Assessment of the Pterygoid Hamulus Dimensions and Morphology in Iranian Women Using Cone-Beam Computed Tomography

Assessment of the Pterygoid Hamulus Dimensions and Morphology in Iranian Women Using Cone-Beam Computed Tomography | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Assessment of the Pterygoid Hamulus Dimensions and Morphology in Iranian Women Using Cone-Beam Computed Tomography Zahra Mahdavi, Ladan Hafezi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3662920/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Objectives: This study aimed to evaluate the morphology and dimensions of the pterygoid hamulus (PH) and its changes by ageing in 20-40-year-old women in the Dental Branch of the Islamic Azad University of Sciences, Tehran, Iran. Materials and Methods: This cross-sectional study was conducted on cone-beam computed tomography (CBCT) scans from 258 women aged 20-40. The morphology, length, width, and angle of the PH in coronal and sagittal planes were investigated. Results: The average length of the right and left hamulus was 5.50±1.37 and 5.37±1.36 mm. The average width of the right and left hamulus was 2.16±0.72 and 2.11±1.06 mm. The average coronal angle of the right and left hamulus was 22.3±9.79° and 30.16±8.99°. The average sagittal angle of the right and left hamulus was 26.11±7.26° and 26.34±7.63°. In contrast with the sagittal angle, the right and left hamulus’s length, width, and coronal angles were not symmetrical. Slender morphology was the most frequent morphology, and it was symmetrical only in the 20-30-year-old age group. Finally, no variable was affected by ageing. Conclusions: Hamulus dimensions and morphology did not change with ageing in women aged 20-40. The PH symmetry varied by age group. Also, CBCT was a suitable tool for investigating hamulus changes. Clinical Relevance: Understanding the characteristics of the PH is crucial for diagnosing and treating various oropharyngeal and craniofacial conditions. It also aids in interpreting radiographs and diagnosing unexplained oropharyngeal pains. CBCT is a valuable tool for precisely visualising these structures, offering clinical insights into this previously understudied area. Cone-Beam Computed Tomography Pterygoid Hamulus Morphology Age Groups Figures Figure 1 1. Introduction The pterygoid hamulus (PH) is a hook-like process with a slightly outward and forward direction extending from the inferior end of the medial pterygoid plate of the sphenoid bone [ 1 , 2 ]. This process has a unique shape and is a crucial part of the skull base, yet it still needs to be more adequately represented on anatomical charts. Due to its proximity to the maxilla and oropharynx regions, PH has attracted the interest of many different fields [ 1 , 3 ]. The normal function of several muscles, including tensor veli palatini, palatopharyngeus, and upper part of the superior pharyngeal constrictor (pars pterygopharyngea), depends on the position, size, and inclination of PH [ 4 ]. Throughout a person's growth and development, these muscles are primarily responsible for maintaining the separation between the nasal and oral cavities during swallowing and sucking [ 3 , 5 ]. An elongated PH is associated with pterygoid hamulus syndrome (PHS), which is characterised by various signs and symptoms in the soft palate and pharynx regions and causes pain and discomfort, especially during swallowing [ 3 ]. In 1987, Hjørting-Hansen et al. introduced the term "pterygoid hamulus syndrome" to refer to discomfort in the palatal and pharyngeal areas resulting from an irregularly shaped PH [ 6 , 7 ]. If a patient feels pain in these areas, it may be necessary to consider PHS as a potential differential diagnosis. On the other hand, insufficient growth of PH in newborns causes inadequate support of the cephalopharyngeal muscle and uncontrolled narrowing of the superior pharynx, resulting in problems like sleep apnoea and snoring [ 3 ]. The knowledge of PH morphology and characteristics is essential and helpful for interpreting head and neck radiographs, including cephalometric radiography, submentovertex view, and Waters view. It provides valuable information for the differential diagnosis of oral and pharynx pains, particularly those without a known aetiology. One of the pioneers in evaluating PH morphology was the study by Eyrich et al. in 1997 [ 8 ]. Identification of this process using Waters view and lateral cephalometry is possible but difficult due to superimpositions and distortions. In contrast, cone-beam computed tomography (CBCT) offers a more precise visualisation of craniofacial structures through 3-dimensional (3D) views from coronal, sagittal, and axial planes [ 9 ]. Despite the importance of understanding PH morphology, few studies have evaluated the morphological features and dimensions of PH, particularly in Iranian society. Therefore, the current study evaluated PH morphology and dimensions using CBCT among 20-40-year-old female patients treated at the Dental Branch of the Islamic Azad University of Medical Sciences, Tehran, Iran. 2. Materials and Methods 2.1. Study Design An analytical cross-sectional observational study. 2.2. Setting and Participants The CBCT scans of female patients between the ages of 20–40 years old who were referred to the radiology department of the Islamic Azad University of Medical Sciences from 9th December, 2021 until 21st September, 2022 were evaluated. All scans in which the posterior region of the maxilla was covered were included. CBCT images with unclear borders of the PH, blurred or low-quality images, images with artefacts that cover the region of interest, and images taken from patients who have had maxillofacial trauma such as PH fracture, traumatic maxillary third molar extraction, pathologic conditions in the posterior maxillary region, and bone deficiencies, including osteoporosis and familial or traumatic skeletal asymmetries, were excluded from the study. The scans were acquired using the Villa Sistemi Medicali device (Rotograph EVO 3D, Rome, Italy) while the patients were in standard position with an image acquisition time of 15 seconds. The exposure parameters were set at 230 kVp, 7 mA, and the required field of view had a voxel size of 8.5 µm × 8.5 µm × 8.5 µm. The images were exported in the Digital Imaging and Communications in Medicine (DICOM) format. 2.3. Variables Measurements of the size (length and width) and the inclination of the PH on the coronal and sagittal planes were conducted using the OnDemand 3D Viewer software (available at https://www.ondemand3d.com ). The coronal sections were used to measure the length and width of the PH. In order to identify the junctional point between the PH and the pterygoid bone, the Multi-Planar Reformat tool was used to compare the coronal and sagittal views of the same side. The PH length was defined as the longest line connecting the medial pterygoid-PH junction to the tip of the PH. The distance between the most prominent points on the lateral and medial sides of the process was measured as the PH width [ 10 ]. The coronal inclination of the PH was defined as the mediolateral angle between the PH long axis and the long axis of the medial pterygoid plane. The PH sagittal inclination was defined as the posteroanterior angle between the long axis of the PH and the long axis of the Medial pterygoid plane (Fig. 1). The PH morphology was categorized as “Slender” or “Triangle” type according to the study by Nerkar et al. [ 11 ]. Examiner percentage error was calculated by repeating 5% of the measurements after two weeks. FIGURE 1 PLACEHOLDER 2.4. Study Size Following the aforementioned eligibility criteria, the CBCT scans from 258 patients were included in the study. 2.5. Statistical Methods Statistical analyses were performed using the Statistical Package for Social Sciences (SPSS) application for Windows, Version 25.0 (SPSS Inc., Chicago, IL, USA). The homogeneity of the variances was evaluated using the Kolmogorov-Smirnov test. An Independent t-test was used to compare numeric variances with normal distribution between the age groups; otherwise, the comparison was made using the Mann-Whitney U test. Moreover, the Wilcoxon signed-rank test was used to conduct the symmetrical analysis of PH size and coronal and sagittal inclinations. The Chi-square and McNemar's analyses were used to compare the morphology between the age groups and the symmetry evaluations. Finally, P-value < 0.05 was considered statistically significant. 