Long-term changes in pharyngeal airway dimensions following activator-headgear and fixed appliance treatment
Open accessAbstract
The aim of this study was to evaluate changes in the pharyngeal airway in growing children and adolescents and to compare these with a group of children who received activator-headgear Class II treatment. The sample consisted of 64 children (32 males and 32 females), 32 had a combined activator-headgear appliance for at least 9 months (study group) followed by fixed appliance therapy in most patients, while the other half received only minor orthodontic treatment (control group). Lateral cephalograms before treatment (T1, mean age 10.4 years), at the end of active treatment (T2, mean age 14.5 years), and at the long-term follow-up (T3, mean age 22.1 years) were traced and digitized. To reveal the influence of somatic growth, body height measurements were also taken into consideration. A two-sample t-test was applied in order to determine differences between the groups. At T1, the study group had a smaller pharynx length (P = 0.030) and a greater ANB angle (P < 0.001) than the controls. The pharyngeal area and the smallest distance between the tongue and the posterior pharyngeal wall also tended to be smaller in the study group. During treatment (T1-T2), significant growth differences between the two groups were present: the study group had a greater reduction in ANB (P < 0.001) and showed a greater increase in pharyngeal area (P = 0.007), pharyngeal length (P < 0.001) and the smallest distance between the tongue and the posterior pharyngeal wall (P = 0.038). At T2, the values for the study group were similar to those of the control group and remained stable throughout the post-treatment interval (T2-T3). Activator-headgear therapy has the potential to increase pharyngeal airway dimensions, such as the smallest distance between the tongue and the posterior pharyngeal wall or the pharyngeal area. Importantly, this increase seems to be maintained long term, up to 22 years on average in the present study. This benefit may result in a reduced risk of developing long-term impaired respiratory function.
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Studies using cephalometry and cone beam computed tomography have demonstrated structural airway enlargement following mandibular advancement, although findings vary across appliance types and populations.
“Studies using cephalometry and cone beam computed tomography (CBCT) have demonstrated structural airway enlargement following mandibular advancement, although findings vary across appliance types and populations [12–14, 41, 43]”
From Long-Term Changes Following Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: a 7-Year Follow-up Study (2026) · cites this paper as [14]
The Method and Discussion report cephalometric evidence of increased pharyngeal airway dimensions after activator-headgear treatment, with substantial individual variation noted in the Conclusions. This paper did not use CBCT: the Discussion describes cone beam imaging as a preferable future method and says long-term data were not yet available. Thus it supports the cephalometry portion of the cited sentence, not the CBCT portion. (LLM, conf=0.88)
Experimental — accuracy not yet measuredPhysiologic growth alone results in modest, region-specific airway enlargement rather than marked or generalized expansion.
“These findings suggest that physiologic growth alone results in modest, region-specific airway enlargement rather than marked or generalized expansion, lending contextual support to the interpretation that the more pronounced airway changes observed in the present cohort may reflect, at least in part, the effect of mandibular advancement therapy.”
From Long-Term Changes Following Orthopedic Mandibular Advancement Therapy in Pediatric Obstructive Sleep Apnea: a 7-Year Follow-up Study (2026) · cites this paper as [14]
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“The differences in growth and individual response to malocclusion treatment were observed in the study (17).”
BackgroundShannon, T. P. (2012) · doi:10.21007/etd.cghs.2012.0284 · Cited by 6 · see citing works
“The majority of orthodontic research on airway health is limited because of technological limitations of cephalometric imaging (Abramson et al. 2009; Finkelstein et al. 2001; Hanggi et al. 2008; Lowe et al. 1986).”
BackgroundArora, S., Grover, S., Harikrishnan, P., Dabas, A., Dogra, N., & Nindra, J. (2023) · Journal of Orofacial Orthopedics / Fortschritte der Kieferorthopädie · doi:10.1007/s00056-023-00449-3 · Cited by 8 · see citing works
İnce-Bingöl, S., & Kaya, B. (2021) · Clinical Oral Investigations · doi:10.1007/s00784-021-03789-9 · Cited by 8 · see citing works
Ahmed, M. J., Diar-Bakirly, S., Deirs, N., Hassan, A., & Ghoneima, A. A. M. (2024) · Head & Face Medicine · doi:10.1186/s13005-024-00410-8 · Cited by 8 · see citing works
“This increase however, has been inconsistently reported with the use of other functional appliances, such as the activator, bionator and X bow [35, 36].”
