ONLINE ONLY

Three-dimensional analysis of pharyngeal

airway in preadolescent children with different
anteroposterior skeletal patterns
Yoon-Ji Kim,a Ji-Suk Hong,a Yong-In Hwang,a and Yang-Ho Parkb
Seoul, Korea

Introduction: In growing patients with skeletal discrepancies, early diagnosis, evidence-based explanations
of etiology, and assessment of functional factors can be vital for the restoration of normal craniofacial growth
and the stability of the treatment results. The aims of our study were to compare the 3-dimensional pharyngeal
airway volumes in healthy children with a retrognathic mandible and those with normal craniofacial growth,
and to investigate possible significant relationships and correlations among the studied cephalometric vari-
ables and the airway morphology in these children. Methods: Three-dimensional airway volume and cross-
sectional areas of 27 healthy children (12 boys, 15 girls; mean age, 11 years) were measured by using
cone-beam computed tomography volume scans, and 2-dimensional lateral cephalograms were created
and analyzed. The subjects were divided into 2 groups based on their ANB angles (group I: 2 # ANB # 5 ;
group II: ANB .5 ), and cephalometric variables, airway volumes, and cross-sectional measurements were
compared. Results: There were statistically significant differences in the following parameters: height of
the posterior nasal plane (P \0.05), pogonion to nasion perpendicular distance (P \0.01), ANB angle
(P \0.01), mandibular body length (P \0.01), facial convexity (P \0.01), and total airway volume (P \0.05).
No statistically significant differences between the 2 groups were found in the cross-sectional area and the
volumetric measurements of the various sections of the airway except for total airway volume, which had
larger values in group I (P \0.05). Conclusions: The mean total airway volume, extending from the anterior
nasal cavity and the nasopharynx to the epiglottis, in retrognathic patients was significantly smaller than
that of patients with a normal anteroposterior skeletal relationship. On the other hand, differences in volume
measurements of the 4 subregions of the airway were not statistically significant between the 2 groups.
(Am J Orthod Dentofacial Orthop 2010;137:306.e1-306.e11)

