ORIGINAL ARTICLE

Comparison of airway space with conventional

lateral headfilms and 3-dimensional
reconstruction from cone-beam computed
tomography
Cameron Aboudara,a Ib Nielsen,b John C. Huang,c Koutaro Maki,d Arthur J. Miller,e and David Hatcherf
San Francisco and Sacramento, Calif, and Tokyo, Japan

Introduction: Changes in the normal pattern of nasal respiration can profoundly affect the development of the
craniofacial skeleton in both humans and experimental animals. The orthodontist is often the first clinician to
notice that a child is breathing primarily through the mouth, either at the initial examination or later during treat-
ment. The lateral headfilm, part of the patient’s normal records, might show increased adenoid masses, sug-
gesting that these could be part of the problem. Previous studies have, however, questioned the validity of the
information from lateral headfilm. Methods: Our aim was to compare imaging information about nasopharyn-
geal airway size between a lateral cephalometric headfilm and a 3-dimensional cone-beam computed tomog-
raphy scan in adolescent subjects. The nasopharyngeal airway area and volume were measured in 35 subjects
(8 boys, 27 girls; average age, 14 years). Results: Volumetric measurement errors ranged from 0% to 5%
compared with known physical airway phantoms used to calibrate. A moderately high (r 5 0.75) correlation
was found between airway area and volume; the larger the area, the larger the volume. However, there was
considerable variability in the airway volumes of patients with relatively similar airways on the lateral headfilms.
Nine of the 35 patients had over 25% of the potential nasopharyngeal airway volume occupied by inferior tur-
binate protuberances, leading to significant airway restriction in some patients. Conclusions: The cone-beam
3-dimensional scan is a simple and effective method to accurately analyze the airway. (Am J Orthod
Dentofacial Orthop 2009;135:468-79)

