Position of the Hyoid Bone in Anteroposterior Skeletal Patterns
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Hindawi
Journal of Healthcare Engineering
Volume 2021, Article ID 7130457, 5 pages
https://doi.org/10.1155/2021/7130457
Research Article
Position of the Hyoid Bone in Anteroposterior Skeletal Patterns
Rabia Bilal
Department of Orthodontics Faculty of Dentistry, Qassim University Kingdom of Saudi Arabia, Buraydah, Saudi Arabia
Correspondence should be addressed to Rabia Bilal; rabia.orthodontist@gmail.com
Received 13 June 2021; Revised 1 August 2021; Accepted 23 August 2021; Published 31 August 2021
Academic Editor: Osamah Ibrahim Khalaf
Copyright © 2021 Rabia Bilal. This is an open access article distributed under the Creative Commons Attribution License, which
permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Introduction. Hyoid bone plays a vital role in the craniofacial dynamics. From the maintenance of pharyngeal airway to phonation,
deglutition, and mandibular movements, it has multifactorial roles to fulfill. The hyoid bone has a spatial relationship with cranial
base, mandible, and cervical vertebrae. This study was performed to determine the position of the hyoid bone in different
anteroposterior growth patterns. Materials and Methods. 75 lateral cephalograms belonging to all three sagittal skeletal patterns
were evaluated in the study. The angular and linear measurements using 10 variables were made to determine the relationship of
the hyoid bone with different craniofacial structures. SPSS was used to calculate the descriptive statistics, mean, and standard
deviation of all the linear and angular variables. The analysis of variance (ANOVA) and post hoc test were used to compare the
means of linear and angular measurement and multiple comparisons, respectively, at p < 0.05 significance level. Results. There was
no significant difference in the mean angular measurements (NSH and MPH) between the 3 groups (p > 0.05). Also, the multiple
comparisons showed no significant difference between the linear measurements (H-FH, H-MP, H-H′, and H-N). However, there
was a significant difference in three linear measurements: H-Rgn, RGN-C3, and C3-H. The values were more in class III subjects,
compared to class I and class II. Conclusion. The linear millimetric distance between points H-RGN, RGN-C3, and C3-H which
determine the relationship and spatial position of the hyoid bone with the mandible and third cervical vertebrae was statistically
significant among groups. The values were more in class III subjects inferring the anterior position of the hyoid bone.
1. Introduction of the hyoid bone with cervicofacial structures are critically
investigated. This depicts the importance of hyoid in the
The hyoid bone is a small horseshoe-shaped solitary bone clinical orthodontics and dentofacial orthopedics [3].
located below the mandible anteriorly in the midline of the Studies have also shown that the change in the position of
neck. It connects the head and neck. It has a body, two lesser the hyoid bone is related to the changes in mandibular
horns, and two greater horns. The hyoid bone keeps the position during mandibular movements [4, 5]. The position
pharyngeal airway open during sleep, phonation, and de- of the hyoid bone was studied by Battagel et al., who
glutition. It helps during the movement of mandible and concluded that the hyoid bone was positioned more pos-
maintains the position of tongue. Moreover, due to its teriorly in class II subjects with narrow upper airways [6].
complex connection between the mandible and the cervical On the contrary, a more anteriorly positioned hyoid bone
spine, it maintains the posture of the head [1]. Despite not was seen in class III subjects when compared to class I [7].
having any bony connection, it joins with tongue, mandible, Literature also supports more the posteriorly placed hyoid
cranial base, thyroid cartilage, sternum, pharynx, and bone in class I horizontal patterns as compared to anteriorly
scapula through supra and infrahyoid muscles. Due to these placed in the class III pattern [8].