T
he effects of respiratory function on craniofacial
growth have been studied for decades, and most
clinicians now understand that respiratory func-
tion is highly relevant to the orthodontic diagnosis and
the treatment plan. In 1907, Angle1 showed that his
Class II Division 1 malocclusion is associated with ob-
struction of the upper pharyngeal airway and mouth
breathing. Clinical features related to impaired breath-
ing have been observed by some authors, and Ricketts2
presented the main characteristics of the respiratory ob-
struction syndrome as adenoid and tonsil hypertrophy,
From the Department of Orthodontics, Kangdong Sacred Heart Hospital,
Hallym University Medical Center, Seoul, Korea.
a
Resident.
b
Associate professor.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Yang-Ho Park, Department of Orthodontics, Kangdong
Sacred Heart Hospital, 445 Gil-Dong, Gangdong-Gu, Seoul, Korea, 134-701.
e-mail, dentpark64@hanmail.net.
Submitted, May 2009; revised and accepted, October 2009.
0889-5406/$36.00
Copyright Ó 2010 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.10.025
crossbite, open bite, narrow external nares, and tongue
thrusting.
Predisposing factors of nasal obstruction can in-
clude adenoid and tonsil hypertrophy, polyps, allergies,
infections, and nasal deformities. A common cause of
mouth breathing arises from the adenoids, which are
a conglomerate of lymphatic tissues located in the pos-
terior pharyngeal airway. Infection and inflammation of
the adenoids leads to upper airway obstruction, and the
term ‘‘adenoid facies’’ is often used to describe a possi-
ble aberrant craniofacial growth pattern related to
mouth breathing characterized by lip incompetency, un-
derdeveloped nose, increased anterior facial height,
constricted dental arches, and proclined maxillary inci-
sors with a Class II occlusal relationship.3,4
In addition to studies that affirm nasal obstruction as
the major factor responsible for dentofacial anomalies,
other studies refute a significant relationship between
airway obstruction and the frequency of malocclusion.
In a study of 500 patients with upper airway problems,
Leech5 discovered that 60% of the mouth-breathing pa-
tients were Class I and concluded that mouth breathing
306.e1
306.e2 Kim et al
Table I. Sample characteristics
Group I
Male Female
Subjects (n) 7 7
Age (y) (mean 6 SD) 11.46 6 0.69 11.71 6 0.86
Range (y) 10.50-12.58 10.67-12.92
has no influence on craniofacial growth. Similarly,
Gwynne-Evans6 determined that facial growth is con-
stant regardless of the mode of breathing. Additionally,
Humphreys and Leighton7 found no significant differ-
ence in the anteroposterior relationship of the jaws be-
tween nose and mouth breathers.
In growing patients with skeletal discrepancies and
clinical signs of adenoid facies, early diagnosis, evi-
dence-based explanations of etiology, and assessment
of the functional factors might be vital for the restora-
tion of normal craniofacial growth and the stability of
treatment results. Morphometric evaluation of the pha-
ryngeal airway has been mostly performed on lateral
cephalometric headfilms, by identifying specific land-
marks and measuring various lengths and areas in the
pharyngeal region.8-10
Despite the vast amount of research concerning air-
way anatomy and its influence on craniofacial growth
and development, most studies have been 2-dimen-
sional (2D) and have used lateral or frontal cephalo-
grams with limited evaluation of lengths and areas.
New 3-dimensional (3D) technology of computed to-
mography (CT) has expanded diagnostic capacities,
making volumetric analysis and accurate visualization
of the airway possible. Most 3D studies of the airway
used multislice CT to evaluate the airway; this has the
advantage of high-quality images to discern hard- and
soft-tissue anatomies, but, because of the high radiation
dose, it is restricted to patients with severe craniofacial
deformities and those undergoing orthognathic surger-
ies.11,12 Recently, cone-beam CT (CBCT) systems
have been developed specifically for the maxillofacial
region. Because a CBCT scan uses a different type of
acquisition than traditional multislice CT, radiation is
reduced and can be used in a wider range of patients,
eg, those having maxillofacial surgery, implantology,
and orthodontics.13 Cross-sectional and volumetric in-
vestigations of the pharyngeal airway have been possi-
ble by using CBCT scans to analyze the complex
airway anatomy, and previous studies have confirmed
that volumetric measurements of airways with CBCT
are accurate with minimal error.14
The aims of our retrospective, cross-sectional study
were (1) to compare the 3D pharyngeal airway volumes
American Journal of Orthodontics and Dentofacial Orthopedics
March 2010
Group II
Male Female Total
5 8 27
10.23 6 0.73 11.09 6 1.03 11.19 6 1.28
9.42-12.33 9.08-12.17 9.08-12.92
in healthy children with a retrognathic mandible and
those with normal craniofacial growth and (2) to inves-
tigate possible significant relationships and correlations
among the studied cephalometric variables and the air-
way morphology in these children.
MATERIAL AND METHODS
Pharyngeal airway structures were studied in 27
healthy children (12 boys, 15 girls) with a mean age
of 11.19 6 1.28 years (Table I) who were referred to
the Department of Orthodontics of Kangdong Sacred
Heart Hospital, Hallym University Medical Center,
Seoul, Korea, for treatment. Those who had symptoms
of upper respiratory infection, pharyngeal pathology
such as adenoid hypertrophy and tonsillitis or a history
of adenoidectomy or tonsillectomy were excluded.
The study protocol was approved by the Ethics
Review Committee of the hospital (IRB 09-57).
CBCT volume scans of all subjects were obtained
by using the Master 3D dental-imaging system (Vatech,
Seoul, Korea), and the imaging protocol used a 12-in
field of view to include the entire craniofacial anatomy.
The axial slice thickness was 0.3 mm, and the voxels
were isotropic.
Patients sat upright with natural head position, and
their jaws were at maximum intercuspation with the
lips and tongue in a resting position. The patients
were asked not to swallow and not to move their heads
or tongues. Almost all 3D imaging modalities (eg, con-
ventional CT or magnetic resonance imaging) require
patients to be supine; this causes significant morpho-
logic changes of the airway, since gravity affects the
soft tissues surrounding the oropharyngeal cavity.15 It
might be reasonable to examine patients in the supine
position for diagnosing such disorders as obstructive
sleep apnea. In most cases (including orthodontic diag-
nosis and treatment planning), however, patients do not
need to be analyzed in the supine position. Recent ad-
vances in CBCT permit the acquisition of axial CT im-
ages in the upright sitting position, which is more valid
for our study.
The axial images were imported to InVivoDental
software (Anatomage, San Jose, Calif), and volumetric
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 3
Fig 1. A volumetric rendering of a subject’s craniofacial skeleton: A, lateral view right; B, frontal view;
C, lateral view left.
Fig 2. For the horizontal reference plane, the FH plane
was constructed from the right and left porions and the
right orbitale, which was set as the origin.
rendering was done for airway and cephalometric anal-
ysis (Fig 1). To standardize the measurements and min-
imize errors, the 3D image was reoriented, by using the
Frankfort horizontal (FH) plane as its reference plane.
The FH plane was constructed from the right and left
porions located in the most laterosuperior point of the
external auditory meatus and the right orbitale (Fig 2).
Cho16 proposed a 3D analysis system from a CBCT vol-
umetric image with a set of landmarks, reference lines,
and reference planes. In his system, the 3D image is re-
oriented according to the nasofrontozygomatic plane
and the FH plane. Lagravère et al17 designated reference
points such as the midpoint between the foramen lac-
Kim et al 306.e3
erum and the middorsum foramen magnum, since they
are easily viewed in the 3D images.
The 2D cephalometric images were derived from
the 3D CT scans by creating an orthogonal projection
with parallel rays, and the images were imported into
V-ceph software (Osstem Implant, Seoul, Korea) for
conventional 2D analysis. Landmark identifications
and physical measurements were performed by the
same investigator (Y.J.K). For the cephalometric analy-
sis, 13 conventional hard-tissue cephalometric land-
marks were identified, and 5 anteroposterior and 5
vertical measurements were calculated (Table II, Fig
3). The subjects were assigned to 2 groups based on
their ANB angles: 14 subjects (7 boys, 7 girls) whose
ANB angles ranged from 2 to 5 were allocated to
group I, and 13 subjects (5 boys, 8 girls) who had
ANB angles greater than 5 were allocated to group II
(Table I).
Five cross-sectional planes (2 frontal and 3 axial
sections) and 5 volumes of the pharyngeal airway
were developed in this study based on the FH plane
and soft-tissue landmarks (Table III; Figs 4 and 5).
Cross-sectional planes of the nasal cavity are perpendic-
ular to the FH plane, whereas the pharyngeal cross-sec-
tions are parallel to the FH plane. Although these cross-
sections are not directly perpendicular to the long axis
of the airway, the FH plane was used as a reference
plane to standardize the plane orientation and minimize
error in identifying the studied cross-sectional planes of
the subjects. Various dimensions of the airway were cal-
culated by the same examiner. Cross-sectional measure-
ments including width, length, and area were calculated
in the sectional views (frontal and axial) because they
provide precise 2D visualization and linear accuracy
of 2D measurements (Fig 5).
306.e4 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2010