R
espiration through the upper airway is a vital
functional process that can have a profound
impact on normal craniofacial development.1-9
Changes in normal airway function during the active
facial growth period can have had a profound influence
on facial development by the time a patient comes for
a
Private practice, Menlo Park, Calif; formerly postgraduate student, Division of
Orthodontics, Department of Orofacial Sciences, School of Dentistry, Univer-
sity of California at San Francisco.
b
Clinical professor, Division of Orthodontics, Department of Orofacial
Sciences, School of Dentistry, University of California at San Francisco.
c
Associate clinical professor, Division of Orthodontics, Department of Orofa-
cial Sciences, School of Dentistry, University of California at San Francisco.
d
Professor and chair, Department of Orthodontics, Showa University, Tokyo,
Japan.
e
Professor, Division of Orthodontics, Department of Orofacial Sciences, School
of Dentistry, University of California at San Francisco.
f
Diagnostic Digital Imaging, Sacramento; associate clinical professor, Division
of Orthodontics, Department of Orofacial Sciences, School of Dentistry, Univer-
sity of California at San Francisco, Calif.
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint request to: Arthur J. Miller, Division of Orthodontics, Department of Or-
ofacial Sciences, School of Dentistry, University of California at San Francisco,
San Francisco, CA, 94143-0438; e-mail, art.miller@ucsf.edu.
Submitted, February 2007; revised and accepted, April 2007.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2007.04.043
468
orthodontic treatment. This makes early diagnosis im-
perative to ensure normal facial development. At the ini-
tial clinical examination, the orthodontist usually notes
enlarged tonsils and breathing patterns.10 Normally,
only limited and subjective evaluations of possible air-
way problems are completed by the clinician, usually
from a lateral cephalometric headfilm.11-13
Clinically, the orthodontist might notice an obstruc-
tive airway on the headfilm. If this obstruction is judged
to be severe enough, the patient might be referred for an
ear, nose, and throat (ENT) evaluation. Most of these re-
ferrals result in a recommendation by the ENT specialist
for continued observation, rather than removal of the
obstructing tissue.14 These recommendations are moti-
vated by 2 issues. ENT specialists question the validity
of using conventional headfilms for evaluation of possi-
ble airway obstruction.13,15 ENT specialists also believe
that the lymphoid tissue will decrease after the adoles-
cent years.16,17 Current pediatric guidelines for tonsil-
lectomy and adenoidectomy require a specific number
of recurrent throat infections per year, sleep apnea, or
severe difficulty with respiration as medical indications
for the removal of these lymphoid tissues.14 Unfortu-
nately, even though airway restrictions can clear
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 4
spontaneously over time, their effects during periods of
rapid facial growth can have serious and long-lasting in-
fluence on dentition, speech, and craniofacial develop-
ment. Orthodontists need to develop credible
diagnostic tools that provide data acceptable to both
themselves and the medical specialists.13
Clinical reports and studies in humans and experi-
mental animals have indicated a link between mouth
breathing and craniofacial development. Children with
enlarged adenoids that obstruct nasal breathing also ex-
hibit certain changes in their craniofacial development,
including narrow maxillary arch, posterior crossbite,
anterior open bite, retroclination of maxillary and man-
dibular incisors, and short mandibular arch.18 These pa-
tients also have increased anterior face height, lower
tongue posture, and increased mandibular plane angles
when compared with control subjects with normal-sized
adenoids.18 In animal studies, morphologic effects of in-
duced nasal occlusion increase anterior face height, in-
crease the occlusal and mandibular plane angles, lower
the mandibular posture, increase the posterior dental
eruption, lead to forward tongue posture, induce ante-
rior crossbites, and can modify interdental relation-
ships.2,4 Removing the nasal obstruction can partially
reverse the palatal, occlusal, and mandibular plane an-
gles toward those of controls.4,19
Airway investigations have attempted to quantify
airway restriction and function by functional or morpho-
logic measurements.11,15,18,20,21 Most morphometric in-
vestigations of the upper airway in orthodontics have
used lateral cephalometric headfilms, with specific skel-
etal and soft-tissue landmarks to characterize the air-
way.22 The nasopharyngeal region was selected
because the lymphatic tissue outline is easy to identify.
Some investigations have shown that airway measure-
ments of the same patient can be different as a result of
variations in head posture.23,24 The posture and the posi-
tion of the head can also modify the airway space. The
airway decreases in retropalatal width between radio-
graphs taken in supine and upright positions of the
same adult. We also believe that a 2-dimensional (2D)
view of the airway space does not give an accurate indi-
cation of the complexity of this structure or its true size.
Our aim in this study was to compare imaging infor-
mation about nasopharyngeal airway size between a lat-
eral headfilm and a 3-dimensional (3D) cone-beam
