Journal of the World Federation of Orthodontists 4 (2015) 114e119

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Research

Three-dimensional effects of twin block therapy on pharyngeal

airway parameters in Class II malocclusion patients
Hanem y Elfeky a, Mona M.S. Fayed b, *
a
b

Senior Resident, Department of Orthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt
Associate Professor, Department of Orthodontics, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt

a r t i c l e i n f o

a b s t r a c t

Article history:
Received 26 September 2014
Received in revised form
13 June 2015
Accepted 29 June 2015

Background: The authors sought to evaluate the three-dimensional effects of a twin block (TB) appliance
on the pharyngeal airway parameters in a sample of Class II patients with mandibular retrusion in
comparison with a control group, by using cone-beam computed tomography (CBCT).
Methods: A sample of 36 female Class II malocclusion patients with mandibular retrusion participated in
this study; 18 patients were treated with the TB appliance for 8 months, and the other 18 had no
treatment and formed the control group. The airway volumetric parameters were assessed by using
CBCT; three-dimensional measurements were performed before treatment and 8 months later in both
groups. Statistical analysis of the collected data was performed.
Results: Airway parameters increased signicantly in the treatment group and after the control period in
the control group. However, the mean changes in the treatment group were signicantly higher than
those of the control group.
Conclusion: The use of the TB appliance in the treatment of Class II mandibular retrusion patients resulted
in a signicant increase in all pharyngeal airway parameters.
2015 World Federation of Orthodontists.

Keywords:
Class II mandibular retrusion
Twin block appliance
Pharyngeal airway
Cone-beam computed tomography

1. Introduction
Class II malocclusion is one of the mostly encountered problems
in the orthodontic practice [1]. It causes aesthetic, functional, and
psychological problems of varying intensities. Patients with Class II
Division 1 malocclusion can exhibit maxillary protrusion, mandibular retrusion, or both [2,3].
Awareness of mandibular deciency as the main contributing
part of the Class II structural etiology [4] had led to the increased
popularity of mandibular advancement appliances or the functional
appliances. The twin block functional appliance, originally developed by William J. Clark [5], has gained increasing popularity and
been shown to be effective in correcting Class II malocclusion [6,7].
Concurrently, the pharyngeal airway has been an area of interest
in orthodontics, with topics such as the relationships between
different skeletal malocclusions and facial types and airway shape
and volume, and the clinicians potential to modify the airway.
Narrowing of the upper airway has been increasingly recognized
as a physiological characteristic in growing patients of Class II
All authors have completed and submitted the ICMJE Form for Disclosure of
Potential Conicts of Interest, and none were reported.
* Corresponding author: Cairo University Faculty of Dentistry, 11 Sarayat ElManial
Street, Faculty of Oral and Dental Medicine, Cairo University, Cairo, Egypt.
E-mail address: monasfayed@yahoo.com (M.M.S. Fayed).
2212-4438/$ e see front matter 2015 World Federation of Orthodontists.
http://dx.doi.org/10.1016/j.ejwf.2015.06.001

division 1 malocclusion with mandibular retrusion [8,9]. The retruded mandible induces a retrodisplacement of the tongue and
hyoid bone that may lead to a concomitant reduction in the upper
airway volume [10,11]. Many studies have demonstrated that the
airway constriction is the most dominating contributor to
obstructive sleep apnea (OSA), among other factors such as postural
changes that might affect structures of the head and neck and
sagittal jaw relationships. OSA affects at least 2% of children and
was conrmed to have long-term adverse effects [12]. Other
possible factors are anatomical variations, pharyngeal dilator
muscle function, lowered arousal threshold, and ventilator control
instability.
One of the rst attempts to evaluate pharyngeal airway in
different anteroposterior malocclusions was carried out by Mergen
and Jacobs [13], followed by Trenouth and Timms [14]; both studies
used cephalometric measurements to evaluate nasopharyngeal
space and functional oropharyngeal airway. They concluded that
the nasopharyngeal area and depth were signicantly larger in
subjects with normal occlusion than in subjects with Class II
malocclusion and that the oropharyngeal airway was positively
correlated with length of the mandible.
Most studies evaluating the airway have been conducted with
two-dimensional lateral or frontal cephalograms with limited
evaluation of lengths and area.