connections, any change in the position of these structures Studies performed on the relationship of the hyoid bone
might have an effect on the position of the hyoid bone [2]. with base of the skull and mandible demonstrated that the
There is wide ranging literature on the functional anatomy, position of the hyoid bone varied in relation to the anterior
morphological characteristics, and diagnostic significance of cranial base of the skull. The hyoid bone was placed back-
the hyoid bone. Also, the relationship and anatomic position ward in class II subjects, while it was forward placed in class2 Journal of Healthcare Engineering
III subjects [9]. Manual change in the position of the after an interval of one week from the first measurements,
mandible has also shown change in the position of the hyoid and intraclass correlation coefficient (ICC) between first and
bone. Surgical advancement of mandible resulted in anterior second measurements was calculated. The tracing and
positioning of the hyoid bone and widening of the minimal landmark identification showed consistency of 99%.
pharyngeal airway space [10], whereas surgical mandibular The angular measurements followed are shown in
setback was associated with posterior positioning of hyoid Figure 1.
and reduction of the sagittal dimensions of the oropha- The linear measurements followed are shown in Figure 2.
ryngeal airway space [11].
Lateral cephalogram was introduced by Broadbent in 3. Data Analysis
1931 and holds the colossal value in diagnostic and thera-
peutic orthodontics [12, 13]. Lateral cephalogram is a The data were analyzed using Statistical Package for Social
common tool used to measure the relationship and position Sciences (SPSS) version 22.0 (IBM Corp., Armonk, N.Y.,
of the hyoid bone with different anatomical structures of the USA). Descriptive statistics were used to calculate the fre-
head and neck [14]. Grabber suggested anatomical land- quency and percentage of different anteroposterior skeletal
marks on lateral cephalogram specific to the assessment of classes of the sample (Figure 3).
hyoid bone position. The linear measurements and angles Also, descriptive statistics were used to calculate mean
formed by joining those landmarks can help determine the and standard deviation of all the linear and angular variables
position of the hyoid bone in static and dynamic state; also, it (Table 1).
helps establish the relationship of the hyoid bone with the The analysis of variance (ANOVA) and post hoc Tuckey
surrounding soft and hard tissues of the face and neck [15]. test were used to compare the means of linear and angular
This study was performed to determine the position of measurement and multiple comparisons, respectively, at
the hyoid bone with reference to cranial base, maxilla, and p < 0.05 significance level.
mandible in anteroposterior plane in different horizontal
growth patterns. This will give an insight to the hyoid pattern 4. Results
in people of this region and will help in better understanding
of postural dynamics in clinical orthodontics. There was no significant difference in the means of angular
and linear measurements, except for three linear measure-
2. Materials and Methods ments, which are H-RGN, RGN-C3, and C3-H (Table 2).
The post hoc Tuckey intergroup comparison showed that
The study was approved by the Ethical Committee of College the class III group had increased the mean length of H-RGn,
of Dentistry, Qassim University (EA/6000/2017). The ret- RGn-C3, and C3-H as compared to class I and class II
rospective data were collected from the lateral cephalograms groups. The larger F values of these three linear readings also
of the patients who presented to OPD clinics for the purpose illustrate larger dispersion and variation in the class III
of consultation or treatment at College of Dentistry. All the group as compared to class I and class II, while there was no
75 lateral cephalograms were taken in a standardized significant difference in class I and class II groups.
manner in natural head position with Soredex Cranex D
panorex + ceph X-ray machine, Tuusula, Finland. 5. Discussion
All the selected cephalograms met the inclusion criteria,
i.e., normal vertical growth pattern, age between 14 and 24 The findings of this study do not suggest any statistically
years, and showing clear craniofacial landmarks. Those with significant difference in the angular measurements of NSH
obstructive sleep apnea had underwent or undergoing or- and MPH angles (p > 0.05). The NSH is the angle formed
thodontic/orthognathic surgical treatment, systemic disease, between the cranial base and hyoid bone; hence, it depicts
congenital abnormality, or history of orofacial trauma were the position of the hyoid bone with reference to the cranial
excluded from the study. The lateral cephalograms were base. The insignificant difference in this study suggests that
divided into three sagittal groups: class I, class II, and class the position of the hyoid bone remains unchanged in dif-
III on the basis of SNA, SNB, and ANB values. The ana- ferent anteroposterior patterns. Also, the value of the MPH
tomical landmarks were identified by putting the cephalo- angle (the angle between the hyoid bone and mandibular
grams on the X-ray view box. Cephalograms were manually plane) was insignificant, which shows there was no differ-
traced on the TruVision cephalometric acetate tracing sheet ence in backward and forward movement of the hyoid bone
(0.003″ thick, 8′x 10″ size) by Ortho Technology, Tampa, during the movement of lower jaw, although the bone is
Florida, USA, with lead pencil. Landmarks were identified, attached to the mandible through the suprahyoid muscles.