2.6. Ethics and Consent to Participate This study was carried out according to the ethical principles of the Declaration of Helsinki, in addition to local ethical and legal requirements. Ethics approval was obtained from the institutional research ethics committee of the Islamic Azad University of Medical Sciences (ID: IR.IAU.TMU.REC.1400.230). The need for written consent was waived by the Institutional Review Board of Islamic Azad University of Medical Sciences based on national regulations and the nature of this study. This study strictly adheres to de-identification techniques, ensuring the anonymity and confidentiality of all participants. Notably, it involves observational methods, and the study techniques employed are entirely harmless and burden-less to participants. Also, before participating in this research, individuals verbally consented to their de-identified data being used strictly for research purposes. 3. Results 3.1. Basic Characteristics A total of 258 CBCT scans from female patients with a mean age of 32.90 ± 5.47 years were assessed in this study. Seventy-nine (31.23%) patients were aged between 21-30, and 174 (68.77%) were between 31-40 years old. 3.2. Size and Inclination The coronal sections were used to measure the length and width of the PH on the right and left sides, while its inclination was measured on both coronal and sagittal views. The mean measured values of the PH size and inclination are presented in Table 1 . According to the independent t-test and Mann- Whitney U analyses presented in Table 2 , there was no significant difference between the two age groups regarding the PH size (length and width) and coronal and sagittal inclinations (P>0.05). TABLE 1 PLACEHOLDER TABLE 2 PLACEHOLDER There was a statistically significant difference in the length (P=0.045), width (P=0.008), and coronal inclination (P<0.001) of the PH between the right and left sides, indicating that the PH is asymmetrical regarding these variables. In contrast, the Wilcoxon signed-rank test did not show a significant difference in the sagittal inclination of right and left side PHs (P=0.427), so the sagittal inclination of PH was symmetrical. The PHs of the first age group (20-30 y/o) had a symmetrical length (P=0.556), width (P=0.558), and sagittal inclination (P=0.857), while the second age group (31-40 y/o) were only symmetrical in terms of the sagittal inclination (P=0.391) 3.3. Morphology The slender type PH was the most frequent morphology on both sides (left: 61.26%, right: 57.31%). The chi-square analysis did not show a significant difference in the left (P=0.697) and right-side (P=0.940) PH morphologies when the two age groups were compared ( Table 3 ). Contrary to the first age group (20-30 y/o) (P=0.302), patients in the second age group (31-40 y/o) had asymmetrical PH morphology (P=0.002) ( Table 4 ). TABLE 3 PLACEHOLDER TABLE 4 PLACEHOLDER 4. Discussion The correlation between the hamulus process and the posterior throat and oropharyngeal region pains was first evaluated in 1989 by Salins et al. [ 12 ] and in 1996 by Shankland et al. [ 9 ]. Position, inclination and dimensions of the hamulus process significantly impact the normal function of the surrounding muscles. When these muscles are contracted, the oral cavity separates from the nasal cavity, and swallowing occurs [ 4 ]. Since the tubar part of the tensor veli palatini (TVP) muscle is linked to the PH, the position and morphology of this process directly affect the function of the TVP muscle and, consequently, the function of the hard palate during swallowing. Furthermore, the PH inclination plays a vital role in a better tension of palatal aponeurosis [ 3 ]. The morphological alterations of the PH, such as growth deficiency in newborns, result in insufficient muscle support, followed by the uncontrolled narrowing of the upper pharynx, sleep apnoea and snoring [ 13 ]. In addition, these changes might be misdiagnosed as temporomandibular disorders or glossopharyngeal neuralgia by mimicking symptoms such as ear pain, pain during chewing and swallowing, and oedema and erythema in the palate’s posterior region [ 3 , 14 ]. PHS, known as the palate and pharynx pains caused by inflammation in the hamular region, is primarily due to hamulus process elongation. These pains might be misjudged with those of impacted third molar or middle ear cysts or tumours [ 15 ]. Also, there is a risk of iatrogenic trauma to the PH during certain maxillofacial surgeries, especially posterior alveolar process operations (e.g., maxillary impacted third molar extraction) [ 16 ]. Dentists must be well-versed in PH anatomical features and functions to diagnose, treat, and prevent maxillofacial pains and iatrogenic surgical traumas properly. They should consider PH-related disorders as a potential differential diagnosis, especially for pains with unknown aetiology. Hence, PH was studied for its morphometric characteristics and its alterations with age in the current study. Unlike the previous studies, we evaluated the effect of all variables simultaneously by measuring the size and inclination of PH on coronal and sagittal sections of 258 CBCT scans on both the right and left sides. Additionally, the PH symmetry was analysed in each age group. Consequently, our findings can help diagnose untraceable pains in the nasal and oropharyngeal regions. Notably, we tried to increase the results' accuracy by limiting the samples to 20-40-year-old women. The measurements showed an average length of 5.50 ± 1.37 mm and 5.37 ± 1.36 mm for right and left PH and an average width of 2.16 ± 0.72 mm and 2.11 ± 1.06 mm, respectively. The coronal and sagittal inclinations of right and left PH were 22.3 ± 9.79°, 30.16 ± 8.99°, and 26.11 ± 7.26°, 26.21 ± 7.80°. There was no significant difference in PH length, width, and coronal and sagittal inclinations between the two age groups, indicating that the PH morphometric parameters did not alter with ageing. Our results were similar to those of the studies by Eyrich et al. [ 8 ] and Orhan et al. [ 4 ], who reported that the right and left PH lengths were 4.5 and 5 mm, and 5.40 ± 2.00 and 5.48 ± 1.94 mm, respectively. Orhan et al. also measured the PH width on the sagittal plane and reported an average width of 1.87 ± 1.17 and 1.72 ± 0.94 mm for right and left PHs [ 4 ]. In contrast, in this study, the PH width was measured on coronal sections. Our study used the pterygoid plane's long axis instead of the true horizontal line [ 2 , 3 , 4 ] to assess the PH's inclinations. However, the lateral and posterior inclinations of PH on coronal and sagittal sections were similar to previous investigations [ 3 , 4 , 16 ]. In accordance with our findings, Komarnitki et al. found a weak correlation between age and PH dimensional changes [ 16 ]. Mehra et al. evaluated the PH size in three age groups: 50 y/o. They reported increased PH length with age, while widths initially decreased, then increased [ 1 ]. In addition, Romoozi et al. stated that rather than the coronal inclination, the length and width of the PH on the sagittal plane significantly depend on age, so the PH length in 21-59-year-old adults increased compared to 15-21-year-old individuals [ 13 ]. On the other hand, patients aged between 60 and 100 y/o had shorter PH than younger adults. They also reported a reduction in PH width and sagittal inclination with age. A significant increase in PH length among adults (21–59 y/o) compared to children (0–9 y/o) and a subsequent reduction in the elderly (60–100 y/o) by an average of 0.5 mm was also reported by Krmpotic-Nemanic et al. [ 3 ]. It has been noted by Orhan et al. that although the association between PH size and age is not significant, older people generally have smaller PH than younger people. In line with our findings, PH did not change in size and inclination during the age of 20–40 years in all previous investigations [ 4 ]. Based on our symmetry analysis, the right and left sides' PHs were only symmetrical in terms of sagittal inclination. According to Orhan et al. , the left side PH was wider than the right in both males and females. However, there was no difference in the lengths of the right and left PHs [ 4 ]. There are also other studies that have found the PH's length and width symmetrical [ 16 ]. The fewer participants and the absence of