CRANIO®

The Journal of Craniomandibular & Sleep Practice

ISSN: 0886-9634 (Print) 2151-0903 (Online) Journal homepage: http://www.tandfonline.com/loi/ycra20

Morphometry of the cranial base and the

cranial–cervical–mandibular system in young
patients with type II, division 1 malocclusion, using
tomographic cone beam

Antonio Bedoya, Zury Landa Nieto, Liliana L. Zuluaga & Mariano Rocabado

To cite this article: Antonio Bedoya, Zury Landa Nieto, Liliana L. Zuluaga & Mariano Rocabado
(2014) Morphometry of the cranial base and the cranial–cervical–mandibular system in young
patients with type II, division 1 malocclusion, using tomographic cone beam, CRANIO®, 32:3,
199-207, DOI: 10.1179/0886963413Z.00000000019

To link to this article: http://dx.doi.org/10.1179/0886963413Z.00000000019

Published online: 24 Jan 2014.

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Orthodontics
Morphometry of the cranial base and the
cranial–cervical–mandibular system in young
patients with type II, division 1 malocclusion,
using tomographic cone beam
Antonio Bedoya1, Zury Landa Nieto2, Liliana L. Zuluaga2, Mariano Rocabado3
1
University Colleges of Colombia (UNICOC), Orthodontist. Sc.D. Specialization in Orthodontics and Maxillary
Orthopedics. Institución Universitaria Colegios de Colombia (Unicoc) at Cali. Colombia, Colegio Odontológico
Colombiano, Cali, Colombia, 2Orthodontics and Maxillary Orthopedics Graduate Program, University Colleges of
Colombia (UNICOC), Orthodontist. Sc.D. Specialization in Orthodontics and Maxillary Orthopedics. Institución
Universitaria Colegios de Colombia (Unicoc) at Cali. Colegio Odontológico Colombiano, Cali, Colombia,
3
University Andrés Bello, Chile

Aims: Traditionally, diagnosis and treatment planning of structural and three-dimensional anomalies have
been performed using two-dimensional X-rays. Cone beam computed tomography (CBCT), the technology
utilized in this study, allows creation of specialized images from the craniofacial region that provide more
precise and reliable results. The growth of the cranial base, position and size of the cervical system, and
the hyoid bone has an influence upon the morphogenesis and the growth of the maxillofacial complex. The
data obtained through this current study offer a better understanding of the origin and manifestation of
malocclusions, and will, therefore, offer a better therapeutic approach. The objective of the current study is
to describe the measurements of the cranial base and the cranial–cervical–mandibular system in young
patients with type II, division 1 malocclusion, using CBCT.
Methodology: Twenty-four CBCT images were obtained for young patients with type II, division 1
malocclusion. The i-CAT Vision (Imaging Sciences International, Hatfield, PA, USA) was used to view the
images. Linear and angular measurements were obtained in the mid-sagittal plane. Univariate and bivariate
analyses, as well as a multivariate analysis of principal components, were conducted.
Results: The only metric with a statistically significant difference regarding gender was S–N major in the
male participants. The metrics SNA–SNB and SNPg are positively related and inversely proportional to the
angles BA–S–N and PO–P McGregor. The inclination of the upper incisor showed an inverse relationship
with the angles SNA–SNB and SNpg. The craniovertebral angle was diminished in the entire sample, and
the variable that vertically relates the hyoid was independent of the other variables.
Conclusions: After evaluating 24 images of young patients with type II, division 1 malocclusion using helical
spiral CBCT, it was concluded that relationships exist between the cranial base structures, the structures
that determine the sagittal position of the maxilla, mandible and chin, and the cervical vertebrae complex
and hyoid bone.
Keywords: Cephalometry, Class II division 1 malocclusion, Cone beam computed tomography, Craniomandibular system

Introduction is subdivided into the cranial base (chondrocranium)

