Correlation Analysis of the Hyoid Bone Position in Relation to the Cranial Base, Mandible and Cervical Part of Vertebra with Particular Reference to Bimaxillary Relations / Teleroentgenogram Analysis

Abstract

Introduction: The relationship among the orofacial system and the rest of the body ,both in functional and anatomical terms was the subject of numerous scientific studies. The optimum position of the bone structures of orofacial system provides performance of intact vital functions, such as breathing or swallowing. Hyoid bone represents a link between the head and neck. Although located in the neck, hyoid bone due to its brachial origin belongs to the visceral skeleton. The purpose of the research: a) To determine the position of the hyoid bone, in relation to the cranial base, mandible and cervical part of the vertebra; b) To determine the linear measures of hyoid bone and its constituents and c) to Identify on the profile teleroengen image, whether there are differences in the position of hyoid bone depending on the saggital maxillo-mandibular relationship. The examinees and methods: 30 profile teleroengen images of patients aged 17-18 years of both sexes were used for this study. To study the position of hyoid bone depending on the saggital maxillo-mandibular relationship respondents were divided into groups based on the ANB-angle values. The first group is ortognat patients with ANB-angle values, from 1 to 4°. The second group included patients with distal jaw relationship, that is, whose values of ANB-angle were greater than / or 5°. The third group consists of patients with ANB-angle value of 0 or negative. Results and Conclusion: The position of hyoid bone is not constant, but depends on the maxillo-mandibular anterior posterior relationships. Length of hyoid bones and greater horns of hyoid bone differs with respect to the sagittal malocclusion. In relation to the cranial base and maxillary bones flat position of the hyoid bone is highly correlated. A positive correlation was found with relation to the cervical vertebra, while the dependence is determined in relation to the steep mandibular plane.

Correlation Analysis of the Hyoid Bone Position in Relation to the Cranial Base, Mandible and Cervical Part of Vertebra

25

ACTA INFORM MED. 2012; 20(1): 25-31 doi: 10.5455/aim.2012.20.25-31

Recieved: 10 September 2011 | Accepted: 13 December 2011

AVICENA 2012

Correlation Analysis of the Hyoid Bone Position in Relation to the Cranial Base, Mandible and Cervical Part of Vertebrawith Particular Reference to Bimaxillary Relations / Teleroentgenogram Analysis

Emsudina Deljo1, Mediha Filipovic2, Rafeta Babacic2, Jasmina Grabus3Health center Gorazde, Bosnia and Herzegovina1Faculty of Dental medicine, University of Sarajevo, Bosnia and Herzegovina2 Health center Travnik, Bosnia and Herzegovina3

Original paper

SUMMARYIntroduction: The relationship among the orofacial system and the rest of the body ,both in functional and anatomical terms was the subject of numerous scientific studies. The optimum position of the bone structures of orofacial system provides performance of intact vital functions, such as breathing or swallowing. Hyoid bone represents a link between the head and neck. Although located in the neck, hyoid bone due to its brachial origin belongs to the visceral skeleton. The purpose of the research: a) To determine the position of the hyoid bone, in relation to the cranial base, mandible and cervical part of the vertebra; b) To determine the linear

measures of hyoid bone and its constituents and c) to Identify on the profile teleroengen image, whether there are differences in the position of hyoid bone depending on the saggital maxillo-mandibular relationship. The examinees and methods: 30 profile teleroengen images of patients aged 17-18 years of both sexes were used for this study. To study the position of hyoid bone depending on the saggital maxillo-mandibular relationship respondents were divided into groups based on the ANB-angle values. The first group is ortognat patients with ANB-angle values, from 1 to 4. The second group included patients with distal jaw relationship, that is, whose values of ANB-angle were greater than / or 5. The third group consists

of patients with ANB-angle value of 0 or negative. Results and Conclusion: The position of hyoid bone is not constant, but depends on the maxillo-mandibular anterior posterior relationships. Length of hyoid bones and greater horns of hyoid bone differs with respect to the sagittal malocclusion. In relation to the cranial base and maxillary bones flat position of the hyoid bone is highly correlated. A positive correlation was found with relation to the cervical vertebra, while the dependence is determined in relation to the steep mandibular plane.