gender exclusivity could explain the difference in the results. Currently, there is no explicit explanation for the asymmetry of PH widths. Nevertheless, several factors may contribute to the observed asymmetry in length and width, including genetic factors and functional differences in oral habits, such as masticatory patterns and occlusal forces between the right and left sides. The variation in coronal inclination may result from asymmetrical growth patterns and development during embryogenesis. The recognition of such asymmetry in the PH is of clinical importance in various dental and maxillofacial procedures, including orthodontic treatments, prosthodontics, and surgical interventions. Dentists and oral surgeons should consider these anatomical variations when planning treatment modalities or surgical procedures that involve the PH. The findings of the current study revealed that the most common PH morphology on both sides was the slender type. However, the differences in the two morphologies’ frequencies were not significant when age groups were compared. In addition, a comparison of the right and left sides showed that the PHs were symmetrical regarding morphology. In contrast to the first age group (20–30 y/o), patients between the ages of 31 and 40 showed asymmetrical PH morphology. Previously, Nerkar et al. have reported that triangular morphology was the most prevalent form in Indian society [ 11 ]. This difference can be explained by racial variations. It is essential to acknowledge the limitations of this study, such as its focus on a specific population (Iranian women aged 20–40). There could have been errors in the comparison results due to the uneven distribution of participants between age groups. In order to strengthen the generalisability of the results in future studies, we suggest evaluating a larger population with data gathered from multiple radiographic centres rather than from a single centre. Future research could explore potential factors influencing PH asymmetry, such as genetics, environmental factors, and functional habits. 5. Conclusion Hamulus process morphometric characteristics did not change with age in women aged 20–40. On the other hand, age-related differences in PH symmetry were observed between the two groups. Finally, CBCT was an appropriate method for studying hamulus alterations. Abbreviations 3D, 3-dimensional; CBCT, cone-beam computed tomography; DICOM, Digital Imaging and Communications in Medicine; PH, pterygoid hamulus; PHS, pterygoid hamulus syndrome; SPSS, Statistical Package for Social Sciences; TVP, tensor veli palatini. Declarations Acknowledgment Not applicable. Author Contribution Statement Contributions to the current study are Zahra Mahdavi in the literature review, data gathering and cleaning, and drafting of the manuscript; Ladan Hafezi in the design, data gathering, cleaning, and analysis, and drafting and revising the manuscript critically for the importance of intellectual content. Both authors have read and approved the final version to be published and agreed to be accountable for all aspects of the work. Also, both authors agreed on the order in which their names are listed in the manuscript. Conflict of Interests The authors declare there is no conflict of interests, whatsoever. Ethical Approval This study was carried out according to the ethical principles of the Declaration of Helsinki, in addition to local ethical and legal requirements. Ethics approval was obtained from the institutional research ethics committee of Islamic Azad University of Medical Sciences (ID: IR.IAU.TMU.REC.1400.230). Informed Consent Statement The need for written consent was waived by the Institutional Review Board of Islamic Azad University of Medical Sciences based on national regulations and the nature of this study. This study strictly adheres to de-identification techniques, ensuring the anonymity and confidentiality of all participants. Notably, it involves observational methods, and the study techniques employed are entirely harmless and burden-less to participants. Also, before participating in this research, individuals verbally consented to their de-identified data being used strictly for research purposes. Funding Support No external funding or sponsorship was received for this research. Transparency Declaration Authors declare that the manuscript is honest, accurate, and transparent. No important aspect of the study is omitted. Patients and Public Partnership The patients or the public were not involved in our research's design, conduct, reporting, or dissemination plans. Data Availability Statement All data produced in the present study are available upon reasonable request to the authors. References Mehra A, Karjodkar FR, Sansare K, Kapoor R, Tambawala S, Saxena VS. Assessment of the dimensions of the pterygoid hamulus for establishing age- and sex-specific reference standards using cone-beam computed tomography. Imaging Sci Dent. 2021;51(1):49–54. Putz R, Kroyer A. Functional morphology of the pterygoid hamulus. Ann Anat. 1999;181(1):85–8. Krmpotic-Nemanic J, Vinter I, Marusic A. Relations of the pterygoid hamulus and hard palate in children and adults: anatomical implications for the function of the soft palate. Ann Anat. 2006;188(1):69–74. Orhan K, Sakul BU, Oz U, Bilecenoglu B. Evaluation of the pterygoid hamulus morphology using cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(2):e48-55. Abe M, Murakami G, Noguchi M, Kitamura S, Shimada K, Kohama GI. Variations in the tensor veli palatini muscle with special reference to its origin and insertion. Cleft Palate Craniofac J. 2004;41(5):474–84. Hjørting-Hansen E, Lous I. The pterygoid hamulus syndrome. Ugeskrift for Laeger. 1987;149(15):979–82. Hjørting-Hansen E, Lous I. Hamulus pterygoid syndrome. Tandlaegebladet. 1987;91(20):833–7. Eyrich GK, Locher MC, Warnke T, Sailer HF. The pterygoid hamulus as a pain-inducing factor. A report of a case and a radiographic study. Int J Oral Maxillofac Surg. 1997;26(4):275–7. Shankland WE, 2nd. Bursitis of the hamular process. Part II: Diagnosis, treatment and report of three case studies. Cranio. 1996;14(4):306–11. Oz U, Orhan K, Aksoy S, Ciftci F, Özdoğanoğlu T, Rasmussen F. Association between pterygoid hamulus length and apnea hypopnea index in patients with obstructive sleep apnea: a combined three-dimensional cone beam computed tomography and polysomnographic study. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2016;121(3):330-9. Nerkar A, Gadgil R, Bhoosreddy A, Shah K, Varma S. Cone-beam computed tomography study of morphometric evaluation of pterygoid hamulus. International Journal of Recent Advances in Multidisciplinary Research. 2017;4(7):2678–82. Salins PC, Bloxham GP. Bursitis: a factor in the differential diagnosis of orofacial neuralgias and myofascial pain dysfunction syndrome. Oral Surg Oral Med Oral Pathol. 1989;68(2):154–7. Romoozi E, Razavi S, Barouti P, Rahimi M. Investigating the morphologic indices of the hamulus pterygoid process using the CBCT technique. Journal of Research in Medical and Dental Sciences 2018. 2018;6 (2):240-4. Dupont JS, Jr., Brown CE. Comorbidity of pterygoid hamular area pain and TMD. Cranio. 2007;25(3):172–6. Kende P, Aggarwal N, Meshram V, Landge J, Nimma V, Mathai P. The Pterygoid Hamulus Syndrome - An Important Differential in Orofacial Pain. Contemp Clin Dent. 2019;10(3):571–6. Komarnitki I, Skadorwa T, Chloupek A. Radiomorphometric assessment of the pterygoid hamulus as a factor promoting the pterygoid hamulus bursitis. Folia Morphol (Warsz). 2020;79(1):134–40. Tables Table 1. The Mean Measured Values of the Pterygoid Hamulus Size and Inclination Variable Minimum Maximum Mean ± SD Left Side Length (mm) 2.27 9.39 5.37 ± 1.36 Width (mm) 0.76 15.04 2.11 ± 1.06 Coronal Inclination ( °) 4.40 58.70 30.16 ± 8.99 Sagittal Inclination ( °) 9.70 49.70 26.34 ± 7.63 Right Side Length (mm) 1.69 10.80 5.50 ± 1.37 Width (mm) 0.83 6.16 2.16 ± 0.72 Coronal Inclination ( °) 8.20 66.00 32.30 ± 9.79 Sagittal Inclination ( °) 6.60 52.60 26.11 ± 7.26 Table 2. Comparison of the Pterygoid Hamulus Size and Inclination on the Right and Left Sides Between the Two Age Groups Variable Age Group Mean P-value Left Side Length (mm) 20-30 y/o 5.15 ± 1.03 0.838 31-40 y/o 5.47 ± 1.32 Width (mm) 20-30 y/o 1.72 ± 0.44 0.699 31-40 y/o 2.29 ± 1.99 Coronal inclination ( °) 20-30 y/o 29.18 ± 9.24 0.244 31-40 y/o 30.60 ± 8.86 Sagittal inclination ( °) 20-30 y/o 26.31 ± 7.66 0.828 31-40 y/o 26.35 ± 7.64 Right Side Length (mm) 20-30 y/o 5.46 ± 1.57 0.506 31-40 y/o 5.89 ± 3.76 Width (mm) 20-30 y/o 2.06 ± 0.67 0.089 31-40 y/o 2.56 ± 3.36 Coronal Inclination ( °) 20-30 y/o 31.40 ± 9.31 0.323 31-40 y/o 32.71 ± 10.00 Sagittal Inclination ( °) 20-30 y/o 26.20 ± 7.04 0.927 31-40 y/o 26.06 ± 7.37 Table 3. Comparison of the Pterygoid Hamulus Morphologies on the Right and Left Sides Between the Two Age Groups Morphology $ Age Group P-value 20-30 y/o 31-40 y/o Left Side Slender Type 47 (59.50%) 108 (62.10%) 0.697 Triangle Type 32 (40.50%) 66 (37.90%) Right Side Slender Type 45 (57.00%) 100 (57.50%) 0.940 Triangle Type 34 (43.00%) 74 (42.50%) $ Reported as frequency (percentage) Table 4. Comparison of the Pterygoid Hamulus Morphological Symmetry $ Reported as frequency. