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Cephalometric evaluation of the airway dimensions in subjects with different

growth patterns

Article  in  Journal of Orthodontic Research · January 2015

DOI: 10.4103/2321-3825.149051

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ORIGINAL ARTICLE
Cephalometric evaluation of the airway
dimensions in subjects with different
growth patterns
Juhi Ansar, Raj Kumar Singh1, Preeti Bhattacharya, Deepak K. Agarwal, Sanjeev K. Verma2,
Sandhya Maheshwari2
Department of Orthodontics, Institute of Dental Sciences, Bareilly, 2Department of Orthodontics and Dental Anatomy,
Aligarh Muslim University, Aligarh, Uttar Pradesh, 1Department of Orthodontics, Sudha Rustagi Dental College,
Faridabad, Haryana, India

ABSTRACT
Objective: The purpose of this study was to compare the pharyngeal airway dimensions by cephalometric examination of
individuals with different morphological patterns. Materials and Methods: The sample comprised pretreatment lateral
cephalometric radiographs of 90 subjects, aged 16-25, which were divided into three distinct groups, according to their
morphological patterns, that is, hypodivergent, normodivergent and hyperdivergent. The upper and lower pharyngeal airways
were assessed according to McNamara’s airways analysis. Results: The results showed that the upper and lower pharyngeal
width in hyperdivergent growth patterns subjects was statistically significantly narrower than in the normodivergent and
hypodivergent growth pattern groups (P < 0.05). Conclusions: Subjects with vertical growth patterns have significantly
narrower upper and lower pharyngeal airways than those with Class II malocclusions and horizontal and normal growth
patterns. These patients may be more prone to mouth breathing as a result of their relatively diminished pharyngeal
dimensions.

Key words: Lateral cephalometry, pharyngeal airway space, vertical growth pattern

Introduction minimal exposure to radiation, as well as being able

to simultaneously analyze head position, craniofacial
Various methods have been used to evaluate the airway, morphology and pharyngeal airway. Normal airway
including, cine-computed tomography (CT), lateral is one of the important factors for the normal growth
cephalogram, magnetic resonance imaging, as well as of the craniofacial structure. Any obstacle in the
polysomnography. [1-4] Cephalometry is, however, the respiratory system causes respiratory obstruction and
most commonly used of the above tests. Cephalometric forces the patient to breathe through the mouth. [7]
measurements of the posterior airway space, although a With the presence of mouth breathing, the mandible
two-dimensional analysis, have proved very reliable in is lowered, and the lips are parted. Tongue assumes a
diagnosing pharyngeal volumes.[5,6] lower position in the oral cavity reducing the support of
the palate and maxillary arch. This result in alteration on
Cephalometry also offers considerable advantages over the forces affecting the facial skeleton causing vertical
other techniques, including low cost, convenience and development of the face, narrow maxilla and a steep
mandibular plane.[8]
Access this article online
Quick Response Code: Various factors responsible for mouth breathing like
Website:
www.jorthodr.org hypertrophic adenoids and tonsils, chronic and allergic
rhinitis, environmental irritants and infections have been
reported.[9] However, jaw malpositions and jaw anomalies
DOI:
10.4103/2321-3825.149051 like retrusion of the maxilla and mandible, vertical maxillary
excess and vertical growth pattern of the mandible may also

Address for correspondence: Dr. Juhi Ansar, Department of Orthodontics and Dentofacial Orthopedics, Institute of Dental Sciences,
Bareilly - 243 006, Uttar Pradesh, India. E-mail: juhiortho10@gmail.com

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Ansar, et al.: Cephalometric evaluation of the airway dimensions