Table II. Two-dimensional cephalometric variables used in this study

Variable Definition

Vertical skeletal pattern

Gonial angle The angle formed by the junction of the posterior and lower borders of the mandible
AFH Distance between nasion and menton
PFH Distance between sella and gonion
FMA The angle formed by the FH plane and the mandibular plane (Go-Me)
AFH/PFH Ratio of AFH to PFH
Anteroposterior skeletal pattern
A to N-perp The linear distance from Point A to nasion perpendicular
Pog to N-Perp The linear distance from pogonion to nasion perpendicular
ANB The difference between SNA and SNB
Mn body length The linear distance of the mandibular plane (Go-Me)
Facial convexity The angle fomed by nasion, Point A, and pogonion

the selected airway region. Finally, the volume of the

Fig 3. Landmarks, anteroposterior measurements, and
vertical measurements used in this study.
Volumetric renderings of the subjects’ CT scans
were acquired with the InVivoDental software, and we
proceeded with volumetric analysis of the defined air-
ways. Since airway is void space surrounded by hard
and soft tissues, inversion of the 3D-rendered image is
required; this converts a negative value to a positive
value, and vice versa. This process removes the hard
and soft tissues of the image and embodies the airway
spaces of the craniofacial region including the paranasal
sinuses and other empty spaces. Then sculpting was
dpme to isolate the desired airway section by removing
unnecessary structures; subsequently, threshold values
were adjusted to eliminate imaging artifacts and refine
designated airway was calculated in cubic millimeters.
Lateral cephalometric variables and airway dimen-
sions of 15 randomly selected CT scans were remeas-
ured by the same investigator 2 weeks after the first
measurements. A paired t test was used to estimate sys-
temic error, and all measurements were free of systemic
error.18 Random error was estimated by using Dahl-
berg’s formula19 (ME2 5 Sd2/2 n). Random errors var-
ied from 0.49 to 2.24 mm in linear measurements, from
11.33 to 36.12 mm2 in area measurements, and from
57.36 to 91.37 mm3 in volume measurements.
Descriptive statistics including the mean and stan-
dard deviation for each group were calculated by using
SPSS for Windows software (version 12.0, SPSS, Chi-
cago, Ill). Differences between groups I and II, and
between the sexes, were tested by using independent
t tests. Pearson’s correlation coefficient test was used
to detect any relationship of different parts of the airway
and between airway volume and 2D cephalometric
variables.
RESULTS
Means and standard deviations for cephalometric,
cross-sectional, and volumetric variables were com-
pared by sex; since no sex differences were found in
any measurement, the subjects were combined for sub-
sequent analysis. Table IV gives the comparison results
of groups I and II. There were statistically significant
differences in the following parameters: height of the
posterior nasal plane (P\0.05), pogonion to nasion per-
pendicular distance (P \0.01), ANB (P \0.01), man-
dibular body length (P \0.01), facial convexity
(P \0.01), and total airway volume (P \0.05). Accord-
ing to the lateral cephalometric analysis, group II had
retruded mandibles and a greater skeletal anteroposte-
rior discrepancy, as evidenced by the pogonion to nasion
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 306.e5
Volume 137, Number 3

Table III. Cross-sectional planes and volumes of the 3D pharyngeal airway

Landmark Definition

Cross-sectional plane
Anterior nasal plane
Posterior nasal plane
Upper pharyngeal plane
Middle pharyngeal plane
Lower pharyngeal plane
Volume
Nasal airway
Superior pharyngeal airway
Middle pharyngeal airway
Inferior pharyngeal airway
Total airway
Ana plane
Pna plane
Uph plane
Mph plane
Lph plane
Airway formed by the Ana and Pna planes
Airway formed by the Pna and Uph planes
Airway formed by the Uph and Mph planes
Airway formed by the Mph and Lph planes
Airway extending from Ana plane to Lph plane
A frontal plane perpendicular to the FH plane passing
through ANS
A frontal plane perpendicular to the FH plane passing
through PNS
An axial plane parallel to the FH plane passing
through PNS
An axial plane parallel to the FH plane passing
through the caudal margin of the soft palate
An axial plane parallel to the FH plane passing
through the superior margin of the epiglottis

perpendicular distance, ANB, and facial convexity
values. No statistically significant difference between
the 2 groups was found in the cross-sectional area and
volumetric measurements of the different parts of the
airway. However, total airway volume, which is the
sum of the 4 separate volumes of the airway, was signif-
icantly greater in group I (P\0.05). The linear measure-
ments of the cross sections indicated that the height of
the posterior nasal plane was the only significant mean
found, with greater values in group I (P \0.05).
Tables V and VI show the correlations among the
studied variables. Table V shows the correlations of sec-
tions of the airway with each other, and Table VI shows
correlations between the 2D cephalometric variables
and the 3D volumetric measurements of the airway.
The nasal airway volume and the superior pharyngeal
airway volume had a positive correlation (P \0.01).
Some analyses from the lateral cephalograms tended
to be correlated with airway volume. The anterior facial
heights showed positive correlations to all volumetric
measurements except the middle pharyngeal airway
volume. Posterior facial height showed significant cor-
relations with total airway volume and inferior pharyn-
geal airway volume (P \0.05). Additionally, total
airway volume was significantly correlated with ANB
angle and mandibular body length (P \0.05).
DISCUSSION
Although the impact of respiratory function on cra-
niofacial growth and its relevance in orthodontics has
long been a controversial issue, many clinical studies
have presented good evidence with sound data support-
ing this hypothesis. To evaluate the airway, nasal resis-
tance and airflow tests, nasoendoscopy, and lateral
cephalometry have been the primary means used for
the last few decades.20,21 As new-generation CBCT sup-
plements the diagnosis and treatment planning of ortho-
dontic patients, 3D analyses of the maxillofacial
skeleton and the soft tissues are possible. Our study of
the pharyngeal airway with CBCT produced anatomi-
cally true images that are 3D reconstructed without
magnification or distortion, allowing accurate measure-
ment in all 3 dimensions (sagittal, frontal, and trans-
verse) to understand fully the pharyngeal morphology
in growing children.22-24
Because of the retrospective design of this study, di-
rect examination of the patients’ nasopharyngeal func-
tions was not possible; selection of subjects was based
on previous clinical chart information at their diagnoses
for orthodontic treatment, and CBCT images were used
additionally to screen subjects with severe adenoid and
tonsillar hypertrophy. Area measurements of adenoids
in lateral cephalograms have been reported to have clin-
ically useful correlations with gold standards such as ac-
tual tissue volumes obtained by adenoidectomy and
direct observations through endoscopy.25-27 However,
Aboudara et al28 found that 2D measurements of the na-
sopharyngeal airway area lacks much of the structural
information, since the 3D structure is compressed into
a 2D image. In our study, subjective grading of the ad-
enoid and tonsil sizes in the 3D image was done, and pa-
tients with severe adenoid or tonsillar hypertrophy were
considered as having infections or allergies, and they
were excluded in this study. As a result, we confirmed
that our patients were free of clinical signs and symp-
toms related to pharyngeal pathology and had no history
of treatment intervention (eg, tonsillectomy or
306.e6 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2010

