International Journal of Pediatric Otorhinolaryngology 75 (2011) 383–386

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Cephalometric evaluation of facial pattern and hyoid bone position in children

with obstructive sleep apnea syndrome
Bruno B. Vieira a,*, Carla E. Itikawa a, Leila A. de Almeida b, Heidi S. Sander b, Regina M.F. Fernandes b,
Wilma T. Anselmo-Lima c, Fabiana C.P. Valera c
a
Division of Orthodontics, Dental School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
b
Departmento of Neurology, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil
c
Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery, School of Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To assess the development of face and hyoid bone in children with obstructive sleep apnea
Received 10 November 2010 syndrome (OSAS) through lateral cephalometries.
Received in revised form 6 December 2010 Materials and methods: Children aged 7–10 years with mixed dentition and with no previous
Accepted 9 December 2010
otorhinolaryngologic, orthodontic or speech therapy treatments were studied. Twenty nasal breathers
Available online 8 January 2011
were compared to 20 mouth breathing children diagnosed as OSAS patients. All children underwent
otorhinolaryngologic evaluation and cephalometries; children with OSAS also underwent nocturnal
Keywords:
polysomnography in a sleep laboratory.
OSAS
Cephalometry
Results: Children with OSAS presented increase in total and lower anterior heights of the face when
Hyoid bone compared to nasal breathers. In addition, children with OSAS presented a significantly more anterior and
Mouth breathing inferior position of the hyoid bone than nasal breathers. No significant differences in upper, anterior or
Children posterior heights of the face were observed between groups.
Growth and development Conclusion: The results suggest that there are evident and early changes in facial growth and
development among children with OSAS, characterized by increased total and inferior anterior heights of
the face, as well as more anterior and inferior position of the hyoid bone.
ß 2010 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Mouth breathing is one of the most frequent symptoms in
childhood, and rhinitis and tonsils hypertrophy are the most
frequent causes for it [1]. It influences the perioral muscles and soft
tissues, and thus affects the apposition of bone tissue during the
infant growth [2]. The severity of respiratory disorders may range
from intermittent nasal obstruction to more exuberant symptoms
such as obstructive sleep apnea syndrome (OSAS) [3].
It has been previously reported that adult patients with OSAS
present a more anterior and inferior hyoid bone position when
compared to controls, associated to lower position of the tongue.
This is related to changes in geniohyoid muscle, which in turn
worsen apnea during sleep [4]. The position of the hyoid bone may
be also related to a poorer prognosis in surgeries for uvulopala-
topharyngoplasty (UPPP) for OSAS in adults, and patients with a
higher distance between the hyoid bone to the mandibular base
present a poorer postoperative success [5].
Tonsils hypertrophy is the main cause of OSAS in children [6]. In
this age group, OSAS may be more subtle and silent, whereas this
characteristic does not prevent the development of serious
neurobehavioral and cognitive impairment, as well as facial and
occlusal changes.
The study of facial development and mainly of the hyoid
position in children precisely diagnosed with OSAS has been
scarcely reported in the literature. The purpose of this study was to
evaluate children in scholar age, comparing children with OSAS
(group 1) to nasal breathers (group 2), in terms of skeletal facial
and hyoid changes.
2. Materials and methods

Twenty patients with OSAS and 20 nasal breathing patients,

* Corresponding author at: Av. Monte Alegre, 3900–128 andar, Bairro: Monte
Alegre, CEP: 14049-900, Ribeirão Preto, São Paulo, Brazil. Tel.: +55 16 36235290;
fax: +55 16 36022860.
E-mail addresses: facpvalera@fmrp.usp.br, facpvalera@uol.com.br (B.B. Vieira).
from 7 to 10 years, and with mixed dentition, were selected.
Patients with systemic disorders and those with adjuvant
orthodontic, speech therapeutic and otorhinolaryngologic treat-
ment were excluded.

