Three-Dimensional Cephalometric Study of
Upper Airway Space in Skeletal Class II and
III Healthy Patients
Patrı́cia Valéria Milanezi Alves, DDS, MS,*1 Linping Zhao, PhD,24 Mary O’Gara, MA, CCC-SLP,kL
Pravin K. Patel, MD,24L** Ana M. Bolognese, DDS, MS, PhD*
Rio de Janeiro, Brazil and Chicago, Illinois, USA
Because the pharynx and the dentofacial structures
have close relationship, a mutual interaction can be
expected to occur between them. The literature
presents skeletal malocclusion as etiology for air-
way morphology changes and/or vice versa. The
present three-dimensional cephalometric study
from computed tomography scans was carried out
to investigate upper airway space in normal nasal
breathing patients presenting skeletal pattern of
classes II and III. In addition, the statistical analysis
was done according to gender criterion. The results
revealed that the majority of the airway measure-
ments have not been affected by type of malocclu-
sion. The three-dimensional technology used in this
study also allowed the volume and surface area
calculations, and no statistical significance was
found. The retroglossal width and posterior nasal
cavity height mean were larger in males than
females in the class II group, but volume and
cross-section area were not statistically significant.
However, in class III group, although the differ-
ences in linear and angular measures means were
not significant, the retropalatal volume and retro-
glossal volume and cross-section area were larger in
males. The authors highlight that the evaluation of
upper airway space should be an integral part of
From the *Federal University of Rio de Janeiro, Rio de Janeiro,
Brazil; 1The Craniofacial Center, University of Illinois at Chicago;
2Plastic and Craniomaxillofacial Surgery, Shriners Hospitals for
Children; 4The Craniofacial Center at University of Illinois at
Chicago; kShriners Hospitals for Children; LNorthwestern Univer-
sity Feinberg School of Medicine, Chicago, Illinois; **Department of
Bioengineering, Marquette University, Milwaukee, Wisconsin.
Support: Brazilian government agency, CAPES Foundation
(Foundation for the Coordination of Higher Education and
Graduate Training), process number BEX 3638-05/7 (Dr Patricia
Alves), and Shriners Hospitals for Children (grant number 8510).
Address correspondence and reprint requests to Patrı́cia Valéria
Milanezi Alves, DDS, MS, 2018 West Adams, Chicago, IL 60612;
E-mail: patricia.alves.p@gmail.com or pvmalves@ig.com.br
Copyright @ 2008 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
diagnosis and treatment planning to achieve func-
tional balance and stability of the results.
Key Words: Upper airway space, malocclusion, three-
dimensional study, computed tomography scans
A
mong the predisposing factors for obstruc-
tion of the pharyngeal airways, there
are hypertrophied adenoids and tonsils,
chronic and allergic rhinitis, environmental
irritants, infections, congenital nasal deformities, nasal
traumas, polyps, and tumors that can result of
narrower airway passages.1 Malocclusion is also
presented in the literature as a natural anatomic
predisposing factor for airway morphology changes
and respiratory problems.2,3
The influences of airway obstruction on the
development of the stomatognathic system have
also been studied.4Y9 The functional matrix theory
proposed by Van der Klaauw and elaborated on by
Moss10 further supports environmental effects on
craniofacial development by suggesting that the
skeletal system responds to the influences of the
adjoining soft tissues.11 In accordance, Ricketts12 pos-
tulated that the oral and nasal structures are inter-
dependent, and normal nasal function is conductive
to normal growth of the maxilla and occlusion.
Developmental pattern of the face and airway
obstruction influence is presented in the literature as
controversial. Martin et al13 assess nasopharyngeal
soft-tissue patterns in patients with ideal occlusion.
They found differences on lower pharynx dimension
in the sample and suggested new lines of investiga-
tion into the relationship between skeletal and dental
anomalies and airway obstruction and possible spe-
cific respiratory patterns for each type of malocclu-
sion. The authors highlight an important limitation
of airway studies that is the use of two-dimensional
(2-D) technique. This does not represent exactly the
nasopharyngeal space and the difficulty in identify-
ing the exact soft-tissue contours on traditional
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Table 1. Sample Size and Mean T SD for Sex, Age, finding in patients with obstructive sleep apnea
and ANB (Anteroposterior Relation Between Maxilla syndrome, none of the subjects in their study had
and Mandible) this diagnosis.
Because of the close relationship between the
Class II Class III
pharynx and the dentofacial structures, a mutual
(n = 30) Mean T SD (n = 30) Mean T SD interaction can be expected to occur between
them.7,18Y21 Thus, it might be considered to be useful
Female Male Female Male
that the assessment of the pharyngeal structures be
Variable (n = 15) (n = 15) (n = 15) (n = 15)
included with the orthodontic/orthognathic surgery
Age 18.0 T 1.8 17.3 T 2.0 17.5 T 2.0 18.2 T 1.2 diagnosis and treatment planning.8
ANB 6.0 T 2.0 5.5 T 2.5 j3.2 T 2.1 j3.5 T 1.2
Despite extensive number of researches about
airway anatomic factors, craniofacial morphology,
and sleep-disordered breathing, there are no articles
cephalograms. Sharing the same purpose and results, in the literature about three-dimensional (3-D) cepha-
Samman et al14 evaluate patients with normal lometric comparison of airway space in normal nasal
skeletal pattern without the ideal occlusion criterion. breathing patients presenting skeletal pattern of class
Several 2-D studies aimed to evaluate the cor- II and class III. Therefore, this study was carried out to
relations of malocclusions and airway dimensions. investigate upper airway space in patients presenting
Freitas et al15 investigated the association of class I or the above-referred conditions.
class II malocclusions and pharyngeal airways. One
of the conclusions was that malocclusion type does
MATERIALS AND METHODS
not influence upper and lower pharyngeal airway
width. However, Kirjavainen and Kirjavainen16 stated
that class II malocclusion is associated with a nar-
rower upper airway structure even without retro-
T he study population comprised 60 adult subjects
presenting skeletal anteroposterior malocclusion,
no vertical discrepancies, no genetic syndromes or
gnathia. Trenouth and Timms17 concluded that congenital deformities, any history of sleep disorder,
oropharyngeal airway was positively correlated snoring, upper airway disease, adenoidectomy, or
with length of the mandible. They affirmed that pathology in the pharynx, and seeking orthodontic
although short mandibular length is a characteristic and orthognathic surgery treatment. All of them