BackgroundAtik, E., Görücü-Coşkuner, H., & Kocadereli, İ. (2017) · Australasian Orthodontic Journal · doi:10.21307/aoj-2020-079 · Cited by 7 · see citing works
Pradhan, T., Dedhiya, N., & Sethia, A. (2020) · Journal of Orofacial Sciences · doi:10.4103/jofs.jofs_36_20 · Cited by 6 · see citing works
Effects of Functional Appliance Therapy on the Depth of the Pharyngeal Airways: Activator vs. Forsus
Taki, A. A. (2015) · Journal of Dental Health Oral Disorders and Therapy · doi:10.15406/jdhodt.2015.03.00082 · Cited by 5 · see citing works
Yavan, M. A., Aycan, M., Aksoyler, D. Y., & Essiz, A. (2021) · APOS Trends in Orthodontics · doi:10.25259/apos_173_2020 · Cited by 5 · see citing works
Orthodontic Perspectives in the Interdisciplinary Management of Pediatric Obstructive Sleep Apnea
Müller-Hagedorn, S., Abadie, V., & Bartzela, T. N. (2025) · Children · doi:10.3390/children12081066 · Cited by 4 · see citing works
“Children receiving combined activator-headgear treatment for skeletal Class II correction presented a significant negative impact on sagittal development of the maxilla (reduction of SNA angle: angle defined by nasion-sella-point A), when compared to controls without headgear treatment [168].”
Shavakhi, M., Mohamadian, F., & Najafi, H. Z. (2019) · Dental and Medical Problems · doi:10.17219/dmp/105957 · Cited by 4 · see citing works
Posterior airway changes during and after Herbst appliance treatment
Bock, N. C., Sonntag, G., Klaus, K., & Ruf, S. (2025) · Clinical Oral Investigations · doi:10.1007/s00784-024-06129-9 · Cited by 3 · see citing works
“…measurements divided by skeletal maturity groups “total”, “pre-peak”, “peak” and “post-peak”: means, standard deviations (SD), standard errors (SE), medians (Med), minima (Min) and maxima (Max) of overjet, wits appraisal, ANB angle, ML/NSL angle and ArGo’Gn angle are given therapy [6 ].”
Craniofacial Growth Modification for OSA Children
Kim, S. (2019) · Springer eBooks · doi:10.1007/978-3-030-24413-2_4 · Cited by 3 · see citing works
The effect of headgear treatment on the development of obstructive sleep apnoea. A systematic review
Studer, V., Koletsi, D., Iliadi, A., & Eliades, T. (2018) · Australasian Orthodontic Journal · doi:10.21307/aoj-2020-076 · Cited by 3 · see citing works
Twin block appliance: Effect on pharyngeal airway
Thapa, V. B., Shrestha, A., Sherchan, P., Poudel, P., & Joshi, L. (2018) · Journal of Kathmandu Medical College · doi:10.3126/jkmc.v7i4.23299 · Cited by 3 · see citing works
“Jena AK et al.(11) tested the hypothesis that twin-block and Mandibular Protraction Appliance-IV (MPAIV) using lateral cephalograms records concluded twin block appliance as more efficient than MPA-IV.”
MethodFARKLI İSKELETSEL MALOKLUZYONLARIN ÜST HAVAYOLU BOYUTLARI ÜZERİNE ETKİLERİ
Ekizer, A., & Türker, G. (2015) · Cumhuriyet Dental Journal · doi:10.7126/cdj.58140.5000033816 · Cited by 3 · see citing works
Functional Appliances in the Treatment of Sleep Apnea in Children: A Systematic Review
Rossi, R. C., Rossi, N. J., & Rossi, N. C. (2015) · otolaryngology · doi:10.4172/2161-119x.1000212 · Cited by 3 · see citing works
“Some of the studies were not able to include enough patients for an statistical result maybe because of the difficulty of suitable sample allocation in the inclusion criteria [5,6,14,42-50,52,59-65].”
BackgroundInfluentialAydil, S. K., Kiyan, E., Ersu, R., Kilicoglu, H., Sayar, G., & Capan, E. (2026) · Clinical Oral Investigations · doi:10.1007/s00784-026-06926-4 · Cited by 2 · see citing works
“The first focuses on craniofa - cial or airway morphology, where mandibular advancement appears to produce structural enlargement during the treat-ment period, although findings are heterogeneous and often short-term [12, 14, 16, 17, 41–43].”