The craniofacial skeleton is composed of the neurocra-
nium, which surrounds the brain, and the viscerocra-
nium, which covers the facial bones. The neurocranium
Correspondence to: Bedoya Antonio, University Colleges of Colombia
(UNICOC), Institucion Universitaria Colegiosde Colombia, nbedoya@unicoc.
edu.co and determinadaarea@yahoo.com. Colegio Odontológico
Colombiano, Cali, Colombia. Email: determinadaarea@yahoo.com
ß W. S. Maney & Son Ltd 2014
DOI 10.1179/0886963413Z.00000000019 CRANIOH: The Journal of Craniomandibular & Sleep Practice
and calvaria, which develop by endochondral ossifica-
tion and intramembranous ossification, respectively.
Defects in the cranial base growth and development
contribute to the formation of different alterations in
the craniofacial level.1 The relationship between dental
occlusion and craniofacial morphology has been a
popular topic of interest among researchers in the field
2014 VOL. 32 NO. 3 199
Bedoya et al. Morphometry in patients with type II, division 1 malocclusion
of orthodontics, orthopedics and maxillofacial growth
and development.2
The cranial base is composed of the occipital bone,
the inferior face of the petrous and squamous parts of
the temporal bone, parts of the body and wings of the
sphenoid bone, the ethmoid bone, the pterygoid
process, the vomer, the horizontal plates of the
palatine, and the palatine processes of the maxilla.3 It
has been determined that cranial base growth has an
influence on morphogenesis of the maxillofacial
complex, relating the superior maxilla to the prior
cranial base and the posterior mandible.4,5 The
cranial base changes dramatically during human
evolution. In primates, the connection of the occipital
and sphenoid bones, vomer, and maxilla shows a
larger anterior–posterior dimension, and the max-
illary region has a prognathic position. In humans,
the viscerocranium is significantly small. Humans
show a retrognathic appearance of the lower and
middle third of the face, which adopts a more vertical
position, and the cranial base is angled. The posterior
cranium fossa also undergoes changes in its shape,
becoming wider and deeper.6
The sphenoid bone plays an important role in
craniofacial morphology. It is united to the occipital,
ethmoid and frontal bones, and is considered an
essential component of the midsagittal part of the
cranial base. The connection between the basilar
portion of the occipital and sphenoid bones is
considered the most important suture in the facial
skeleton. It is made of thick fibrous cartilage used to
absorb impact like a buffer, and at the same time, it
allows growth, allowing for adjustments to external
tensions. The vomer transmits the dynamic forces of
the maxillary complex to the cranial base. The
dynamic mechanism of the craniofacial skeleton, the
temporal bone, also plays a leading role due to its
anatomic position. Its influence is crucial because
many muscles affect its movement, including two of
the primary muscles for mastication: the temporal
and the masseter.7
The direction of superior maxillary displacement
is influenced by the dynamic states of the occipital–
sphenoethmoid connection of the cranial base.
Watanabe et al.8 described three types of maxillary
growth: translation of the frontal bone, vertical
elongation, and anterior rotation. Each of these
maxillary growth types gives origin to different
malocclusions. The rotational movement of the
cranial base takes place in the sphenoid–occipital
articulation. The rotatory axes of sphenoid and
occipital bones are part of the sella turcica and the
frontal part of the principal occipital foramen,
200 CRANIOH: The Journal of Craniomandibular & Sleep Practice
respectively. The rotatory movement of the sphenoid
bone is transmitted to the mandible through the
vomer, which results in anterior–inferior thrust of
the maxilla. This anterior–inferior push explains
how the movement of the cranial bone affects
the maxilla and offers an explanation for the
development of characteristics that lead to bone
and dental malocclusions.
To adequately diagnose and treat the morphologic
and functional alterations of the stomatognathic
system and the adjacent structures, it is necessary to
understand the complex existing relationships
between the diverse components of the cranial–
cervical–mandibular system. An important element
to include is a study of the cervical vertebrae in
patients with malocclusion, as this shows the
vertebrae’s association with head position and their
relationship with craniofacial morphology and hyoid
position. The cervical vertebral spine supports the
head and is composed of seven vertebrae. The first
and second cervical vertebrae, the Atlas and Axis,
form a sub-occipital functional segment that connects
the spine to the cranium. The occipital muscles
determine the position of the head by controlling
flexion and extension, as well as lateral flexion and
rotation. The Atlas dimensions, along with the
position of the neck and head, are associated with
craniofacial morphology, including the cranial base
and superior airways, and with occlusion and
temporomandibular disorders. Additionally, the
position of the head is related to the development
and function of the dentofacial structures. Cervical
posture has been associated with mandible longitude,
and this association also shows a direct correlation
with the alignment of the cervical spine (straight
inverted or in lordosis).8 Ishida et al. suggests that
hyoid displacement is related to events in the oral
cavity and pharyngeal area. Functionally, phonation
is related to the hyoid, the tongue and the mandible.
These discoveries suggest that anatomic variations in
craniofacial morphology, as well as variations in
position and size of the mandible could affect the
movement of the tongue during deglutition, possibly
generating alterations in the movement pattern of the
hyoid, due to its close connection with the tongue.9
The World Health Organization considers mal-
occlusion the third leading cause of dental disease.10
Class II malocclusion was identified by Angle,11 and
is defined as the distal relationship of the inferior
dental arch to the superior one. The characteristics of
division 1 include a tight and long superior arcade,
and facial imbalance commonly associated with a
dolichofacial pattern. Maxillary prognathism and
2014 VOL . 32 NO . 3