Fig 4. Five cross-sectional planes of the pharyngeal airway used in this study: A, right lateral view
and B, frontal view of volume rendered images. a, Anterior nasal plane (Ana); b, posterior nasal plane
(Pna); c, upper pharyngeal plane (Uph); d, middle pharyngeal plane (Mph); e, lower pharyngeal plane
(Lph). C, The cross-sectional planes are shown in the lateral cephalogram.

adenoidectomy) in the pharyngeal area. Thus, we as-
sumed that the subjects were relatively healthy and
showed normal patterns of nasorespiratory function.
Obviously, this method of patient selection is not ideal,
and we could have included patients with mild pharyn-
geal diseases that could not be detected. According to
a study by Laine-Alava and Minkkinen,29 however,
a history or symptoms of upper respiratory diseases
have no influence on variables related to nasorespiratory
function when the measurements are made during an
asymptomatic period.
The nasopharyngeal airway is mainly influenced by
the adenoids, which are known to follow the lymphoid
growth curve shown by Scammon et al.30 They increase
rapidly from infancy, reach a peak before adolescence,
and then gradually decrease to their adult sizes. Sub-
telny and Baker31 concluded that the growth peak of
the adenoids varies from 9 to 15 years of age. In our
study, children aged 9 to 12 years were selected. Ac-
cording to the curves of general growth of Scammon
et al,30 which the maxillomandibular growth is known
to follow, this period is the end of the second phase of
growth when the growth rate is steady and constant be-
fore the adolescent growth spurt. Therefore, children at
these preadolescent ages can have adenoids that have
reached their maximum size, and considerable facial
growth has occurred to reflect functional influences be-
cause they might be predisposed to the natural anatomic
conditions of narrower nasopharyngeal airways.
The 2D lateral cephalometric images were created
from the CBCT scans primarily to assign the subjects
to the 2 groups and also to ascertain significant correla-
tions among the cephalometric variables and the airway
volumes. Linear accuracy of the CBCT-derived lateral
cephalometric images has been studied.32-34 Moshiri
et al35 compared linear measurements of lateral cepha-
lograms derived from CBCT with those of conventional
cephalograms and direct measurements on a dry human
skull, which was considered to represent the anatomic
truth. For most linear measurements calculated in the
sagittal plane, they found that the CBCT-derived 2D lat-
eral cephalograms were more accurate than conven-
tional lateral cephalograms. Moreover, generation of
2D cephalometric images from CBCT data prevents un-
necessary irradiation of the patients. Regarding patient
positioning, Hassan et al33 compared linear measure-
ments on 3D surface-rendered images, 2D tomographic
multiplanar reformatted slices, and 2D projection im-
ages in both ideal and rotated positions of dry human
skulls. They concluded that linear measurements on
all 3 images were accurate in the ideal skull position;
however, the rotated skull provided linear accuracy
only for 3D surface-rendered images and 2D tomo-
graphic slices.
To classify the subjects based on their anteroposte-
rior skeletal relationships, Korean norms for the ANB
angle were used.36 Several reports about the ANB angle
have indicated its lack of clinical significance and reli-
ability in the determination of the anteroposterior jaw
position. Hussels and Nanda37 showed that the ANB an-
gle is influenced by rotation and vertical growth of the
jaws, anteroposterior position of the nasion, and vertical
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 306.e7
Volume 137, Number 3

Fig 5. Cross-sectional views of the pharyngeal airway in the 5 planes: a represents the length (axial
slice) or height (frontal slice) of the airway defined by the greatest distance in the anteroposterior or
vertical direction of the airway cross section; b is the width of the airway defined by the greatest dis-
tance in the right and left directions of the airway cross section. The colored region indicates the
cross-sectional area of the airway.