Li, H., Li, D., Liu, L., Tian, Y., Li, Y., & Tan, J. (2024) · Clinical Oral Investigations · doi:10.1007/s00784-024-06066-7 · Cited by 2 · see citing works
“Studies on vBHGA are relatively scarce, with most focusing on headgear or cervical-headgear [12–16].”
InfluentialTanaka, M., Seto, Y., & Kobayashi, S. (2023) · Australasian Orthodontic Journal · doi:10.2478/aoj-2023-0028 · Cited by 2 · see citing works
A Cephalometric Evaluation of Oropharyngeal Airway Changes Duing Twin-Block Appliance Treatment
Trenouth, M. J., & Desmond, S. R. (2016) · International Journal of Dentistry and Oral Science · doi:10.19070/2377-8075-si04004 · Cited by 2 · see citing works
“These findings are consistent with those in the control groups of the studies by Ozbek et al [5], Hänggi et al [7], Jena et al [9], Ghodke et al [10], Iwasaki et al [11].”
ResultPediatric Obstructive Sleep Apnea: Orthodontic Management
Fagundes, N. C. F., Almeida, F. R., & Flores‐Mir, C. (2021) · Springer eBooks · doi:10.1007/978-3-030-65574-7_39 · Cited by 2 · see citing works
Sınıf II Aktivatör İle Tedavi Edilmiş Bireylerde Havayolu Değişikliklerinin İncelenmesi
Sayar, G., & Kılınç, D. D. (2018) · Selcuk Dental Journal · doi:10.15311/selcukdentj.297801 · Cited by 2 · see citing works
Gu, M., Lin, Y., McGrath, C. P. J., Hägg, U., Wong, R., & Yang, Y. (2020) · APOS Trends in Orthodontics · doi:10.25259/apos_83_2020 · Cited by 2 · see citing works
Kim, S., & Kim, K. B. (2021) · Springer eBooks · doi:10.1007/978-3-030-54146-0_9 · Cited by 1 · see citing works
A Retrospective Lateral Cephalometric Growth Study of Sagittal Airway Changes
Woo, G. H. (2017) · The Scholars Repository - LLU (Loma Linda University) · Cited by 1 · see citing works
Cephalometric Evaluation of Stability of Airway Changes Obtained with Twin-block Therapy
Manohar, M. R., & Gupta, G. (2021) · CODS Journal of Dentistry · doi:10.5005/jp-journals-10063-0063 · Cited by 1 · see citing works
Laird, A. M., Yetkiner, E., Kadioğlu, O., & Currier, G. F. (2019) · Springer eBooks · doi:10.1007/978-3-030-00722-5_6 · Cited by 1 · see citing works
ElAbbasy, D. O. (2019) · Egyptian Dental Journal /Egyptian Dental Journal · doi:10.21608/edj.2015.71735 · Cited by 1 · see citing works
“This is augmented by the results of Hanggi et al, 2008 who reported no changes in airway dimensions during adolescence.”
BackgroundResultFour years stability evaluation of the changes obtained by twin force bite corrector appliance
Yousif, A. (2014) · Egyptian Orthodontic Journal · doi:10.21608/eos.2014.78898
“5 mm in TFBC group and 1 mm in JJ group which considered insignificant changes these result came in accordance with Hänggi MP et al((58)) for activator-headgear and fixed appliance treatment.”