mandibular retrognathism impose a tendency toward
facial convexity. Similarly, dental protrusion stops
labial sealing, and the upper incisors rest on the lower
lip,2 which may be related to a variety of occlusal
situations that affect dentition in three planes. The
vertical relationship may range from a deep overbite
to an open bite, depending on the etiologic factors
associated with the problem. Cephalometrically, the
prevailing characteristic is the intermaxillary skeletal
relationship, type II, resulting from maxillary protru-
sion, mandibular retrusion, or a combination of both
alterations. Vertical alterations of the inferior facial
third may also affect this relationship. The capacity
and characteristics of growth are genetically codified,
and are related to racial aspects. Additionally,
environmental factors may have a great influence.2
Nobuyuki et al.12 reported the following discov-
eries in a population of Japanese patients with
malocclusion type II, division 1: slightly obtuse
cranial base angle; slight forward position of the
superior maxilla; significantly short mandibular
ramus; mandibular retrognathia; slightly obtuse
gonial angle; high facial angle pattern; and an
association between relatively diminished posterior
facial height and ramus shortness. Many studies have
tried to characterize type II, division 1 malocclusion
with common traits at the skeletal level. However, the
influence of some of these characteristics has not been
fully evaluated in Colombian population.
Imaging is an important component in the clinical
evaluation of orthodontic patients. Broadbent in the
United States and Hofrath in Germany introduced
cephalometric radiology to orthodontics in 1931 and
developed standardized methods to obtain X-rays
using a cephalostat.13 The analysis of craniofacial
structures through lateral images has been used to
predict growth, diagnosis and planning for many
years. Standard cephalometrics are an important
reference for orthodontic diagnosis; however, factors
such as age, gender and ethnicity must be accounted
for since these factors influence cranial morphology.14
For many years, the diagnosis and planning of
treatments for three-dimensional malocclusions have
been based on two-dimensional images due to their
validity, efficiency, and low cost. However, issues
with distortion, magnification and superposition of
the right and left structures, as well as difficulty
identifying and registering the anatomic structures,
have been widely documented. This has resulted in
the development of other diagnostic alternatives to
evaluate craniofacial form and size, including com-
puterized tomography, magnetic resonance imaging,
and optical reading surface.
CRANIOH: The Journal of Craniomandibular & Sleep Practice
Bedoya et al. Morphometry in patients with type II, division 1 malocclusion
The most recent technology is three-dimensional
cephalometry. Its preciseness has been evaluated and
compared to metrics done physically. Results show
metrics with high precision and without significant
discrepancies. However, relatively high doses of
radiation, cost and limited availability have pre-
vented it from becoming a routine diagnostic tool.
Cone beam computed tomography (CBCT) has
recently emerged as a promising technology with
the potential for replacing three-dimensional cepha-
lometry.15 CBCT provides tomographic views and
volumetric reconstructions with lower doses of
radiation and reduced costs. Because of this, it has
become the imaging modality frequently used in
orthodontics, implant planning, and maxillofacial
surgery.16,17
Steiner’s classification of SNA, SNB and ANB
measured in two-dimensional X-rays are used to
evaluate the relationship of maxillomandibular posi-
tion in orthodontics; however, in recent studies that
evaluate skeletal discrepancies, angular indicators
have shown errors regarding the sagittal position of
the maxilla and mandible, since these variables do not
represent the morphology and size of the maxillo-
mandibular bones. Additionally, the visualization of
some reference points is not clear using conventional
cephalometry, which necessitates a three-dimensional
image that allows for detailed measurement.17 Since
the introduction of cone beam imaging dedicated to
the maxillofacial region is causing a true shift in the
paradigm of two- and three-dimensional imaging,
metrics in this study will be evaluated using helical
spiral CBCT.18
The general objective of the current study is to
describe cranial base metrics of the midline sagittal
plane and cranial–cervical–mandibular system in
young Colombian patients with type II, division 1
malocclusion, using CBCT imaging. Specific objec-
tives are to determine if there are common para-
meters in the examined population that allow
morphometric results to be characterized and asso-
ciated with malocclusion type II, division 1, and to
evaluate whether gender affects metric variation.
Materials and Methods
A transversal cut descriptive study was done, and data
were obtained from a database in a Cali, Colombia
radiological center. Sixty CBCT images of young
patients between the ages of 8 and 12 years old, who
presented with malocclusion type II, division 1, were
selected. From this group, 24 images met the following
inclusion criteria: overjet equal to or greater than
5 mm; ANB greater than 4 degrees; and a diagnosis of
2014 VOL . 32 NO . 3 201
Bedoya et al. Morphometry in patients with type II, division 1 malocclusion

Figure 1 Cephalometric landmarks to measure the variables.