planes were drawn, and linear and angular measurements A study done by Amayeri showed different findings from
were measured by two different observers. Interobserver our study. His study concluded that the angular measure-
reliability was determined by using Cohen’s Kappa coeffi- ments of NSH and MPH differed with different facial pat-
cient. K � 0.88 (K < 1). The K value shows a good agreement terns. The hyoid bone moved backward in class II and
between the observers in identification of landmarks and moved forward in class III pattern [3]. Other studies also
measurement of planes and angles. showed class II subjects having a posteriorly placed hyoid
Intraobserver reliability was measured by asking the bone and class III subjects having the anteriorly placed hyoid
same observer to trace randomly selected 10 cephalograms bone [6, 7, 9]. These outcomes can be credited to the softJournal of Healthcare Engineering 3
tissue pull between the hyoid and mandibular bones, re-
sponsible for the forward and backward movement of the
N hyoid bone during the jaw movements.
S The insignificant difference between the values and
sagittal class in our study suggests there was perhaps no
P Or significant change in the position of the hyoid bone during
jaw movements. A study performed by Ingervall suggested
that though some agreement exists on the backward
movement of hyoid during cranial extension and forward
A movement during flexion, but mostly maintains its level,
moving slightly backward during mandibular movement
[16].
Go For the linear values, H-SN, H-FH, and H-MP per-
pendicular distance in mm was also not statistically sig-
B
nificant (p � 0.972, 0.844, and 0.449, respectively). These
C3 H readings relate the hyoid bone with cranial base, Frankfurt
Gn horizontal, and mandibular plane, respectively. The insig-
nificant values depict somewhat similar position of the hyoid
Figure 1: The angular measurements used to determine the po-
sition of the hyoid bone. bone in reference to these anatomical planes in all three
anteroposterior classes. The linear millimetric distance of
H-H′ and H-N, which relates the hyoid position with
mandible and anterior cranial base, was also statistically
insignificant.
Although in the study done by Amayeri et al. [3], the
N H-SN and H-FH were statistically significant, but the linear
S measurements in relation to the anterior cranial base in the
anteroposterior direction (H-N perpendicular) was statis-
P tically insignificant among the study and control groups as
Or
exhibited in our study. This was in disagreement with a study
conducted by Adamidis and Spyropoulos [7] who reported
that the distance between the hyoid bone and the nasion was
smaller in class III patients.
A
The linear millimetric distance between points H-RGn,
RGn-C3, and C3-H determines the relationship and spatial
Go position of the hyoid bone with the mandible and 3rd cervical
vertebrae. These measurements correlate the hyoid bone
with mandible, mandible with C3, and C3 with the hyoid
B
C3 H′ bone. This is integral in defining the position of the hyoid
RGn
bone with lower jaw movements, postural activity of tongue,
H
Me Gn and width of upper airway. In our study, the distance was
significantly larger in class III subjects (42.75 mm, 79.00 mm,
Figure 2: The landmarks and linear measurements used in the and 38.75 mm) (p � 0.000) as compared to class I and class
study.
II subjects, in which the distances were almost same. Same
results were found in a study done by Amayeri et al. [3] in
which the third vertebrae to the hyoid bone distance was
statistically greater in class III as compared to class I and
40 class II. The same result was found in a study performed by
(49%) 37
35 Ismail and Husamettin [17]. The authors concluded a reverse
30 relationship between the ANB angle and H-C3 distance.
