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
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OBJECTIVE: The purpose of this study was to evaluate the morphological changes of upper airway after Twin Block (TB) treatment in growing patients with Class II division 1 malocclusion and mandibular retrusion compared with untreated Class II patients by cone beam computed tomography (CBCT). MATERIALS AND METHODS: Thirty growing patients who have completed TB treatment were recruited into TB group. The control group (n = 30) was selected from the patients with the same diagnosis and without TB treatment. CBCT scans of the pre-treatment (T1) and post-treatment (T2) data of TB group and control data were collected. After three-dimensional (3D) reconstruction and registration of T1 and T2 data, the morphological changes of upper airway during TB treatment were measured. The statistical differences between T1 and T2 data of TB group as well as T2 and control data were accessed by t-test. RESULTS: During the TB treatment, the mandible moved advanced by 3.52 ± 2.14 mm in the horizontal direction and 3.77 ± 2.10 mm in the vertical direction. The hyoid bone was in a more forward and inferior place. The upper airway showed a significant enlargement in nasopharynx, oropharynx and hypopharynx. In addition, the nasopharynx turned more circular, and the oropharynx became more elliptic in transverse shape. However, the transverse shape of the hypopharynx showed no significant difference. After comparison between T2 and control data, only the horizontal movement of the hyoid bone, the volumetric expansion of the oropharynx and hypopharynx, and changes of the oropharyngeal transverse shape showed significant difference. CONCLUSION: Compared to the untreated Class II patients, the upper airway of growing patients with Class II division 1 malocclusion and mandibular retrusion showed a significant enlargement in the oropharynx and hypopharynx as well as a more elliptic transverse shape in the oropharynx, and the hyoid bone moved to an anterior position after TB treatment.
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Orthopedic correction of mandibular retrognathism seems to increase the airway space in the short term in 3-dimensional perspective.
“The nature of the variations that induce mandibular growth with functional appliances is not yet clear but orthopedic correction of mandibular retrognathism seems to increase the airway space in the short term in 3-dimensional (3D) perspective.”
From Effectiveness of functional orthodontic appliances in obstructive sleep apnea treatment in children: literature review (2022) · cites this paper as [13]
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Effect of functional appliances on the airway in Class II malocclusions
Padmanabhan, S. (2020) · Journal of the World Federation of Orthodontists · doi:10.1016/j.ejwf.2020.08.006 · Cited by 8 · see citing works
Arora, 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
“Our re-sults are in accordance with studies by Liu et al. [24] who stated that anterior displacement of the tongue along with the mandible by the functional appliances leads to the increase in airway dimensions behind.”
Radwan, E. S., Maher, A., & Montasser, M. A. (2023) · Orthodontics and Craniofacial Research · doi:10.1111/ocr.12696 · Cited by 10 · see citing works
Thakur, V. K., Londhe, S. M., Kumar, P., Sharma, M. R., Jain, A. B., & Pradhan, I. (2020) · Medical Journal Armed Forces India · doi:10.1016/j.mjafi.2020.01.007 · Cited by 8 · see citing works
“reported that changes in the upper airwaywere significant after TB therapyusing 3DCBCT.(14) Their findings were concurred by Elfeky and coworkers, showing the positive three-dimensional changes in the upper airway.”
BackgroundEffects of two different removable functional appliances on depth of the posterior airway space
Hourfar, J., Kinzinger, G. S. M., Meißner, L. K., & Lisson, J. A. (2016) · Journal of Orofacial Orthopedics / Fortschritte der Kieferorthopädie · doi:10.1007/s00056-016-0071-z · Cited by 8 · see citing works
Xu, J., Sun, R., Wang, L., & Hu, X. (2018) · The Angle Orthodontist · doi:10.2319/040518-253.1 · Cited by 7 · see citing works
“lack of transverse dimensions, and overlap of bilateral craniofacial structures.(13) However, the 3D morphology of the airway can be evaluated by cone-beam computed tomography (CBCT), which provides more accurate and reliable measurements than those obtained by traditional methods.”