malocclusion type II, division 1. The images were
taken using i-CAT VisionH technology,17–19 featuring
a tube potential of 120 kV and a 160 mA current. To
take the images, the following technique was used: The
patient was placed in a resting position after inhaling
and exhaling three times. Following the last exhala-
tion, the machine was adjusted to the patient’s head
and chin, keeping the Frankfort plane parallel to the
ground and the midsagittal line perpendicular to the
floor. Reference points taken by Björk and Solow
were taken into account. Additionally, other reference
points determined by the researchers were included
(Table 1 and Fig. 1). Lineal and angular measure-
ments were done on the midsagittal plane of the
cranial base and the cranial–cervical–mandibular
system. (Tables 2 and 3, Figs. 2 and 3)
The McGregor plane, defined by the distance
between the posterior nasal spine and the most
inferior point of the occipital bone, was taken into
account during the measurement process. The line
passing through the most anterior–inferior point of
C2 and the most superior point of the odontoid
process, the odontoid plane, was also drawn in order
to relate the McGregor and odontoid planes, and
obtain the craniocervical angle (Fig. 4).
Statistical analysis
The metrics were tabulated in an Excel database, and
the statistical analysis was done using SPSS Inc.,
version 17. Central tendency metrics and dispersion
metrics were evaluated. Once the data were obtained,
a univariate analysis was performed to determine the
socio-demographic characteristics of the population
evaluating the independent variables age and gender.
The analysis and a description of the dependent
variables (metrics taken in the sagittal medium and

Table 1 Reference points to measure the variables

Point Definition

Basion (Ba) Most posterior–inferior point of the clivus

Nasion (Na) Most anterior point of the frontal–nasal suture
Sella (S) Geometric center of the sella turcica
(A) Most posterior point of the curvature that is formed between the anterior nasal spine and prosthion
(B) Most posterior point of the curvature that is formed between the alveolar process and pogonion
Pogonion (Pg) Craniometric point localized in the most anterior part of the mandibular symphysis contour
Upper incisor (ls) Intersection between the upper incisor axis with its incise border
Inferior Incisor (li) Intersection of the inferior incisor axis with its incisor border
C3 Most anterior inferior point of the third cervical vertebrate
Hyoid (H) Most superior and anterior point of the hyoid bone body
Apophysis Geni (AG) Most posterior–inferior point of the mandible symphysis
*AA Most anterior point of the Atlas vertebral body
Superior Clivus (Cs) Point situated in the superior third of the clivus
Inferior Clivus (Ci) Point situated in the inferior third of the clivus
Posterior nasal spine (ENP) Most posterior point of the union of the palatine bones
*CIA Most inferior point of the Atlas contour
*CSA Most superior point of the Axis contour
Odontoid (Od) Most superior point of the odontoid process
*CAA Most anterior point of the Atlas in coronal line
*COP Most posterior point of the Atlas in coronal line

202 CRANIOH: The Journal of Craniomandibular & Sleep Practice 2014 VOL . 32 NO . 3
 Bedoya et al. Morphometry in patients with type II, division 1 malocclusion

Table 2 Linear measurements definitions in sagittal and coronal sections

Variable Definition

S–N Distance in mm from sella turcica to nasion

Cls–Cli Distance in mm between these two points
Od–Ba Vertical measurement in mm between both points
Od–ENP Sagittal distance between these points
AA–ENP Sagittal distance between these points
ENP–H Vertical distance between these two points
Alt. P McGregor–Od Vertical distance between these two points
*CIA–CSA Distance between the inferior contour of the C1 and the superior of the C2
C3–H Distance between C3 and point H
Height of the Hyoid triangle Height of the triangle formed by the points C3–H–AG
*CAA–ENP Distance between the anterior contour of the Atlas to ENP
*CPA–ENP Distance between the posterior contour of the atlas to ENP

coronal cuts) appear in Tables 3 and 4. For the
bivariate analysis, the non-parametric Mann–
Whitney test was used to determine if significant
differences exist between these variables due to
gender (Table 5). To observe how these variables
relate and how the variation percentage is explained,
a multivariate analysis of principal components was
performed. Since the first two principle components
explain 51.639% of the variation, these principles
were analyzed graphically using a rotated compo-
nents analysis (Fig. 5).
Results
Characterization of the study population according
to gender is as follows: In a 24-patient sample, 14
participants, or 58.3% were male, and 10 participants,
or 41.7%, were female. The average age of the
subjects studied was 9.83 years with a standard
deviation of 1.167 years. The minimum age of the
subjects was 8, and the maximum age was 12.
After independently analyzing metric variability by
gender, it was observed that the variables with lower
variation coefficients (between 2.9 and 14.6) were the
variables that measure the anterior cranial base
longitude and the variables relating to the cranial
base: the superior maxillary, mandible and symphy-
sis (S–N/Ba–S–N/S–N–A/S–N–B/S–N–Pg). The most
homogeneous variable was Ba–S–N. The measure-
ment of the craniocervical angle (Po–PMcG) was also
very consistent among the male subjects evaluated. In
the female participants, results show homogeneity in
the same variables, as well as in the inter-incisor angle
metric, which had a variation coefficient of 5.3.
In contrast, metrics with larger variations for both
genders related to the cervical vertebrae structures:
the odontoid and hyoid triangle, which comprised the

