IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(2):106–111

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IP Indian Journal of Orthodontics and Dentofacial Research

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Original Research Article

Correlation between the cranial base, mandible, and hyoid bone in Class II skeletal
individuals- A cephalometric study
Jaffer Sadik1 , Akhil Shetty1, *
1 Dept. of Orthodontics and Dentofacial Orthopedics, AB Shetty Memorial Institute of Dental Sciences (ABSMIDS), Nitte
(Deemed to be University), Mangalore, Karnataka, India

ARTICLE INFO ABSTRACT

Article history: Aim: The aim of this study was to assess the relationship between the cranial base, mandible, and hyoid
Received 25-04-2023 bone in Class II skeletal individuals.
Accepted 12-05-2023 Materials and Methods: The retrospective study included lateral cephalograms of 40 Skeletal Class
Available online 03-06-2023 II subjects divided into maxillary prognathism (n=20) and mandibular retrognathism(n=20) based on
Burstone’s N⊥A and N⊥B values. The angular measurements using 10 variables were used to determine
the relationship between the cranial base, mandible, and hyoid bone in Class II subjects. Statistical analyses
Keywords: were performed using IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. An
Cranial base
Independent t-test was used to compare the two groups and a p-value less than 0.05 was considered
Mandible
statistically significant. Post-Hoc Bonferroni was applied to examine any changes among any two groups
Hyoid bone that were found to differ statistically.
Skeletal class II
Results: NSAr, C3HyD, SArHy, and NSHy angles were measured in both groups. NSAr and NSHy angles
Malocclusion
showed significance between the two groups of skeletal class II whose p-value <0.05 whereas C3HyD and
SArHy angles did not show any significance.
Conclusion: The condylar position was anterior in maxillary prognathism compared to mandibular
retrognathism of Skeletal Class II. The hyoid bone was positioned forward and upward in maxillary
prognathism individuals and downward and backward in mandibular retrognathism individuals belonging
to skeletal class II.
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1. Introduction base using cephalometric radiographs. 1 The cranial base

establishes the limit of the skull and facial skeleton. The
Understanding skeletal deformities that contribute to
mandible is connected to the posterior cranial base, whereas
malocclusion is of paramount importance in the field of
the nasomaxillary complex is connected to the anterior
orthodontics and dentofacial orthopaedics. The clinical
cranial base. Therefore, the structure and form of the
diagnosis has a considerable impact on the treatment
anterior cranial base have a significant role in determining
and orthodontic mechanics used. It is therefore crucial to
the position of the maxilla. 2
identify the factors contributing to the etiology of skeletal
discrepancies. However, in the relationship to the mandible, any
alteration in the posterior cranial base will impact the
Björk established a correlation between the morphology
glenoid fossa’s displacement, which in turn will directly
of the cranial base and the relationship between the jaw
impact the mandibular position. 2 Therefore, there is a strong
* Corresponding author. relationship between the alteration in the cranial base and
E-mail address: [email protected] (A. Shetty). the sagittal malposition of the jaws. The mandibular position

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 Sadik and Shetty / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(2):106–111 107