computed tomography (CBCT) scan in adolescent
subjects.
MATERIAL AND METHODS
Our sample included all consecutive adolescents at
1 dental imaging center (Diagnostic Digital Imaging,
Aboudara et al 469
Table I. Sample characteristics
n Mean SD Range
Total 35 14 y 0 mo 2 y 2 mo 7 y 7 mo-16 y 9 mo
Boys 8 14 y 11 mo 2 y 4 mo 12 y 8 mo-16 y 4 mo
Girls 27 13 y 9 mo 1 y 4 mo 7 y 7 mo-16 y 9 mo
Table II. Reasons for referral for CBCT analysis
Reason n
TMJ 31
TMJ/airway 1
Maxilla 1
Impacted tooth 2
Total 35
Sacramento, Calif) for either orthodontic, temporoman-
dibular joint (TMJ), or possible pathology evaluation
over 18 months. The project was approved by the Com-
mittee on Human Research at the University of Califor-
nia, San Francisco (CHR approval #H893-22337-01).
The subjects were between 6 and 17 years of age (Table
I). All subjects had a CBCT scan and a lateral cephalo-
metric headfilm taken within 1 week. Subjects were ex-
cluded if they wore a bite splint, or had a documented
craniofacial anomaly or previous orthognathic surgery.
We examined 123 possible subjects, and 35 met the in-
clusion criteria. The most common reason for exclusion
of a subject was that the 2 sets of images were not taken
within 1 week of each other. The most common reason
for imaging referral was TMJ evaluation (Table II).
Lateral headfilm studies of the airway have included
both linear and area measurements based on specific
cephalometric landmarks and subjective classification
of airway restriction based on an ordinal scale. Using
the lateral headfilm leads to certain problems. The land-
marks are assumed to be located in the midline of the
craniofacial lateral view.11 Some landmarks are difficult
to identify accurately because of superimposition of lat-
eral structures on the headfilm. Also, a lateral headfilm
often outlines the contours of bony objects that are not
anatomically related. The most significant disadvantage
of headfilm measurements for airway size is the inabil-
ity to quantify the transverse dimension, as evident in
the frontal plane.
One factor from this study limited the region of
comparison between the 2 methods. The CBCT scans
were taken in the supine position, whereas all lateral
headfilms were taken in an upright position. Previous
studies by other investigators indicated that head posi-
tion can modify the airway space. Because of postural
differences in airway dimensions,23,24 measurements
470 Aboudara et al
Fig 1. Cephalometric region of interest and CBCT slices in a subject: A, Lateral headfilm with naso-
pharyngeal region of interest outlined in green; B, CBCT axial sections with airway outlined in green.
were made above the level of the soft palate and poste-
rior to the maxilla, because this airway region is best vi-
sualized on the lateral headfilm for direct comparison.
This area is termed the nasopharyngeal airway (Fig 1).
The anatomy of the nasopharynx is complex, with
the posterior border bound superiorly by the basilar
portion of the occipital bone and inferiorly by the first
2 cervical vertebrae.25,26 Overlying these bones is the
pharyngobasilar fascia and the superior pharyngeal
constrictor muscle. These structures pass laterally and
attach to the pterygoid hamulus and the medial ptery-
goid plate composing the lateral borders of this space.
The levator and tensor veli palatini muscles as well as
the entrance of the eustachian tube pass through the lat-
eral borders. The superior border of the pharynx con-
sists of the vomer and sphenoid bones. Adenoid tissue
usually extends from the bony recess at the region of
the spheno-occipital suture inferiorly along the poste-
rior pharyngeal wall. The lateral bony border of the na-
sopharynx is the medial plate of the pterygoid process of
the sphenoid bone. The medial pterygoid muscle at-
taches along its lateral aspect. The anterior border of
this potential space is the entrance to the nasal cavity,
or the choanae, which represents the posterior aspect
of the maxilla and the palatine bones. These skeletal
American Journal of Orthodontics and Dentofacial Orthopedics
April 2009
structures seen on a lateral cephalometric headfilm are
the pterygomaxillary fissure. The confluence of the out-
line of the pterygomaxillary fissure continues inferiorly
to the posterior nasal spine.
The following anatomic structures as seen on the
lateral headfilm were used as boundaries of the nasopha-
ryngeal airway for all subjects: (1) the axial (horizontal)
CBCT reconstruction plane passing through the poste-
rior nasal spine (PNS), (2) the plane perpendicular to
the axial reconstruction plane from PNS extending to
the superior aspect of the pterygomaxillary fissure,
and (3) the soft-tissue contour of the posterior pharyn-
geal wall extending from the superior aspect of the
pterygomaxillary fissure inferiorly to the axial recon-
struction plane. These same planes were transferred
into the 3D scan to measure airway volume over the
same anatomic boundaries.
Lateral 2D cephalometric headfilms were taken un-
der standardized conditions with a magnification of
9.8%. The headfilms were then scanned at 150 to 300
dpi for analysis. All image measurements were made
with a software program, 3-D Doctor (Able Software,
Lexington, Mass).
Three-dimensional CBCT volume scans were ob-
tained by using the same NewTom-9000 computed
American Journal of Orthodontics and Dentofacial Orthopedics Aboudara et al 471
Volume 135, Number 4