Table 3 Descriptive results (average, standard deviation and variation coefficients of the variables by gender (male)

Confidence interval 95%

Coefficient % Coefficient
Variable Average Standard deviation Lower limit Upper limit of variation of variation

Ba–S–N (angle) 131.45 3.90 124.84 138.05 0.03 2.97

S–N–A (angle) 80.75 3.80 74.12 87.37 0.05 4.71
S–N–B (angle) 74.70 2.80 71.88 77.51 0.04 3.75
S–N–Pg (angle) 76.00 3.20 71.84 80.15 0.04 4.21
Ii (angle) 108.27 7.41 96.49 120.06 0.07 6.84
N–Pg–Is (angle) 35.30 3.71 29.38 41.21 0.11 10.51
N–Pg–Ii (angle) 38.55 2.24 34.97 42.12 0.06 5.81
Cls–Cli(mm) 31.82 1.67 29.15 34.49 0.05 5.25
S–N (mm) 66.65 2.54 62.61 70.69 0.04 3.81
O–Ba (mm) 4.07 1.60 1.56 6.58 0.39 39.31
Ba–ENP (mm) 41.23 2.50 37.24 45.21 0.06 6.07
H–ENP (mm) 49.90 5.90 41.04 58.75 0.12 11.82
AA–ENP (mm) 30.02 2.19 26.53 33.51 0.07 7.30
Alt.O–PMcG (mm) 3.92 3.00 20.78 8.63 0.77 76.53
CIA–CSA (mm) 2.97 0.97 1.43 4.53 0.33 32.66
C3–H (mm) 31.20 8.61 18.00 45.39 0.28 27.59
C3–AG (mm) 62.40 4.57 55.11 69.63 0.07 7.32
H–AG (mm) 34.50 3.65 28.73 40.36 0.11 10.58
Alt–ÙH (mm) 2.41 0.49 1.62 3.18 0.20 20.46
PO–PMcG (angle) 95.30 13.95 73.06 117.48 0.15 14.64
ENP–CPO (mm) 36.30 2.82 31.81 40.78 0.08 7.77
ENP–CPA (mm) 32.07 1.51 29.67 34.47 0.05 4.71

CRANIOH: The Journal of Craniomandibular & Sleep Practice 2014 VOL . 32 NO . 3 203
Bedoya et al. Morphometry in patients with type II, division 1 malocclusion
Figure 2 Graphic drawing of linear measurements in mid sagittal and axial tomography sections.
height of the McGregor Plane, the distance between the
first and second cervical vertebrae (CIA–CSA), and the
height of the hyoid triangle, which was the most
heterogeneous in both groups, with a 95.7 coefficient in
males and 70.8 in females. In the bivariate analysis,
with the objective of determining if statistically
significant differences exist between the variables
comparing both genders, the non-parametric Mann–
Whitney statistic test showed the following results:
Differences in the average variables C3–AG/SNA and
C3H were larger in the females. The inclination of the
upper incisor compared to the vertical that passes
through N–Pg and the S–N distance were larger in
males. The S–N distance was the only variable with a
significant difference: P50.004 (Table 5).
Multivariet analysis
Rotated components matrix
According to components one and two, the following
relationships between the variables that relate the
Figure 3 Graphic drawing of angular measurements in midsagittal tomographic sections.
204 CRANIOH: The Journal of Craniomandibular & Sleep Practice 2014
cranial base with the maxilla, mandible and chin are
S–N–A/S–N–B and S–N–Pg. These variables have an
inversely proportional relationship with angles Ba–S–N
and P, Odontoid–P and McGregor. When the angle
that determines cranial flexion (Ba–S–N) and/or the
longitude of the anterior base (S–N) increases, the
angles SNA–SNB and SNPg decrease. The inclination
of the upper incisor is inversely related with variables
AA–ENP/H–AG and H–C3. A decrease in the
cranial–vertebral angle, with averages of 95.2 and
95.9 degrees for males and females, was consistently
observed in sample subjects. The variable that relates
the position of the hyoid in a vertical sense behaves
independently, which means it does not relate to any
other variable. The nasion–pogonion (N–Pg–Is) ver-
tical and the longitude of the anterior cranial base
(S–N) are inversely proportional to C3–AG, O–Ba, the
anterior and posterior contour of the Atlas, superior-
clivus distance – inferior clivus, H–AG, and inter-
incisor angle, AA–ENP.
VOL . 32 NO . 3
 Bedoya et al. Morphometry in patients with type II, division 1 malocclusion