Fig 1 Three-dimensional model of skeletal class II (AVlateral view right, BVquarter view right, and CVfrontal view) and
class III (DVlateral view right, EVquarter view right, and FVfrontal view).

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 UPPER AIRWAY SPACE IN SKELETAL CLASS II AND III PATIENTS / Alves et al

provided consent for research publications. The
sample was divided into 2 groups based on skeletal
deformities and molar relation of class II or class III
(Table 1; Fig 1). Despite the authors wish, a third
group representing skeletal class I malocclusion, due
to ethic reasons, it could not be possible because the
examination would expose the subjects to radiation
without treatment reasons. In addition, each group
was divided into 2 subgroups according to sex.
Three-Dimensional Computed Tomography
Archived three-dimensional computed tomography
(3-D CT) scans were used in this study with a local
institutional review board approval. Spiral CT-based
3-D used standard scanning protocols and has the
advantage in which details of hard- and soft-tissue
anatomy not otherwise discernible can be detected
and all measurements are real size (1:1), which al-
lowed cross-sectional area of the airway at any po-
sition along its length, comparison of 3-D distances,
accurate volume measurement, linear projective, and
orthogonal airway assessment.
To obtain a standardized position of the oropha-
ryngeal structures, the examinations were taken at the
end of expiration, without swallowing, natural head
posture, and in centric occlusion. According to
Pracharktam et al,22 centric occlusion minimizes

Table 2. Definitions of Anatomic Landmarks Used in This Study

Landmarks Definition

Hard tissues
S The center of the hypophyseal fossa
N The midpoint of the frontonasal suture
A The midline point of the maximum concavity of the maxillary alveolar process
B The midline point of the maximum concavity of the mandibular alveolar process
ANS The most anterior midpoint of the anterior nasal spine of the maxilla
PNS The most posterior midpoint of the posterior nasal spine of the palatine bone
EnmL Distocervico point of the left first molar
EmnR Distocervico point of the right first molar
CoL The most posterosuperior point of the left mandibular condyle in the sagittal plane
CoR The most posterosuperior point of the right mandibular condyle in the sagittal plane
GoL The most posteroinferior point of the left mandibular angle, where the body and ramus join in the region of the attachment of the
masseter muscle
GoR The most posteroinferior point of the right mandibular angle, where the body and ramus join in the region of the attachment of the
masseter muscle
D6L Distocervico point of the left second molar
D6R Distocervico point of the right second molar
Pog The most anterior point on the chin
SPAwRP2 The most anterior point on the spine in the same horizontal plane of the AwRP2 point
SPAwRP3 The most anterior point on the spine in the same horizontal plane of the AwRP3 point
SPAwRG1 The most anterior point on the spine in the same horizontal plane of the AwRG1 point
C3 The most anteroinferior limit of the third cervical vertebra
Upper airway
AwRP1 The point on the retropalatal anterior pharyngeal wall, just behind the PNS point
AwRP2 The point on the retropalatal posterior pharyngeal wall, in the same horizontal plane of the AwRP1 point. It will build the upper plane of the
retropalatal region (RP), which is determined from the level of hard palate to the caudal margin of the soft palate.
AwRP3 The point on the retropalatal posterior pharyngeal wall, in the same horizontal plane of the SoftPal point. It will build the plane that divides
the RP and retroglossal region (RG).
AwRG1 The point on the retroglossal posterior pharyngeal wall, in the same horizontal plane of the Epg point. It will build the lower plane of the
RG, which is determined from the caudal margin of the soft palate to the base of the epiglottis.
AwRG2 The point on the retroglossal anterior pharyngeal wall, just behind the hyoid bone
AwRG3 The point on the retroglossal posterior pharyngeal wall, in the same horizontal plane of the AwRG2 point
SoftPal The midpoint of the caudal margin of the soft palate
SoftPalTL Left pharyngeal wall on the same plane of the SoftPal point
SoftPalTR Right pharyngeal wall on the same plane of the SoftPal point
Epg The midpoint of the base of the epiglottis
EpgTL Left pharyngeal wall on the same plane of Epg point
EpgTR Right pharyngeal wall on the same plane of Epg point
AwNL The most lateral point of the nasal cavity left side
AwNR The most lateral point of the nasal cavity right side
RtN The most superior point of the nasal cavity in the same vertical plane of the ANS point
RtNP The most superior point of the nasal cavity in the same vertical plane of the PNS point
AwAg1 Angle between AwRP1, AwRP2, and AwRP3 points
AwAg2 Angle between AwRP1, AwRP2, and AwRG1 points