H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119
Table 1
Demographic data and cephalometric measurements showing no signicant differences between the treatment and the control group before the start of treatment
and control period
Measurements

Group

Mean
(pre)

Age

Control
11.27
Treatment
11.89
A point, nasion,
Control
7.51
B point ( )
Treatment
8.28
A-B diff Nv
Control
9.77
(mm)
Treatment
11.29
AFH
Control
107.21
(mm)
Treatment 107.97
PFH
Control
63.16
(mm)
Treatment
61.80
S-InGo/N-menton Control
0.59
Treatment
0.55
Sella nasion point Control
81.75
A ( )
Treatment
81.27
A-Nv
Control
1.57
(mm)
Treatment
1.06
Sella nasion point Control
73.97
B ( )
Treatment
73.00
B-Nv
Control
8.71
(mm)
Treatment 10.05

SD
2.19
1.85
1.81
1.19
2.19
1.85
4.24
3.73
2.14
3.95
0.04
0.04
3.52
3.58
1.40
2.75
2.30
3.24
2.57
3.29

Diff. of SEM T
means

P Value

Table 3
Landmarks and reference planes for the pharyngeal airway analysis
Landmarks
(Abbreviation)

Denition

1. Posterior nasal
spine (PNS)
2. Pterygomaxillary
points (PTM)

PNS; most posterior point on the bony hard palate

0.62

0.26

1.21 0.335453

0.77

0.86

0.22 0.824477

1.52

0.22

0.66 0.515559

0.76

0.56

1.36 0.183461

3. C3
Reference planes
1. PTM-PNS
2. PNS plane

1.3

0.60

1.35 0.187069

3. C3 plane

0.04

0.41 0.95 0.186032

0.48

0.38 1.05 0.299779

0.5

0.37 1.16 0.254151

0.97

0.25 0.24 0.815096

1.3

0.20 0.50 0.622139

Nv, Nasion vertical; AFH, anterior facial height; PFH, posterior facial height; s-InGo/
N-menton, Sella-intergonion/nasion-menton
* Signicant P < 0.05.

Presently, cone-beam computed tomography (CBCT) systems

have been developed specically for the maxillofacial region. CBCT
scans use a greatly reduced radiation dose compared with
computed tomography. Cross-sectional and volumetric investigations of the pharyngeal airway have been possible by using
CBCT scans to analyze the complex airway anatomy. Oh et al. [15],
Kim et al. [16], and El and Palomo [9] used CBCT in airway analyses
and concluded that children with Class II malocclusion had smaller
volumes of the pharyngeal airway than did children with Class I and
III malocclusions.
Ozbek et al. [17], Schtz et al. [18], and Vinoth et al. [19] investigated the effects of different functional appliances, including
Herbst, Frankel, mandibular advancement, and twin block appliances on the pharyngeal airway, and all showed positive results in
the form of increases in oropharyngeal dimensions and the

Table 2
Parameters of GALILEOS CBCT scanner
Technical parameter

Value

X-ray source voltage

X-ray source current
Gray scale depth
Scanning time
Radiation source
Exposure time/image
Current time product
Effective radiation time
Rotation (orbital angle)
Projections per rotation
Detector type
Detector size
Field of view
Voxel size (mm)
Scanned volume dimensions
Matrix (voxel set)
Patient positioning
Rotation center to focal spot
Data output
Effective dose value (Deff)
Focal spot size
Primary reconstruction time

85 KVp
21 mA
12 bit
Approx. 14 s
Pulsed
10e30 ms
42 mAs
2e6 seconds
204
200
Image intensier-charged coupled device
21.5 cm (8 in) diameter
6 in 15 cm  15 cm  15 cm
0.3  0.3  0.3 mm3
15 cm  15 cm  15 cm
512  512  512
Standing or seated with at occlusal plane
333 mm (131/8 in)
DICOM
ICRP 1990 29 mSv, ICRP 2007 54 mSv
0.5
Approx. 2.5 min

115

Intersection of the inferior border of the foramen

rotundum with the posterior wall of the
pterygomaxillary ssure
Inferior anterior point of the third cervical vertebra
Plane connecting right and left PTM passing PNS
Plane passing through PNS perpendicular to the
sagittal plane
Plane passing through inferior anterior point of third
cervical vertebra perpendicular to the sagittal plane

posterior airway space and movement of the hyoid bone to a more

anterior position. However, all these studies used cephalometric
analysis as their measurement tool.
Although clinical studies have been done on skeletal and dentoalveolar changes associated with twin block therapy in Class II
malocclusions [6,7], its effect on the pharyngeal airway volume was
not investigated thoroughly, especially using an advanced threedimensional analysis as that provided by CBCT.
Therefore, the aim of the present research was to evaluate the
three-dimensional effects of twin block appliance on the pharyngeal airway parameters in comparison to a control group by using a
detailed CBCT assessment.
2. Materials and methods
This study was approved by the Research Ethics Committee of
the Faculty of Oral and Dental Medicine, Cairo University. All patients parents were informed about the study procedures, and
written consent forms were signed.
2.1. Subjects
2.1.1. Study power analysis
An a priori statistical power analysis was performed, with effect size (ES) d .9. With an alpha .05 and power of 0.8, the
suggested sample size was 44 for both groups (22 patients in each
group) (G Power 3.1). An oversizing of the sample was done to
compensate for patient dropouts. Thus, the study was conducted
on 53 female subjects presented at the Outpatient Clinic of the

Fig. 1. Nasopharyngeal airway landmarks.