distance between Points A and B. Ferrario et al38 sug-
gested that the orthodontic diagnosis should be based
on more than 1 anteroposterior appraisal. However,
the ANB angle is a commonly used cephalometric pa-
rameter in clinical orthodontics,39 and Ishikawa et al40
corroborated that it is reliable for determining the ante-
roposterior relationship of the jaws. Additionally, these
authors showed that the ANB angle and the angle of
convexity in the prepubertal assessment have high pre-
diction accuracy for postpubertal jaw relationships. In
our study, the anteroposterior analyses displayed statis-
tically significant differences except Point A to nasion
perpendicular distance, reaffirming the reliability of
the ANB angle, which was used to classify our subjects.
The number of subjects in our study was limited and,
therefore, this investigation should be considered a pilot
study. Because of the small number of subjects, data
from both sexes were collected, and, fortunately, no sex-
ual dimorphism in any cross-sectional and volumetric
measurements was observed. These findings agree
with those of Ceylan and Oktay41 and Freitas et al.42
Vertical cephalometric means of the 2 groups were
within normal limits, and no statistically significant
differences in the vertical measurements between
groups I and II were observed (Table IV), eliminating
the possible effects of the vertical skeletal pattern that
might have contributed to the variations of the airway
dimensions. In the longitudinal study of Akcam et
al,43 upper and lower pharyngeal airways were mea-
sured in preadolescents according to the different rota-
tion types, and hyperdivergent subjects had narrower
lower pharyngeal airways.
All cross-sectional area and volumetric measure-
ments of the subregions of the pharyngeal airway
were greater in group I. However, they were not statis-
tically significant, indicating that segmental airway ca-
pacities are not related to mandibular deficiencies
(Table IV). This agrees with previous 2D studies that
claimed no association of airway dimensions with mal-
occlusion types.12,41,42 Ceylan and Oktay41 asserted
that, as skeletal anteroposterior relationship changes,
pharyngeal structures undergo postural modifications,
and hence the size of the airway remains constant. Inter-
estingly, total airway volume, the sum of the 4 subre-
gions of the airway from the nasal cavity and the
nasopharynx to the oropharyngeal region above the
306.e8 Kim et al American Journal of Orthodontics and Dentofacial Orthopedics
March 2010

Table IV. Descriptive statistics of groups I and II

Group I (n 5 14) Group II (n 5 13)
Intergroup difference
Mean SD Mean SD P

Ana plane Height 44.62 6.03 40.32 8.67 0.16

Width 16.48 1.55 14.91 3.07 0.11
Cross-sectional area 263.51 71.47 216.92 95.07 0.17
Pna plane Height 22.15 1.17 19.42 2.01 0.03*
Width 25.85 2.14 25.40 2.25 0.61
Cross-sectional area 292.93 70.77 258.04 77.46 0.24
Uph plane Length 22.98 5.61 22.45 4.64 0.79
Width 29.72 5.55 28.63 5.12 0.61
Cross-sectional area 494.93 159.05 467.64 161.03 0.67
Mph plane Length 18.25 5.65 15.44 4.44 0.17
Width 25.38 5.68 23.57 4.11 0.36
Cross-sectional area 321.86 129.11 250.96 99.99 0.13
Lph plane Length 17.34 4.96 16.18 5.39 0.57
Width 29.63 3.12 28.72 4.14 0.53
Cross-sectional area 427.68 183.11 363.66 148.17 0.34
Cephalometric analysis Gonial angle 125.94 5.90 125.30 5.26 0.77
AFH 116.02 5.06 111.96 6.81 0.10
PFH 73.09 5.61 69.32 5.49 0.10
PFH/AFH 0.63 0.04 0.62 0.02 0.41
FMA 29.72 4.05 32.22 2.25 0.06
Point A to nasion perpendicular –1.15 2.87 –1.16 2.29 1.00
Pogonion to nasion perpendicular –6.84 5.05 –12.79 3.91 0.01*
ANB 2.42 1.10 5.85 1.15 \0.01†
Mandibular body length 68.22 4.99 63.10 3.03 \0.01†
Facial convexity 5.04 3.33 12.10 3.18 \0.01†
Airway volume Nasal airway 13479.62 2547.12 11124.00 3302.82 0.06
Superior pharyngeal airway 2620.77 899.23 2138.38 658.27 0.13
Middle pharyngeal airway 1581.23 509.83 1402.92 662.49 0.45
Inferior pharyngeal airway 3278.00 1101.55 2498.77 1095.03 0.08
Total airway 20959.62 3611.26 17164.08 4238.46 0.02*

Linear measurements (mm), area measurements (mm2), volumetric measurements (mm3), angular measurements ( ).
*P \0.05; †P \0.01.

epiglottis, appeared to be significantly greater in group
I. From these contrasting results, we inferred that each
subregion of the upper airway does not specifically rep-
resent a patient’s whole upper airway capacity, and,
therefore, comprehensive assessment of the entire upper
airway is needed in patients who require functional ex-
amination. Further studies with larger samples are
needed to investigate certain airway subregions that
might be significantly correlated to other skeletal pat-
terns such as mandibular prognathism and vertical
growth pattern. Additionally, evaluation of discriminat-
ing capacities of airway parts limited by different ana-
tomic landmarks might show specific regions of the
airway that are responsible for significant relationships
between the airway and the craniofacial structures.
Linear analysis of the cross-sections showed that the
nasal airway dimension is influenced by skeletal
pattern. The height of the posterior nasal cavity was sig-
nificantly greater in group I, and the rest of the cross-
sectional dimensions showed greater values in group I,
but they lacked statistical significance. Alves et al12
compared 3D airways of adult skeletal Class II and
Class III patients, and concluded that nasal cavity width
had statistical significance between the 2 groups,
whereas the height of the nasal cavity did not. In con-
trast, Kikuchi11 found in his 3D airway study that the
oropharyngeal region of the airway was influenced by
the skeletal pattern. He maintained that airway mor-
phology, rather than size, is influenced by the anteropos-
terior position of the mandible and suggested that
airway volume remains constant by horizontal and ver-
tical compensation mechanisms of the muscles adjacent
to the pharynx.
Nasal airway volume and superior pharyngeal air-
way volume were positively correlated (Table V), indi-
cating a close relationship of the anterior and posterior
parts of the upper airway. Located above the hard palate,
these 2 sections of the airway are not only anatomically
adjacent, but also their volumetric dimensions have
a direct relationship. Linder-Aronson3 studied the
American Journal of Orthodontics and Dentofacial Orthopedics Kim et al 306.e9
Volume 137, Number 3