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Coronal Plane, B. Sagittal Plane\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1TheInclinationofthePH.png","url":"https://assets-eu.researchsquare.com/files/rs-3662920/v1/996499d6790b846b4ee0997d.png"},{"id":48229098,"identity":"e0595090-d0f8-442f-b8de-c61995b5d304","added_by":"auto","created_at":"2023-12-14 18:27:32","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1873647,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3662920/v1/9e43aab0-de67-4f9a-95c3-e1c93c2b85ee.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Assessment of the Pterygoid Hamulus Dimensions and Morphology in Iranian Women Using Cone-Beam Computed Tomography","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eThe pterygoid hamulus (PH) is a hook-like process with a slightly outward and forward direction extending from the inferior end of the medial pterygoid plate of the sphenoid bone [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This process has a unique shape and is a crucial part of the skull base, yet it still needs to be more adequately represented on anatomical charts. Due to its proximity to the maxilla and oropharynx regions, PH has attracted the interest of many different fields [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The normal function of several muscles, including tensor veli palatini, palatopharyngeus, and upper part of the superior pharyngeal constrictor (pars pterygopharyngea), depends on the position, size, and inclination of PH [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Throughout a person's growth and development, these muscles are primarily responsible for maintaining the separation between the nasal and oral cavities during swallowing and sucking [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. An elongated PH is associated with pterygoid hamulus syndrome (PHS), which is characterised by various signs and symptoms in the soft palate and pharynx regions and causes pain and discomfort, especially during swallowing [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In 1987, Hj\u0026oslash;rting-Hansen \u003cem\u003eet al.\u003c/em\u003e introduced the term \"pterygoid hamulus syndrome\" to refer to discomfort in the palatal and pharyngeal areas resulting from an irregularly shaped PH [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. If a patient feels pain in these areas, it may be necessary to consider PHS as a potential differential diagnosis. On the other hand, insufficient growth of PH in newborns causes inadequate support of the cephalopharyngeal muscle and uncontrolled narrowing of the superior pharynx, resulting in problems like sleep apnoea and snoring [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe knowledge of PH morphology and characteristics is essential and helpful for interpreting head and neck radiographs, including cephalometric radiography, submentovertex view, and Waters view. It provides valuable information for the differential diagnosis of oral and pharynx pains, particularly those without a known aetiology. One of the pioneers in evaluating PH morphology was the study by Eyrich \u003cem\u003eet al.\u003c/em\u003e in 1997 [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Identification of this process using Waters view and lateral cephalometry is possible but difficult due to superimpositions and distortions. In contrast, cone-beam computed tomography (CBCT) offers a more precise visualisation of craniofacial structures through 3-dimensional (3D) views from coronal, sagittal, and axial planes [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite the importance of understanding PH morphology, few studies have evaluated the morphological features and dimensions of PH, particularly in Iranian society. Therefore, the current study evaluated PH morphology and dimensions using CBCT among 20-40-year-old female patients treated at the Dental Branch of the Islamic Azad University of Medical Sciences, Tehran, Iran.\u003c/p\u003e"},{"header":"2. Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study Design\u003c/h2\u003e \u003cp\u003eAn analytical cross-sectional observational study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Setting and Participants\u003c/h2\u003e \u003cp\u003eThe CBCT scans of female patients between the ages of 20\u0026ndash;40 years old who were referred to the radiology department of the Islamic Azad University of Medical Sciences from 9th December, 2021 until 21st September, 2022 were evaluated. All scans in which the posterior region of the maxilla was covered were included. CBCT images with unclear borders of the PH, blurred or low-quality images, images with artefacts that cover the region of interest, and images taken from patients who have had maxillofacial trauma such as PH fracture, traumatic maxillary third molar extraction, pathologic conditions in the posterior maxillary region, and bone deficiencies, including osteoporosis and familial or traumatic skeletal asymmetries, were excluded from the study.\u003c/p\u003e \u003cp\u003eThe scans were acquired using the Villa Sistemi Medicali device (Rotograph EVO 3D, Rome, Italy) while the patients were in standard position with an image acquisition time of 15 seconds. The exposure parameters were set at 230 kVp, 7 mA, and the required field of view had a voxel size of 8.5 \u0026micro;m \u0026times; 8.5 \u0026micro;m \u0026times; 8.5 \u0026micro;m. The images were exported in the Digital Imaging and Communications in Medicine (DICOM) format.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Variables\u003c/h2\u003e \u003cp\u003eMeasurements of the size (length and width) and the inclination of the PH on the coronal and sagittal planes were conducted using the OnDemand 3D Viewer software (available at \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ondemand3d.com\u003c/span\u003e\u003cspan address=\"https://www.ondemand3d.com\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The coronal sections were used to measure the length and width of the PH. In order to identify the junctional point between the PH and the pterygoid bone, the Multi-Planar Reformat tool was used to compare the coronal and sagittal views of the same side. The PH length was defined as the longest line connecting the medial pterygoid-PH junction to the tip of the PH. The distance between the most prominent points on the lateral and medial sides of the process was measured as the PH width [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The coronal inclination of the PH was defined as the mediolateral angle between the PH long axis and the long axis of the medial pterygoid plane. The PH sagittal inclination was defined as the posteroanterior angle between the long axis of the PH and the long axis of the Medial pterygoid plane (Fig.\u0026nbsp;1). The PH morphology was categorized as \u0026ldquo;Slender\u0026rdquo; or \u0026ldquo;Triangle\u0026rdquo; type according to the study by Nerkar \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Examiner percentage error was calculated by repeating 5% of the measurements after two weeks.\u003c/p\u003e \u003cp\u003e \u003cspan type=\"BoldItalicUnderline\" class=\"BoldItalicUnderline\" name=\"Emphasis\"\u003eFIGURE 1 PLACEHOLDER\u003c/span\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e2.4. Study Size\u003c/h2\u003e \u003cp\u003eFollowing the aforementioned eligibility criteria, the CBCT scans from 258 patients were included in the study.