0165-5876/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2010.12.010
384 B.B. Vieira et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 383–386
Group 1 patients (OSAS) were selected at the Mouth Breathing
Center of the School of Medicine of Ribeirão Preto, University of São
Paulo, and group 2 patients (nasal breathers) were selected at the
Pediatric Clinic of the Dental School of Ribeirão Preto, University of
São Paulo. All childrens’ parents gave informed consent prior the
evaluations, and the patient was included in the study only if their
parents agreed to perform the whole study.
Otorhinolaryngologic evaluation was performed in each patient
to confirm the breathing pattern. This evaluation included a
questionnaire about the intensity and frequency of respiratory
symptoms and a specific otorhinolaryngologic examination. The
palatine tonsils were graded according to Brodsky [7] and
percentage of adenoid obstruction on choanal area was graded
by nasoendoscopy.
Mouth breathing group also underwent to nocturnal diagnostic
polysomnographic examination, according to the 2007 criteria of
the AASM [8]. Only children with an apnea-hypopnea index higher
than 1 and symptoms of OSAS were included in this group. For
ethical reasons, the control group was not submitted to
polysomnography.
After the inclusion in each group, a complete orthodontic
evaluation and documentation was performed in each child,
including lateral cephalometric radiograph. Based on this exam,
the following linear measurements were obtained (Fig. 1):
N–Me: linear distance from N (nasion) to Me (menton);
represents the total anterior facial height
N–ANS: linear distance from N to ANS (anterior nasal spine);
represents the upper anterior height of the face
ANS–Me: linear distance from ANS to Me; represents the lower
anterior height of the face
S–Go: linear distance from S (sella) to Go (gonion); represents
the total posterior facial height
[()TD$FIG]
Fig. 1. Cephalometric tracing illustrating the points and linear measurements
employed in this study: N–Me: total anterior facial height; N–ANS: upper anterior
height of the face; ANS–Me: lower anterior height of the face; S–Go: total posterior
height of the face; HyS: vertical distance from Hy to sella; vert.dH: vertical distance
from H to the palatal plane; HyMP: vertical distance from Hy to the mandibular
plane; horiz.dH: horizontal distance from H to the posterior wall of the
hipopharynx; C3–H: linear measure from H to the most anterior point of C3.
HyS: linear vertical distance from Hy (uppermost point of the
hyoid) to S
vert.dH: linear vertical distance from H (most anterior point of
the hyoid) to the palatal plane
HyMP: vertical distance from Hy to the mandibular plane
horiz.dH: linear horizontal distance from H to the posterior wall
of the hypopharynx
C3–H: linear measure from the H to the most anterior and
inferior point of C3.
The study was approved by the Research Ethics Committee of
the University Hospital, School of Medicine of Ribeirão Preto,
University of São Paulo (protocol no. 4212/2009).
2.1. Statistical analysis
Otorhinolaryngologic evaluation and polysomnography were
used to stratify the patients into the different groups and no
statistical analysis was applied to these data. The orthodontic
measures were compared statistically by unpaired parametric
tests, through ANOVA. The GraphPad Instat 3.0 software was used
for the analyses.
3. Results
A total of 40 non-obese children were selected, from which 20
belonged to the group of nasal breathers (mean age 7.35 years) and
20 were from OSAS group (mean age 7.85 years).
3.1. Otolorayngologic and polysomnographic exams
All patients in the OSAS group presented a history of snoring
and apnea witnessed by their parents. In addition, these children
had obstructive adenoids (more than 70% of the choana) and/or
grade III or IV palatine tonsils. The polysomnographic diagnosis
showed that OSAS was mild in 10 children, moderate in 6 and
severe in 4.
In contrast, nasal breathing group did not present obstructive
respiratory symptoms for more than 15 consecutive days. ENT
exams revealed that adenoids obstructed less than 50% of the
choana and palatine tonsils were grade I or II in all patients.
3.2. Orthodontic exam
The cephalometric facial measures demonstrated a significant
increase of the total anterior facial height (N–Me, 109.9  5.0 for
OSAS vs. 106.1  5.6 for controls, P < 0.05), due to a significant
increase of the lower anterior facial height (ANS–Me, 65.9  4.6 for
OSAS vs. 62.3  4.3 for controls, P < 0.05). No significant difference
was observed in upper anterior height (N–ANS) or the posterior
height (S–Go) of the face (Table 1).
Hyoid bone measures revealed a significant lower position in
relation to the skull base (HyS, 98.7  8.6 for OSAS vs. 88.9  5.9 for
controls, P < 0.0005), to the palatal plane (vert.dH, 56.9  6.9 for
OSAS vs. 47.6  3.7 for controls, P < 0.0001) and to the mandibular
plane (HyMP, 16.4  6.5 for OSAS vs. 8.1  4.8 for controls,
Table 1
Comparison of cephalometric facial data between the OSAS and nasal breathing
groups.
Nasal breathing OSAS P
N.Me 106.0  5.6 109.9  5.0 0.024
N.ANS 46.7  3.1 48.4  2.3 0.065
ANS.Me 62.3  4.3 65.8  4.6 0.017
S.Go 65.5  4.3 67.5  4.0 0.144