will create a functional and esthetic imbalance,

Figure 4 Angle formed by McGregor plane and odontoid
plane.
The height of the hyoid bone relates negatively
with the inclination of the superior and inferior incise
(Ii). As the inter-incisor angle decreases, the distance
between H–AG and Ce–AG decreases. The posterior
nasal hyoid–spine variable is completely independent.
Discussion
The existing relationship between the size and
morphology of the cranial base and the growth
and development of the maxillofacial complex is
widely accepted. When morphogenesis and special
positioning of these structures does not occur
correctly, they may cause adverse conditions that
including postural, muscular and functional adap-
tations that manifest as signs of malocclusion. The
cranial base is relatively stable; however, great varia-
tions are observed at an individual level. As previously
shown, any change in flexion, form or size of the
superior maxilla or mandible may alter the sagittal
relationship, and influence the development of
malocclusion.19
The results of the present study determined existing
relationships between the structures of the anterior
and posterior cranial base, the structures that
determine the sagittal position of the superior
maxilla, mandible and symphysis, the cervical ver-
tebrae complex and hyoid bone. Watanabe et al.8
reported that the size and morphology of the cervical
vertebral system, along with the position of the head
and neck, relate with craniofacial morphology and
with type II, division 1 malocclusion. In the current
study, postural adaptations are observed as conse-
quences of the inadequate relationships between the
maxillaries.
Imaging is a very important tool for diagnosis and
treatment planning. Given the widely studied limita-
tions of the conventional lateral X-ray, other
technologies have been developed. With the arrival
of the CBCT specific for craniofacial images, it is
possible to gather volumetric information in three
planes of space with a one-to-one relationship. In
2010, Grauer et al.20 established that the identifica-

Table 4 Descriptive results (average, standard deviation and variation coefficients of the variables by gender (female)

Confidence interval 95%

Standard Lower Upper Coefficient % Coefficient

Variable Average deviation limit limit of variation of variation

Ba–S–N (angle) 128.91 3.90 125.12 132.71 0.03 3.03

S–N–A (angle) 85.55 3.40 81.93 89.17 0.04 3.97
S–N–B (angle) 78.97 4.20 74.60 83.33 0.05 5.32
S–N–Pg (angle) 79.45 3.50 75.95 82.96 0.04 4.41
Ii (angle) 114.52 4.95 109.94 119.11 0.04 4.32
N–Pg–Is (angle) 27.98 2.76 25.42 30.54 0.10 9.86
N–Pg–Ii (angle) 38.01 3.59 34.68 41.34 0.09 9.44
Cls–Cli (mm) 34.27 2.10 32.22 36.31 0.06 6.13
S–N (mm) 62.08 2.39 59.87 64.29 0.04 3.85
O–Ba (mm) 5.88 1.34 4.64 7.12 0.23 22.79
Ba–ENP (mm) 41.16 3.19 38.21 44.11 0.08 7.75
H–ENP (mm) 49.78 4.30 45.77 53.79 0.09 8.64
AA–ENP (mm) 33.98 1.71 32.40 35.56 0.05 5.03
Alt.O–PMcG (mm) 2.57 1.03 1.61 3.52 0.40 40.08
CIA–CSA (mm) 5.28 2.34 3.12 7.45 0.44 44.32
C3–H (mm) 33.30 2.75 30.75 35.84 0.08 8.26
C3–AG (mm) 68.48 4.34 64.47 72.50 0.06 6.34
H–AG (mm) 35.60 2.46 33.32 37.87 0.07 6.91
Alt–ÙH (mm) 2.97 2.15 0.98 4.96 0.72 72.37
PO–PMcG (angle) 95.98 3.60 92.64 99.32 0.04 3.75
ENP–CPO (mm) 38.10 3.69 34.68 41.51 0.10 9.69
ENP–CPA (mm) 34.35 3.84 30.79 37.91 0.11 11.18

CRANIOH: The Journal of Craniomandibular & Sleep Practice 2014 VOL . 32 NO . 3 205
Bedoya et al. Morphometry in patients with type II, division 1 malocclusion