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e2.5. Statistical Methods\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the Statistical Package for Social Sciences (SPSS) application for Windows, Version 25.0 (SPSS Inc., Chicago, IL, USA). The homogeneity of the variances was evaluated using the Kolmogorov-Smirnov test. An Independent t-test was used to compare numeric variances with normal distribution between the age groups; otherwise, the comparison was made using the Mann-Whitney U test. Moreover, the Wilcoxon signed-rank test was used to conduct the symmetrical analysis of PH size and coronal and sagittal inclinations. The Chi-square and McNemar's analyses were used to compare the morphology between the age groups and the symmetry evaluations. Finally, P-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e2.6. Ethics and Consent to Participate\u003c/h2\u003e \u003cp\u003e This study was carried out according to the ethical principles of the Declaration of Helsinki, in addition to local ethical and legal requirements. Ethics approval was obtained from the institutional research ethics committee of the Islamic Azad University of Medical Sciences (ID: IR.IAU.TMU.REC.1400.230). The need for written consent was waived by the Institutional Review Board of Islamic Azad University of Medical Sciences based on national regulations and the nature of this study. This study strictly adheres to de-identification techniques, ensuring the anonymity and confidentiality of all participants. Notably, it involves observational methods, and the study techniques employed are entirely harmless and burden-less to participants. Also, before participating in this research, individuals verbally consented to their de-identified data being used strictly for research purposes.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003ch2\u003e3.1. Basic Characteristics\u003c/h2\u003e\n\u003cp\u003eA total of 258 CBCT scans from female patients with a mean age of 32.90 \u0026plusmn; 5.47 years were assessed in this study. Seventy-nine (31.23%) patients were aged between 21-30, and 174 (68.77%) were between 31-40 years old. \u003c/p\u003e\n\u003ch2\u003e3.2. Size and Inclination\u003c/h2\u003e\n\u003cp\u003eThe coronal sections were used to measure the length and width of the PH on the right and left sides, while its inclination was measured on both coronal and sagittal views. The mean measured values of the PH size and inclination are presented in \u003cstrong\u003eTable 1\u003c/strong\u003e. According to the independent t-test and Mann- Whitney U analyses presented in \u003cstrong\u003eTable 2\u003c/strong\u003e, there was no significant difference between the two age groups regarding the PH size (length and width) and coronal and sagittal inclinations (P\u0026gt;0.05).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTABLE 1 PLACEHOLDER\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTABLE 2 PLACEHOLDER\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere was a statistically significant difference in the length (P=0.045), width (P=0.008), and coronal inclination (P\u0026lt;0.001) of the PH between the right and left sides, indicating that the PH is asymmetrical regarding these variables. In contrast, the Wilcoxon signed-rank test did not show a significant difference in the sagittal inclination of right and left side PHs (P=0.427), so the sagittal inclination of PH was symmetrical. The PHs of the first age group (20-30 y/o) had a symmetrical length (P=0.556), width (P=0.558), and sagittal inclination (P=0.857), while the second age group (31-40 y/o) were only symmetrical in terms of the sagittal inclination (P=0.391)\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e3.3. Morphology\u003c/h2\u003e\n\u003cp\u003eThe slender type PH was the most frequent morphology on both sides (left: 61.26%, right: 57.31%). The chi-square analysis did not show a significant difference in the left (P=0.697) and right-side (P=0.940) PH morphologies when the two age groups were compared (\u003cstrong\u003eTable 3\u003c/strong\u003e). Contrary to the first age group (20-30 y/o) (P=0.302), patients in the second age group (31-40 y/o) had asymmetrical PH morphology (P=0.002) (\u003cstrong\u003eTable 4\u003c/strong\u003e).\u003cstrong\u003e\u003cem\u003e\u003cu\u003e\u0026nbsp;\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTABLE 3 PLACEHOLDER\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u003cu\u003eTABLE 4 PLACEHOLDER\u003c/u\u003e\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe correlation between the hamulus process and the posterior throat and oropharyngeal region pains was first evaluated in 1989 by Salins \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and in 1996 by Shankland \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Position, inclination and dimensions of the hamulus process significantly impact the normal function of the surrounding muscles. When these muscles are contracted, the oral cavity separates from the nasal cavity, and swallowing occurs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Since the tubar part of the tensor veli palatini (TVP) muscle is linked to the PH, the position and morphology of this process directly affect the function of the TVP muscle and, consequently, the function of the hard palate during swallowing. Furthermore, the PH inclination plays a vital role in a better tension of palatal aponeurosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe morphological alterations of the PH, such as growth deficiency in newborns, result in insufficient muscle support, followed by the uncontrolled narrowing of the upper pharynx, sleep apnoea and snoring [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In addition, these changes might be misdiagnosed as temporomandibular disorders or glossopharyngeal neuralgia by mimicking symptoms such as ear pain, pain during chewing and swallowing, and oedema and erythema in the palate\u0026rsquo;s posterior region [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. PHS, known as the palate and pharynx pains caused by inflammation in the hamular region, is primarily due to hamulus process elongation. These pains might be misjudged with those of impacted third molar or middle ear cysts or tumours [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Also, there is a risk of iatrogenic trauma to the PH during certain maxillofacial surgeries, especially posterior alveolar process operations (e.g., maxillary impacted third molar extraction) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDentists must be well-versed in PH anatomical features and functions to diagnose, treat, and prevent maxillofacial pains and iatrogenic surgical traumas properly. They should consider PH-related disorders as a potential differential diagnosis, especially for pains with unknown aetiology. Hence, PH was studied for its morphometric characteristics and its alterations with age in the current study. Unlike the previous studies, we evaluated the effect of all variables simultaneously by measuring the size and inclination of PH on coronal and sagittal sections of 258 CBCT scans on both the right and left sides. Additionally, the PH symmetry was analysed in each age group. Consequently, our findings can help diagnose untraceable pains in the nasal and oropharyngeal regions. Notably, we tried to increase the results' accuracy by limiting the samples to 20-40-year-old women.\u003c/p\u003e \u003cp\u003eThe measurements showed an average length of 5.50\u0026thinsp;\u0026plusmn;\u0026thinsp;1.37 mm and 5.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.36 mm for right and left PH and an average width of 2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;0.72 mm and 2.11\u0026thinsp;\u0026plusmn;\u0026thinsp;1.06 mm, respectively. The coronal and sagittal inclinations of right and left PH were 22.3\u0026thinsp;\u0026plusmn;\u0026thinsp;9.79\u0026deg;, 30.16\u0026thinsp;\u0026plusmn;\u0026thinsp;8.99\u0026deg;, and 26.11\u0026thinsp;\u0026plusmn;\u0026thinsp;7.26\u0026deg;, 26.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.80\u0026deg;. There was no significant difference in PH length, width, and coronal and sagittal inclinations between the two age groups, indicating that the PH morphometric parameters did not alter with ageing. Our results were similar to those of the studies by Eyrich \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and Orhan \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], who reported that the right and left PH lengths were 4.5 and 5 mm, and 5.40\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00 and 5.