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H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119

In the treatment group, nine discontinued the treatment at

different times and due to different reasons. Thus, the two groups
consisted of 18 patients each.
A post-hoc statistical power analysis was performed (total
number of patients and controls 36). The ES in this study was d
2.3, with an alpha .05 and revealed a power > 0.85 (G Power 3.1).
2.2. Clinical procedures

Fig. 2. Nasopharyngeal airway volume.

Department of Orthodontics, Faculty of Oral and Dental Medicine,

Cairo University.
2.1.2. Selection criteria
 Female patients aged 10 to 12 years with stage 3 or 4 cervical
vertebral maturational indicator according to Hassel and
Farman [20] as assessed from the pretreatment cephalometric
radiographs obtained from CBCT
 Patients with features of skeletal Class II malocclusion with
components of mandibular deciency and vertical growth
pattern as veried clinically and radiographically; ANB angle
greater than 4 , AeB difference more than 4 mm (Table 1)
 Patients with Class II molar and/or canine relationship
 Patients had no potential airway problems or abnormalities as
conrmed by an ear-nose-throat specialist.
The participants were sequentially assigned into groups A and B,
and this procedure was implemented by another person who was
blinded to the nature of the research. Thus, group A consisted of 27
patients who received a twin block functional appliance for
8 months, and group B consisted of 26 patients who received no
treatment for 8 months (control group).
2.1.3. Patient dropouts
In the control group, eight of the control patients did not nish
the control period, as they wanted to start treatment immediately.

Fig. 3. Oropharyngeal airway landmarks.

The twin block appliance as described by Clark [5,6] was used,

and the same construction steps, wearing time, and follow-up
protocol were followed. The subjects were instructed to wear the
appliance for 24 hours a day, even during mealtimes. The overall
treatment period was 8 months. The control group received no
treatment for the same observation period, According to the recommendations of Lund and Sandler [7] and Clark [5,6], who stated
that to ensure that the patient does not have a dual bite, the
appliance is worn a minimum of 7 to 9 months. The treatment was
nished when Class I canine and molar relations and normal overjet
and overbite were established.
2.3. CBCT imaging
CBCT scanning was done before wearing the appliance and after
8 months for the treatment group and before and after 8 months for
the control group. The CBCT scans were obtained using the Sirona
GALILEOS CBCT machine (Sirona Dental systems GmbH-Operating
Instructions GALILEOS). CBCT scanning was performed according to
the manufacturers protocol and by the same operator. Patients sat
upright on the chair of CBCT unit in the natural head position, and
their teeth were at maximum intercuspation with the lips and
tongue in a resting position. The patients were asked not to swallow
and not to move their head or tongue. Parameters of the CBCT
scanner was set according to the recommendations of De Vos et al.
[21] (Table 2).
The CBCT volumetric data sets were imported into the Dolphin
imaging and Management Solution, version 11.0 (Chatsworth, CA)
software package that reconstructs three-dimensional images and
facilitates making measurements.
2.4. Airway volume analysis
The analysis was performed according to the following steps:
1. The borders of the selected portion were drawn according to
the identied landmarks. The landmarks and reference planes
used for the analysis are listed in Table 3.

Fig. 4. Oropharyngeal airway volume.

H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119

117

Table 4
Description of the three-dimensional pharyngeal airway parameters investigated in the study
Variable

Description

Nasopharyngeal airway
The anterior border that is a line connecting pterygomaxillary point (PTM) and posterior nasal spine (PNS). The inferior border was a
Nasopharyngeal airway volume
plane parallel to the Frankfort through the PNS. The posterior border was the posterior wall of the pharynx (Fig. 1).
The volume between these landmarks calculated from the software (Fig. 2)
Oropharyngeal airway
The superior border was a plane parallel the Frankfort through the PNS and that was the inferior border of the nasopharyngeal airway.
Oropharyngeal airway volume
The inferior border was a plane passing through inferior anterior point of third cervical vertebra parallels the Frankfort horizontal
(FH) (Fig. 3).
The volume between these landmarks calculated from the software (Fig. 4)
Minimal constricted axial area The minimal constricted axial area of pharyngeal airway location was determined relative to posterior nasal spine plane was done
by using the software (Fig. 5).