Key words: the hyoid bone position, cranial base, mandible, bimaxillary relations, teleroentgenogram anylysis

Figure 1. Correlation of hyoid bone with other anatomical structures (2)

1. INTRODUCTION

The relationship among the oro-facial system and the rest of the body is both in functional and anatomical terms and the subject of numerous scientic studies. The optimum position of the bone structures of orofacial system provides performance of intact vital functions such as breathing or swallowing.

Hyoid bone represents a link between the head and neck. Although located in the neck, hyoid bone because of its brachial origin belongs to the visceral skeleton (1). This bone is over stilohyoid ligament (liga-

mentum stylohyoideum) stilohyoid muscle (musculus stylohyoideus) and last digastric abdominal muscle (posterior venter musculi digastrici) related to the base of the skull, through geniohyoid muscle (musculus geniohyoideus) milohyoid muscle (musculus mylohyoi-deus) and anterior digastric muscle belly (venter anterior musculi digastrici) is related to the lower jaw. In addition, the connection exist with the up-

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per mediastinum (musculus musculus sternohyoideus et thyreohyoideus), paddle (omohyoideus musculus), and the thyroid cartilage larynx (ligamentum thyreohyoideum). Over fascia cervicalis may result in connection with the cervical verte-brae. In addition hyoid oblique muscles are involved in the construction of the language (chondroglossus et musculus musculus hyoglossus).

Due to the above mentioned dierent contacts with the surrounding bones, hyoid bone is a real link between the dierent structures of the cervical and mandibular areas (3), and the movers muscles that attach to this bone has a central role in lowering the lower jaw, that is, in opening the mouth. So by suprahyoid muscle contraction comes to rise of hyoid bone, larynx and pharynx if the jaw is xed, and if the muscle is xed by infrahyoid comes to lowering of hyoid bone and retreat back the lower jaw, which allows you to open your mouth. The optimum position of the cranio-cervical structures is a prerequisite for performing various vital functions such as breathing or swallowing. Dysfunction of any structure in cranio-cervical region can lead to disorders, which can manifest itself in other structures of the cranio-cervical region. To what extent will a disorder manifested depends on a lot on the individual ability of individuals to adapt to the disturbance occurred (4).

2. THE PURPOSE OF THE RESEARCH:

Determine the position hyoid bone in relation to the cranial base, mandible and cervical part of the vertebra.

Determine the linear measures of hyoid bone and its constituents.

Determine the by the prole teleroengen image whether there are dierences in the position of hyoid bone depending on the saggital maxillo-mandibular relationship.

3. THE EXAMINEES AND METHODS

30 prole teleroengen records of patients aged 17-18 years of both sexes were used for this study.

From the study were excluded subjects with any form of cerebral palsy, muscular dystrophy or any diagnosed syndrome, whose clinical picture can aect the position of the maxilla or mandible in the sagittal, transverse or vertical direction. Also, from the study were

excluded the patients who were in orthodontic treatment, or patients who are carrying a mobile or xed orthodontic appliance.

To study the position of hyoid bone depending on the saggital maxillo-mandibular relationship respondents were divided into

S Sella Mid contour of sella turcicaSe The center hole of sella turcicaN Nasion Point where connects internazal with nasofrontal suture A Subspinale Point with the largest premaxilla concavityB Supramentale Point with greatest chin profile chin concavity

C3 The most inferior and most anterior point of the third cervical

vertebraRGn Retrognation The most distal point of the mandible symphysis

H1 Hioid 1 The most anterior and most superior point of the hyoid bone

body

H2 Hioid 2 Most distal point of the hyoid bone greater horn

H3 Hioid 3 The most superior point at the junction of the hyoid bone body

and greater hornSnA Spina nasalis anterior Top of the anterior nasal spine SnP Spina nasalis posterior Top of the posterior nasal spine