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.94 mm, respectively. Orhan \u003cem\u003eet al.\u003c/em\u003e also measured the PH width on the sagittal plane and reported an average width of 1.87\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17 and 1.72\u0026thinsp;\u0026plusmn;\u0026thinsp;0.94 mm for right and left PHs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In contrast, in this study, the PH width was measured on coronal sections.\u003c/p\u003e \u003cp\u003eOur study used the pterygoid plane's long axis instead of the true horizontal line [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] to assess the PH's inclinations. However, the lateral and posterior inclinations of PH on coronal and sagittal sections were similar to previous investigations [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In accordance with our findings, Komarnitki \u003cem\u003eet al.\u003c/em\u003e found a weak correlation between age and PH dimensional changes [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Mehra \u003cem\u003eet al.\u003c/em\u003e evaluated the PH size in three age groups: \u0026lt;20 y/o, 20\u0026ndash;50 y/o, and \u0026gt;\u0026thinsp;50 y/o. They reported increased PH length with age, while widths initially decreased, then increased [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. In addition, Romoozi \u003cem\u003eet al.\u003c/em\u003e stated that rather than the coronal inclination, the length and width of the PH on the sagittal plane significantly depend on age, so the PH length in 21-59-year-old adults increased compared to 15-21-year-old individuals [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. On the other hand, patients aged between 60 and 100 y/o had shorter PH than younger adults. They also reported a reduction in PH width and sagittal inclination with age. A significant increase in PH length among adults (21\u0026ndash;59 y/o) compared to children (0\u0026ndash;9 y/o) and a subsequent reduction in the elderly (60\u0026ndash;100 y/o) by an average of 0.5 mm was also reported by Krmpotic-Nemanic \u003cem\u003eet al.\u003c/em\u003e [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. It has been noted by Orhan \u003cem\u003eet al.\u003c/em\u003e that although the association between PH size and age is not significant, older people generally have smaller PH than younger people. In line with our findings, PH did not change in size and inclination during the age of 20\u0026ndash;40 years in all previous investigations [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eBased on our symmetry analysis, the right and left sides' PHs were only symmetrical in terms of sagittal inclination. According to Orhan \u003cem\u003eet al.\u003c/em\u003e, the left side PH was wider than the right in both males and females. However, there was no difference in the lengths of the right and left PHs [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. There are also other studies that have found the PH's length and width symmetrical [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The fewer participants and the absence of gender exclusivity could explain the difference in the results. Currently, there is no explicit explanation for the asymmetry of PH widths. Nevertheless, several factors may contribute to the observed asymmetry in length and width, including genetic factors and functional differences in oral habits, such as masticatory patterns and occlusal forces between the right and left sides. The variation in coronal inclination may result from asymmetrical growth patterns and development during embryogenesis. The recognition of such asymmetry in the PH is of clinical importance in various dental and maxillofacial procedures, including orthodontic treatments, prosthodontics, and surgical interventions. Dentists and oral surgeons should consider these anatomical variations when planning treatment modalities or surgical procedures that involve the PH.\u003c/p\u003e \u003cp\u003eThe findings of the current study revealed that the most common PH morphology on both sides was the slender type. However, the differences in the two morphologies\u0026rsquo; frequencies were not significant when age groups were compared. In addition, a comparison of the right and left sides showed that the PHs were symmetrical regarding morphology. In contrast to the first age group (20\u0026ndash;30 y/o), patients between the ages of 31 and 40 showed asymmetrical PH morphology. Previously, Nerkar \u003cem\u003eet al.\u003c/em\u003e have reported that triangular morphology was the most prevalent form in Indian society [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. This difference can be explained by racial variations.\u003c/p\u003e \u003cp\u003eIt is essential to acknowledge the limitations of this study, such as its focus on a specific population (Iranian women aged 20\u0026ndash;40). There could have been errors in the comparison results due to the uneven distribution of participants between age groups. In order to strengthen the generalisability of the results in future studies, we suggest evaluating a larger population with data gathered from multiple radiographic centres rather than from a single centre. Future research could explore potential factors influencing PH asymmetry, such as genetics, environmental factors, and functional habits.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eHamulus process morphometric characteristics did not change with age in women aged 20\u0026ndash;40. On the other hand, age-related differences in PH symmetry were observed between the two groups. Finally, CBCT was an appropriate method for studying hamulus alterations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e3D, 3-dimensional; CBCT, cone-beam computed tomography; DICOM, Digital Imaging and Communications in Medicine; PH, pterygoid hamulus; PHS, pterygoid hamulus syndrome; SPSS, Statistical Package for Social Sciences; TVP, tensor veli palatini.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgment\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003eAuthor Contribution Statement\u003c/p\u003e\n\u003cp\u003eContributions to the current study are Zahra Mahdavi in the literature review, data gathering and cleaning, and drafting of the manuscript; Ladan Hafezi in the design, data gathering, cleaning, and analysis, and drafting and revising the manuscript critically for the importance of intellectual content. Both authors have read and approved the final version to be published and agreed to be accountable for all aspects of the work. Also, both authors agreed on the order in which their names are listed in the manuscript.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConflict of Interests\u003c/p\u003e\n\u003cp\u003eThe authors declare there is no conflict of interests, whatsoever.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical Approval\u003c/p\u003e\n\u003cp\u003eThis study was carried out according to the ethical principles of the Declaration of Helsinki, in addition to local ethical and legal requirements. Ethics approval was obtained from the institutional research ethics committee of Islamic Azad University of Medical Sciences (ID: IR.IAU.TMU.REC.1400.230).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInformed Consent Statement\u003c/p\u003e\n\u003cp\u003eThe need for written consent was waived by the Institutional Review Board of Islamic Azad University of Medical Sciences based on national regulations and the nature of this study. This study strictly adheres to de-identification techniques, ensuring the anonymity and confidentiality of all participants. Notably, it involves observational methods, and the study techniques employed are entirely harmless and burden-less to participants. Also, before participating in this research, individuals verbally consented to their de-identified data being used strictly for research purposes.\u003cspan dir=\"RTL\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/p\u003e\n\u003cp\u003eFunding Support\u003c/p\u003e\n\u003cp\u003eNo external funding or sponsorship was received for this research.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTransparency Declaration\u003c/p\u003e\n\u003cp\u003eAuthors declare that the manuscript is honest, accurate, and transparent. No important aspect of the study is omitted.