In the current study, the size of the anterior cranial

Figure 5 Principal Components rotational graph.
tion of reference points is easier and more precise
using tomography. Kobayashi et al.21 reported that
cephalograms extracted from tomographic images
are more precise than those extracted from conven-
tional radiography.
The angle that determines flexion of the cranial
base (Ba–S–N) has an inversely proportional beha-
vior to the angles SNA–SNB and SNPg. When the
longitude S–N increments in points A, B and Pg are
posteriorly displaced, the angles SNA–SNB and
SNPg close. The inclination of the upper incisor is
inversely proportional to the distance AA–ENP, as
its inclination increases an hourly rotation in the
mandible, reducing the distance between the points
apophysis genio-hyoid and C3–hyoid. In this way,
the patient tries to compensate for the airway
decrease by adopting oral respiration. The variable
ENP–H is totally independent (Figs. 2 and 3).
base distance (S–N) is related to the maxillary
position, which coincides with what Hayashi reported
in a 2003 article.22 The data gathered in the authors’
sample population show a constant increase in the
angle of the cranial base (Ba–S–N), coinciding with
findings reported by Kasai et al.5
Rocabado et al.23,24 reported that the craniover-
tebral angle is, on average, 101u, with a range of 65u.
He related posterior rotation of the cranium with
angles ,96u and related anterior rotation with angles
.106u. In the current study, the authors found this
angle diminished in males and females, with an
average of 95.2u for males and 95.9u for women,
which coincides with the typical characteristics of
patients with type II, division 1 malocclusion. In an
article about the hyoid triangle, Bibby and Preston25
found great variability regarding the affect of hyoid
bone position on head position, even with light
movements. In this study, the variable that measures
the position of the hyoid bone was very stable and
behaved independently; i.e. it was not related to any
other variable.
Conclusions
After evaluating 24 images of young patients with
type II, division 1 malocclusion using helical spiral
CBCT, it was concluded that relationships exist
between the cranial base structures, the structures
that determine the sagittal position of the maxilla,
mandible and chin, and the cervical vertebrae
complex and hyoid bone.

Table 5 Comparison of average values between genders

Gender Average P value Gender Average P value

Ba–S–N (angle) Male 131.45 0.464 H–ENP (mm) Male 49.90 0.884
Female 128.91 Female 49.78
S–N–A (angle) Male 80.75 0.143 AA–ENP(mm) Male 30.02 0.334
Female 85.55 Female 33.98
S–N–B (angle) Male 74.70 0.218 Alt.O–PMcG (mm) Male 3.92 0.705
Female 78.97 Female 2.57
S–N–Pg (angle) Male 76.00 0.598 CIA–CSA (mm) Male 2.97 0.325
Female 79.45 Female 5.28
Ii (angle) Male 108.27 0.77 C3–H (mm) Male 31.20 0.154
Female 114.52 Female 33.30
N–Pg–Is (angle) Male 35.30 0.128 C3–AG (mm) Male 62.40 0.067
Female 27.98 Female 68.48
N–Pg–Ii (angle) Male 38.55 0.292 H–AG(mm) Male 34.50 0.226
Female 38.01 Female 35.60
Cls–Cli (mm) Male 31.82 0.953 Alt–ÙH (mm) Male 2.41 0.555
Female 34.27 Female 2.97
S–N (mm) Male 66.65 0.004 PO–PMcG (angle) Male 95.30 0.85
Female 62.08 Female 95.98
O–Ba (mm) Male 4.07 0.482 ENP–CPO (mm) Male 36.30 0.578
Females 5.88 Female 38.10
Ba–ENP (mm) Male 41.23 0.292 ENP–CPA(mm) Male 32.07 0.747
Female 41.16 Female 34.35