Go gonion Most lower and most distal point in the region of the mandible

ramus

Gn gnation The lowest point of the chin in the medial plane

Me menton Lowest point where are merged the shadow of the chin and the

lower border of the mandibleOr Orbitale The lowest point of the lower edge of the orbit Po porion The highest point of acusticus meatus externusii Incision inferius Top of the lower incisor crownis Incision superius Top of the crown of labial upper central incisor iia Top of the labial apex of the lower incisorsisa Top of the apex of the upper central labial incisor Cd Condilion highest point of the mandible ramusPg Pogonion The most prominent point of the chin

Ar Articulare Cross-section of the shadow of caput mandibulae to the body of

occipital bone

Table 1. Cephalometric points

SN The basic plane of the skull base front part NSe Length of anterior cranial baseNA Line maxillary prognathismNB Line of mandibular prognathismSnA-SnP Palatal planeGo-Gn Go-Me Mandibular planePo-Or Frankfurt Horizontalii-iia Shaft of the most labial lower incisors Is-isa Shaft of the labial upper central incisor

C3H1 The line connecting the most inferior anterior point of the third cervical vertebra and the

anterior most superior point of the hyoid bone body

H1RGn The line connecting the most superior anterior point of the hyoid bone body and

retrognation

RGn C3 The line that connects retrognation and most inferior anterior point of the third cervical

vertebra

SH1 The line that connects sella turcica and most superior anterior point of the hyoid bone

body

NH1 The line connecting the nasion and the most superior anterior point of the hyoid bone

bodyH1-H2 Length of the hyoid bone

H2-H3 Length of the hyoid bone greater horn H1-H3 Length of hyoid bone body

Table. 2. Cephalometric lines

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N-Se Length of anterior cranial pit N-Me The front face heightS-Go Posterior heightH1-H2 Length of the hyoid bone

H2-H3 Length hyoid bone greater hornsH1-H3 Length of hyoid bone bodyH1-C3 Distance of hyoid bones body from vertebrae H1-RGn Distance of hyoid bone body from the mandible C3-RGn Distance between the vertebra and mandible

S-H1 Distance from the hyoid bones body and Sella turcica PP-H1 Distance of hyoid bone body from the maxillary plane MP-H1 Distance of hyoid bone body from the mandibular plane H1-tangenta C3-Rgn The height of the triangle H1-C3-RGnSnA- SnP / tangenta iz A The length of the upper jaw bodyTangent mandible/ iz Pg The length of the lower jaw bodyTangent rami mandible iz Cd Length of lower jaw ramus

Table 3. The linear measurement

Figure 2. Profile teleroengen image

groups based on the ANB-angle values. The rst group is ortognat patients with ANB-angle values from 1 to 4. The second group included patients with distal jaw relationship, that is, whose values

ANB-angle is greater than/ or 5. The third group consists of patients with ANB-angle value of 0 or negative.

For the analysis of teleroengen prole images was used the computer soware AX-Ceph, which is specially designed and adapted to this type of research.

Analysis of prole teleroengen images took place as follows: Preparation of x-ray image for computer analysis.

Input of cephalometric points positions.

Measurement of angles and linear measures.

For the analysis teleroengen

prole image the following cephalometric points will be used,

which are shown in the Table 1 and Figure 3.

For the analysis of the teleroengen prole image will be used following

cephalometric lines, resulting by combination of these cephalometric points, which are shown in Table 3.

For the calculation of linear measure as a basic measure will use the value of NSE expressed in mm, and whose value will be presented for comparison with the value 1.

Linear measures that will be used in the study are shown in Table 3 and in Figures 4, 5 and 6.

