Download Relation of Pharynx with Orofacial Structures in Jaipur (India

JIOS
10.5005/jp-journals-10021-1038
ORIGINAL ARTICLE
Relation of Pharynx with Orofacial Structures in Jaipur (India) Population Exhibiting Normal Occlusion with Respect to Sex
Relation of Pharynx with Orofacial Structures in
Jaipur (India) Population Exhibiting Normal
Occlusion with Respect to Sex:
A Cross-sectional Study
1
Vijay Agarwal, 2Y Giridhar Reddy, 3Sandhya Jain, 4Vinod Goyal, 5Tina Chugh
ABSTRACT
Objective: To investigate the relation of pharynx with orofacial structures in Jaipur (India) population exhibiting normal occlusion with
respect to sex.
Materials and Methods: The relation of pharynx with orofacial structures was examined on the lateral cephalometric head films of 180
subjects, 90 males and 90 females. The age groups of the subjects were between 15 to 25 years. The effect of sex on the pharyngeal
parameters was analyzed by means of variance analysis (ANOVA).
Results and Conclusion: It was observed that five measurements Ba-PNS, apw2-ppw2, t-ppw, hy-apw2 and Ho perp. to ANS-PNS plane
were different for males and females.
Keywords: Pharynx, Orofacial structures, Cephalogram.
How to cite this article: Agarwal V, Reddy YG, Jain S, Goyal V, Chugh T. Relation of Pharynx with Orofacial Structures in Jaipur (India)
Population Exhibiting Normal Occlusion with Respect to Sex: A Cross-sectional Study. J Ind Orthod Soc 2011;45(4):207-211.
INTRODUCTION
The pharynx is a tube-shaped structure formed by muscles and
membranes. It is located behind the nasal and oral cavities and
the larynx, and extends from the cranial base to the level of the
sixth cervical vertebra and the lower border of the cricoid
cartilage. Its length is approximately 12 to 14 cm and it is divided
into three parts: Nasopharynx, oropharynx and laryngopharynx.
The nasopharynx, forming the upper part of the respiratory
system, is situated behind the nasal cavity and above the soft
palate. Anteriorly, it is connected with the nasal cavity and
posteriorly, it continues downward as the oropharynx. The
oropharynx, opening into the oral cavity by an isthmus, extends
from the second cervical vertebra to the fourth cervical vertebra.
The laryngopharynx joins the oropharynx at the level of
pharyngoepiglottic fold and the hyoid, and then it continues to
the level of the sixth cervical vertebra.1,2
1,5
Senior Lecturer, 2,3Professor and Head, 4Reader
Department of Orthodontics, NIMS Dental College, Jaipur
Rajasthan, India
3
Department of Orthodontics, Government Dental College, Indore
Madhya Pradesh, India
1,2,4,5
Corresponding Author: Vijay Agarwal, Senior Lecturer
Department of Orthodontics, 148, Guru Nanak Pura, Raja
Park, Adarsh Nagar, Jaipur-302004, Rajasthan, India
e-mail: [email protected]
Received on: 20/9/11
Accepted after Revision: 14/10/11
The nasopharynx and the oropharynx have significant
locations and functions because both of them form part of the
unit in which respiration and deglutition are carried out. Because
of the close relationship between the pharynx and the dentofacial
structures, a mutual interaction is expected to occur between
the pharyngeal structure and the dentofacial pattern, and
therefore justifies orthodontic interest. A significant relationship
exists between airway space and facial morphology,3 also,
airway space may be affected by conditions such as functional
anterior shifting,4 head posture,5 sagittal skeletal relation6 and
maxillary protraction.7
Studies involving the pharyngeal space relation are
somewhat limited in orthodontic literature, and most of them
are related to obstructive sleep apnea. Till date no such
cephalometric study has been done in Jaipur population. So,
this study was undertaken to establish the norms of different
pharyngeal parameters with lateral cephalograms in Jaipur
population, and to compare different pharyngeal parameters
between male and female.
The aims of the study were as follows:
1. To establish the norms of different pharyngeal parameters
in Jaipur (India) population.
2. To evaluate and compare the relation of pharynx with
orofacial structures between male and female.