2. The threshold, which is a Dolphin 3D software tool that controls the lling degree of the air, was adjusted to 73, which is
considered the proper threshold for airway measurements [22].
In our study, the airway volume sensitivity was measured at
threshold 73; below this threshold, no air was detected by the
software in most cases, which is why it was used as the standard threshold for all the cases.
3. The pharynx was isolated and divided into nasopharyngeal
according to Park et al. [23] (Figs. 1 and 2) and oropharyngeal
airways according to Oh et al. [15] (Figs. 3 and 4). The denitions of the airway parameters are described in Table 4, Fig. 5.

correlation showed high intraobserver reliability for all measurements (Table 6).
3.1. Control group results
There was a statistically signicant increase in the mean values
of nasopharyngeal airway volume, oropharyngeal airway volume,
and the minimal constricted area post control period (Table 7).
3.2. Treatment group results

All measurements were repeated by the same observer after

2 weeks to assess intraobserver reliability.

There was a statistically signicant increase in the mean values

of nasopharyngeal airway volume, oropharyngeal airway volume,
and the minimal constricted area post treatment (Table 8).

2.5. Statistical analysis

3.3. Treatment and control group comparison results

Data were presented as mean and standard deviation (SD)

values. The signicant level was set at P  0.05. Kolmogorove
Smirnova and ShapiroeWilk tests were used to assess data
normality. Intraclass correlation was used to assess intraobserver
reliability, and ManneWhitney test were used for between-group
comparisons. Paired t-test was used to compare within groups.

The mean difference in the measurements of the studied airway

parameters in the treatment group was signicantly higher than
the mean difference in the control group (Table 9).

3. Results
Demographic data and cephalometric measurements showed
no signicant differences between the treatment and the control
group before the start of treatment and control period (Table 1).
There was no signicant difference between the two groups before
treatment in all pharyngeal airway parameters (Table 5). Intraclass

4. Discussion
A reduction in the pharyngeal airway dimensions in skeletal
Class II patients with mandibular retrusion was demonstrated in
the orthodontic literature [9,10], consequently having a negative
effect on the facial and mandibular growth in those patients. The
twin block appliance is considered a well-accepted approach in
correcting Class II division 1 malocclusion with mandibular retrusion in recent years. Previous studies indicated that the twin
block appliance is effective in mandibular forward repositioning
and thereby achieves a more harmonious facial prole [6,7]. Lin
et al. [24] evaluated the pharyngeal airway after mandibular
advancement in growing patients with retrognathia and suggested that the anteroposterior dimension of pharyngeal airway
did not change signicantly. Other studies [17e19] found that
signicant changes in pharyngeal space, hyoid bone, and tongue

Table 5
Comparison between the mean differences in airway parameters between the two
groups before treatment and control period
Pharyngeal airway
parameter

Control group

Treatment group

Mean

Mean

SD

P Value

SD

Minimal constricted area

211.99
51.87
190.25
49.52 0.214
before treatment (mm2)
14,981.63 2878.92 14,423.24 3123.05 0.58
Oropharyngeal airway
before treatment (mm3)
4628.53 954.07
3750.5 1025.61 0.13
Nasopharyngeal airway
before treatment (mm3)
Fig. 5. Minimal constricted axial.

*Signicant P < 0.05.

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H.y Elfeky, M.M.S. Fayed / Journal of the World Federation of Orthodontists 4 (2015) 114e119

Table 6
Intraobserver reliability of all pharyngeal airway measurements
Pharyngeal airway parameter

Minimal constricted area before

treatment (mm2)
Oropharyngeal airway before
treatment (mm3)
Nasopharyngeal airway before
treatment (mm3)
Minimal constricted area after
treatment (mm2)
Oropharyngeal airway after
treatment (mm3)
Nasopharyngeal airway after
treatment (mm3)
Total