Table III. Technical specifications of the NewTom 9000

CBCT system
Reconstruction angle (F x h) 15 x 15 cm
Scan angle 360
Scan time 70 s
Effective exposure time 18 s
X-ray beam Conic, pulsed
kV 110
mA (maximum) 15
mAs/scan (typical) 100
X-ray area detector 400 cm2, 262,000 pixels
Spatial resolution 0.3 mm in x, y, and z directions

tomography machine (Quantitative Radiology, Verona,

Italy).27 This 3D conical scanner uses a cone-shaped
x-ray beam centered on an x-ray area detector (Table
III). The tube-detector system performs a complete
360 rotation around the subject’s head, during which
a series of exposures (1 ) are made, providing digital
images. The digital images provide the raw data for
the reconstruction of the examined volume (9 cm
high, 9 cm in diameter). The x-ray beam is pulsed and
synchronized with both the acquisition system and the
scanner. The x-ray area detector is a special image in-
tensifier (6 in) coupled with a solid-state (CCD) TV
camera. Digital radiographs are acquired in 512 3
512 pixel format, with the resulting spatial resolution
of 0.3 mm in the x, y, and z directions. Digital image
files were exported in DICOM (digital imaging and
communications in medicine) format for analysis and
measurement in 3-D Doctor. The resulting image slice
thickness was 0.8 to 1 mm with an in-plane resolution
of 0.3 3 0.3 mm.
All physical measurements were performed with
3-D Doctor by the primary author (C.A.). Two airway
phantoms were used to test the accuracy of volumetric
measures and validate the segmentation method (Fig
2). The phantoms consisted of an air-filled plastic tube
of known volume surrounded by water as a soft-tissue
equivalent. The simulated airway tube in 1 phantom
was placed parallel to the long (vertical) axis of the
CBCT scan. In the other phantom, the tube was placed
at an angle (35 ) to the long (vertical) axis of the scan.
The total phantom circumference was approximately
that of a human head. Phantom dimensions were mea-
sured to the nearest 0.1 mm with digital calipers. The
phantoms were imaged in the same CBCT machine.
The extent of the air-filled tube in each slice was delin-
eated in the scan by setting gray-scale threshold limits.
Phantom volumes were determined from the summation
of the airway area by using 1-mm axial CBCT slices.
Lateral headfilms were calibrated for size. Each
boundary line was manually placed, and all measure-
Fig 2. The 2 types of phantoms used to calibrate the
NewTom CBCT system. A lateral view (upper) indicates
the first phantom had an acrylic glass tube inside a larger
Plexiglas chamber. The second phantom had the inner
tube at an angle to account for some of the nasopharyn-
geal angle seen in a lateral view of the head. A view from
above (lower) indicates the relative size of the inner and
outer tubes. The inner tube had only air, and the outer
tube contained water.
ments were corrected for magnification. The CBCT ax-
ial reconstruction plane was transferred to the lateral
headfilm by measurement of the angle between the axial
reconstruction plane and the palatal plane (from anterior
nasal spine to PNS) on a lateral scout view of the CBCT
scan. The average angle between the axial reconstruc-
tion plane and the palatal plane was 2.5 6 2.7 . The
vertical height of the airway was determined as the dis-
tance from PNS to the height of the pterygomaxillary
fissure along a line perpendicular to the axial (horizon-
tal) reconstruction plane. The soft-tissue outline of the
posterior pharyngeal wall was traced to complete the
nasopharyngeal area. Airway volumes were determined
from the summation of the airway area by using 0.8 to 1
mm axial CBCT slices over the vertical height of the na-
sopharyngeal airway determined from the lateral head-
film. The extent of the airway in each axial section was
delineated by setting gray-scale threshold limits (Fig 3).
Protuberances of the inferior turbinate into the nasopha-
ryngeal potential space posterior to the plane
472 Aboudara et al
Fig 3. Montage view of sequential axial slices in a subject with the airway designated at each slice
(green outline).
corresponding to the posterior aspect of the maxilla
were manually outlined and then sectioned.
The following measurements of the nasopharyngeal
airway space were made: (1) subjective airway classifi-
cation (1-5) from the lateral headfilm performed by an
author (I.N.); (2) airway area of the region of interest
from the lateral cephalometric headfilm; (3) airway vol-
ume over the same of region of interest from the CBCT
scan (Fig 4), with all segmented 3D volumes in this
study at the same scale and magnification for compari-
son; and (4) volume of the soft- and hard-tissue compo-
nents of the inferior turbinates that protruded into the
nasopharyngeal potential space.
The subjective airway classification of airway
restriction, defined by Linder-Aronson,18 was used
with a scale of 1 through 5, with 5 the most
restricted.18,20,28-30
Statistical analysis
The Lin concordance and Pearson product correla-
