Original Article

Effect of Class III bone anchor treatment on airway

Tung Nguyena; Hugo De Clerckb,c; Michael Wilsond; Brent Goldene
ABSTRACT
Objectives: To compare airway volumes and minimum cross-section area changes of Class III
patients treated with bone-anchored maxillary protraction (BAMP) versus untreated Class III
controls.
Materials and Methods: Twenty-eight consecutive skeletal Class III patients between the ages of
10 and 14 years (mean age, 11.9 years) were treated using Class III intermaxillary elastics and
bilateral miniplates (two in the infra-zygomatic crests of the maxilla and two in the anterior
mandible). The subjects had cone beam computed tomographs (CBCTs) taken before initial
loading (T1) and 1 year out (T2). Twenty-eight untreated Class III patients (mean age, 12.4 years)
had CBCTs taken and cephalograms generated. The airway volumes and minimum crosssectional area measurements were performed using Dolphin Imaging 11.7 3D software. The
superior border of the airway was defined by a plane that passes through the posterior nasal spine
and basion, while the inferior border included the base of the epiglottis to the lower border of C3.
Results: From T1 to T2, airway volume from BAMP-treated subjects showed a statistically
significant increase (1499.64 mm3). The area in the most constricted section of the airway (choke
point) increased slightly (15.44 mm2). The airway volume of BAMP patients at T2 was
14136.61 mm3, compared with 14432.98 mm3 in untreated Class III subjects. Intraexaminer
correlation coefficients values and 95% confidence interval values were all greater than .90,
showing a high degree of reliability of the measurements.
Conclusion: BAMP treatment did not hinder the development of the oropharynx. (Angle Orthod.
2015;85:591596.)
KEY WORDS: Skeletal anchorage; Airway; Class III

INTRODUCTION

headgear with or without rapid palatal expansion and/

or chin cup therapy in the early to mixed dentition.3 The
main effects of these treatment modalities were more
dentoalveolar than skeletal in nature, with a significant
chance of relapse to reverse overjet once mandibular
growth is completed. With the introduction of boneanchored maxillary protraction (BAMP), both maxillary
protraction and restraint of mandibular growth with
minimal dentoalveolar change is now possible. BAMP
restricts the forward growth of the mandible through a
combination of closure of the gonial angle, distalization
of the ramus, and posterior positioning of the condyles
with corresponding remodeling of the glenoid fossa.46
Recent studies have shown that mandibular setback surgery to correct Class III malocclusion results
in a significant decrease to oropharyngeal and
hypopharyngeal airway volumes.7,8 This is of major
concern since narrowing of the oropharynx is major
risk factor for the development of obstructive sleep
apnea (OSA).8 Initial studies correlating airway space
reduction with OSA used two-dimensional (2D) cephalometric films and were often considered controver-

The prevalence of Class III malocclusion is only 1%

to 3% in whites but can be as high as 4% to 14% in
some Asian populations.1,2 Limited and even shortlived success has been achieved using reverse-pull
Assistant Professor, Department of Orthodontics, School of
Dentistry, University of North Carolina, Chapel Hill, NC.
b
Adjunct Professor, Department of Orthodontics, School of
Dentistry, University of North Carolina, Chapel Hill, NC.
c
Private practice, Brussels, Belgium.
d
Dental student, School of Dentistry, University of North
Carolina, Chapel Hill, NC.
e
Assistant Clinical Professor, Department of Oral Maxillofacial
Surgery, School of Dentistry, University of North Carolina,
Chapel Hill, NC.
Corresponding author: Dr Tung Nguyen, Department of
Orthodontics, University of North Carolina, 264 Brauer Hall,
CB #7450, Chapel Hill, NC 27516
(e-mail: nguyent@dentistry.unc.edu)
a

Accepted: August 2014. Submitted: May 2014.

Published Online: September 23, 2014
G 2015 by The EH Angle Education and Research Foundation,
Inc.
DOI: 10.2319/041614-282.1

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NGUYEN, CLERCK, WILSON, GOLDEN

Table 1. Demographic and Statistical Comparison for BAMP and Untreated Class III Controlsa
Measurement

BAMP Mean

SD

Control Mean

SD

P Value

Significance

Age, y
SNA, u
SNB, u
ANB, u
Wits, mm
MPA (SN-GoMe)
U1-SN, u
L1-MP, u

11.88
81.22
81.96
20.74
24.20
33.33
108.06
86.10

1.15
4.13
4.81
1.63
2.61
5.41
7.70
6.51

12.35
81.17
81.52
20.35
23.93
35.52
107.39
85.15

1.22
3.79
4.04
2.15
2.5
5.56
6.50
7.49

.159
.932
.674
.429
.756
.150
.777
.642

NS
NS
NS
NS
NS
NS
NS
NS

BAMP indicates bone-anchored maxillary protraction.