MATERIALS AND METHODS
This study included lateral cephalometric radiographs of 90
male and 90 female subjects. About 1500 subjects from various
colleges and schools were screened for the collection of sample
and a team of a laymen, an artist, a general dentist and a senior
The Journal of Indian Orthodontic Society, October-December 2011;45(4):207-211
207
Vijay Agarwal et al
orthodontist selected 180 subjects. Before participation in the
study, written informed consents were given by the parents of
subjects or by the subjects themselves. General dentist and
layman screened 200 subjects out of 1500 subjects on the basis
of well-balanced facial profile. Photographs of these individuals
were shown to orthodontist who selected 185 good looking
photographs. Finally, artist selected 180 subjects from them.
The selection criteria of the subjects:
1. Jaipur subjects, age ranging from 15 to 25 years.
2. Average built without any physical deformity.
3. Subjects without any facial asymmetry and/or mandibular
deviation.
4. Angle Class I molar relation and canine relation.
5. Presence of all permanent teeth from second permanent
molar to second permanent molar in both the arches.
6. Overjet and overbite < 3 mm.
7. Absence of crowding, rotation, dental/skeletal protrusions,
crossbite, dental asymmetry, ectopic eruptions,
supernumerary teeth, retained deciduous teeth and deep
curve of Spee.
8. No history of previous orthodontic treatment.
9. Breathe comfortably through the nose.
10. Absence of any deglutition, visual or hearing disorder.
11. Absence of any wound, burn and scar tissue in the neck
region.
selected cephalograms were traced twice by the same operator
to evaluate the reliability and reproducibility of landmarks and
measurements. Minimal errors indicated that the measurements
were reliable.
Statistical Analysis
The different measurements were measured from the tracing of
cephalograms of 180 subjects and then tabulated. Arithmetic
mean and standard deviation values were calculated for each
measurement. Group differences were analyzed with one-way
analysis of variance (ANOVA). Twelve linear measurements
were used to assess the pharyngeal structures.
CEPHALOMETRIC LANDMARKS (FIG. 1)
•
S (Sella)
•
Ba (Basion)
•
Ho (Hormion)
•
ptm
•
ad1
•
ad2
•
•
ANS
PNS
•
t
Radiographic Technique
•
ppw
The lateral cephalograms were taken with the sagittal plane at
a right angle to the path of the X-rays; the Frankfort plane was
parallel to the horizontal plane, the teeth were in centric
occlusion, and the lips were lightly closed. Kodak X-ray films
(8" × 10") were exposed at 70 kVp; 30 mA from a fixed distance
of 60 inches for 2 seconds in the Department of Orthodontics
and Dentofacial Orthopedics, NIMS Dental College, Jaipur.
The lateral cephalograms obtained were traced on acetate
tracing sheets of 0.5 micron thickness with a sharp 4H pencil
on a view box, using transilluminated light in a dark room,
eliminating stray light. Angular and linear measurements were
obtained nearest to 0.5° and 0.5 mm by ruler scale and
protractor.
All radiographs were traced manually, and whole angular
and linear measurements were recorded by a single author and
were reviewed twice by other investigators for accurate
landmark identification. To eliminate error, 30 randomly
•
ppw1
•
ppw2
•
ppw4
•
apw2
•
apw4
•
cv2ia
•
cv3ia
•
cv4ia
•
hy
The following records were taken for all the subjects:
1. Lateral cephalograms
2. Models—Upper and lower
3. Facial photographs:
a. Front view
b. Right-side view
c. Left-side view
d. Teeth in occlusion, front view.