BackgroundKochhar, A. S., Sidhu, M. S., Bhasin, R., Kochhar, G. K., Dadlani, H., Sandhu, J., & Virk, B. (2021) · World Journal of Radiology · doi:10.4329/wjr.v13.i2.40 · Cited by 8 · see citing works
Faccioni, P., Butera, A., Bazzanella, S., Albanese, M., Gallo, S., Pascadopoli, M., Scribante, A., & Pardo, A. (2023) · Applied Sciences · doi:10.3390/app13063908 · Cited by 6 · see citing works
The ADAMTS9 gene is associated with mandibular retrusion in a Chinese population
Cai, Y., Ni, Z., Chen, W., & Zhou, Y. (2020) · Gene · doi:10.1016/j.gene.2020.144701 · Cited by 6 · see citing works
Zhang, W., Firwana, A., Wang, H., Sun, L., & Wang, J. (2019) · Indian Journal of Dental Research · doi:10.4103/ijdr.ijdr_526_18 · Cited by 6 · see citing works
Bokhari, F., Yosaf, U., Qayyum, F., Jamil, A., & Jameel, M. (2022) · Pakistan Journal of Medical and Health Sciences · doi:10.53350/pjmhs2216721 · Cited by 5 · see citing works
Meriç, P., & Karadede, M. İ. (2022) · CRANIO® · doi:10.1080/08869634.2022.2147283 · Cited by 5 · see citing works
“In studies evaluating the airway after the use of functional appliances, there are publications reporting that the hyoid bone moves downward [23,35], and there are also studies reporting that there is no change in the position of the hyoid bone [36].”
BackgroundMethodResultInfluentialBatra, A., & Shetty, V. (2022) · The Journal of Contemporary Dental Practice · doi:10.5005/jp-journals-10024-3289 · Cited by 5 · see citing works
“8,9 The twin-block appliance moves the lower jaw forward, preventing the posterior positioning of the tongue and improving the PAP, supplemented with an enhancement of facial esthetics.”
Correlation between different boundaries used in upper airway assessment
Aksoz, G., El, H., & Palomo, J. M. (2025) · BMC Oral Health · doi:10.1186/s12903-024-05402-3 · Cited by 4 · 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
Guimarães, T. M., Bariani, R. C. B., Iafigliola, S. G., Guimarães, C. M., Chaves, C. M., Ferraz, O., Cappellette, M., Cunha, T. C. A., Fabbro, C. D., Rossi, R., et al. (2019) · Sleep Science · doi:10.5935/1984-0063.20190066 · Cited by 4 · see citing works
Hansen, C., Bakke, M., & Sonnesen, L. (2024) · Journal of Oral and Maxillofacial Research · doi:10.5037/jomr.2024.15305 · Cited by 3 · see citing works
Yang, G., Liu, A., Pan, J., Zhao, Y., Yu, L., Sun, L., Tong, X., Li, Y., & Liu, Y. (2025) · BMC Oral Health · doi:10.1186/s12903-025-06697-6 · Cited by 3 · see citing works
“This finding is consistent with preceding studies, which have affirmed that MAA effectively mitigate UA constriction, thereby substantively augmenting its volume [45, 46].”
InfluentialOğuz, F., Bor, S., Khanmohammadi, A., & Kıranşal, M. (2025) · Applied Sciences · doi:10.3390/app15052794 · Cited by 3 · see citing works
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
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
Büyükçavuş, M. H., Orhan, H., & Kocakara, G. (2020) · Atatürk Üniversitesi Diş Hekimliği Fakültesi Dergisi · doi:10.17567/ataunidfd.780079 · Cited by 3 · see citing works
Ishida, T., Manabe, A., & Ono, T. (2022) · Research Square · doi:10.21203/rs.3.rs-1505014/v1 · Cited by 3 · see citing works
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
Dave, R. D. (2023) · Archives of Dental Research · doi:10.18231/j.adr.2023.007 · Cited by 2 · see citing works
Tanaka, 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
“Li et al [30] used cone beam computed tomography to measure volume and cross-sectional area of the oropharyngeal airway before and after Twin-block treatment.”