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THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 6 November 2008

variability in mandibular and soft-tissue measure- Determination of Landmarks and

ments often associated with rest position.
Producing accurate 3-D anatomic virtual models
is important for the analysis. This previous procedure
is necessary to segment the structures, also to remove
artifacts that need to be cleaned. From a set of axial
cross-sectional slices, specific software then builds 3-
D virtual models that allow virtual navigation. The
software used in this study to build the 3-D virtual
models and to perform the 3-D analysis was Materi-
alise Mimics ver 10.11 (Materialise, Inc, Belgium) and
was operated by the same investigator.
The next step was the segmentation, which is
the process of outlining the shape of anatomic struc-
tures visible in the cross-sections of a volumetric data
set. After this procedure, a 3-D graphic rendering of
the volumetric object allows navigation between
voxels in the volumetric image and the 3-D graphics
with zooming, rotating, and planning. (Voxels is a
volume element representing a value on a regular grid
in 3-D space. This is analogous to a pixel, which rep-
resents 2-D image data.)
Cephalometric Analysis
The landmark system has been developed in this
study. Landmarks, cross-section planes, and cephalo-
metric measures used in this present study are
presented in Tables 2 and 3 and Figures 2 and 3.
Reliability Study
Investigation of the reliability of the measurements
was performed. Measurement error was established
by repetition of 6 randomly selected cases at 3
different times.23,24 The Pearson correlation mean
observed was 0.998, with a statistical significance of
P G 0.05. This result suggests reliability of the
measurements.
Statistical Analysis
Descriptive statistics including means and standard
deviation for each group was performed by analysis
using SPSS 12.0.1 for Windows (SPSS Inc, Chicago,

Table 3. Three-Dimensional Cephalometric Measurements Used in This Study

Variables Interpretation

Hard tissues
Maxilla
ANB, deg Angle between maxilla and mandible
SNA, deg Angle between maxilla and cranial base
ANS-PNS, mm Maxillary length
EnmL-EmnR, mm Maxillary width
Mandible
SNB, deg Angle between mandible and cranial base
CoL-GoL, mm Left mandibular ramus height
CoR-GoR, mm Right mandibular ramus height
D6L-D6R, mm Mandibular width
GoL-Pog, mm Left mandibular body length
GoR-Pog, mm Right mandibular body length
Upper airway
AwRP1-AwRP2, mm Upper retropalatal region length
SoftPal-AwRP3, mm Retropalatal and retroglossal intersection region length
SoftPalTR-SoftPalTL, mm Retropalatal region width
Epg-AwRG1, mm Lower RG length
EpgTR-EpgTL, mm Retroglossal region width
AwRG2-AwRG3, mm Laryngopharyngeal region length
AwNR-AwNL, mm Nasal cavity width
AwAg1, deg Retropalatal region angulation, sagittal view
AwAg2, deg Retroglossal region angulation, sagittal view
AwAg1-AwAg2, deg Difference between retropalatal and retrogossal region angulation
Hard tissues/airway distance
RtN-ANS, mm Anterior nasal cavity height
RtNP-PNS, mm Posterior nasal cavity height
PNS-AwRP1, mm Distance between maxilla and retropalatal anterior pharyngeal wall
AwRP2-SPAwRP2, mm Distance between retropalatal posterior pharyngeal wall and spine, in the upper retropalatal region
AwRP3-SPAwRP3, mm Distance between retropalatal posterior pharyngeal wall and spine, in the lower retropalatal region
AwRG1-SPAwRG1, mm Distance between retroglossal posterior pharyngeal wall and spine, in the retropalatal and retroglossal intersection region
AwRG3-C3, mm Distance between retroglossal posterior pharyngeal wall and spine, in the laryngopharyngeal region.