tions were used to assess the reliability of duplicate
measurements. Although the Pearson correlation
estimates only the degree of linear association (ie, as
one increases, the other tends to increase), the Lin con-
American Journal of Orthodontics and Dentofacial Orthopedics
April 2009
cordance correlation estimates the degree that the dupli-
cates are coincident (ie, exactly the same compared with
a 45 reference line of equality). The Bland-Altman
method31 of comparing the mean of the duplicates to
the differences between the duplicates graphically,
with 95% confidence intervals, was also used to assess
reliability. Intraexaminer error measurements of airway
area, airway volume, and turbinate volume were deter-
mined by using 10 repeated measurements. A linear re-
gression of the area to the volume was determined to
discern associations and correlation coefficients. Age
and airway classification were added alone and together
to the regression analysis to determine their effects on
associations. Descriptive statistics for airway dimen-
sions and turbinate protuberances were determined.
All statistical analyses were done with Statview (version
5.0.1, SAS Institute, Cary, NC).
RESULTS
Evaluating the CBCT with the 2 phantoms showed
that there was some imaging noise at either end of the
scan. Applying a range of values for the airway space
was not as effective as visually evaluating each trans-
verse image and designating the airway volume.
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 135, Number 4
Fig 4. Three-dimensional volume of the nasopharyngeal airway of a subject: A, lateral view and B, at
an angle.
Table IV.Percentage of error in the repeated CBCT eval-
uation (n 5 6) of the known volume of the air-filled
space in the 2 types of phantoms
Mean SD Minimum Maximum
Vertical phantom error (%) 5.0 0.23 4.6 5.2
Angled phantom error (%) 0.2 0.22 –0.5 0.2
Volume measurement through variable threshold seg-
mentation showed half the error of constant threshold
segmentation when compared with the known volume.
Therefore, in each axial section, the gray-scale thresh-
old value was adjusted so that the entire internal portion
of the air-filled tube or airway was selected for both the
phantoms and the subjects. This defined the extent of the
airway in each axial section.
Six repeated measures of each airway phantom were
assessed. The average error between the known volumes
and the volumes determined through variable threshold
segmentation of the CBCT scan for the 6 repeated mea-
sures are shown in Table IV. Two times the standard de-
viation of the repeated measures made up less than 0.5%
of the absolute mean volumes calculated for the vertical
and angled phantoms, showing that the segmentation
procedure was repeatable.
Evaluation of the duplicate measures produced Lin
concordance and Pearson product correlations above
0.9, indicating excellent reliability for measurements
of airway area, airway volume, and turbinate volume.
The Bland-Altman method for airway volume indicated
excellent reliability, with all measurements within the
95% confidence intervals and close to zero with no ev-
Aboudara et al 473
ident error trends. The Bland-Altman method for the 2
measures of airway area and turbinate volume showed
only 1 measurement outside the 95% confidence inter-
vals. Measurements were close to zero with no evident
error trends, indicating very good to excellent reliabil-
ity. The mean percentage error and mean absolute error
were relatively small for airway area, 2.0% (6.7 6 7.6
mm2); airway volume, 1.6% (48.7 6 41.1 mm3); and
turbinate volume, 5.7% (49.2 6 50.1 mm3).
The orthodontically derived subjective airway scale
was applied to all subjects who had the lateral headfilm
and CBCT analysis. No significant sex differences were
found for any measurement, so all data were combined.
Most subjects had airway classifications that were low
on the scale, indicating many airways without large
adenoid restrictions. The average airway classification
was 1.7 6 0.8. No subjects were in the most severe
airway classification of 5 in our sample, and only 1
had a classification of 4.
The area measurements with the lateral cephalomet-
ric approach and volume measurements with the CBCT
indicated a distinct difference between the 2 approaches.
There was more variability in volume than in area as a per-
centage of the means. There was also a much wider range
in the volume determined as a percentage of the means.
The overall area-to-volume linear regression (Fig 5)
shows a positive association between the measurements
with a moderately high correlation coefficient value (r
5 0.75, P \0.001). Age and airway classification did
not have a high correlation coefficient with volume.
When age and airway classification were added to the re-
gression model either together or alone, no significant in-
crease in the regression coefficient was determined.
474 Aboudara et al American Journal of Orthodontics and Dentofacial Orthopedics
April 2009