Table V. Correlations among airway volumes

Nasal Superior pharyngeal Middle pharyngeal Inferior pharyngeal
airway airway airway airway

Nasal airway Pearson correlation 1 0.542 0.343 0.159

P value ˙ 0.004* 0.086 0.437
Superior pharyngeal airway Pearson correlation 0.542 1 0.199 0.362
P value 0.004* ˙ 0.330 0.069
Middle pharyngeal airway Pearson correlation 0.343 0.199 1 0.375
P value 0.086 0.330 ˙ 0.059
Inferior pharyngeal airway Pearson correlation 0.159 0.362 0.375 1
P value 0.437 0.069 0.059 ˙
*P \0.01.

Table VI. Correlations between cephalometric variables and airway volumes

Gonial angle AFH PFH PFH/AFH FMA Pt A to N perp Pog to N perp ANB Mn body Facial conv

Nasal airway Pearson 0.01 0.57 0.37 0.00 0.00 –0.12 0.05 –0.36 0.33 –0.28
correlation
P value 0.95 \.01† 0.07 0.99 0.99 0.56 0.80 0.07 0.10 0.16
Superior pharyngeal Pearson –0.13 0.51 0.39 0.07 –0.10 –0.09 –0.07 –0.14 0.33 –0.09
airway correlation
P value 0.53 \.01† 0.06 0.74 0.63 0.67 0.73 0.49 0.10 0.66
Middle pharyngeal Pearson 0.15 0.33 0.19 –0.04 –0.01 0.07 0.21 –0.31 0.22 –0.25
airway correlation
P value 0.46 0.10 0.36 0.83 0.95 0.73 0.31 0.13 0.27 0.23
Inferior pharyngeal Pearson –0.33 0.41 0.39 0.18 –0.37 –0.15 0.06 –0.32 0.32 –0.34
airway correlation
P value 0.10 0.03* 0.04* 0.39 0.06 0.46 0.77 0.12 0.11 0.09
Total airway Pearson –0.08 0.66 0.47 0.05 –0.12 –0.13 0.07 –0.42 0.42 –0.35
correlation
P value 0.70 \.01† 0.02* 0.80 0.57 0.52 0.74 0.03* 0.03* 0.08

Pt, Point; N, nasion; perp, perpendicular; Pog, pogonion; Mn, mandibular; conv, convexity.
*P \0.05; †P \0.01.