lead to narrowing of the pharyngeal airway, predisposing Upper pharyngeal width was taken as a point on the
patients to mouth breathing.[10,11] posterior outline of the soft palate to the closest point on
the posterior pharyngeal wall. The average nasopharynx is
Significant relationships between the pharyngeal approximately 15-20 mm in width. Lower pharyngeal width
structures and craniofacial structures have been was measured from the point of intersection of the posterior
reported in the literature.[12,13] Recently, an interest has border of the tongue and the inferior border of the mandible
been focused on pharyngeal dimensions because of a to the closest point on the posterior pharyngeal wall.
potential relationship between size and structure of upper
airway and sleep-induced breathing disturbances. [14] Statistics
Narrowing of the airway in individuals at a young age Continuous data were summarized as mean ± standard
may predispose them to obstructive episodes as they deviation while discrete (categorical) in percentage.
mature. Because subjects with narrow airway may have Continuous variables were compared by one-way analysis
aberrant skeletal and soft tissue patterns, it has been of variance (ANOVA) and the significance of mean
proposed that cephalometry may help to identify the difference between the groups was done by Tukey’s post
patient in whom the skeletal anomalies contribute to hoc test after ascertaining the normality and homogeneity
airway obstruction. Therefore, to further investigate this of variances by Shapiro-Wilk test and Levene’s test,
assumption, our objective in this study was to compare respectively. Categorical variables were compared by
the pharyngeal dimensions of subjects with different Chi-square (χ2) test. A two-sided (α = 2) P < 0.05 was
vertical growth patterns. considered statistically significant. All analyses were
performed on statistica statistical software.
Materials and Methods
The sample comprised lateral cephalograms of 90 untreated
Results
patients, with the age range of 16-25 years having full Pharyngeal Airway Measurements
complement of teeth (with the exception of third molars)
To ascertain reliability, cephalometric films of 12 randomly
and who were to undergo orthodontic treatment. Further
selected subjects were retraced and remeasured at 3 week’s
screening of subjects for inclusion was done after detailed
interval. A paired sample t-test was used to determine
case history and clinical examination. A written informed
measurement accuracy. No statistically significant
consent was obtained from each participant or his or her
difference was found between the first and second
parents, and an ethical clearance was obtained from the
measurements (P > 0.05).
Institutional Ethical Committee before inclusion in our
study. Upper Airway Width
Subjects having any history of congenital defect, The upper airway widths of three groups are summarized
orthodontic treatment, surgery in the head and neck in Table 1. The mean upper airway width of hypodivergent
region, joint disorder, cervical spine disorder and any group was the highest followed by normodivergent group
neuromuscular disorder or history of nasal obstruction and least in hyperdivergent group. When comparing
were excluded from the study group. Lateral cephalometric
radiographs were taken using a standardized technique,
with the jaw in centric relation and the teeth in occlusion,
the lips relaxed, and the head in the natural head position[15]
by the same operator with a cephalostat (Rotograph plus
Villa system Medical, Italy).

Subjects were divided into three groups according to

vertical growth pattern of mandible. SN-MP angle was used
to divide the sample into hypodivergent, normodivergent,
hyperdivergent growth patterns with values of <26°,
26-38° and >38° respectively as proposed by Isaacson
et al.[16] The upper and lower pharyngeal airways width
were measured using McNamara’s airway analysis
[Figure 1].[17] Figure 1: Upper and lower pharyngeal airways width

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Ansar, et al.: Cephalometric evaluation of the airway dimensions

Table 1: Upper and LAW width (mean ± SD) of three groups

Characteris cs Hypodivergent Hyperdivergent Normodivergent P
UAW (mm), mean±SD 20.55±3.94 (14-28) 16.75±3.39 (10-21) 18.75±2.51 (14-23) 0.003
LAW (mm), mean±SD 11.00±3.23 (5-17) 8.10±2.53 (4-13) 9.85±3.31 (5-19) 0.014
SD: Standard deviation, UAW: Upper airway, LAW: Lower airway

the mean upper airway width of three groups, ANOVA Table 2: Significance (P) of mean difference of upper airway
[Table 1] revealed significant difference in the upper airway width between the groups by Tukey test
width among the groups (P < 0.01). Further, Tukey test Comparisons P
[Table 2] revealed that the mean upper airway width of Hypodivergent versus hyperdivergent 0.002
hyperdivergent group was significantly lower as compared Hypodivergent versus normodivergent 0.211
to hypodivergent group (P < 0.01). However, the mean Hyperdivergent versus normodivergent 0.148
upper airway width did not differ significantly between
hypodivergent and normodivergent and hyperdivergent
Table 3: Significance (P) of mean difference of lower airway
and normodivergent group (P > 0.05).
width between the groups by Tukey test

Lower Airway Width Comparisons p value

Hypodivergent vs. Hyperdivergent 0.011
Comparing the mean lower airway width of three groups, Hypodivergent vs. Normodivergent 0.461
ANOVA [Table 1] revealed a significantly different lower Hyperdivergent vs. Normodivergent 0.173
airway width among the groups (P < 0.05). Tukey test
[Table 3] revealed that the mean lower airway width of
airway width when compared to normodivergent and
hyperdivergent group was significantly lower as compared
hypodivergent growth pattern (P ≤ 001). However, no
to hypodivergent group (P < 0.05). However, no significant
statistically significant difference was found in the upper
difference was found in the lower airway width between
airway width between normodivergent and hypodivergent
hypodivergent and normodivergent and hyperdivergent
growth pattern and, normodivergent and hyperdivergent
and normodivergent (P > 0.05).
growth pattern.