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 UPPER AIRWAY SPACE IN SKELETAL CLASS II AND III PATIENTS / Alves et al

Fig 2 Software window showing the combination of 2-D cephalograms and 3-D virtual model used in this study.

IL). Differences between skeletal class II and class III
malocclusion, as well as between males and females,
were tested using paired t-test considering a signifi-
cance of P G 0.05. Because the distribution of these
variables is unknown, Mann-Whitney, Wilcoxon, and
Kolmogorov-Smirnov statistical tests have also been
conducted to compare the variable means in 2
groups. The P G 0.05 level of significance was chosen
for all tests.
RESULTS
and Figure 4. As can be seen from the tables, the
consistency from all of statistical tests indicated that
the maxillary mean values were not statistically
significant. Despite means representing mandibular
dimensions that show difference statistically signifi-
cant between skeletal class II and class III malocclu-
sions, the airway measures did not, except transversal
measure of the nasopharynx.
The linear distance between the pharyngeal
posterior wall and spine was performed, as well the
nasal cavity height. The retroglossal area and spine
distance were the only significant mean found,

P retreatment 3-D measures for hard tissue and

upper airway space are shown in Tables 4 and 5
showing larger values in class III group. During the
study development, the investigator observed a

Fig 3 Three-dimensional landmark system (defined in Tables 2 and 3) and cross-section planes used for the cephalometric
measures (AVlateral view right, BVquarter view right, and CVfrontal view).

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THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 6 November 2008

Table 4. Means T SD for Angular and Linear Measurements of Skeletal Classes II and III
Class II Class III Class II/III Difference

Mann-Whitney/ 2-Sample
Wilcoxon Asymp. Kolmogorov-Smirnov
(n = 30) (n = 30) Pared t-Test Sig. (2-tailed) Test

Variable* Mean T SD Mean T SD Mean T SD P P P

Hard tissues
Maxilla
ANB, deg 6.1 T 2.0 j3.3 T 1.8 6.3 T 2.3 0.0004 0.0004 0.0004
SNA, deg 80.3 T 4.2 80.0 T 4.7 0.5 T 6.8 0.659 0.842 0.952
ANS-PNS, mm 52.0 T 4.1 50.8 T 3.1 1.2 T 5.2 0.186 0.280 0.134
EnmL-EmnR, mm 32.4 T 3.2 32.5 T 3.5 j0.1 T 5.5 0.944 0.871 0.952
Mandible
SNB, deg 75.1 T 5.1 82.3 T 5.0 j7.2 T 7.0 0.0004 0.0004 0.0004
CoL-GoL, mm 55.8 T 7.0 61.2 T 4.4 j5.3 T 7.4 0.0004 0.0022 0.0072
CoR-GoR, mm 57.0 T 7.4 61.5 T 4.2 j4.5 T 7.9 0.0042 0.0131 0.0161
D6L-D6R, mm 53.3 T 4.0 57.0 T 4.5 j3.7 T 6.3 0.0032 0.0042 0.0351
GoL-Pog, mm 83.1 T 6.5 90.0 T 5.8 j6.2 T 10.0 0.0022 0.0004 0.0032
GoR-Pog, mm 83.0 T 5.8 90.0 T 6.1 j6.3 T 9.3 0.0012 0.0004 0.0072
Upper airway
AwRP1-AwRP2, mm 18.3 T 5.0 17.0 T 4.2 1.2 T 7.2 0.353 0.412 0.388
SoftPal-AwRP3, mm 33.1 T 6.5 31.5 T 7.2 1.5 T 9.4 0.389 0.535 0.799
SoftPalTR-SoftPalTL, mm 18.3 T 6.4 17.7 T 4.8 0.6 T 8.7 0.707 0.824 0.586
Epg-AwRG1, mm 14.0 T 3.7 14.0 T 5.5 0.0 T 7.4 0.981 0.712 0.799
EpgTR-EpgTL, mm 28.5 T 4.1 26.7 T 6.1 1.7 T 8.7 0.278 0.132 0.135
AwRG2-AwRG3, mm 15.3 T 2.8 14.5 T 2.4 0.8 T 3.7 0.250 0.391 0.952
AwNR-AwNL, mm 28.0 T 2.5 30.0 T 3.5 j1.9 T 4.1 0.0151 0.0331 0.071
AwAg1, deg 101.5 T 10.0 103.2 T 11.1 j1.7 T 14.4 0.513 0.690 0.952
AwAg2, deg 99.0 T 9.6 100.0 T 10.1 j1.0 T 12.8 0.671 0.894 0.998
AwAg1-AwAg2, deg 2.5 T 5.4 3.3 T 4.2 j0.7 T 6.8 0.558 0.767 0.855
Hard tissues/airway distance
RtN-ANS, mm 38.0 T 4.1 37.8 T 3.5 0.1 T 4.5 0.828 0.842 0.586
RtNP-PNS, mm 25.6 T 2.8 26.1 T 4.0 j0.5 T 5.0 0.561 0.906 0.952
PNS-AwRP1, mm 5.1 T 2.2 4.7 T 2.0 0.4 T 2.9 0.461 0.668 0.952
AwRP2-SPAwRP2, mm 11.3 T 5.2 10.4 T 5.3 0.8 T 7.9 0.547 0.399 0.388
AwRP3-SPAwRP3, mm 6.0 T 3.0 6.5 T 3.0 j0.5 T 3.5 0.400 0.311 0.586
AwRG1-SPAwRG1, mm 3.7 T 0.9 5.1 T 2.4 j1.3 T 2.9 0.0201 0.0531 0.134
AwRG3-C3, mm 8.8 T 3.7 10.1 T 3.8 j1.3 T 5.3 0.197 0.162 0.586