208
Midpoint of sella turcica, determined by
inspection
Lowermost point on anterior margin of
foramen magnum
Most inferior point of sphenooccipital
synchondrosis
Pterygomaxillary point. Most inferior
point on average of right and left outlines
of pterygomaxillary fissure
Point of intersection of posterior
pharyngeal wall and line ptm to Ba
Point of intersection of posterior
pharyngeal wall and line from ptm as
normal perpendicular to S-Ba
Tip of anterior nasal spine
Tip of posterior nasal spine of palatine
bone in hard palate
Dorsal tongue surface intersecting
occlusal plane
Posterior pharyngeal wall intersecting
occlusal plane
Posterior pharyngeal wall intersecting
with ANS-PNS line
Posterior pharyngeal wall intersecting
with cv2ia and hy
Posterior pharyngeal wall along line
intersecting cv4ia and hy
Anterior pharyngeal wall along line
intersecting cv2ia and hy
Anterior pharyngeal wall along line
intersecting cv4ia and hy
Most inferoanterior point on body of
second cervical vertebra
Most inferoanterior point on body of third
cervical vertebra
Most inferoanterior point on body of
fourth cervical vertebra
Most superior and anterior point on body
of hyoid bone
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Relation of Pharynx with Orofacial Structures in Jaipur (India) Population Exhibiting Normal Occlusion with Respect to Sex
LINEAR MEASUREMENTS (FIG. 2)
1
Ba-ad1
Distance between the Basion and lower
adenoid mass (ad1)
2
Ba-ad2
Distance between the Basion and upper
adenoid mass (ad2)
3
Ba-PNS
(depth of the
nasopharynx)
Distance between the Basion and PNS
4
ptm-ad1
(width of
lower adenoid
mass)
Distance between the pterygomaxillary
point and lower adenoid mass (ad1)
5
ptm-ad2
Distance between the pterygomaxillary
(width of upper point and upper adenoid mass (ad2)
adenoid mass)
6
PNS-ppw1
Distance between the posterior nasal
(nasopharyngeal spine and posterior pharyngeal wall 1
airway space)
7
apw2-ppw2
Distance between the anterior
(upper depth
pharyngeal wall 2 and posterior
of oropharynx) pharyngeal wall 2
8
apw4-ppw4
Distance between the anterior
(lower depth of pharyngeal wall 4 and posterior
oropharynx)
pharyngeal wall 4
9
hy-apw2
Distance between the hyoid and
anterior pharyngeal wall 2
10 hy-apw4
Distance between the hyoid and
anterior pharyngeal wall 4
11 t-ppw
Distance between the tongue to
posterior pharyngeal wall
12 Ho Perp. to
ANS-PNS
Distance between the hormion
perpendicular and ANS-PNS plane
ad1 and ad2
apw
ppw
—
—
—
Lower and upper adenoid masses
Anterior pharyngeal wall
Posterior pharyngeal wall
Fig. 1: Cephalometric landmarks
Fig. 2: Cephalometric landmarks and linear measurements
DISCUSSION
Pharyngeal Parameters
RESULTS
The present study was conducted on 180 lateral cephalograms
of subjects with normal occlusion. Each of 12 parameters was
measured in all 180 lateral cephalograms. The observations
collected for the parameters were subjected to various statistical
analyses. The data thus obtained was used to study any
relationship of these parameters between males and females
(Table 1).
According to ANOVA results, statistically significant
differences were found in Ba-PNS, apw2-ppw2, hy-apw2,
t-ppw and Ho perpendicular to ANS-PNS.
Good compatibility for age and sex was observed in the present
cross-sectional study. Because only healthy pharyngeal subjects
with Class I malocclusion were selected, we estimated that the
nasopharyngeal airway space would reflect only natural
anatomic conditions without pathology. To eliminate the
influences of growth and aging, postpubertal subjects were
selected for the current study.