depends on the length and direction of the condyle’s growth previous orthodontic or surgical treatment, habits like mouth
as well as the displacement of the mandibular body caused breathing, tongue thrusting, etc., and history of trauma,
by the sutural growth of the cranial base. 2 pathologies and facial asymmetries were excluded from the
The hyoid bone and its relation to facial patterns and study.
probable influence, has garnered a great deal of attention The following cephalometric landmarks were used:
during the last two decades. 3 The hyoid bone is an [Figure 1]
anatomical structure that relates the position of the head
with the neck. The hyoid bone is attached to the cranial
base and the mandible with various muscular attachments. 1. Nasion (N): The deepest point on the frontonasal
This bone is crucial for carrying out some physiological suture.
functions such as breathing, speaking, and swallowing. 2. Sella (S): The midpoint of the shadow of the pituitary
Alteration in the position of the hyoid bone in relation to the fossa (Sella turcica).
mandible has been described by Gobeille and Bowman 4 and 3. Articulare (Ar): An intersection points of the posterior
Cuozzo and Bowman. 5 This may be due to the muscular margin of the mandible and the basilar border of the
and ligamentous attachments of the hyoid bone, thereby occipital bone.
acting as a functional interface between the cranium, 4. Point D: A lateral cephalogram shows this location as
cervical spine, and mandible. Thus, any alterations in the the center of the mandibular symphysis.
hyoid bone may provide significant functional ramifications. 5. Hyoidale (Hy): The most superior, anterior point on
The results of the aforementioned studies suggest that the the body of the hyoid bone. 9
positional alteration of the hyoid bone is closely related to 6. C3: The point at the most inferior anterior position on
malocclusion. Jarvinen linked SNA and NSAr and found the third cervical vertebra. 9
them to be related to facial patterns. 5,6 He found large
NSAr angles were related to relatively small SNA angles,
while small NSAr angles were connected with large SNA 2.1. Angular measurements taken in the study
angles. In 1984 he also found the NSAr angle varied
Saddle angle (NSAr): Lines connecting Nasion to Sella and
significantly between Class II and Class III malocclusions,
Sella to Articulare form this angle. It represents the cranial
with significantly higher NSAr angular values in Class III
base flexure. [Figure 2]
malocclusion. 7
Researchers have demonstrated that changes in the Hyoidale angle (C3HyD): A line connecting C3 to
mandibular position are related to the changes in the hyoid Hyoidale and from Hyoidale to Point D forms an angle. One
bone and that the position of the hyoid bone responds to can read the hyoidale angle as the superior angle formed by
changes in the anteroposterior position of the head. 8 the two planes. [Figure 3]
The aim of this study was to assess the relationship SArHy angle: A line joining Sella and Articulare and
between the cranial base, mandible, and hyoid bone in a line joining Articulare and Hyoidale forms this angle.
Class II skeletal individuals with maxillary prognathism and [Figure 4]
mandibular retrognathism. NSHy angle: A line joining Nasion to Sella and Sella to
Hyoidale forms this angle. [Figure 5]
2. Materials and Methods For calibration, a pilot test was conducted selecting
The retrospective study included lateral cephalograms 20 lateral head films in which the cephalometric tracing
of 40 Skeletal Class II subjects divided into maxillary was performed. The same radiographs were measured once
prognathism (n=20) and mandibular retrognathism(n=20) again by the operator after two weeks to verify coincidence,
based on Burstone’s N⊥A and N⊥B values. All the subjects and that there were no errors thus achieving intra-operator
for the study were selected from patients who reported reliability. Two weeks later, the same radiographs were
to the Department of Orthodontics seeking orthodontic traced by the professor to verify that there were no errors.
treatment during the years 2020 to 2022. The data were
taken from the archives of the Department of Orthodontics 2.2. Statistical analysis
and Dentofacial Orthopaedics, at the A.B Shetty Memorial
Institute of Dental Sciences in Mangalore. Clearance for the Statistical analyses were performed using IBM SPSS
study was obtained from the Institutional Ethics Committee Statistics for Windows, Version 25.0. Armonk, NY: IBM
(Cert.no: ABSM/EC67/2021). Corp. An Independent t-test was used to compare the
Lateral cephalogram records of individuals between the two groups and a p-value less than 0.05 was considered
age group 15-30, individuals with healthy periodontium, statistically significant. Post-Hoc Bonferroni was applied
and who had a full set of dentitions upto second molars to examine any changes among any two groups that were
in both arches were included in the study. Individuals with found to differ statistically.
108 Sadik and Shetty / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(2):106–111

3. Results

Comparison of NSAr, C3HyD, SArHy, and NSHy

angle between maxillary prognathism and mandibular
retrognathism in skeletal class II.

3.1. Saddle angle (NSAr)

The mean saddle angle measured in the maxillary
prognathism group was found to be 120.78◦ ±5.33, whereas
it was found to be 124.75◦ ±4.80 in the mandibular
retrognathic group. The study revealed a statistically
significant difference between the two groups in the skeletal
class II pattern (p< 0.05). (Table 1) (Graph 1)

Fig. 3:

Fig. 1:

Fig. 4:

Fig. 2:
Fig. 5:
 Sadik and Shetty / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(2):106–111 109

Graph 1:

Table 1: Comparison of NSAr, C3HyD, SArHy, and NSHy angles between maxillary prognathism and mandibular retrognathism in
skeletal class II
Skeletal Class II Group N Mean Std. Deviation P value
Maxillary prognathism 20 120.78 5.33
NSAr 0.018*
Mandibular retrognathism 20 124.75 4.80
Maxillary prognathism 20 159.14 11.87
C3Hy-PtD 0.137
Mandibular retrognathism 20 166.25 17.24
Maxillary prognathism 20 133.33 5.52
SArHy 0.546
Mandibular retrognathism 20 134.45 6.13
Maxillary prognathism 20 87.55 3.68
NSHy 0.001*
Mandibular retrognathism 20 92.95 3.36
*Statistically significant (p<0.05)

3.2. Hyoidale angle (C3HyD) 3.4. NSHy angle

The mean hyoidale angle measured in the maxillary The mean NSHy angle measured in the maxillary
prognathism group was found to be 159.14◦ ±11.87, prognathism group was found to be 87.55◦ ±3.68, whereas
whereas it was found to be 166.25◦ ±17.24 in the it was found to be 92.95◦ ±3.36 in the mandibular
mandibular retrognathic group. The study revealed a retrognathic group. The study revealed a statistically
statistically non-significant difference between the two significant difference between the two groups in the skeletal
groups in the skeletal class II pattern (p >0.05). (Table 1) class II pattern (p < 0.05). (Table 1) (Graph 1)
(Graph 1)
4. Discussion