P values and significance level of the difference between them.

*Definition indicated in Table 3.
1P G 0.05.
2P G 0.01.
4
P G 0.001.

dimensional variability of the cervical vertebrae, what
could explain the above results.
The 3-D technology used in this study also
allowed the volume and cross-section area calcula-
tions. The results of the comparisons between the 2
groups are presented in Table 5. No statistical
significance was found.
In addition, each group was divided into 2
subgroups according to sex, and the statistical
analysis was performed (Tables 6 and 7). According
to airway variables results, retroglossal width in class
II and nasal cavity posterior region height in both
groups were statistically significant between females
and males. In general, the mean values for males were
larger than for females.
As can be seen in Table 7, more statistical
significance was found between class III females
and males concerning volume and area than in class
II. As a consequence of retroglossal width differences,
the retroglossal cross-section area mean in retro-
gnathic cases was found larger in male than in female
subgroup. On the other hand, retropalatal volume,
retroglossal volume and area, and, in consequence,
total volume and area means were larger in male
subgroup in prognathic cases.
DISCUSSION
I n this 3-D study, the SNA (angle between maxilla
and cranial base), SNB (angle between mandible

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 UPPER AIRWAY SPACE IN SKELETAL CLASS II AND III PATIENTS / Alves et al

Table 5. Means T SD for Volume and Area Measurements of Skeletal Classes II and III
Class II Class III Class II/III Difference

Mann-Whitney/Wilcoxon 2-Sample
Asymp. Kolmogorov-Smirnov
(n = 30) (n = 30) Pared t-Test Sig. (2-tailed) Test

Variable Mean T SD Mean T SD Mean T SD P P P

RP, mm3 5453.7 T 1744.0 5809.5 T 2302.0 j355.7 T 2942.5 0.513 0.657 0.799
RP, mm2 2440.6 T 524.0 2348.0 T 560.1 92.5 T 815.1 0.539 0.584 0.952
RG, mm3 6140.0 T 2498.8 6423.7 T 2709.7 j283.7 T 3718.4 0.679 0.712 0.799
RG, mm2 2639.0 T 812.5 2585.0 T 919.0 54.0 T 1341.2 0.827 0.605 0.799
NC, mm3 25,328.2 T 5222.0 23,343.5 T 6591.4 1984.7 T 9631.4 0.268 0.095 0.071
NC, mm2 17,470.6 T 2315.7 16,706.4 T 2792.4 764.2 T 4354.7 0.344 0.160 0.388
CP1 X, mm2 838.8 T 247.6 773.8 T 256.5 65.0 T 389.4 0.368 0.535 0.799
CP2 X, mm2 381.1 T 183.6 393.3 T 186.5 j12.2 T 268.6 0.804 0.894 0.799
CP3 X, mm2 530.4 T 208.2 460.9 T 209.6 69.4 T 336.4 0.267 0.209 0.236
Total 1, mm3 11,593.7 T 3711.8 12,233.2 T 4569.5 j639.5 T 5969.4 0.562 0.522 0.522
Total, mm3 36,922.0 T 7890.6 35,576.7 T 7992.4 1345.2 T 12,302.5 0.554 0.550 0.532
Total 1, mm2 4317.3 T 966.8 4146.1 T 1114.3 171.1 T 1642.2 0.572 0.540 0.540
Total, mm2 20,110.3 T 2722.5 19,305.0 T 3000.4 805.4 T 4833.7 0.369 0.323 0.321

P values and significance level of the difference between them.