Fig 5. Linear regression plot comparing the area as defined from the lateral cephalometric view of
the full head compared with the same region evaluated as a volume from the CBCT data with 95%
confidence bands.

Table V. Descriptive statistics of the nasopharyngeal area and volume in subjects classified by subjective scale of 1
through 5
Classification Measurement n Mean SD Minimum Maximum r P

All Area (mm2) 35 358.3 6 74.2 185.7 528.0 0.75 \0.001

All Volume (mm3) 35 3667.8 6 1414.3 877.2 7839.3
1 Area (mm2) 16 398.0 6 54.8 312.2 528.0 0.60 0.01
1 Volume (mm3) 16 4176.4 6 1419.4 1389.2 7839.3
2 Area (mm2) 12 339.6 6 75.5 244.8 453.9 0.79 0.001
2 Volume (mm3) 12 3614.7 6 1344.6 1753.1 6261.5
3 Area (mm2) 6 318.3 6 49.4 246.2 361.5 0.74 0.10
3 Volume (mm3) 6 2883.1 6 670.2 1837.7 3889.0
4 Area (mm2) 1 185.7 NA 185.7 185.7 NA NA
4 Volume (mm3) 1 877.2 NA 877.2 877.2
5 Area (mm2) 0 NA NA NA NA NA NA
5 Volume (mm3) 0 NA NA NA NA

Although the regression plot of the area to volume
shows a moderately high correlation, when the individ-
ual data were viewed and sorted by airway classification
severity (Table V), much airway volume variability
could be seen over small changes in airway area. Over
the midrange of the sample, there was much variability
in airway volume measured from the CBCT scans for
similar airway areas measured from the lateral headfilm
(Fig 6). The area varied over a narrow range, between
325 and 375 mm2, for many patients, yet the volume
varied from 1000 to 5000 mm3, with most in the range
of 2000 to 4000 mm3.
All subjects except 1 had some soft and hard tissue of
the interior turbinate protruding into the nasopharyngeal
airway space. The total nasopharyngeal potential space
was determined as the measured airway volume plus
the volume of the inferior turbinate protuberance, and
the percentage of the inferior turbinate protuberance
was calculated. We found considerable variability in
the actual volume of the tissue that protruded into the
space (Table VI). Nine of the 35 subjects had inferior tur-
binate protuberances into this space that occupied more
than 25% of the total potential volume. These subjects
included 9 of the 11 overall smallest volumes measured.
Although the lateral headfilm of the subject in Fig-
ure 7 shows no obvious nasopharyngeal airway restric-
tion, the 3D scan shows severe restriction caused by the
inferior turbinates. This subject had the largest turbinate
American Journal of Orthodontics and Dentofacial Orthopedics Aboudara et al 475
Volume 135, Number 4