206 CRANIOH: The Journal of Craniomandibular & Sleep Practice 2014 VOL . 32 NO . 3

N With greater angulation of the cranial base, the angles
that relate the cranial base to the superior maxillary,
mandible and chin are smaller.
N The authors found that, with greater inclination of
the upper incisor, the distance between the posterior
nasal spine and the most anterior point of the first
cervical vertebrae is diminished; i.e. when this
inclination is increased, the cranium rotates poster-
iorly, decreasing the space for the upper airway or
nasopharynx. Additionally, the distance between the
hyoid bone and the cervical column is decreased.
N The hyoid bone was vertically very stable, with an
average distance of 50 mm from the posterior nasal
spine point. The height of the hyoid triangle presented
an average of 5.45 mm in males and 3.84 mm in females.
N In sagittal sense, the hyoid bone suffers modifications
in measurements when it is related with points C3 and
AG. The distances between C3–H, H–AG diminished
in patients with type II, division 1 malocclusion.
N The variable sella nasion was the only variable with
statistically significant differences between males and
females. The probability of observing this variable
increased in males.
Recommendations
(i) It is necessary to compare hyoid position in
patients with normal occlusion to those with
malocclusion type II.
(ii) Since it was determined that the variable ENP–
AA is directly related to malocclusion, its
evaluation is recommended during the diagnosis
of type II malocclusion as a complement to the
functional evaluation of the patient’s breathing.
(iii) The authors recommend increasing the sample
size, relating these variables to other structures,
including transversal metrics in further research
to complement the current study.
Disclaimer statements
Contributors Authors give thanks to Mr Julian
Tamayo for his collaboration in the statistical
analysis and Dr. Paula Bermudez for his contribution
in the methodological development of this document.
Funding There was no economic support from any
organization for the development of this investigaion.
Conflicts of interest It is manifested that there is no
conflict of interest.
Ethics approval The ethics committee of the
University Institution Schools Colombia (UNICOC)
assessed and supported the development of this research.
References
1 Shum L, Wang X, Kane AA, Nuckolls GH. BMP4 promotes
chondrocyte proliferation and hypertrophy in the endochondral
cranial base. Int J Dev Biol. 2003;47:423–31.
CRANIOH: The Journal of Craniomandibular & Sleep Practice
Bedoya et al. Morphometry in patients with type II, division 1 malocclusion
2 Karlsen AT. Craniofacial morphology in children with Angle
class II-1 malocclusion with and without deepbite. Angle
Orthod. 1994;64(6):437–46.
3 Delgado A. Anatomı́a Humana Funcional y Clı́nica. Cali:
Universidad del Valle; 1994.
4 Bastir M, Rosas A, O’Higgins P. Craniofacial levels and the
morphological maturation of the human skull. J Anat.
2006;209:637–54.
5 Kasai K, Moro T, Kanazawa E, Iwasawa T. Relationship
between cranial base and maxillofacial morphology. Eur J
Orthod. 1995;17(5):403–10.
6 Nie X. Cranial base in craniofacial development: developmental
features, influence on facial growth, anomaly, and molecular
basis. Acta Odontol Scand. 2005;63:127–35.
7 Sato S. A treatment approach to malocclusions under the
consideration of craniofacial dynamics. Meaw Publishing
House; 2001. Kanagawa, Japan.
8 Watanabe M, Yamaguchi T, Maki K. Cervical vertebra
morphology in different skeletal classes. Angle Orthod.
2010;80:719–24.
9 Mays KA, Palmer JB, Kuhlemeier KV. Influence of craniofa-
cial morphology on hyoid movement: a preliminary correla-
tional study. Disphagia. 2009;24:71–6.
10 Canut B. Ortodoncia Clı́nica y Terapéutica. Barcelona: Masson
E; 2000.
11 Angle EH. Classification of malocclusion. Dental Cosmos.
1899;41(248–264):350–7.
12 Ishii N, Deguchi T, Hunt NP. Craniofacial morphology of
Japanese girls with Class II division 1 malocclusion. J Orthod.
2001;28:211–5.
13 Hechler S. Cone-beam CT: applications in orthodontics. Dent
Clin N Am. 2008;52:809–23.
14 Axelsson S, Kjaer I, Bjørnland T, Storhaug K. Longitudinal
cephalometric standards for the neurocranium in Norwegians
from 6 to 21 years of age. Eur J Orthod. 2003;25:185–98.
15 Hassan B, van der Stelt P, Sanderink G. Accuracy of three-
dimensional measurements obtained from cone beam computed
tomography surface-rendered images for cephalometric analy-
sis: influence of patient scanning position. Eur J Orthod.
2009;31:129–34.
16 Markose E, Vikraman B, Veerabahu M. Three dimensional
CT reconstruction: a comparison between 2D, 3D CT and
original anatomical structures. J Maxillofac Oral Surg. 2009;8(1):
8–12.
17 Hayashi I. Morphological relationship between the cranial base
and dentofacial complex obtained by reconstructive computer
tomographic images. Eur J Orthod. 2003;25:385–91.
18 Scarfe WC, Farman AG. What is cone-beam CT and how does
it work? Dent Clin N Am. 2008;52:707–30.
19 Proff P, Will F, Bokan I, Fanghänel J, Gedrange T. Cranial
base features in skeletal Class III patients. Angle Orthod.
2008;78(3):433–9.
20 Grauer D, Cevidanes LSH, Styner MA, Heulfe I, Harmon ET,
Zhu HT, et al. Accuracy and landmark error calculation using
cone-beam computed tomography-generated cephalograms.
Angle Orthod. 2010;80:286–94.
21 Kobayashi K, Shimoda S, Nakagawa Y, Yamamoto A.
Accuracy in measurement of distance using limited conebeam
computerized tomography. Int J Oral Maxillofac Implants.
2004;19:228–31.
22 Hayashi I. Morphological relationship between the cranial base
and dentofacial complex obtained by reconstructive computer
tomographic images. Eur J Orthod. 2003;25:385–91.
23 Rocabado M. Análisis biomecánico cráneocervical a través de
la teleradiografı́a lateral. Rev Chil Ortod. 1984;1:42–52.
24 Rocabado M. Atlas clinico 2, congruencia craneo-cervico
mandibular. Aplicación practico clinica. CEDIME. 2012.
25 Bibby RE, Preston CB. The hyoid triangle. Am J Orthod.
1981;80:92–7.
2014 VOL . 32 NO . 3 207