To study the position hyoid bone

Figure 6. Linear measures of hyoid bone

Figure 7. ANB-angle

depending on the saggital maxillomandibular relationship subjects will be divided into groups based on the ANB-angle values. The rst group is ortognat patients with ANB-angle values from 1 to 4. The second group included patients with distal jaw relationship, that is, whose values

ANB-angle greater than/or 5. The third group consists of patients with ANB-angle value of 0 or negative.

Angular measures that will be

Figure 3. Cephalometric points

Figure 4. Linear measure

Figure 5. The height of the triangle H1-C3-RG

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SNA The angle of the anterior-posterior position of the upper jaw relative to the

skull base

SNB The angle the anterior-posterior position of the lower jaw in relation to the

base of the skull

ANB Angle, which shows the anterior-posterior relationship of the upper and

lower jawC3HRGn The angles, which describe the relationship of hyoid bone body with the body of the lower jaw and third cervical vertebrae

H1RGn C3 RGnC3H1

SNH1 The angle of the hyoid bone body position in relation to the base of the skull H1H3H2 The angle of hyoid bone inclinationH1H2- SN The angle of hyoid bone position in relation to the base of the skullH1H2- PP The angle of hyoid bone position in relation to the palatal planeH1H2- MP The angle of hyoid bone position in relation to the mandibular plane H1H2-FP The angle of hyoid bone position in relation to the Frankfurt horizontal NSAr+SArGo+ArGoGn Bjorks summary angle for assessment the type of growth

Table 4. Angular cephalometric measurements

I group ANB-angle from 1 to 4 II group > 4 III group< 1 Total girls boys girls boys girls boys9 7 6 4 1 3 30

Table 5. Research subjects

used in the study are shown in Table 4 and in Figures 8 and 9.

3.1. Statistical analysis

From the data, which will be obtained in the survey will be formed a computer database using Microso Excel 2007, which will be used for descriptive statistical analysis.

It will use the following methods of statistical analysis: Percentages and rates, Mean, Standard deviation, Correlation analysis.

4. RESULTS

In the study participated 30 patients who were divided into three groups considering the size of ANB-angle. Angle h1h3h2/ hyoid bone inclination

Mean value of h1h3h2 -angle was 157.5 min122 max 180 SD 20.278888 Mean hyoid bone inclination for class I 162.2143

Mean hyoid bone inclination for class II 149.75

Mean hyoid bone inclination for class III 137

High correlation with: <H1H3:PP0.719515454 <H1H3:MP0.714731772 <H1H3:FP -0.717035631

H1H2H30.87658266 IP:H1H2 maxilla0.892861019 IP:H1H2 mandible0.875687118 We can see that this angle

correlates highly with the maxillary plane, mandibular plane, and the position of the incisors in relation to hyoid bone. There are signicant dierences in the inclination of hyoid bone in relation to makilomandibular relations in

anterior and posterior direction. Hyoid bone length H1-H2 Mean value 33.75min 29 max 37 SD 2.97361345 Mean value for class I 33.857 Mean value for class II 35.75 Mean value for class III 29 High correlation with: Maxilla length 0.779277696 NSe length of anterior cranial base 0.732660303

Distance of hyoid bone body from vertebrae 0.818102434In patients from group II is the

longest length of the hyoid bone. Interesting is the correlation with the length of the anterior cranial base and the length of the maxilla. Length of hyoid bone body Mean value 8.225 min 6 max 10.25 SD 1.335675027 Mean value for class I 8.5357 Mean value for class II 8.25 Mean value for class IIIWe did not nd signicant

correlations with other structures. Length of hyoid bone greater horns

Mean value 26.2 min 22.5 max 30 SD 2.201009869 Mean vale for class I 25.857 Mean vale for class II 28.5 Mean vale for class III 24 High correlation with: SNH1 0.815994936 Angle H1H2/SN Angle of hyoid bone position in relation to skull base

Mean angle value 33.95 min 24 max 51 SD 10.6287085

Mean angle value for class I 34.57 Mean angle value for class II 36.75 Mean angle value for class III 24

High correlation with: H1H2:PP 0.940556591 H1H2:MP 0.830133678 IP:H1H2 maxilla 0.738949768 We can conclude that hyoid bone

somehow maintains a static and dynamic balance of the skull and neck, as the hyoid bones axes compared to the at cranial base showed signi-cant interdependence in relation to the palatal plane, as well as in relation to the mandibular plane at different maxilla-mandible relations.