MethodGuo, B., & Lu, R. (2020) · PubMed Central · doi:10.7518/hxkq.2020.04.012 · Cited by 2 · see citing works
“1%,患者常常伴有白天嗜睡、注意力不集中、睡 眠憋气、频繁觉醒等临床表现,严重影响人们的日 常生活[2]。OSAS的发病与颅颌面形态密切相关,其 中下颌发育的不足导致安氏II类错 畸形患者常伴 有上呼吸道的缩窄和软腭的易塌陷[3],而上气道的 狭窄是OSAS的主要病理机制。口腔矫治器能够通 过前导下颌一定程度上改变口咽部的阻力,从而改 善OSAS患者的临床症状。有研究[4]报道,在骨性II 类错 畸形患者中,垂直向不调者占50%~60%。本 文以伴骨性II类错 畸形的OSAS患者为研究对象, 旨在通过锥形束CT(cone beam CT,CBCT)比较 研究口腔矫治器治疗前后,不同垂直骨面型患者口 咽气道三维形态的变化特点,希望有…”
Airway-centric Orthodontics: A Narrative Review of Current Evidence and Clinical Implications
Hussein, L. M., & Kadhum, A. S. (2026) · European Journal of Dentistry · doi:10.1055/s-0046-1824593 · Cited by 1 · see citing works
Cone beam computed tomography (CBCT) in pediatric dentistry
Theys, S., & Olszewski, R. (2022) · NEMESIS Negative effects in medical science oral and maxillofacial surgery · doi:10.14428/nemesis.v25i1.67713 · Cited by 1 · see citing works
Dental sleep medicine: A comprehensive overview
Bhad, W. A., Baheti, N., Chavan, S. J., & Sonwane, S. (2020) · IP Indian Journal of Orthodontics and Dentofacial Research · doi:10.18231/j.ijodr.2020.013 · Cited by 1 · see citing works
Costello, C. J., Sambevski, J., Cheng, L. L., & Darendeliler, M. A. (2018) · Australasian Orthodontic Journal · doi:10.21307/aoj-2020-054 · Cited by 1 · see citing works
“Recent studies using two-dimensional or three-dimensional imaging have shown similar results.(19,20) This indicated that the use of SBTB could alter the sagittal dimension of the nasopharynx, similar to MAS used in OSA patients.”
MethodCone beam computed tomography: A newer avenue in orthodontic diagnosis and treatment planning
Tilekar, N. R., Swami, V., Sabane, A., Shinde, S., & Sable, R. (2017) · International Journal of Orthodontic Rehabilitation · doi:10.4103/ijor.ijor_8_17
“Li et al.[19] studied the morphological changes of upper airway after twin block treatment in thirty growing patients with Class II division 1 malocclusion and mandibular retrusion compared with untreated Class II patients by CBCT.”
BackgroundMethodOrthodontische diagnostiek en behandeling van OSAS bij kinderen
Remmelink, H. J. (2017) · Bohn Stafleu van Loghum eBooks · doi:10.1007/978-90-368-1784-4_6
Polat, M. Y., Çeylan, İ., & Polat, M. E. (2019) · Harran Üniversitesi Tıp Fakültesi Dergisi · doi:10.35440/hutfd.626686
Dong, J., Zhang, Y., Shi, Q., Lin, F., Hu, R., Wang, Y., & Zheng, H. (2021) · Research Square · doi:10.21203/rs.3.rs-154227/v1
“[10] Moreover, enlargement in the oropharynx and hypopharynx airway dimensions was also observed following Twin block treatment [11].”
BackgroundOrthodontic Treatment and Voice and Wind Instrument Performance
Hamdan, A., & Trollinger, V. L. (2021) · Springer eBooks · doi:10.1007/978-3-030-69109-7_11
Lago, C., Cordeiro, J. F. B., Klüppel, L. E., Sebastiani, A. M., & Scariot, R. (2022) · Research Society and Development · doi:10.33448/rsd-v11i1.25238
Advances in the Study of Upper Airway Characteristics in Children with Malocclusion
<p>Yanli Mo<sup>1, 2. (2022) · International Journal of Frontiers in Medicine · doi:10.25236/ijfm.2022.040902
Gupta, C., Ramegowda, S., & S, S. K. (2022) · GLOBAL JOURNAL FOR RESEARCH ANALYSIS · doi:10.36106/gjra/0301622
GENÇ, E. E., Karaman, A., & Püskül, G. (2022) · Journal of Dentistry Indonesia · doi:10.14693/jdi.v29i3.1411
Дрогомирецька, М. С., & Садек, А. С. М. (2023) · Scientific and practical journal Stomatological Bulletin · doi:10.35220/2078-8916-2023-48-2.21
Дрогомирецька, М. С., Sadeq, A., Dienha, O. V., Pyndus, T. O., Vyshnevska, H. O., Шнайдер, С. А., & Dorosh, I. V. (2023) · World of Medicine and Biology · doi:10.26724/2079-8334-2023-3-85-61-65
Ishida, T., Manabe, A., & Ono, T. (2024) · Cureus · doi:10.7759/cureus.70741
“We believe that our results further support the previous reports that the functional appliances used in orthodontic treatment, such as TB or MPA, promote not only maxilla-mandibular growth but also UA growth [18,22,23].”