Malkoc et al8 has stated that cephalometric films are
significantly reliable and reproducible in determining airway
dimensions. When computed tomography (CT) and
cephalometric films were compared in subjects with skeletal
malocclusion, Cameron et al9 found a significant positive
The Journal of Indian Orthodontic Society, October-December 2011;45(4):207-211
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Vijay Agarwal et al
Table 1: Showing mean, standard deviation of pharyngeal parameters of male and female healthy subjects of Jaipur
S. no.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Parameters
Distance between the Ba and ad1 (Ba-ad1) mm
Distance between the Ba and ad2 (Ba-ad2) mm
Distance between the Ba and PNS (Ba-PNS) mm
Distance between the pterygomaxillary point and ad1 (ptm-ad1) mm
Distance between the pterygomaxillary point and ad2 (ptm-ad2) mm
Distance between the posterior nasal spine and ppw1 (PNS-ppw1) mm
Distance between the apw2 and ppw2 (apw2-ppw2) mm
Distance between the apw4 and ppw4 (apw4-ppw4) mm
Distance between the hy and apw2 (hy-apw2) mm
Distance between the hy and apw4 (hy-apw4) mm
Distance between the t and ppw (t-ppw) mm
Distance between the ho perpendicular and
ANS-PNS plane (Ho Perp. to ANS-PNS) mm
N
Male
Mean
SD
N
Female
Mean
SD
90
90
90
90
90
90
90
90
90
90
90
90
24.35
37.34
52.03
21.04
13.95
27.23
15.65
16.00
24.99
21.61
20.70
21.42
3.723
3.992
3.647
3.827
3.642
4.022
3.714
3.873
5.182
3.223
2.015
2.098
90
90
90
90
90
90
90
90
90
90
90
90
23.32
36.40
47.62
20.83
13.85
26.13
13.14
15.58
19.97
17.56
18.77
19.38
3.714
3.725
3.393
3.795
3.458
4.168
3.245
2.854
3.974
2.059
2.242
2.381
From the above sample’s observations we conclude that M1 ≠ M2 and there is much significant difference between male and female and the
average statistic for male is much greater than female at any level of significance.
H0: M1 = M2 = M3; H1: M1 ≠ M2 ≠ M3
relationship between nasopharyngeal airway size on
cephalometric films and its true volumetric size as determined
from CBCT scan in adolescents.
Distance between Ba-ad1 and Ba-ad2 was 23.71 and 36.87
mm respectively. Males and females did not show any
significant difference in both parameters.
Distance between Ba-PNS (anteroposterior size of the
posterior pharyngeal wall) was more in male subjects than
female.
Subtelny10 found that the nasopharyngeal depth was constant
from infancy to maturity in female but increased moderately
from 3 years, 9 months to maturity in males.
Distance between ptm-ad1, ptm-ad2 and PNS-ppw1 was
not affected by sex. This finding is supported by study of Kerr11
who investigated that there was a low correlation between the
nasopharyngeal and dentofacial structures when the nasal
function was normal.
The study of Ceylan and Oktay12 stated that the majority of
pharyngeal parameters in different ANB angle cases do not show
any difference.
Distance between apw2-ppw2 and apw4-ppw4: Distance
between apw2-ppw2 was more in male (16.65 mm) subjects
than female subjects (13.14 mm).
Distance between hy-apw2 and hy-apw4: Distance between
hy-apw2 and hy-apw4 was 24.99 and 21.611 mm for male
subjects which was much higher than female measurements
(19.97 mm and 17.56 mm respectively).
The study done by Ceylan and Oktay12 on the pharyngeal
size in different skeletal pattern also showed that two pharyngeal
parameters hy-apw2 and t-ppw showed significant difference
between the sexes.
Distance t-ppw for males and females differed significantly.
Mean value of distance t-ppw for male was 20.70 mm and in
female it was 19.73 mm.
Ho perp. to ANS-PNS plane for male (21.422 mm) was
greater than female (19.388 mm).
Studies involving the pharyngeal space relation are
somewhat limited in orthodontic literature, and most of them
210
are related to obstructive sleep apnea. As we know that different
growth patterns have different facial types [Schudy,13 Popovich
and Thompson,14 Siriwat and Jarabak,15 Bishara and Jacobson16]
so there is a possibility that pharynx which has a close proximity
to dentofacial structure could also affect them. There might be
a mutual interaction between them. Joseph et al17 reported that
the nasopharyngeal airway in hyperdivergent individuals was
significantly narrower than that in normodivergent individuals.
However, they suggested that this difference occurred because
of the relative bimaxillary retrusion exhibited by the
hyperdivergent group. Significant differences in craniofacial
morphology and orofacial airway dimensions of Class I subjects
with different growth patterns were identified by Faruk Izzet
Ucar and Tancan Uysal.18
CONCLUSION
Statistically significant differences were identified in following
craniofacial measurements among Class I subjects with different
sex: Ba-PNS, apw2-ppw2, t-ppw, hy-apw2 and Ho perp. to
ANS-PNS.
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