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePatients and Public Partnership\u003c/p\u003e\n\u003cp\u003eThe patients or the public were not involved in our research\u0026apos;s design, conduct, reporting, or dissemination plans.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData Availability Statement\u003c/p\u003e\n\u003cp\u003eAll data produced in the present study are available upon reasonable request to the authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMehra A, Karjodkar FR, Sansare K, Kapoor R, Tambawala S, Saxena VS. Assessment of the dimensions of the pterygoid hamulus for establishing age- and sex-specific reference standards using cone-beam computed tomography. Imaging Sci Dent. 2021;51(1):49\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePutz R, Kroyer A. Functional morphology of the pterygoid hamulus. Ann Anat. 1999;181(1):85\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrmpotic-Nemanic J, Vinter I, Marusic A. Relations of the pterygoid hamulus and hard palate in children and adults: anatomical implications for the function of the soft palate. Ann Anat. 2006;188(1):69\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOrhan K, Sakul BU, Oz U, Bilecenoglu B. Evaluation of the pterygoid hamulus morphology using cone beam computed tomography. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2011;112(2):e48-55.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbe M, Murakami G, Noguchi M, Kitamura S, Shimada K, Kohama GI. Variations in the tensor veli palatini muscle with special reference to its origin and insertion. Cleft Palate Craniofac J. 2004;41(5):474\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHj\u0026oslash;rting-Hansen E, Lous I. The pterygoid hamulus syndrome. Ugeskrift for Laeger. 1987;149(15):979\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHj\u0026oslash;rting-Hansen E, Lous I. Hamulus pterygoid syndrome. Tandlaegebladet. 1987;91(20):833\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eEyrich GK, Locher MC, Warnke T, Sailer HF. The pterygoid hamulus as a pain-inducing factor. A report of a case and a radiographic study. Int J Oral Maxillofac Surg. 1997;26(4):275\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShankland WE, 2nd. Bursitis of the hamular process. Part II: Diagnosis, treatment and report of three case studies. Cranio. 1996;14(4):306\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eOz U, Orhan K, Aksoy S, Ciftci F, \u0026Ouml;zdoğanoğlu T, Rasmussen F. Association between pterygoid hamulus length and apnea hypopnea index in patients with obstructive sleep apnea: a combined three-dimensional cone beam computed tomography and polysomnographic study. Oral Surgery, Oral Medicine, Oral Pathology and Oral Radiology. 2016;121(3):330-9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNerkar A, Gadgil R, Bhoosreddy A, Shah K, Varma S. Cone-beam computed tomography study of morphometric evaluation of pterygoid hamulus. International Journal of Recent Advances in Multidisciplinary Research. 2017;4(7):2678\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSalins PC, Bloxham GP. Bursitis: a factor in the differential diagnosis of orofacial neuralgias and myofascial pain dysfunction syndrome. Oral Surg Oral Med Oral Pathol. 1989;68(2):154\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRomoozi E, Razavi S, Barouti P, Rahimi M. Investigating the morphologic indices of the hamulus pterygoid process using the CBCT technique. Journal of Research in Medical and Dental Sciences 2018. 2018;6 (2):240-4.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDupont JS, Jr., Brown CE. Comorbidity of pterygoid hamular area pain and TMD. Cranio. 2007;25(3):172\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKende P, Aggarwal N, Meshram V, Landge J, Nimma V, Mathai P. The Pterygoid Hamulus Syndrome - An Important Differential in Orofacial Pain. Contemp Clin Dent. 2019;10(3):571\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKomarnitki I, Skadorwa T, Chloupek A. Radiomorphometric assessment of the pterygoid hamulus as a factor promoting the pterygoid hamulus bursitis. Folia Morphol (Warsz). 2020;79(1):134\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. The Mean Measured Values of the Pterygoid Hamulus Size and Inclination\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"520\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"38.15028901734104%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMinimum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMaximum\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean \u0026plusmn; SD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.716763005780347%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.433526011560694%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e2.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e9.39\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e5.37 \u0026plusmn; 1.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.13907284768212%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidth (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e0.76\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e15.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e2.11 \u0026plusmn; 1.06\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.13907284768212%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal Inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e4.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e58.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e30.16 \u0026plusmn; 8.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.13907284768212%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSagittal Inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e9.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e49.70\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e26.34 \u0026plusmn; 7.63\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"12.716763005780347%\" rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"25.433526011560694%\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e1.69\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e10.80\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.616570327552985%\"\u003e\n \u003cp\u003e5.50 \u0026plusmn; 1.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.13907284768212%\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidth (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e0.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e6.16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e2.16 \u0026plusmn; 0.72\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.13907284768212%\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal Inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e8.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e66.00\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e32.30 \u0026plusmn; 9.79\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"29.13907284768212%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSagittal Inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e6.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e52.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.620309050772626%\"\u003e\n \u003cp\u003e26.11 \u0026plusmn; 7.26\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Comparison of the Pterygoid Hamulus Size and Inclination on the Right and Left Sides Between the Two Age Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"530\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.31947069943289%\" colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e\u003cstrong\u003eMean\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.232514177693762%\" rowspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.08695652173913%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e5.15 \u0026plusmn; 1.03\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.838\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e5.47 \u0026plusmn; 1.32\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.065359477124183%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidth (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\"\u003e\n \u003cp\u003e1.72 \u0026plusmn; 0.44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.699\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e2.29 \u0026plusmn; 1.99\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.065359477124183%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\"\u003e\n \u003cp\u003e29.18 \u0026plusmn; 9.24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.244\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e30.60 \u0026plusmn; 8.86\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.065359477124183%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSagittal inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\"\u003e\n \u003cp\u003e26.31 \u0026plusmn; 7.