(33%). 25 Lesser angle was associated with larger distance. The study
25
20 by Saleh and Nadeem [18] concluded that in subjects with
raised ANB angle, the hyoid bone moved in a more posterior
15
(17%) 13 position. This illustrates that the smaller hyoid bone to third
10
vertebrae distance will be seen in the class II sagittal pattern
5 as compared to the class III pattern in which the distance will
0 0 be increased. A study done by Mortazavi et al. [19] showed
Class I Class II Class III
the similar results. They established that the anteriorly
Series1
positioned hyoid bone makes the lower section of the upper
Figure 3: The frequency and percentage of different sagittal classes. airway wider.4 Journal of Healthcare Engineering
Table 1: Showing the means of angular and linear measurements.
Class I Class II Class III
Angular and linear measurements
Mean Mean Mean
NSH (angle) 90.79° 89.99° 87.30°
MPH (angle) 18.68° 19.76° 14.55°
H_SN (linear distance) 78.44 mm 77.95 mm 79.10 mm
H_FH (linear distance) 62.99 mm 63.46 mm 61.08 mm
H_MP (linear distance) 11.72 mm 11.98 mm 8.73 mm
H_H (linear distance) 4.22 mm 4.10 mm 1.99 mm
H_N (linear distance) 48.33 mm 45.76 mm 48.30 mm
H_RGN (linear distance) 35.99 mm 37.02 mm 42.95 mm
RGN_C3 (linear distance) 69.88 mm 70.08 mm 79.09 mm
C3_H (linear distance) 34.98 mm 34.06 mm 38.81 mm
Table 2: The multiple comparisons by ANOVA and post hoc Tuckey test.
Angular and linear measurements Sum of squares df Mean square F statistic Significance
NSH 45.9 2 22.9 0.127 0.984
MPH 83.3 2 41.6 0.701 0.505
H_SN 4.6 2 2.3 0.028 0.977
H_FH 17.5 2 8.7 0.170 0.848
H_MP 35.5 2 17.7 0.814 0.454
H_H′ 20.4 2 10.2 0.628 0.541
H_N 64.8 2 32.4 0.249 0.783
H_RGN 167.1 2 83.6 240.4 0.000∗
RGN_C3 3111.2 2 155.6 123.5 0.000∗
C3_H 69.5 2 34.7 64.4 0.000∗
∗
Statistically significant difference.
An interesting study was performed on the skeletal class and MPH angles. The linear distances H-SN, H-FH, and
II growing subjects who were treated with an activator. This H-MP are perpendicular, and also, H-H′ and H-N were
functional growth therapy resulted in a significant dis- statistically insignificant. However, the linear distance be-
placement of the hyoid bone in anterior direction; also, the tween points H-RGn, RGn-C3, and C3-H which determine
linear distance between hyoidale and the third cervical the relationship and spatial position of the hyoid bone with
vertebrae (C3-H) was increased. The linear distance between the mandible and C3 was statistically significant in all
the mandible from retrognathion and the third cervical groups. The values were more in class III subjects; this shows
vertebrae (RGn-C3) was also significantly increased [20–22]. the anterior position of the hyoid bone in the class III pattern
All these outcomes are same as the findings of our study as compared to class I and class II. This is an important
and also those found in literature, in which the linear finding which should be borne in mind while performing the
measurements are lesser in class II and class I subjects as orthopedic and orthognathic treatment modalities on pa-
compared to class III. This perhaps explains short upper tients of this region, as the position of the hyoid bone plays
airway dimensions in class II and obstructive sleep apneic an important role in postural dynamics in clinical ortho-
patients, where the mandible and hyoid bones are posteri- dontics. Further studies with a larger sample size and more
orly placed, and subsequent distances between the hyoid diverse inclusion of various regions across kingdom are
bone, RGn, and C3 are reduced. The opposite holds true for recommended.
class III subjects.
Most of the studies on the hyoid bone are done on Data Availability
Caucasian, Orientals, and South American population.
There does not exists ample information on the position of The data used to support the findings of this study are
the hyoid bone in Saudi population. This study gave an available from the author upon request.
important insight on the hyoid bone in Saudi populace.
More studies with larger samples are recommended for a Conflicts of Interest
more comprehensive information on the role of the hyoid
bone in orthodontics and dentofacial orthopedics. The author declares that there are no conflicts of interest.
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