Fig 6. The area of the nasopharynx (green diamonds) ranked in increasing order for subjects with the
same subjective restriction scale (1-5) and compared with the volume (blue bars) of the same naso-
pharyngeal region.

Table VI. Descriptive statistics for the inferior turbinates

Mean SD Minimum Maximum

Volume of inferior turbinate protuberance into potential nasopharyngeal airway space (mm3) 706.5 593.3 0 2896.4
Percentage of potential nasopharyngeal airway space taken up by inferior turbinate protuberance (%) 16.9 14.7 0 67.6

protuberance measured. The patient in Figure 8 had the
most restricted airway, with a classification of 4. The 3D
view shows that the airway space has a small anteropos-
terior dimension with significant inferior turbinate pro-
tuberances.
DISCUSSION
This is one of the first studies that has attempted to
use CBCT to evaluate the airway.15,21 The study in-
volved developing a method to complete the analysis
of the same region that is depicted on the lateral view
of the head in a full headfilm. Validation of the volumet-
ric measurement method used in this study was essential
because of the lower resolution and increased noise of
this first-generation maxillofacial scanner. Although
computed tomography scans are not usually indicated
for soft-tissue imaging, the significant contrast gradient
between air and any other soft- or hard-tissue structure
allowed development of accurate segmentation proce-
dures to quantify airway and turbinate volumes. The dif-
ferential error seen in our methodology test between the
angled and vertical phantoms can be attributed to over-
estimation of the in-plane volume over the slice thick-
ness along the angled border. The nasopharyngeal
airway volume borders can be thought of as angled on
the posterior and lateral surface, and vertical along the
476 Aboudara et al
Fig 7. Subject with the largest turbinate protuberance: A, lateral headfilm view of region of interest;
B, rendered airway volume at off-angle view; C, CBCT axial sections at levels of maximum constric-
tion caused by the inferior turbinates.
anterior and inferior surfaces. The borders of the airway
are, however, less discrete than the phantom because of
the variability in the soft-tissue lining of the airway.
There were some imaging artifacts caused by the denser
skeletal elements of the skull. The percentage error of
our measurements compared with the true volume was
between 0% and 5%, and probably closer to 5%. The in-
creased error with the turbinate measurements was
probably higher because they were manually outlined,
instead of using the systematic variable gray-scale
threshold method.
The influence of airway function on facial morphol-
ogy takes place over a long time. Although there is still
some controversy about airway function and its effect
on facial morphology, almost every study found in-
creased anterior face height in persons with impaired
nasal breathing. This can have adverse consequences
on dental function and esthetics.3,5,9,22,32,33 No func-
tional information on breathing pattern, tongue posture,
American Journal of Orthodontics and Dentofacial Orthopedics
April 2009
or mandibular posture was available on the subjects in
our study. Since our data were retrospective, cross-sec-
tional, and predominately comprising female patients
referred for temporomandibular disorder problems, no
attempt was made to correlate the subjects’ facial mor-
phology with individual airway size. This study was pri-
marily designed to evaluate the clinical value of
cephalometric headfilms as a tool for nasopharyngeal
airway assessment, compared with quantification of
the 3D morphology of the nasopharyngeal airway
with CBCT scans.
The airway in adolescents changes rapidly; therefore,
the CBCT scan and the lateral headfilm needed to be
taken at the same time for accurate comparison. Even
though the cutoff point for the images was 1 week,
most subjects had images taken at the same time. In 30
of the 35 subjects, the images were taken within 2 days.
The cephalometric headfilm provided a good
general overall indicator for nasopharyngeal airway
American Journal of Orthodontics and Dentofacial Orthopedics Aboudara et al 477
Volume 135, Number 4