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.828\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e26.35 \u0026plusmn; 7.64\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.232514177693762%\" rowspan=\"8\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.08695652173913%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLength (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e5.46 \u0026plusmn; 1.57\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.506\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e5.89 \u0026plusmn; 3.76\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.065359477124183%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eWidth (mm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\"\u003e\n \u003cp\u003e2.06 \u0026plusmn; 0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.089\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e2.56 \u0026plusmn; 3.36\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.065359477124183%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eCoronal Inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\"\u003e\n \u003cp\u003e31.40 \u0026plusmn; 9.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.323\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e32.71 \u0026plusmn; 10.00\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"30.065359477124183%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eSagittal Inclination (\u003c/strong\u003e\u0026deg;)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" valign=\"top\"\u003e\n \u003cp\u003e20-30 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\"\u003e\n \u003cp\u003e26.20 \u0026plusmn; 7.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"23.311546840958606%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.927\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e31-40 y/o\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e26.06 \u0026plusmn; 7.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Comparison of the Pterygoid Hamulus Morphologies on the Right and Left Sides Between the Two Age Groups\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"530\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.31947069943289%\" colspan=\"2\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eMorphology \u003csup\u003e$\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"40.45368620037807%\" colspan=\"2\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge Group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eP-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"50%\" valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003e20-30 y/o\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"50%\"\u003e\n \u003cp\u003e\u003cstrong\u003e31-40 y/o\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.232514177693762%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eLeft Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.08695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSlender Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e47 (59.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e108 (62.10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.697\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.20454545454545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTriangle Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.397727272727273%\"\u003e\n \u003cp\u003e32 (40.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.397727272727273%\"\u003e\n \u003cp\u003e66 (37.90%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"13.232514177693762%\" rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eRight Side\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.08695652173913%\"\u003e\n \u003cp\u003e\u003cstrong\u003eSlender Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e45 (57.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\"\u003e\n \u003cp\u003e100 (57.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"20.226843100189036%\" rowspan=\"2\"\u003e\n \u003cp\u003e0.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"39.20454545454545%\"\u003e\n \u003cp\u003e\u003cstrong\u003eTriangle Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.397727272727273%\"\u003e\n \u003cp\u003e34 (43.00%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"30.397727272727273%\"\u003e\n \u003cp\u003e74 (42.50%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003cem\u003e$ Reported as frequency (percentage)\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4. Comparison of the Pterygoid Hamulus Morphological Symmetry\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cimg 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width=\"963\" height=\"284\"\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e$ Reported as frequency.\u003c/em\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Cone-Beam Computed Tomography, Pterygoid Hamulus, Morphology, Age Groups","lastPublishedDoi":"10.21203/rs.3.rs-3662920/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3662920/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eObjectives:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to evaluate the morphology and dimensions of the pterygoid hamulus (PH) and its changes by ageing in 20-40-year-old women in the Dental Branch of the Islamic Azad University of Sciences, Tehran, Iran.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMaterials and Methods:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis cross-sectional study was conducted on cone-beam computed tomography (CBCT) scans from 258 women aged 20-40. The morphology, length, width, and angle of the PH in coronal and sagittal planes were investigated.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe average length of the right and left hamulus was 5.50±1.37 and 5.37±1.36 mm. The average width of the right and left hamulus was 2.16±0.72 and 2.11±1.06 mm. The average coronal angle of the right and left hamulus was 22.3±9.79° and 30.16±8.99°. The average sagittal angle of the right and left hamulus was 26.11±7.26° and 26.34±7.63°. In contrast with the sagittal angle, the right and left hamulus’s length, width, and coronal angles were not symmetrical. Slender morphology was the most frequent morphology, and it was symmetrical only in the 20-30-year-old age group. Finally, no variable was affected by ageing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHamulus dimensions and morphology did not change with ageing in women aged 20-40. The PH symmetry varied by age group. Also, CBCT was a suitable tool for investigating hamulus changes.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eClinical Relevance:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eUnderstanding the characteristics of the PH is crucial for diagnosing and treating various oropharyngeal and craniofacial conditions. It also aids in interpreting radiographs and diagnosing unexplained oropharyngeal pains. CBCT is a valuable tool for precisely visualising these structures, offering clinical insights into this previously understudied area.\u003c/p\u003e","manuscriptTitle":"Assessment of the Pterygoid Hamulus Dimensions and Morphology in Iranian Women Using Cone-Beam Computed Tomography","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-12-14 18:03:22","doi":"10.21203/rs.3.rs-3662920/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"adc65ee6-5ef1-4584-ad4e-248b12b3ff13","owner":[],"postedDate":"December 14th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2023-12-14T18:03:25+00:00","versionOfRecord":[],"versionCreatedAt":"2023-12-14 18:03:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3662920","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3662920","identity":"rs-3662920","version":["v1"]},"buildId":"7rjqhiLT3MXkJMwkYKINL","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}