sial because the film captured only a small cross

section of the overall airway volume. Recently, airway
studies have incorporated the use of cone beam
computed tomography (CBCT) to assess the upper
airway anatomy because CBCT offers numerous
advantages when compared with lateral cephalograms,
including volumetric rather than linear measurements,
distortion-free measurements, and measurements that
are independent of head positioning.911 Although the
predictive factors for the development of OSA are
multifactorial, 3D airway studies have supported the
findings that a decrease of airway volume and minimum
cross-sectional area (choke point) are key contributors
in the development of OSA.1214
The prevalence of pediatric OSA has increased in
recent years, with an estimated 2% to 3% of US
children affected.15,16 Because BAMP corrects Class III
malocclusion partially by a mechanism of mandibular
restraint, it is important to determine whether or not
this treatment modality will affect airway development
in growing children. The aim of this study is to compare
airway volumes and minimum cross-section area
changes of Class III patients treated with BAMP
versus untreated Class III controls. The null hypothesis
is that BAMP treatment decreases oropharyngeal
airway.

duration of the T1T2 interval was 1.2 years. The

mean age for the control group was 12.4 6 1.2 years.
The study was approved by the University of North
Carolina Committee for Research on Human Subjects
(12-1496).
BAMP Orthopedic Protocol
BAMP subjects had four miniplates placed, two in
the infra-zygomatic crest of the maxillary buttress and
two between the mandibular lateral incisors and
canines. Small mucoperiosteal flaps were elevated,
and the modified miniplates (Bollard, Tita-Link, Brussels, Belgium) were secured to the bone by two
(mandible) or three (maxilla) screws (2.3-mm diameter, 5-mm length). The extensions of the plates
perforated the attached gingiva near the mucogingival
junction. Three weeks after surgery, the miniplates
were loaded using Class III elastics applied at an initial
force of 100 g on each side (Figure 1). The force was
increased to 200 g after 1 month of traction and to
250 g after 3 months. The patients were asked to
replace the elastics at least once a day and to wear
those 24 hours per day. In cases with increased
overbite, a removable bite plate was inserted in the
upper arch to eliminate occlusal interference in the

MATERIALS AND METHODS

Subjects
Twenty-eight consecutive patients treated with
BAMP (14 girls and 14 boys) were enrolled in the
study. The untreated Class III control group consisted
of 29 patients (16 girls, 12 boys). All subjects had
Class III malocclusion in the mixed or permanent
dentitions characterized by an anterior crossbite or
incisor end-to-end relationship, Class III molar relationship, and Wits appraisal of 21 mm or less
(Table 1). All patients were of white ancestry, with a
prepubertal stage of skeletal maturity according to the
cervical vertebral maturation method (CS1CS3). The
mean age at T1 for the BAMP sample was 11.9 6
1.2 years, and it was 13.1 6 1.1 years at T2. The mean
Angle Orthodontist, Vol 85, No 4, 2015

Figure 1. Elastic traction is applied from the upper bone plates to the
lower bone plates for 24 hours a day over a period of 1 year.

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EFFECT OF BAMP ON AIRWAY VOLUME

Figure 2. Surface models are oriented to Frankfort horizontal/

transverse planes using the following reference lines: (A) porion
orbitale in the sagittal view, (B) trans-orbitale in the coronal view, and
(C) Crista Gallimiddle of basion in the transverse view.

incisor region until correction of the anterior crossbite

was obtained.
Image Analysis Protocol
CBCT scans were acquired using an iCAT machine
at a resolution of 0.3 mm 3 0.3 mm 3 0.3 mm
(Imaging Sciences International, Hatfield, Penn) with a
20-second scan time and a 16-cm 3 22-cm field of
view using software (Dolphin 3D 11.7, Dolphin
Imaging, Chatsworth, Calif). The scans were taken in
maximal intercuspation. Attempts were made to
standardize inspiration/expiration capture on all subjects. The CBCT volume was oriented with the inferior
orbital rim of the left and right orbits parallel to true

Figure 4. Three-dimensional image of a segmented airway from

bone-anchored maxillary protractiontreated patient. The volume of
the hypopharynx is shown, while the minimum cross-section area
(choke point) is designated as the circle.

