar A, Singh G, Singh A, Tandon P.
Cephalometric evaluation of hyoid bone position and
pharyngeal spaces following treatment with Twin-block
appliance. J Orthod Sci. 2012;1:7782.
19. Schutz T, Dominguez G, Hallinan M, Cunha T, Tufik S.
Class II correction improves nocturnal breathing in adolescents. Angle Orthod. 2011;81:222228.
20. Ulusoy C, Canigur Bavbek N, Tuncer B, Tuncer C, Turkoz
C, and Gencturk Z. Evaluation of airway dimensions and
changes in hyoid bone position following Class II functional
therapy with activator. Acta Odontol Scand. 2014;72:
917925.
21. Abramson Z, Susarla S, Troulis M, Kaban L. Age-related
changes of the upper airway assessed by 3-dimensional
computed tomography. J Craniofac Surg. 2009;20:
16291630.
22. Allhaija E, Al-Khateeb S. Uvulo-glosso-pharyngeal dimensions in different anteroposterior skeletal patterns. Angle
Orthod. 2005;75:10121018.
23. Arslan S, Dildea N, Kama J. Cephalometric investigation of
first cervical vertebrae morphology and hyoid position in

24.

25.

26.

27.

28.

29.

30.

31.

32.

33.

34.

35.

36.

37.

young adults with different sagittal skeletal patterns.

Scientific World Journal. 2014; Article ID 159784.
Adamidis I, Spyropoulos M. Hyoid bone position and
orientation in Class I and Class III malocclusions.
Am J Orthod Dentofacial Orthop. 1992;101:308312.
Sahoo N, Jayan B, Ramakrishna N, Chopra S, Kochar G.
Evaluation of upper airway dimensional changes and hyoid
position following mandibular advancement in patients with
skeletal Class II malocclusion. J Craniofac Surg. 2012;23:
E623E627.
Yassaei S, Bahrololoomi Z, Sorush M. Changes of tongue
position and oropharynx following treatment with functional
appliance. J Clin Pediat Dent. 2007;31:287290.
Hanggi MP, Teuscher UM, Roos M, Peltomaki TA. Long-term
changes in pharyngeal airway dimensions following activatorheadgear and fixed appliance treatment. Eur J Orthod. 2008;
30:598605.
Dillehay JK. Changes in pharyngeal airway dimensions due
to MARA treatment in Class II malocclusions. 2013;
Retrieved from ProQuest Dissertations and Theses. (Accession Order No.AAT 1536670)
Tan R, Pangrazio V, Kulbersh R, Al-Qawasmi R. CBCT
evaluation of changes in the total pharyngeal airway in
subjects from seven to eighteen years. In: Park, J., ed.
Computed Tomography: New Research. New York: Nova
Science; 2013:393400.
Zeng J, Gao X. A prospective CBCT study of upper airway
changes after rapid maxillary expansion. Int J Pediat Otorhinolaryngol. 2013;77:18051810.
Chang Y, Koenig L, Pruszynski J, Bradley T, Bosio J, Liu D.
Dimensional changes of upper airway after rapid maxillary
expansion: A prospective cone-beam computed tomography study. Am J Orthod Dentofacial Orthop. 2013;143:
462470.
Zhao Y, Nguyen M, Gohl E, Mah J, Sameshima G, Enciso
R. Oropharyngeal airway changes after rapid palatal
expansion evaluated with cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2010;137:S71S78.
El H, Palomo J. Three-dimensional evaluation of upper
airway following rapid maxillary expansion: a CBCT study.
Angle Orthod. 2014;84:265273.
Pangrazio V, Wine P, Haughey M, Pajtas B, Kaczynski R.
Cone beam computed tomography evaluation of changes in
the naso-maxillary complex associated with two types of
maxillary expanders. Angle Orthod. 2012;82:448457.
Smith T, Ghoneima A, Stewart K, Liu S, Eckert G, Halum S,
Kula K. Three-dimensional computed tomography analysis
of airway volume changes after rapid maxillary expansion.
Am J Orthod Dentofacial Orthop. 2012;141:618626.
Pae E, Lowe A, Sasaki K, Price C, Tsuchiya M, Fleetham J.
A cephalometric and electromyographic study of upper
airway structures in the upright and supine position.
Am J Orthod Dentofacial Orthop. 1994;106:5259.
Camacho M, Capasso R, Schendel S. Airway changes in
obstructive sleep apnea patients associated with a supine
versus an upright position examined using cone beam
computed tomography. J Laryngol Otol. 2014;128:824830.

Angle Orthodontist, Vol 86, No 6, 2016