Angle H1H2/PP Angle of hy-

Figure 8. Angular cephalometric measures

Figure 9. Hyoid bone inclination

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oid bone position in relation to palatinal plane Mean angle value 25.15 min 12 max 48 SD 11.83227695 Mean angle value for class I 24.357 Mean angle value for class II 31

Mean angle value for class III 19

High correlation with:

H 1 H 2 / S N 0.940556591 H 1 H 2 : M P 0.852225772 H 1 H 2 : F P 0.930661406 IP:H1H2 maxilla 0.860342007 IP:H1H2 mandible 0.768543969 These ndings also

speak in favor that position of hyoid bone depends on maxilla mandible relations. Incisor inclination was also signicantly conditioned by the position of hyoid bone. H1-C3 /Distance of hyoid bone body from vertebrae

Mean value 37.65 min 30 max 45 SD 4.262563131 Mean value for class I 38 Mean value for class II 40.25 Mean value for class III 30

High correlation with: ANB 0.72009612 NSe 0.801715542 H1-H2 0.818102434Distance of hyoid bones from the

cervical part of the vertebra is not constant, but depends largely on maxilla mandible relationship and the length of the anterior cranial base, which speaks in favor of these results. H1/MP Mean value 18.2 min 9.25 max 25.5 SD 5.366821944 Mean value for class I 19.821 Mean value for class II 14 Mean value for class III

9.25

High correlation with: H1/PP 0.71738916 S-H1 0.705548291 H1: C3-RGn 0.857587138 Angle RGnC3H1 0.793735748 Angle C3H1RGn 0.825562851 Also these results speak in favor

that the hyoid bone with right bears the name link of the head and neck. Position of hyoid bone depends on the bimaxillary relationship and the cervical spine.

5. DISCUSSION

It is proved that the orofacial system aects the static and dynamic functions throughout the body, but has not yet been explained in detail the nature and interdependence of these relationships.

Broadbent (1931, 1937) with the discovery of lateral cephalometry

investigated the sagittal and transverse topographical relationships between the lower jaw and the coronary suture, and temporo zygomatic pterigomaxillar suture of the human skull. These relations are constant from the rst year of life until the end of life (5). Sprague (1943) found that the evolution of hyoid bones is closely associated with human orofacial functions (6). King (1952) studied the X-ray relations of hyoid bones with the neck part of the spine and found that the distance between hyoid bone and cervical spine is constant before puberty (7). Frankel (1963) described the connection between mouth breathing and irregular position of the tongue, where the imbalance between suprahyoid and infrahyoid muscles leading to dorsal-caudal position of the hyoid bone (8). Sloan et all (1967) found that the hyoid bone is placed somewhat more higher and ventrally in individuals with malocclusion of the second grade as opposed to the compared to persons with neutrooclusion to mandible (9). Grabber (1978) was followed in the treatment of subjects with under chin cap. Aer three years of therapy with under chin cap found that the hyoid bone was shied posterior inferior relative to its initial position (10). their study found that there are gender dierences in the position of hyoid bones, and that the position hyoid bones is stable and independent of orofacial dysfunction and function (11). Galvao (1983) in his research compare the position of the hyoid bones in subjects with dierent disgnatia, and found that the position of the hyoid bones diers (12).

Nobili and Adverse (1996)

pointed to the body posture at various disgnatia. So people with distooclusion keep their head slightly forward, as opposed to people with mezioclusion, who hold head more to the back, and thus indirectly changing the position of the hyoid bone (13).