horizontal in the frontal view and the porion to orbitale

line (Frankfurt horizontal plane) parallel to true
horizontal in the sagittal view (Figure 2). Two-dimensional cephalograms were generated from the CBCTs
and digitized. Using the airway autosegmentation
feature in the midsagittal view, a line connecting the
most posterior point of the bony nasal spine to basion
defined the superior border, and a line from the inferior
edge of C3 to the base of the epiglottis defined the
inferior border (Figure 3). Once the borders were
defined, 3D models of the airway were constructed.
The constructed airway volume, midsagittal airway
area, and transverse minimum cross-sectional area
were computed from the 3D models (Figure 4). The
DICOM files were also used to create lateral cephalograms for both the T1 and T2 BAMP group using
Dolphin Imaging (version 11.7, Dolphin Imaging).
Cephalometric films were traced by one examiner.
Ten randomly selected cephalograms were retraced
1 week later. Measurement accuracy was assessed by
using intraclass correlation coefficients, which were
between .90 and .98 for all measurements.
Statistical Analysis

Figure 3. Borders of airway volume are shown. The superior border

includes the most posterior point of the bony posterior nasal spine to
basion, while the inferior border is defined by a line from the inferior
edge of C3 to the base of the epiglottis.

Data analysis was conducted using the SPSS

statistical software package (version 12.0; SPSS,
Chicago, Ill). Descriptive statistics were calculated for
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NGUYEN, CLERCK, WILSON, GOLDEN

Table 2. Descriptive Statistics for Bone-Anchored Maxillary Protraction T1T2 Cephalometric Changes

Mean
SD

D SNA, u

D SNB, u

D ANB, u

D Wits, mm

D MPA, u

D U1-SN, u

D L1-MP, u

2.23
1.45

20.97
1.20

3.20
1.61

5.49
2.19

20.94
1.36

0.52
3.10

2.01
1.73

T1, T2 subjects and untreated controls to describe

their skeletal and dental characteristics. T1 and T2
longitudinal airway changes for the BAMP group were
assessed using a paired t-test. Differences between
the T2 BAMP group and untreated Class III controls
were assessed using independent t-test. Statistical
significance was tested at P , .05. Repeated
measurements on 30 randomly selected subjects were
made after 1 week by an examiner, and intraexaminer
correlation coefficients (ICCs) were used to evaluate
the reliability of repeated measures. A one-sample ttest was performed on duplicate measurements to test
for systematic errors.

against untreated Class III controls, there was no

statistical difference between the groups (BAMP 5
14,432.98 mm3, 674.36 mm2, and 174.56 mm2; control
5 14,560.33 mm3, 643.67 mm2, and 170.94 mm2;
Table 4).
ICC values and 95% confidence intervals of the ICC
for each linear and angular measurement are reported
in Table 5. All variables had ICC values greater than
.90, showing high levels of reliability. A one-sample ttest showed (1) no significant difference between the
repeated measurements and (2) the within-subject
error is small enough, relative to between-subject
variability, indicating no systematic bias.

RESULTS

DISCUSSION

Descriptive statistics for T1 BAMP subjects and

untreated Class III control patients are summarized in
Table 1. Patients were well matched with regard to
age, skeletal classification (SNA, SNB, and ANB),
incisal angulation (U1-SN) and (L1-MP), and mandibular plane angle (SN-GoMe). The average age of
BAMP subjects at T1 was 11.9 years, compared with
12.4 years for untreated Class III controls. Table 2
shows skeletal changes resulting BAMP treatment.
The SNA increased by 2.23u, SNB decreased by
0.97u, and the average Wits correction was 5.49 mm.
In addition, the mandibular plane angle decreased by
0.94u.
From our previous study, we have shown that BAMP
was effective in restraining mandibular growth46;
however, the restraint of anterior-posterior growth of
the mandible did not appear to affect the development
of the oropharynx. The mean airway volume of the
oropharynx showed a statistically significant increase
from T1 (12,636.89 mm3) to T2 (14,136.61 mm3;
Table 3). The midsagittal area showed a statistically
significant increase, and the minimum cross-sectional
area increased slightly from 148.21 mm2 to 163.65 mm2,
although this was not statistically significant. When we
compared the posttreatment BAMP airway volume,
midsagittal area, and minimum cross-sectional area

The effects of Class III orthopedics on airway

development have been extensively studied in the
literature, with conflicting results. Some have reported
short- and long-term improvements of nasopharyngeal
and upper airway space following maxillary protraction.17,18 Kaygisiz et al.18 found that the improved
airway dimensions obtained from face mask treatment
were retained 4 years posttreatment. Others, including
Baccetti et al.,19,20 have reported no difference in
nasopharyngeal or oropharyngeal airway dimensions
between face mask subjects and untreated controls.
Studies on chin-cup therapy have also reported similar
findings. Tuncer et al.21 examined airway dimensions
in an adolescent population following chin-cup therapy.
Although chin-cup subjects had significant downward
and backward rotation of the mandible, the rotation
had no impact on oropharyngeal airway dimensions.
However, these studies had limitations because they
use 2D lateral cephalograms for airway. CBCTs have
been shown to be more accurate in measuring airway
volume and are not prone to the distortion or position
errors that can occur with 2D imaging.2224 Furthermore, CBCT scans report 3D volumes rather than 2D
regions, which might not reflect the true anatomic
structure of interest. Our 3D study showed an increase
in airway volume, sagittal dimension, and minimum