RP indicates retropalatal region; RG, retroglossal region; NC, nasal cavity; CP1 X, the first cross-section plane, correspondent to upper retropalatal plane; CP2 X,
the second cross-section plane, correspondent to retropalatal and retroglossal division plane; CP3 X, the third cross-section plane, correspondent to lower
retroglossal plane; Total 1, RP plus RG regions; Total, RP plus RG plus NC regions; mm3, volume measures; mm2, area.

and cranial base), and ANB (angle between maxilla
and mandible) angles from Steiner 2-D cephalometric
analysis were adopted to classify the subjects accord-
ing to their anteroposterior dentofacial discrepancy.
These angles were selected because they are the most
commonly used, facilitating the scientific communi-
cation. Ishikawa et al25 reported that ANB angle is one
of the most reliable and accurate measurements of
the anteroposterior jaw relationship. The comparison
of class II and class III means of the present evalua-
tion shows that the SNB angle was responsible for
the statistical difference of the ANB angle. The sam-
ple was carefully selected according to malocclusion
severity, and then both groups presented low range
with maximum and minimum values of ANB. The
maxillary anteroposterior and transversal measures
suggest that all subjects did not present statistically
significant differences of the middle face. However,
skeletal class II malocclusion group had smaller
means of values relative to the mandible than class
III malocclusion group, and the SNB can suggest
either micrognathia or retrognathia.
Relative growth and size of the soft tissue
surrounding the skeletal structures mainly determine
pharyngeal space size. Tourne2 has stated that
nasopharyngeal depth is formed at the early ages
of life, and then it usually remains the same. The
width and height increments of the nasopharynx

Fig 4 Three-dimensional virtual model of upper airway space. AYC, Lateral view right, quarter right view, and frontal view
of skeletal class II. DYF, The correspondent views of skeletal class III.

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Table 6. Means T SD, P Values, and Significance Level of Female and Male Subgroups Measures
Class II Class III

Female (n = 15) Male (n = 15) Female/male Female (n = 15) Male (n = 15) Female/male

Variable* Mean T SD Mean T SD P Mean T SD Mean T SD P

Hard tissues
Maxilla
ANB, deg 6.0 T 2.0 5.5 T 2.5 0.130 j3.2 T 2.1 j3.5 T 1.2 0.413
SNA, deg 80.0 T 3.1 81.0 T 4.7 0.302 80.0 T 4.3 78.6 T 5.3 0.828
ANS-PNS, mm 51.5 T 4.7 52.8 T 3.8 0.549 50.0 T 2.6 52.7 T 3.1 0.0062
EnmL-EmnR, mm 32.0 T 3.0 33.4 T 3.3 0.234 33.2 T 3.6 32.2 T 3.4
Mandible
SNB, deg 73.4 T 4.8 76.4 T 5.0 0.120 81.5 T 4.3 81.0 T 6.0 0.749
CoL-GoL, mm 53.0 T 8.0 60.0 T 4.3 0.0221 60.0 T 3.1 62.5 T 6.0 0.197
CoR-GoR, mm 55.2 T 9.6 60.0 T 4.2 0.083 60.0 T 2.4 63.7 T 5.5 0.0431
D6L-D6R, mm 53.0 T 4.2 54.0 T 4.2 0.424 56.6 T 4.0 58.7 T 4.7 0.276
GoL-Pog, mm 80.0 T 6.2 86.3 T 5.8 0.0092 86.7 T 4.3 93.5 T 6.3 0.0072
GoR-Pog, mm 81.0 T 5.6 85.6 T 5.4 0.0201 86.8 T 4.3 94.5 T 6.0 0.0032
Upper airway
AwRP1-AwRP2, mm 17.0 T 4.8 19.1 T 5.2 0.221 15.7 T 4.0 17.1 T 3.6 0.300
SoftPal-AwRP3, mm 32.3 T 5.5 35.2 T 6.7 0.113 30.0 T 6.1 33.2 T 9.7 0.299
SoftPalTR-SoftPalTL, mm 19.5 T 6.2 17.2 T 6.4 0.363 16.4 T 5.6 18.3 T 4.0 0.352
Epg-AwRG1, mm 13.4 T 2.5 15.4 T 4.0 0.082 11.7 T 3.8 15.0 T 7.7 0.301
EpgTR-EpgTL, mm 27.5 T 3.4 30.5 T 3.5 0.0171 24.1 T 4.4 28.2 T 8.3 0.168
AwRG2-AwRG3, mm 15.2 T 2.2 16.0 T 3.0 0.397 14.1 T 2.0 14.5 T 2.8 0.738
AwNR-AwNL, mm 28.0 T 3.1 28.2 T 1.9 0.689 28.8 T 2.3 30.4 T 4.0 0.092
AwAg1, deg 102.8 T 8.3 101.0 T 12.0 0.602 106.4 T 11.2 101.4 T 12.1 0.410
AwAg2, deg 99.0 T 9.5 99.4 T 10.3 0.887 104.2 T 10.3 97.0 T 10.0 0.189
AwAg1-AwAg2, deg 3.8 T 5.3 2.6 T 5.3 0.867 2.2 T 4.7 4.4 T 5.1 0.785
Hard tissues/airway distance
RtN-ANS, mm 37.2 T 4.5 40.0 T 3.3 0.104 38.0 T 3.2 40.0 T 3.1 0.176
RtNP-PNS, mm 24.5 T 3.0 27.1 T 2.0 0.0131 24.5 T 1.5 30.0 T 4.4 0.0111
PNS-AwRP1, mm 5.2 T 2.2 5.2 T 2.5 0.967 4.8 T 1.4 5.3 T 2.8 0.591
AwRP2-SPAwRP2, mm 12.4 T 5.1 11.0 T 5.5 0.497 10.1 T 6.0 11.1 T 5.6 0.572
AwRP3-SPAwRP3, mm 5.4 T 1.6 6.6 T 4.0 0.278 6.7 T 2.8 6.6 T 3.7 0.962
AwRG1-SPAwRG1, mm 4.0 T 1.0 3.5 T 1.0 0.198 4.4 T 1.8 6.0 T 3.3 0.243
AwRG3-C3, mm 9.3 T 3.4 8.6 T 4.3 0.596 14.1 T 2.0 14.5 T 2.8 0.738