3.3. SArHy angle The field of Orthodontics places an emphasis on growth

and the factors that influence it. The Spheno-occipital
The mean SArHy angle measured in the maxillary synchondrosis lengthens the basicranium and has a
prognathism group was found to be 133.33◦ ±5.52, whereas noteworthy influence on post-natal growth. According to
it was found to be 134.45◦ ±6.13 in the mandibular Enlow, 10 the growth of the maxilla is under the effect of the
retrognathic group. The study revealed a statistically non- basal component of the cranium which is directly influenced
significant difference between the two groups in the skeletal by the development of the brain. Whereas the mandible
class II pattern (p >0.05). (Table 1) (Graph 1) grows in an independent manner, however, it is also affected
110 Sadik and Shetty / IP Indian Journal of Orthodontics and Dentofacial Research 2023;9(2):106–111

by the location of the glenoid fossa. Thus, the relationship a correlation between mandibular retrognathism and the
between the maxilla and mandible is determined by the NSHy angle. This observation may be explained by the
cranial base. muscle attachment to the hyoid bone and the mandible,
According to Hopkin et al, 11 the basicranium played which causes it to move backwards and forwards in tandem
an important role in sagittal orthodontic discrepancies. with the jaw in the sagittal plane. 14
In addition, Scott 12 stated that the flexion of the cranial The Articulare was used as a cephalometric landmark in
base, the relative anterior movement of the maxillary and the present study, however, certain authors such as Varjanne
mandibular components in relation to the cranium, surface and Koski 15 preferred the Basion due to its proximity to
deposition between the Nasion and Menton affects facial the cranial base. However, Bhatia and Leighton 16 1993,
prognathism. demonstrated a high correlation between these two points
There is significant debate about whether the posterior and the selection between these points is unlikely to
base should be measured from the Basion or the Articulare, contradict the study findings. Hence, the Ar was selected
despite the fact that the N-S length is typically employed as a landmark point in this study. Further research may
to calculate the anterior cranial base. As Articulare is be carried out using the Basion as a landmark for a
simpler to recognize than Basion, Bjork 1 recommended comprehensive investigation.
using it instead. Later, further research employed Articulare According to Jarvinen, the SN plane may be rotated and
to specify the posterior boundary of the cranial base. 12 hence is not reliable, he suggested the usage of the Frankfurt
Over the past 20 years, several studies had been done plane for the purpose of investigation. In order to examine
to determine the hyoid bone position in relation to facial this in more detail, a study considering the Frankfurt plane
morphology, as it is connected to the cranium as well as as a reference plane may be carried out. Furthermore, linear
to the mandible. Research has shown the adaptation of the measurements of the cranial base and growth patterns have
hyoid bone in diverse malocclusions and after orthognathic not been considered in this study which has been shown to
surgeries. be a greater influence on skeletal discrepancies in studies by
The present study investigated the influence of the Andria et al and Dhopatkar, Bhatia, and Rock.
cranial base and the position of the hyoid bone on skeletal Hence, further research needs to be conducted to
relationships and vice-versa in skeletal Class II individuals demonstrate the influence of cranial base angulations and
with the prognathic maxilla and retrognathic mandible. hyoid bone position.
The saddle angle (NSAr) was evaluated among the
mandibular retrognathic and the maxillary prognathic 5. Conclusion
cases in the class II group and was noticed to be
statistically significant. (p < 0.05) with mean values in the The condylar position was anterior in maxillary
mandibular retrognathic group being substantially higher prognathism compared to mandibular retrognathism of
when compared to the maxillary prognathic group (Table 1). Skeletal Class II. The hyoid bone was positioned forward
This is in agreement with a study by Mestriner, Junior, and upward in maxillary prognathism individuals and
and Valente where large NSAr values were associated with downward and backward in mandibular retrognathism
mandibular retrognathism. 13 individuals belonging to skeletal class II.
The hyoidale angle was further assessed and
compared between maxillary prognathism and mandibular 6. Conflict of Interest
retrognathism subgroups in Class II skeletal pattern. The None
mandibular retrognathic group revealed higher mean
averages compared to the maxillary prognathic group 7. Source of Funding
however, the differences were noticed to be not statistically
significant. (p> 0.05) (Table 1). This research did not receive any specific grant from
When the SArHy angle was assessed in the Class II funding agencies in the public, commercial, or not-for-profit
group among the maxillary prognathic and mandibular sectors.
retrognathic subjects, no statistically significant results were
noticed. (p > 0.05) (Table 1). References
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