ResultEvaluation of Changes in Airway Dimensions with Twin Block Therapy in Class II Malocclusion
Suresh, K. R., Peedikayil, F. C., Kottayi, S., Sreedharan, A., Aravind, A., & Ramesh, A. (2025) · Journal of Primary Care Dentistry and Oral Health · doi:10.4103/jpcdoh.jpcdoh_45_24
Võ, T. T. H., Thị, K. L. T., Nguyễn, A. C., Vũ, H. T., Phạm, T. T. H., Tạ, T. A., Phan, T. B. H., & Phạm, T. N. (2025) · VietNam Military Medical Unisversity · doi:10.56535/jmpm.v50i5.1179
Barreto, L. S. D. C., das Neves, B. M., Kühlman, D. C., Palomares, N. B., Carvalho, F., Suh, H., Bianchi, J., Oh, H., Batista, K. B. D. S. L., & Miguel, J. A. M. (2025) · CRANIO® · doi:10.1080/08869634.2025.2601531
“Additional reference planes were established for enhanced spatial accuracy [36]: the Sella Horizontal Plane, defined as the plane passing through the Sella point parallel to the FH plane, and the Sella Perpendicular Plane, defined as the plane passing through the Sella point parallel to the Frontal…”
Pradhan, T., Joseph, A. S., & Sethia, A. (2025) · Journal of Orofacial Sciences · doi:10.4103/jofs.jofs_143_25
Milia, O. M., Moreno, M. M., de la Cruz-Vigo, S., & Lopez-Jimenez, A. (2026) · Dentistry Journal · doi:10.3390/dj14100648
“More recent studies have incorporated three-dimensional CBCT techniques, as in the cases reported by Duan [21], Khurdal [22], Yildirim [23], Li [24] and Kumar [25].”
Semi-Supervised Airway Segmentation in CBCT Using an Enhanced No-New-Net Framework
Lin, Y.-K., Chang, W.-P., Hsu, H.-J., & Yang, W.-L. (2026) · doi:10.3390/engproc2026159016
- Authors
- Li, L., Liu, H., Cheng, H., Han, Y., Wang, C., Chen, Y., Song, J., & Liu, D.
- Affiliations
- Shandong University (CN)
- Stomatological Hospital of Chongqing Medical University (CN)
- Corresponding author
- Song, Jinlin
- Liu, Dongxu
- Venue
- PLoS ONE
- Publisher
- Public Library of Science (PLoS)
- Published
- 2014-04-04
- Volume
- 9
- Issue
- 4
- Pages
- e94378
- ISSN
- 1932-6203 (ISSN-L)
- PMC
- PMC3976395
- OpenAlex
- W2037928859
- Cited by
- 92
- References
- 33
- Citations by year
- 2026: 3 · 2025: 8 · 2024: 5 · 2023: 12 · 2022: 10 · 2021: 8 · 2020: 11 · 2019: 10 · 2018: 5 · 2017: 7 · 2016: 7 · 2015: 6
- FWCI
- 9.73
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- PLoS ONE (publishedVersion, cc-by)
- Europe PMC (PubMed Central) (publishedVersion, cc-by)
- PubMed Central (publishedVersion, cc-by)
- PubMed (publishedVersion)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion)
- Funders
- Shandong University
- Topics
- Health Sciences › Dentistry › Orthodontics › Orthodontics and Dentofacial Orthopedics
- Health Sciences › Dentistry › Oral Surgery › Dental Radiography and Imaging
- Health Sciences › Medicine › Surgery › Nasal Surgery and Airway Studies
- Keywords
- Twin Block appliance, Class II division 1 malocclusion, mandibular retrusion, upper airway morphology, oropharynx, hypopharynx, nasopharynx, hyoid bone position, mandibular advancement, orthodontic treatment, growing patients, cone-beam computed tomography
- MeSH terms
- Child, Female, Humans, Hypopharynx, Male, Malocclusion, Angle Class II, Nasopharynx, Oropharynx, Case-Control Studies, Treatment Outcome, Cone-Beam Computed Tomography, Retrognathia
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