*Definition indicated in Table 3.

1P G 0.05.
2P G 0.01.

continue until adulthood, as well as the total area.
However, other studies suggested that from 20 to
50 years of age, the nasopharyngeal skeleton hardly
changes, increasing the posterior nasopharyngeal
depth and the posterior pharyngeal wall becoming
thinner.13,26 The age average in this present study was
18 years, when the skeletal growth expressed major
increase. To avoid interferences from different ages
on the airway measures, as suggested by the above
authors, the sample was selected with subjects of
approximate ages.
The 3-D cephalometry allows asymmetry assess-
ment and the differentiation of left and right side
values. All bilateral cephalometric points are studied
separately, and this is one of the advantages of 2-D
cephalometry that projects both to a sagittal plane. In
a future project, the authors purpose to assess the
hyoid bone positioning and morphology of the
mandible in this sample in terms of asymmetry and
to correlate statistical significance.
The subjects that establish the present sample
consist of normal breathing, and the results showed
that most airway measurements have not been
affected by type of malocclusion. Supported by
several 2-D studies, those have found that the soft
tissue of the pharynx is a relatively independent
variable in its relation to other dimensions of the facial
complex. Ceylan and Oktay8 developed a study on
the pharynx in healthy patients with different skeletal
patterns and claimed that pharyngeal structures were
not affected by the changes of the ANB angle. Their
findings are similar to those of Freitas et al,15 Solow
et al,19 and Mergen and Jacobs.20
Cephalometric radiographs alone may not give
a completely accurate representation of 3-D airway
size in 2 dimensions. Airway information over the

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Copyright @ 2008 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 UPPER AIRWAY SPACE IN SKELETAL CLASS II AND III PATIENTS / Alves et al

Table 7. Means T SD for Volume and Area Measurements of Female and Male Subgroups
Class II Class III

Female (n = 15) Male (n = 15) Female/Male Female (n = 15) Male (n = 15) Female/Male

Variable* Mean T SD Mean T SD P Mean T SD Mean T SD P

3
RP, mm 5496.0 T 2104.1 5643.7 T 1340.6 0.794 4593.6 T 1475.2 5846.2 T 1825.1 0.051*
RP, mm2 2507.2 T 604.0 2441.5 T 453.0 0.737 2091.3 T 392.6 2368.1 T 494.4 0.139
RG, mm3 5613.4 T 1670.3 7219.2 T 2697.0 0.081 4712.3 T 2166.0 6920.0 T 2332.5 0.054*
RG, mm2 2529.0 T 495.8 2951.4 T 891.7 0.158 2010.5 T 618.5 2913.8 T 1028.8 0.035*
NC, mm3 24,227.2 T 6092.7 26,657.0 T 4386.2 0.189 21,136.7 T 3755.4 26,748.1 T 8255.7 0.066
NC, mm2 17,419.1 T 2730.0 17,708.3 T 1993.3 0.716 16,527.1 T 1764.4 17,783.2 T 3025.0 0.107
CP1 X, mm2 786.8 T 244.5 888.2 T 264.2 0.271 734.6 T 254.0 755.7 T 237.7 0.802
CP2 X, mm2 406.3 T 198.6 373.6 T 169.8 0.682 328.5 T 106.2 354.0 T 1340.0 0.628
CP3 X, mm2 455.6 T 147.2 649.3 T 197.1 0.0071 365.0 T 196.3 454.5 T 220.1 0.372
Total 1, mm3 11,109.4 T 3202.7 12,863.0 T 3695.1 0.192 9306.0 T 2791.3 12,766.2 T 3602.8 0.033*
Total, mm3 35,336.7 T 8209.4 39,520.0 T 7317.3 0.135 30,442.7 T 5305.4 39,514.3 T 7556.4 0.0071
Total 1, mm2 4223.5 T 766.4 4645.7 T 978.6 0.225 3444.6 T 650.8 4573.8 T 1241.5 0.033*
Total, mm2 20,069.1 T 2952.0 20,577.5 T 2464.2 0.559 18,502.5 T 1963.8 20,845.6 T 2912.0 0.011*