 B.B. Vieira et al. / International Journal of Pediatric Otorhinolaryngology 75 (2011) 383–386
Table 2
Comparison of the cephalometric data regarding hyoid position between OSAS and
nasal breathing groups.
Nasal breathing OSAS
HyS 88.9  5.9 98.6  8.6
HyMP 8.1  4.8 16.4  6.5
Dh.H 25.5  2.8 27.4  2.5
Dv.H 47.6  3.7 56.9  6.9
C3–H 30.2  3.1 33.4  2.9
P < 0.0001), in addition to an anterior position in relation to the
posterior wall of the nasopharynx (horiz.dH, 27.4  2.5 for OSAS vs.
25.5  2.8 for control, P < 0.05) and to C3 (C3–H, 33.4  2.9 for OSAS
vs. 30.2  3.1 for controls, P < 0.005) (Table 2).
4. Discussion
OSAS in children has been extensively related to syndromic
craniofacial changes, especially those in the middle and lower
thirds of the face. However, the relation between non-syndromic
craniofacial changes and OSAS in children is not definitive, and few
cephalometric investigations are available in the literature for this
group [8–10].
It is known that children with OSAS, in a mouth-breathing
adaptation, change the posture of the head and the mandible, as
well as the tonicity of the tongue and orofacial muscles [11]. When
persistent, this adaptation changes the equilibrium of muscle
pressure on the facial bones and on teeth, influencing facial growth
[12,13].
In the present study, we observed that children with OSAS
presented a significant increase of total anterior facial height (N–
Me) compared to control group. This increase was due to the
increase of lower anterior facial height (ANS–Me), also with a
significant difference between groups. However, the upper
anterior (N–ANS) and the posterior (S–Go) facial heights did not
reach statistical difference between groups. The present findings
are in agreement with the data reported by Zettergren-Wijk et al.
[14] and Juliano et al. [15], who also observed increased anterior
facial height growth in patients with OSAS compared to an aged-
matched control group.
D’Ascanio et al. [16] observed quite a similar result, with
increase in total and lower anterior facial heights, in a old-
matched mouth-breathing group (7–12 years old), which
respiratory cause of it was septum deviation. Their results, along
with ours, suggest that persistent mouth-breathing are associated
to changes in the craniofacial pattern, irrespective to the
obstructive cause.
Particularly relevant are the findings of Lyberg et al. [17], who
observed similar results in OSAS patients but in adulthood, and
described an increase in the anterior facial height and growth of
the mandible in a clock-wise direction in this group. As these are
the same pattern of changes observed in our study, we believe that
mouth breathing changes craniofacial pattern in OSAS patients
early in life, and these changes could favor the maintenance or
recurrence of OSAS in adulthood.
In the present study, the position of the hyoid bone showed a
highly significant difference between groups. The increased
measures of HyS, HyMP and vert.dH demonstrated a more inferior
hyoid bone position related to the skull base, the maxilla and the
mandible in children with OSAS. In addition, the significant
increase of the horiz.dH and C3–H measures demonstrated a more
anterior hyoid position in relation to the posterior wall of the
pharynx and to C3 in this group.
385
The specific position of the hyoid bone in children with OSAS
has been little explored in the literature, and controversial results
have been reported. Also, the available studies usually evaluate
P mouth breathing children without a polysomnographic character-
0.0002 ization of the respiratory disorder.
<0.0001 In agreement with the present results, Juliano et al. [15]
0.031 observed that the C3–H measure was increased in mouth breathing
<0.0001
children. According to the authors, this finding could occur because
0.002
these patients extend their head in an attempt to improve their
new respiratory pattern, through mouth.
However, different results have also been reported in the
literature. Ferraz et al. [18] concluded that the hyoid bone
maintains a stable position independent of the respiratory pattern,
whereas Janicka et al. [19], studying adults and children (9–35
years of age), detected a more inferior but also posterior hyoid
position in patients with respiratory disorders.
Thus, we observed that the facial and hyoid bone morphological
pattern of adult individuals with OSAS are already present in
school-age children, probably as a mechanism of physiological
adaptation. These facial skeletal characteristics, in turn, lead to a
more likely prognosis of future development of OSAS. However, in
view of the scarce literature available, further studies on well-
defined groups of children with OSAS are needed for the
determination of the specific position of the hyoid bone.
5. Conclusion
Based on the present study, we may conclude that there is an
important change in facial growth and development in children
with OSAS, with a significant increase in the total and lower
anterior heights of the face.
The hyoid bone was found to be in a more anterior and inferior
position in children with OSAS, with extremely significant
statistical results compared to nasal breathing children.
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