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Anteroposterior Jaw Position and Pharyngeal Airway Morphology in Young Adult Patients: A CBCT Study Martin C. Avey, D.M.D. Background and Objectives: Much previous attention has been paid in the orthodontic literature to craniofacial skeletal patterns and morphology of the upper airway and their association with obstructive sleep apnea (OSA). However, the majority of 3D airway investigations in recent years have analyzed the relationship of the airway with various anteroposterior (AP) skeletal patterns using traditional 2D cephalometric landmarks and measurements, such as SNA and SNB. The Six Elements of Orofacial Harmony is a diagnostic and treatment philosophy that proposes a more accurate and clinically relevant approach to evaluating the position of teeth and jaws. Element II specifically assesses AP position of the jaws relative to a reproducible landmark, the goal anterior limit line (GALL). The specific aim of this study was to utilize cone-beam computed tomography (CBCT) to investigate pharyngeal airway morphology relative to various AP jaw positions as described by Element II. Experimental Design and Methods: A sample of 86 CBCT scans of pre-treatment orthodontic patients aged 18-30 from the private practice of Dr. Thomas Shipley was used for this study. IRB-approval was obtained, and a letter of permission was obtained from Dr. Shipley to use the records from his office. Exclusion criteria included history of orthodontic treatment, complex open bite with divergent occlusal planes, craniofacial/developmental deformity, adenoid hypertrophy, history of tonsillectomy/adenoidectomy, and poor image quality or artifacts. Pre-treatment CBCT scans were de-identified and DICOM files were analyzed using Dolphin Imaging 11.5 software. CBCT slices were used to extract a 2D lateral cephalogram for each subject. Subjects were then divided into groups based on craniofacial variables classified by the Six Elements (experimental) and traditional cephalometric measurements (control). Dolphin 3D was utilized to measure each subject’s lower pharyngeal airway volume (AV), airway length (AL), and minimum crosssectional area (mCA). These airway dimensions, as well as calculated mean cross-sectional area (MCA) and uniformity percentage (U%), were compared between groups for each craniofacial variable. Data was analyzed using one-way ANOVA and unequal variances t-tests to determine statistical significance of the results. Results: In the optimal Mx-GALL group, the average AV (23296.1 +/1095.6 mm 3 ) and MCA (332.3 +/16.4 mm 2 ) were significantly higher (p = 0.011 and 0.023) than every other position group. No other craniofacial variable groups had statistically significant differences in airway dimensions. Conclusions: The anteroposterior position of the maxilla relative to GALL has a significant correlation with lower pharyngeal airway size and shape. Subjects with an optimally positioned maxilla had airways with a significantly higher volume and larger average axial area than subjects in every other group for maxillary position. This is a novel and clinically relevant finding that can have a significant influence on surgical and non-surgical treatment planning. iii ACKNOWLEDGEMENTS I would like to acknowledge the support and assistance I have received during the undertaking of this thesis and throughout my orthodontic residency. I would never have been able to accomplish this project without your help, and I thank you. Dr. Tim Tremont, for serving as my thesis advisor and chair of my committee. You have provided guidance, thought-provoking conversation, and unwavering confidence in my abilities. Your mentorship has been invaluable to me. Thank you. Dr. Peter Ngan, for your feedback and wisdom throughout my thesis project. You have dedicated your life to the education and inspiration of future orthodontists and the search for truth in our profession through evidence and research. You have been a wonderful chairman and I owe you a great debt of gratitude for allowing me to realize my professional dreams. Thank you. Dr. Chris Martin, for serving on my thesis committee and being a constant presence during my orthodontic education. Thank you. Dr. Rick Jurevic, for serving on my thesis committee and offering your perspectives and feedback to build a solid research foundation. Thank you. Dr. Thomas Shipley, for graciously allowing access to your office and your patient database. Your dedication to improving our understanding of orthodontics is greatly appreciated. Thank you. Dr. Erdogen Gunel and Stefan Avey, for your time and effort in preparing and interpreting the statistical analyses conducted during this project. Thank you. Dr. Tim Glass and Dr. Jason Lawrence – my classmates and my great friends, for your insight, company, and fellowship these past three years. I couldn’t imagine going through the program with a better group of guys and I know we will all have amazing careers and lasting friendships. Thanks guys. Nick, Travis, Jen, Lance, Nicole, and Deepa – my former co-residents, for being great friends and teachers. You all taught me many things while we were in school together and I am grateful for the chance to have spent that time with you. Thank you. Uyen, Marina, DoBin, MacKenzie, Tyler, and Amer – my fellow residents, for being eager learners and dedicated students. You have reminded me that the future of our profession is bright and I wish you all the best of luck in your careers ahead. Thank you. Katie – my wife and my partner, for always being by my side. None of this is possible without you. I love you. Thank you.