relationship of the upper and lower parts of the airway,
and reported that a smaller nasopharyngeal airway is ac-
companied by a larger oropharyngeal airway. Ricketts2
and Dunn et al44 stated that oral breathing is related to
a narrow nasopharyngeal airway width because it is eas-
ily blocked by adenoid enlargement. In our study, no
significant correlations were found among the rest of
the airway volumes below the hard palate.
The relationship of conventional cephalometric
analyses and airway volumes were evaluated; anterior
and posterior facial heights were positively correlated
to nasal, superior pharyngeal, and inferior pharyngeal
airways, as well as to total airway volume (Table VI).
This indicates that patients with vertical growth patterns
are likely to have an expanded airway; this is inconsis-
tent with studies that reported an inverse relationship
between pharyngeal volume and vertical facial
height.2,3,42,44,45 However, the variables used to assess
vertical craniofacial patterns are different from those
used in previous studies; this makes the comparison
less compatible. Interestingly, anterior facial height
showed strong correlations (P \0.01) to the upper
part of the airway, and the nasal and superior pharyngeal
airway; this agrees with Freitas et al,42 who noted that
vertical growth patterns have significant correlations
with the upper part of pharyngeal airways.
Anteroposterior discriminants such as ANB angle
and mandibular body length showed significant correla-
tions with total airway volume, supporting the inter-
group comparison of different anteroposterior skeletal
patterns in this study. The negative correlation of the
ANB angle and the total airway can be explained by
group I (2 #ANB#5 ) having significantly greater air-
way volume than group II (ANB .5 ). Mandibular
body length and total airway volume were both signifi-
cantly greater in group I (Table IV), demonstrating
a positive correlation. Hwang et al46 reported that a con-
stricted nasopharyngeal airway is associated with
retruded mandible and maxilla. On the other hand,
Abu Allhaija and Al-Khateeb47 concluded that
306.e10 Kim et al
anteroposterior pharyngeal airway dimensions were not
affected by changes of the ANB angle. Since these pre-
vious studies were based on lateral cephalograms, more
3D studies are needed to clarify this conflicting issue.
The standard deviations of the airway dimensions
were significantly large in cross-sectional area and vol-
umetric measurements. This agreed with the findings of
Ozbek et al,48 who analyzed airway dimensions includ-
ing width, area, and angulation in lateral headfilms of
skeletal Class II growing children. The area measure-
ment of the oropharnynx had large standard deviations,
whereas the rest of the measurements such as airway
width and angulation showed narrow ranges. The wide
ranges of certain airway data were also evident in an-
other study of airway morphology in skeletal Class II
and Class III adults.12 Whereas angular and linear mea-
surements on the 3D airway model were typical of the
designated lengths and angles, cross-sectional areas
and volumes showed markedly large standard devia-
tions in both skeletal types.
In a comparative study of the nasopharyngeal air-
way size using a lateral cephalometric headfilm and
a CBCT scan, Aboudara et al14 found that volume has
a much wider range than area of the same region of
the airway, asserting that determination of airway vol-
ume from 2D lateral cephalograms is inaccurate be-
cause of inconsistencies of the 3D airway anatomy.
Determined as percentages of the means, the standard
deviations of the area and volume in our study ranged
from 24% to 43% and 17% to 47%, respectively, indi-
cating great variability in both parameters. Since
a CBCT scan provides the most accurate dimensional
analysis, it could be interpreted that much anatomic in-
formation is lost when the imaging modalities are 2D,
and linear and angular measurements do not give
enough information about the targeted structure.14,22-24
We showed that healthy preadolescent children with
retruded mandibles have decreased total pharyngeal air-
way volumes. Therefore, orthodontists should be aware
of the pharyngeal morphologies that might predispose
these children to impaired craniofacial growth. Future
investigations of longitudinal airway changes in patients
with different skeletal patterns and assessment of their
craniofacial growth with 3D superimpositions will
allow better understanding of the relationship between
respiratory function and craniofacial morphology.
CONCLUSIONS
The number of subjects available for this investiga-
tion was small; therefore, it should be considered a pilot
study. It was conducted to examine a possible signifi-
cant relationship between airway size and maxillom-
American Journal of Orthodontics and Dentofacial Orthopedics
March 2010
andibular growth patterns in healthy preadolescent
children without evident pharyngeal pathology. Accord-
ing to our results, we can conclude the following.
1. Accurate volumetric determination of 3D pharyn-
geal airway is possible in preadolescents by using
CBCT scans.
2. There is no sexual dimorphism in the 2D lateral
cephalometric analysis or the 3D airway measure-
ments of preadolescents.
3. The mean total airway volume, extending from the
anterior nasal cavity and the nasopharynx to the
epiglottis, of retrognathic patients was significantly
smaller than that of patients with a normal antero-
posterior skeletal relationship. On the other hand,
differences in volume measurements of the 4 subre-
gions of the airway were not found to be signifi-
cantly different between the 2 groups.
4. In preadolescents, volumetric measurements of the
airway are significanlty correlated to anteroposte-
rior and vertical cephalometric variables, mainly
anterior facial height and ANB angle.
We thank Kyung-Min Oh for her contributions to
data collection for this study.
REFERENCES
1. Angle E. Treatment of malocclusion of the teeth. Philadelphia: SS
White Manufacturing Company; 1907.
2. Ricketts RM. Respiratory obstruction syndrome. Am J Orthod
1968;54:495-507.
3. Linder-Aronson Adenoids S. Their effect on mode of breathing
and nasal airflow and their relationship to characteristics of the fa-
cial skeleton and the denition. A biometric, rhino-manometric and
cephalometro-radiographic study on children with and without
adenoids. Acta Otolaryngol Suppl 1970;265:1-132.
4. Moore A. Observations on mouth breathing. Bull N Z Soc Perio-
dontol 1972;9-11.
5. Leech H. A clinical analysis of orofacial morphology and behav-
ior of 500 patients attending an upper respiratory research clinic.
Dent Pract 1958;9:57-68.
6. Gwynne-Evans E. Discussion on the mouth-breather. Proc R Soc
Med 1958;51:279-82.
7. Humphreys HF, Leighton BC. A survey of antero-posterior abnor-