Intraclass correlation

95% Condence
interval
Lower
limit

Upper
limit

0.995

0.95

0.99

0.999

0.995

0.995

0.945

0.966

0.715

0.996

0.998

0.976

0.992

0.927

0.999

positions took place in OSA patients when functional appliances

were used.
The majority of the studies examined the changes of the upper
airway through lateral cephalometric radiography. This method
limited the accuracy of airway measurement since the twodimensional images only allowed an anteroposterior dimension
measurement in sagittal plane and failed to provide a full-scale
view of the upper airway.
In this study, we investigated the effects of the twin block
appliance on the nasopharyngeal and oropharyngeal airway volumes and the minimal constricted area in growing patients with
Class II division 1 malocclusion and mandibular retrusion in comparison to a control group through three-dimensional volumetric
assessment. The present study sample was a homogeneous sample
of female patients with the same level of skeletal maturity and an
average age of 10 to 12 years with a post-hoc power analysis of
greater than 85%, which is regarded as a considerably high power.
Patients were sequentially allocated into the groups to minimize
bias and distortion of the results.
The use of CBCT imaging in this study and the analysis of the
airway parameters using the Dolphin software gave detailed
volumetric measurements of the airway parameters, which was
not performed in previous studies that investigated the same
subjects.
In both groups, the airway parameters investigated increased
signicantly after twin block appliance use in the treatment
group and after the control period in the control group. However,
the mean changes in the treatment group were signicantly
higher than in the control group. This denotes that natural
mandibular growth process in the Class II patients simultaneously leads to an increase in the airway dimensions, but with
the use of twin block appliances, a more signicant increase
occurs. So far, only one study, by Li et al. [25], evaluated the effect
Table 7
Comparison between airway parameters in the control group before and after the
control period (paired t-test)
Parameter

Minimum constricted
area (mm2)
Oropharyngeal
airway (mm3)
Nasopharyngeal
airway (mm3)

Precontrol period

Postcontrol period

Mean

Mean

SD

P Value

SD

211.99

51.87

243.77

52.97

<0.001y

14,981.63

2878.92

15,719.81

2996.84

<0.001y

4628.53

954.07

4779.78

952.74

<0.001y

*Signicant P < 0.05.

y
Highly signicant P < 0.001.

Table 8
Comparison between airway parameters in the treatment group before and after
treatment (paired t-test)
Parameter

Minimum constricted
area (mm2)
Oropharyngeal
airway (mm3)
Nasopharyngeal
airway (mm3)

Pretreatment

Posttreatment

Mean

Mean

SD

P Value

SD

190.25

49.52

282.25

74.52

<0.001y

14,423.24

3123.05

17,475.69

3696.34

<0.001y

3750.5

1025.61

4251.84

1121.72

<0.001y

*Signicant P < 0.05.

y
Highly signicant P < 0.001.

of twin block appliances on the airway parameters using CBCT.

Their results showed that during the twin block treatment, the
hyoid bone was in a more forward and inferior place and a signicant enlargement in nasopharynx, oropharynx, and hypopharynx occurred.
Although the latter study had similar results to the present
research, the Li et al. [25] study was carried out as a retrospective
nonrandomized study with a mixed male/female sample. The
gender difference in this case would affect the results at a growing
age. The comparison was carried out in the present research between two groups before and after treatment for 8 months as
recommended by Clark [6,7] and before and after the control
period, which was the same as the treatment group (8 months).
However, in the Li et al. [25] study, they compared the pretreatment
and posttreatment measurements to preorthodontic treatment
Class II patients only as the control group without assessing the
differences in pharyngeal airway parameters after the control
period, which would reect inaccurate results, as it was shown in
our study that a signicant increase in all airway parameters
occurred in the control group over the control period. The threedimensional assessment of the most constricted cross-sectional
area of the pharyngeal airway space, and the effect of the twin
block on this specic parameter performed in the current study was
not investigated previously. An improvement in a restrictive point
in the airway might be more important than the achievement of an
overall volume increase. The results of the current research clearly
demonstrate a further advantage to the use of the twin block in
treating skeletal Class II patients with mandibular retrusion, which
is improving airway parameters.
5. Conclusion
There was a signicant increase in nasopharyngeal, and
oropharyngeal airway volumes and the most constricted area in
both the treatment and control groups. The mean difference in the
treatment group was signicantly higher than that observed in the
control group.
Table 9
Comparison between the mean differences in airway parameters in the precontrol
and postcontrol periods and the pretreatment and posttreatment periods in the
control and treatment groups by ManneWhitney test
Pharyngeal
airway parameter

Control group

Treatment group

Mean

Mean

SD

P Value

SD

Minimal constricted 31.7778 17.69522

92.0000
38.90511 <0.001y
area (mm2)
Oropharyngeal
738.1778 507.11486 3052.4529 1281.20255 <0.001y
airway (mm3)
Nasopharyngeal
151.2556 104.97998 501.3353 282.34160 <0.001y
airway (mm3)
*Signicant P < 0.05.
y
Highly signicant P < 0.001.

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