Tallgren (1987) found that the position of hyoid bone is in relation to the cervical spine quite stable,

Chart 1. Length of hyoid bone i relation to ANB- angle

Chart 2. length of hyoid bone greater horns

Chart 3. Distance of hyoid bone body from vertebrae

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but compared to the mandibular or maxillary plane (14). Behlfelt (1990) examined the position of the head, the position hyoid bones and the position of tongue in children with enlarged and normal tonsils. He found that children with enlarged tonsils have a lower position of hyoid bone and the vertical position of the tongue (14). Adamidis and Spyropoulus (1992) examined the dierences in position between the hyoid bones of subjects from I and III class. They found that respondents with III class hyoid bone position and anterior to the opposite inclination relative to the mandibular plane (14). Harlabakis (1993) comparing the position of the hyoid bone in subjects with deep and open bite, concluded that there are dierences in the direction of the anterior posterior position of hyoid bones, but there is a strong inclination of hyoid bone in relation to the palatal plane, but not in relation to the mandibular plane (14).

Trenouth and Timms (1999) described a positive correlation between the length of the mandible (measured from the points of Gon-Men) with the distance between the third cervical vertebra and hyoid bone (C3H) (15).

Kolias in 1999 I and II followed the changes in the position of hyoid bone by longitudinal study. It has been noted that with age comes to lowering of hyoid bone, which is more pronounced in men, while anterior posterior position remains stable. Tongue comes in the upright position (16,17).

Kaduk (2003) compare the position of hyoid bones in children with cle and children without cles. These are mainly determined by higher values in children with cles. Position of hyoid bones in children with cle is signicantly more anterior and caudal, which is explained as a mechanism for adaptive closing of velopharingeal valves and swallowing (18). Similar ndings were identied in the study in children with Pierre-Robins syndrome (19,20).

Allhaija and Al-Khateeb (2005) found that there are dierences in

the position of hyoid bone with respect to the sagittal maxillomandibular relationships. They also found that there are sex dierences in the position hyoid bone in class I and III, and that the position of the hyoid bones is signicantly correlated with the ANB angle (21).

Juliano (2009) research the impact of mouth breathing by cephalometric and polysomnograhic methods. Thus it was established that children who breathe through the mouth tend to have retro positioned mandible relative to cranial base, strongly inclining occlusal base, set up more horizontal lower edge of the mandible, and the tall part of the cervical spine and placed nearer to hyoid bone (22).

Sun 2009 examined subjects whose occlusion was in the rst class. Aim of this study was to determine whether there is a correlation between the position of the hyoid bone and incisor position in something larger incisors, that is, in which the clinical picture is manifested with the protrusion, and in which occurs with standard (rotated) position of the incisors. It was found that in subjects with dental protrusion hyoid bone is in anterior-superior position, unlike other groups of respondents (23).

Sierpinski 2009 has examined the position of hyoid bones in older subjects wearing complete dentures for at least ve years and has been proven to reduce vertical dimensions, or the height of the bite aects the hyoid bone position change, which is down below and change the orofacial muscle activity (24).

This study has shown interesting

relationships of hyoid bone with adjacent structures. But if we take into consideration that no account was taken of the vertical maxillary mandible relations, as well as the bimaxillary transverse relationships, this research would be good to extend to a larger number of subjects taking into account the vertical and transversal parameters.

6. CONCLUSION

Position of hyoid bone is not con-

stant, but depends on the maxillomandibular anterior and posterior relationships. Length of hyoid bone and greater horns of hyoid bone differs with respect to the sagittal malocclusion. In relation to the cranial base and maxillary bones at position hyoid is highly correlated. A positive correlation was found with relation to the cervical vertebra, while the dependence is determined in relation to the mandibular plane.

Conflict of interest: none declared.

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Corresponding author: Emsudina Deljo, MDD. Health center Gorazde, B&H. E-mail: [email protected]

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