malities of the jaws in children between the ages of 2 and 5 1/2
years of age. Br Dent J 1950;88:3-15.
8. Arun T, Isik F, Sayinsu K. Vertical growth changes after adenoi-
dectomy. Angle Orthod 2003;73:146-50.
9. Kirjavainen M, Kirjavainen T. Upper airway dimensions in Class
II malocclusion. Effects of headgear treatment. Angle Orthod
2007;77:1046-53.
10. Martin O, Muelas L, Viñas MJ. Nasopharyngeal cephalometric
study of ideal occlusions. Am J Orthod Dentofacial Orthop
2006;130:436.e1-9.
11. Kikuchi Y. Three-dimensional relationship between pharyngeal
airway and maxillo-facial morphology. Bull Tokyo Dent Coll
2008;49:65-75.
12. Alves PV, Zhao L, O’Gara M, Patel PK, Bolognese AM. Three-di-
mensional cephalometric study of upper airway space in skeletal
American Journal of Orthodontics and Dentofacial Orthopedics
Volume 137, Number 3
Class II and III healthy patients. J Craniofac Surg 2008;19:
1497-507.
13. Ludlow JB, Davies-Ludlow LE, Brooks SL, Howerton WB. Do-
simetry of 3 CBCT devices for oral and maxillofacial radiology:
CB Mercuray, NewTom 3 G and i-CAT. Dentomaxillofac Radiol
2006;35:219-26.
14. Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D.
Comparison of airway space with conventional lateral headfilms
and 3-dimensional reconstruction from cone-beam computed
tomography. Am J Orthod Dentofacial Orthop 2009;135:468-79.
15. Battagel JM, Johal A, Smith AM, Kotecha B. Postural variation in
oropharyngeal dimensions in subjects with sleep disordered
breathing: a cephalometric study. Eur J Orthod 2002;24:263-76.
16. Cho HJ. A three-dimensional cephalometric analysis. J Clin
Orthod 2009;43:235-52.
17. Lagravère MO, Hansen L, Harzer W, Major PW. Plane orientation
for standardization in 3-dimensional cephalometric analysis with
computerized tomography imaging. Am J Orthod Dentofacial
Orthop 2006;129:601-4.
18. Houston WJ. The analysis of errors in orthodontic measurements.
Am J Orthod 1983;83:382-90.
19. Dahlberg G. Statistical methods for medical and biological stu-
dents. London, United Kingdom: G: Allen & Unwin; 1940.
20. Major MP, Flores-Mir C, Major PW. Assessment of lateral ceph-
alometric diagnosis of adenoid hypertrophy and posterior upper
airway obstruction: a systematic review. Am J Orthod Dentofacial
Orthop 2006;130:700-8.
21. Vig KW. Nasal obstruction and facial growth: the strength of ev-
idence for clinical assumptions. Am J Orthod Dentofacial Orthop
1998;113:603-11.
22. Parks ET. Computed tomography applications for dentistry. Dent
Clin North Am 2000;44:371-94.
23. Mah J, Hatcher D. Three-dimensional craniofacial imaging. Am
J Orthod Dentofacial Orthop 2004;126:308-9.
24. Ziegler CM, Woertche R, Brief J, Hassfeld S. Clinical indications
for digital volume tomography in oral and maxillofacial surgery.
Dentomaxillofac Radiol 2002;31:126-30.
25. Maw AR, Jeans WD, Fernando DCJ. Inter-observer variability in
the clinical and radiological assessment of adenoid size, and the
correlation with adenoid volume. Clin Otolaryngol Allied Sci
1981;6:317-22.
26. Holmberg H, Linder-Aronson S. Cephalometric radiographs as
a means of evaluating the capacity of the nasal and nasopharyn-
geal airway. Am J Orthod 1979;76:479-90.
27. Jeans WD, Fernando DC, Maw AR. How should adenoidal en-
largement be measured? A radiological study based on interob-
server agreement. Clin Radiol 1981;32:337-40.
28. Aboudara CA, Hatcher D, Nielsen IL, Miller A. A three-dimen-
sional evaluation of the upper airway in adolescents. Orthod Cra-
niofac Res 2003;6:173-5.
29. Laine-Alava MT, Minkkinen UK. Should a history of nasal symp-
toms be considered when estimating nasal patency? Angle Orthod
1999;69:126-32.
30. Scammon RE, Harris JA, Jackson CM. The measurement of man.
Minneapolis: University of Minnesota Press; 1930.
31. Subtelny JD, Baker HK. The significance of adenoid tissue in
velopharyngeal function. Plast Reconstr Surg 1956;17:235-50.
Kim et al 306.e11
32. Brown AA, Scarfe WC, Scheetz JP, Silveira AM, Farman AG.
Linear accuracy of cone beam CT derived 3D images. Angle
Orthod 2009;79:150-7.
33. Hassan B, van der Stelt P, Sanderink G. Accuracy of three-dimen-
sional measurements obtained from cone beam computed tomog-
raphy surface-rendered images for cephalometric analysis:
influence of patient scanning position. Eur J Orthod 2009;31:
129-34.
34. Kumar V, Ludlow J, Soares Cevidanes LH, Mol A. In vivo com-
parison of conventional and cone beam CT synthesized cephalo-
grams. Angle Orthod 2008;78:873-9.
35. Moshiri M, Scarfe WC, Hilgers ML, Scheetz JP, Silveira AM,
Farman AG. Accuracy of linear measurements from imaging plate
and lateral cephalometric images derived from cone-beam com-
puted tomography. Am J Orthod Dentofacial Orthop 2007;132:
550-60.
36. Joo MJ. Analysis of the dento-facial complex in Koreans. Korean
J Orthod 1970;1:21-7.
37. Hussels W, Nanda RS. Analysis of factors affecting angle ANB.
Am J Orthod 1984;85:411-23.
38. Ferrario VF, Sforza C, Miani A Jr, Tartaglia GM. The use of linear
and angular measurements of maxillo-mandibular anteroposterior
discrepancies. Clin Orthod Res 1999;2:34-41.
39. Del Santo M Jr. Influence of occlusal plane inclination on ANB
and Wits assessments of anteroposterior jaw relationships. Am
J Orthod Dentofacial Orthop 2006;129:641-8.
40. Ishikawa H, Nakamura S, Iwasaki H, Kitazawa S. Seven parame-
ters describing anteroposterior jaw relationships: postpubertal
prediction accuracy and interchangeability. Am J Orthod Dentofa-
cial Orthop 2000;117:714-20.
41. Ceylan I, Oktay H. A study on the pharyngeal size in different
skeletal patterns. Am J Orthod Dentofacial Orthop 1995;108:
69-75.
42. de Freitas MR, Alcazar NM, Janson G, de Freitas KM,
Henriques JF. Upper and lower pharyngeal airways in subjects
with Class I and Class II malocclusions and different growth pat-
terns. Am J Orthod Dentofacial Orthop 2006;130:742-5.
43. Akcam MO, Toygar TU, Wada T. Longitudinal investigation of
soft palate and nasopharyngeal airway relations in different rota-
tion types. Angle Orthod 2002;72:521-6.
44. Dunn GF, Green LJ, Cunat JJ. Relationships between variation
of mandibular morphology and variation of nasopharyngeal
airway size in monozygotic twins. Angle Orthod 1973;43:
129-35.
45. Behlfelt K, Linder-Aronson S, McWilliam J, Neander P, Laage-
Hellman J. Cranio-facial morphology in children with and without
enlarged tonsils. Eur J Orthod 1990;12:233-43.
46. Hwang YI, Lee KH, Lee KJ, Kim SC, Cho HJ, Cheon SH, et al.
Effect of airway and tongue in facial morphology of prepubertal
Class I, II children. Korean J Orthod 2008;38:74-82.
47. Abu Allhaija ES, Al-Khateeb SN. Uvulo-glosso-pharyngeal
dimensions in different anteroposterior skeletal patterns. Angle
Orthod 2005;75:1012-8.
48. Ozbek MM, Memikoglu TU, Gogen H, Lowe AA, Baspinar E.
Oropharyngeal airway dimensions and functional-orthopedic
treatment in skeletal Class II cases. Angle Orthod 1998;68:
327-36.