Table 3. Statistical Comparison of T1 and T2 Airway Measurementsa

Volume, mm
Midsagittal area, mm2
Min cross-sectional area, mm2

T1 BAMP Mean

SD

T2 BAMP Mean

SD

P Value

Significance

12,636.98
616.68
148.21

3531.12
133.03
54.19

14,136.61
674.36
163.65

3761.73
121.81
64.22

.027
.004
.160

*
**
NS

BAMP indicates bone-anchored maxillary protraction.

* P , 0.05, * P , 0.005, NS indicates not significant.

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EFFECT OF BAMP ON AIRWAY VOLUME

Table 4. Statistical Comparison of T2 BAMP vs Control Airway Measurements

Volume, mm
Midsagittal area, mm2
Min cross-sectional area, mm2
a

T2 BAMP Mean

SD

Control Mean

SD

P Value

Significance

14,136.61
674.36
163.65

3761.73
121.81
64.22

14,560.33
643.67
170.94

5742.14
136.19
83.25

.816
.281
.582

NS
NS
NS

BAMP indicates bone-anchored maxillary protraction.

cross-sectional area (choke point) in patients treated

with the BAMP protocol. Furthermore, posttreatment
airway measurements from BAMP subjects were
comparable with untreated Class III controls, indicating
that the orthopedic growth modification to redirect
mandibular growth in a posterior direction did not
hinder airway development. A limitation of this study is
the lack of T1 control samples. Ideally, comparing
volumetric changes over the same treatment duration
between BAMP-treated subjects and untreated Class
III controls would provide a more meaningful comparison, but ethical considerations regarding additional
radiation dosage to untreated subjects precluded this.
However, comparing airway volumes between wellmatched (age and skeletal classification) BAMP and
untreated Class III controls allows us to evaluate if the
increase in airway of the BAMP group was equivalent
to natural growth in Class III subjects.
In addition to redirecting mandibular growth in a
posterior direction, BAMP treatment produces significant protraction of the entire midface.25 It is possible
that midface protraction can increase airway volume,
especially in the upper segment of the oropharynx.
However, cephalometric studies have concluded that
while maxillary protraction increased the nasopharyngeal airway, it did not significantly affect the oropharynx.26,27 Mucedero et al.20 compared Class III patients
treated with protraction face mask, protraction face
mask with rapid palatal expansion, and untreated
controls. While there were statistically significant
skeletal improvements with the protraction groups
compared with the untreated Class III controls, there
was no difference in nasopharyngeal and oropharyngeal dimension between the groups. A recent 3D
CBCT study compared airway volumes of subjects
treated with protraction face mask and untreated
controls.27 They reported no significant change in the
oropharynx as a result of face mask treatment.
Interestingly, the authors noted that the oropharyngeal
Table 5. Intraclass Correlation Coefficient (ICC) with 95%
Confidence Interval (CI)

Volume
Midsagittal area
Minimum crosssectional area

ICC

Lower 95% CI

Upper 95% CI

.931
.963

0.836
0.890

0.971
0.988

.972

0.916

0.991

volume in the face mask group was smaller than in

untreated controls. This is the first study to compare
3D airway dimensions of BAMP-treated subjects and
untreated Class III controls.
An important consideration in airway studies is that
increases/decreases in airway dimension or 3D
volumes do not necessarily correlate with physiologic
function. Many factors during image acquisition can
affect the recorded volume of the airway, including
inspiration vs expiration, supine vs upright position,
neck flexure, and scan time. Airflow monitors remain
the gold standard for evaluating respiratory obstruction
and breathing efficiency. However, recent studies have
made strong correlations between the minimum crosssectional area of the oropharynx and OSA.12,13,25 Yucel
et al.28 reported that patients with severe OSA had the
narrowest cross-sectional area at the level of the uvula
in expiration. In our study, the choke point of the
oropharynx was consistently located at or slightly
above the level of the uvula. In addition, our study
showed that BAMP-treated subjects exhibited an
increased in choke point dimensions and that these
measurements were comparable with those of untreated Class III controls.
CONCLUSIONS
N Subjects treated with BAMP showed an increase in
airway volume and oropharyngeal dimensions.
N Furthermore, airway volume and minimum crosssectional area were similar for BAMP subjects and
untreated Class III controls.
ACKNOWLEDGMENTS
Supported by NIDCR D005215 and the American Association
of Orthodontics Foundation (AAOF).

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