Fig 8. Subject with a large adenoid contour and severe airway restriction: A, lateral headfilm with na-
sopharyngeal region of interest outlined in green and a red line at the height of contour of the ade-
noids; B, CBCT axial sections corresponding to those at and surrounding the red line in the lateral
headfilm view with the airway outlined in green; C, rendered airway volume from lateral view; D, ren-
dered airway volume at an off-angle view.
478 Aboudara et al
patency. The subject with the smallest airway area
viewed on the lateral cephalometric headfilm had the
smallest corresponding airway volume; thus, the head-
film can provide valuable information about severe re-
strictions in this portion of the airway. Unfortunately,
this point cannot be generalized because only 1 subject
had a severe airway restriction classification as shown
on the lateral headfilm. However, the purpose of this
study was to compare airway size measured in 2
ways, not to determine adenoid volume. For airway
classifications 1 and 2—the least restricted—there was
considerable volume variability and range between sub-
jects with similar airway areas. The correlation coeffi-
cient was the weakest for the least restricted airways;
thus, predicting volumes from airways that appear
wide open on the headfilm might be difficult. These
facts make accurate volumetric nasopharyngeal airway
estimates from the lateral headfilm questionable be-
cause there could be a small volume that is not detected
in a patient.
In our subjects, we observed the inferior turbinate
protruding significantly into the nasopharyngeal poten-
tial space. This anatomic variation is not accounted for
in cephalometric airway analysis and most clinical eval-
uations of orthodontic patients. Our subjective classifi-
cation system did not take this into account. Our
finding with the CBCT is contrary to what most anat-
omy textbooks depict: the inferior turbinates are shown
ending at the posterior aspects of the maxilla.25,26 In our
group of older adolescents, the turbinates appeared to
contribute as much to airway obstructions as did the ad-
enoids. The lack of significant adenoid tissue was ex-
pected because most subjects were beyond their peak
development of hypertrophic adenoid tissue.17
All CBCT scans were done with the patient in the
supine position, whereas the headfilms were taken
with the patient standing upright. This difference in po-
sition was solved by evaluating only the nasopharynx.
In future studies, it would be preferable to record the pa-
tient sitting upright for the CBCT studies. It was not our
purpose to compare the anatomic definition of the air-
way to the airway dynamics and the physiologic param-
eters of airflow. Future studies need to address this
association. One question this study design did not ad-
dress was the quantification of a threshold for airway re-
striction severe enough to affect nasal airway function.
Because functional tests were not performed in our sub-
jects, we cannot answer this question, and further stud-
ies are needed. Considerable volumetric size and shape
variability was seen in our adolescent sample. Resis-
tance to airflow is not only related to airway size, but
also to airway shape.12,34 Airway volume could be
large, but, if the airflow passageway is tortuous, the ef-
American Journal of Orthodontics and Dentofacial Orthopedics
April 2009
fective airway resistance could be great enough to affect
function. Future research with 3D imaging might pro-
vide better evaluation of the size and 3D form of all
parts of the airway to better understand and discriminate
patients with potential airway problems and their conse-
quences.35 With more discriminating diagnosis of those
with true airway restrictions, irrespective of the loca-
tion, better research can be done to discern the associa-
tions between facial morphology and respiratory
pattern.
CONCLUSIONS
1. In adolescents, there is a significant positive rela-
tionship between nasopharyngeal airway size on
a headfilm and its true volumetric size from
a CBCT scan.
2. Accurate determination of airway volume for a
patient from a headfilm is difficult because of the
great variability in the 3D airway.
3. The inferior turbinates can protrude significantly
into the nasopharyngeal airway space and cause
severe airway restrictions for some patients.
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