ResultChanges in Pharyngeal Airway Dimensions Due to MARA Treatment in Class II Malocclusions
Dillehay, J. (2013) · doi:10.21007/etd.cghs.2013.0071 · Cited by 1 · see citing works
Filho, M., & Araraquara, F. D. O. D. (2010)
Keerthana, P., & Chitra, P. (2020) · INTERNATIONAL JOURNAL OF SCIENTIFIC RESEARCH · doi:10.36106/ijsr/4203158
Lin, S.-H., Chen, Y., & Tseng, Y. (2021) · Chǐʼèjiǎozhèng xuéhuì zázhì/Journal of Taiwan Association of Orthodontists · doi:10.38209/2708-2636.1088
Three-dimensional Pharyngeal Volume Evaluation after Functional Appliance Therapy
Prasad, P. N., Kumar, T., Sharma, T., Gupta, M., Sharan, S., & Shrivastava, S. B. (2021) · Journal of Research and Advancement in Dentistry · doi:10.53064/jrad.2021.12.3.04
Marques, T. Y. L. A. (2021) · doi:10.11606/d.25.2021.tde-01122021-100649
“(HAN et al., 2014; HÄNGGI et al., 2008; JENA; SINGH; UTREJA, 2012; PHAN et al., 2006; ULUSOY et al., 2014) Three-dimensional imaging (3D) using cone-beam computed tomography (CBCT) to evaluate changes in airway dimensions is preferred to a lateral cephalometric radiograph, but this method has a…”
Method(2010) · Current Opinion in Allergy and Clinical Immunology · doi:10.1097/aci.0b013e3283355458
Nayyer, N., Jena, A. K., & Sharan, J. (2021) · Orthodontic Journal of Nepal · doi:10.3126/ojn.v11i2.43284
“Keeping in view the plausible long-term effects of functional appliances, 45,46,48 it may be postulated that widening of a narrow upper airway passage by functional appliances in children could eliminate the risk of developing OSA in adulthood.”
Ertuğrul, B. Y. (2022) · Selcuk Dental Journal · doi:10.15311/selcukdentj.813770
Дрогомирецька, М. С., & Садек, А. С. М. (2023) · Scientific and practical journal Stomatological Bulletin · doi:10.35220/2078-8916-2023-48-2.21
A Cephalometric Study of Pharyngeal Dimensions Following Twin Block Treatment
Khan, A. N., Arshad, O., Abid, A. M., & Tariq, S. (2023) · Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University · doi:10.48036/apims.v19i3.815
Masoud, A. I., & Ghoneim, S. H. (2025) · American Journal of Orthodontics and Dentofacial Orthopedics · doi:10.1016/j.ajodo.2025.02.007
Mohamed, A. M., Chen, Y., Badawy, R. E.-S., Al-balaa, M., Bakr, A., Albarakani, A. Y., Wang, Y., Meng, Y., & Yang, Y. (2025) · Digital Dentistry Journal · doi:10.1016/j.ddj.2025.100038
Büyükbayraktar, Z. Ç., & Camcı, H. (2024) · Figshare · doi:10.6084/m9.figshare.26565015
- Authors
- Hanggi, M. P., Teuscher, U. M., Roos, M., & Peltomaki, T. A.
- Affiliations
- University of Zurich (CH)
- ORCID
- Roos, M.
- Venue
- The European Journal of Orthodontics
- Publisher
- Oxford University Press (OUP)
- Published
- 2008-10-28
- Volume
- 30
- Issue
- 6
- Pages
- 598-605
- ISSN
- 0141-5387 (ISSN-L)
- 1460-2210
- OpenAlex
- W2109923971
- Cited by
- 85
- References
- 49
- Citations by year
- 2026: 2 · 2025: 4 · 2024: 4 · 2023: 6 · 2022: 1 · 2021: 11 · 2020: 8 · 2019: 7 · 2018: 3 · 2017: 8 · 2016: 4 · 2015: 9 · 2014: 5 · 2013: 6 · 2012: 3
- FWCI
- 1.96
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- European Journal of Orthodontics (publishedVersion)
- PubMed (publishedVersion)
- Zurich Open Repository and Archive (University of Zurich) (acceptedVersion, other-oa)
- reroDoc Digital Library (submittedVersion)
- Zurich Open Repository and Archive (University of Zurich) (submittedVersion, other-oa)
- Zurich Open Repository and Archive (University of Zurich)
- Topics
- Health Sciences › Dentistry › Orthodontics › Orthodontics and Dentofacial Orthopedics
- Health Sciences › Medicine › Surgery › Nasal Surgery and Airway Studies
- Life Sciences › Biochemistry, Genetics and Molecular Biology › Genetics › Cleft Lip and Palate Research
- Keywords
- pharyngeal airway, Class II malocclusion, fixed orthodontic appliances, ANB angle, long-term follow-up, children and adolescents, physical growth, respiratory function
- MeSH terms
- Activator Appliances, Adolescent, Airway Resistance, Cephalometry, Child, Combined Modality Therapy, Extraoral Traction Appliances, Female, Humans, Longitudinal Studies, Male, Malocclusion, Angle Class I, Malocclusion, Angle Class II, Oropharynx, Orthodontic Appliances, Orthodontics, Corrective, Pharynx, Reference Values, Treatment Outcome, Sleep Apnea, Obstructive, Young Adult
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