Discussion Similarly, the mean lower airway width of hypodivergent

group was the highest followed by normodivergent group,
Pretreatment lateral head cephalograms of subjects in natural
head position were taken evaluate to pharyngeal airway and least in hyperdivergent group. The most significant
dimensions in different vertical growth patterns. Controversy difference was found between lower airway width of
exists as the cephalogram depicts two-dimensional views of hyperdivergent and hypodivergent group (P = 0.011),
three-dimensional structures. We chose lateral cephalograms However, the mean lower airway width did not differ
for this study because posterior airway space, as measured significantly between hypodivergent and normodivergent,
by lateral cephalometric radiography, was highly correlated and hyperdivergent and normodivergent group. Analyzing
with measurements using three-dimensional CT scan, with these results, we can infer that the upper airway width is
92% accuracy in predictability.[18] Aboudara et al.[19] also influenced by the craniofacial growth pattern.
compared CT and cephalometric films in subjects with
Ucar et al.[20] studied Class I subjects with different vertical
skeletal malocclusion and found a significant positive
growth patterns (low, normal, and high angle). They
relationship between nasopharyngeal airway size on lateral
reported be larger nasopharyngeal airway space and upper
cephalogram and its true volumetric size as determined
from CT scan in adolescents. Cephalometry also offers pharyngeal airway space in low angle subjects than in high
considerable advantages over other techniques, including angle subjects. Palatal tongue space and tongue gap were
low cost, and minimal exposure to radiation. larger in high angle subjects than in low angle subjects and
tongue gap was statistically greater in high angle than in
In the present study, we found that the mean upper airway normal angle subjects. Similarly Batool et al.[21] compared
width of hypodivergent group was the highest followed the subjects with Class II malocclusions with horizontal
by normodivergent group and hyperdivergent group, and vertical growth patterns and found that subjects with
the least. When comparing upper airway width among vertical growth patterns have significantly narrower upper
various growth patterns, hyperdivergent growth pattern and lower pharyngeal airways than those with horizontal
subjects showed a statistically significant narrow upper growth patterns. Akcam et al.[22] reported a decrease in the

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Ansar, et al.: Cephalometric evaluation of the airway dimensions

upper airway dimensions of subjects who had posterior morphology between these groups. The findings of their
mandibular rotation. This reveals a close association study demonstrated that children with obstructed nasal
between the pharyngeal airway and positioning of the jaws. breathing were characterized by increased lower face
height, increased total facial height, and more retrognathic
Joseph et al.[11] compared the pharyngeal dimensions of mandibles compared to the control group. In addition, the
hyperdivergent and normodivergent facial types and found sagittal depth of the bony nasopharynx was found to be small
that hyperdivergent group had a narrower anteroposterior in the mouth breathers when compared with the controls.
pharyngeal dimension than the normodivergent control
group. Memon et al. [23] showed in their study that Narrow pharyngeal airway space is one of the predisposing
hyperdivergent facial pattern subjects belonging either factors for mouth breathing and obstructive sleep
to skeletal Class I or Class II malocclusion showed a apnea.[27] Early diagnosis of the hyperdivergent skeletal
statistically significant narrow upper pharyngeal airway pattern with a concomitant pharyngeal narrowing may
width as compared to normodivergent and hypodivergent identify individuals at risk for breathing disorder and
facial patterns. However, he found no statistically cephalometrics radiographs may be useful in diagnosis
significant difference in lower pharyngeal airway widths such patients. When diagnosing and treating patients with
among three vertical growth patterns. Similar findings malocclusion, orthodontists should recognize pharyngeal
were reported by de Freitas et al.[24] in subjects with airway morphologies that might be predisposing factors of
untreated Class I and Class II malocclusions, and normal undesirable craniofacial development. Our study showed
and vertical growth patterns. They reported that the upper statistically significant differences in pharyngeal width
pharyngeal width was affected by vertical growth pattern among three different growth patterns. Hyperdivergent
but, growth pattern do not influence the lower pharyngeal subjects have statistically significant narrower upper and
airway width. However in the present study, we found lower pharyngeal width when compared to other two
that the hyperdivergent growth pattern subjects showed vertical patterns, revealing that growth pattern, whether
a statistically significantly narrow the lower pharyngeal low or high, has an effect on pharyngeal airway space.
airway width when compared to normodivergent and However, it is recommended that a similar study with a
hypodivergent facial patterns. larger sample size should be conducted. This study was
conducted to evaluate only pharyngeal airway widths, and
As, hyperdivergent patients had the lowest mean for not airway flow capacities, which would have required a
this measurement, these patients may be more prone to more complex three-dimensional and dynamic evaluation.
mouth breathing as a result of their relatively diminished
pharyngeal dimensions. Small pharyngeal dimensions in Conclusion
hyperdivergent group may be attributed to downward
and backward rotation of mandible that might lead to Based on the assessment of the facial pattern data produced
a posterior postured tongue, increasing the chances of in this study, we found that hyperdivergent patients
impaired respiratory function. Therefore, the “reduction” had statistically significant narrower upper and lower
of the pharyngeal airway in hyperdivergent patients cannot pharyngeal width a when compared to normodivergent
be attributed only to the larger adenoids or the presence of and hypodivergent growth patterns.
soft tissue in the posterior nasopharyngeal region. Reduced
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