*P G 0.05.
1P G 0.01.
***P G 0.001.
P values and significance level of the difference between them in each malocclusion type.
RP indicates retropalatal region; RG, retroglossal region; NC, nasal cavity; CP1 X, the first cross-section plane, correspondent to upper retropalatal plane; CP2
X, the second cross-section plane, correspondent to retropalatal and retroglossal division plane; CP3 X, the third cross-section plane, correspondent to lower
retroglossal plane; Total 1, RP plus RG regions; Total, RP plus RG plus NC regions; mm3, volume measures; mm2, area.

same anatomic area in the nasopharynx was com-
pared between lateral cephalometric headfilms and
cone beam CT scans. Computed tomography airway
volume showed more variability than corresponding
headfilm airway area.27 Magnetic resonance imaging
shows superior quality for tissues contrast and air-
way analysis; however, in the current clinical rea-
lity of several countries, it is still far away. Therefore,
the authors of the present 3-D study performed the
measures using 3-D CT scans, believing that the meth-
odology could be reliable and possible to be repro-
duced in another clinical experiment.
Computed tomography and magnetic resonance
imaging are routinely obtained in the supine posi-
tion. Cone beam CT scan is taken in upright position,
but its indication for airway soft-tissue assessment
is questionable, needing more related researches.
Pracharktam et al22 assessed upper airway passage
in the upright seated and in lying down posture, and
the conclusion was that upright 2-D cephalometric
evaluation was found to provide the same discrimi-
nant information as supine position. The presented
study was based on CT scans taken in supine position,
which is required by the equipment.
Miles et al28 studied the reliability of upper air-
way landmarks identification on 2-D records, and the
results suggested that future airway-related research
should consider the potential inaccuracies when at-
tempting to identify these dynamic 3-D structures on
static 2-D images. However, Ono et al29 reported high
accuracy with less than 3% measurement errors using
a prototype of 3-D helical CT scans. Other studies for
cephalometric measurements have yielded equivalent
accuracy.30,31 To obtain more accuracy in the current
study, when a point was indicated by the investigator
on the cephalogram image generated from the CT
scan, the 3-D point should be positioned on the bone
surface and vice versa. Therefore, the geometrical re-
lationship between cephalograms and CT image
volume is a prerequisite if one is to benefit from the
combination of CT and virtual cephalograms. This
combination of 2-D and 3-D information (Fig 2) is the
key to accurate indication of landmarks in a repea-
table way. The reliability study conducted in the
current study suggested a high repeatability of this
method. However, the investigator needs a specific
training in both anatomy and software applications.
Interinvestigator reliability needs to be studied in the
future.
According to the findings of the performed stu-
dy, some 2-D cephalometric studies are inconsistent
with the results and also with those studies that re-
ported no relationship between pharyngeal structures
and ANB angle.16,17,32 These authors observed that
most measurements used to assess the pharyngeal
structures have been affected by the ANB angle. They
reported that a normal nasal airway is dependent
on sufficient anatomic dimensions of the airway. In
addition, the size of nasopharynx is of particular
importance in determining whether the mode of

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Copyright @ 2008 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
THE JOURNAL OF CRANIOFACIAL SURGERY / VOLUME 19, NUMBER 6
breathing is nasal or oral.21 Lopatiene and Babarskas9
correlated patients who pronounced difficulty in
breathing through the nose with class II, increased
overjet, and posterior cross-bite.
The relevance of airway obstruction changes in
function and its assumed effect on facial growth
continues to be debated. As mentioned, 2-D studies
failed to prove the existence of the relation between
upper airway space problems and the frequency of
malocclusion.15,19,20 Leech33 determined that these
problems do not have any influence on dentofacial
morphology. Gwynne-Evans and Ballard34 noticed
that they induce neither changes in jaw growth nor
malocclusion and anomalies of dental position.
However, Joseph et al3 affirmed that skeletal features
such as retrusion of the maxilla and mandible may
lead to narrower anteroposterior dimensions of the
airway. Despite the present evaluation found the
mandible positioned backward according to Steiner
cephalometric analysis any subject presented with
respiratory or sleep problems. Also, this study did not
compare the airway measures in terms of normal,
enlarged, or reduced size but in terms of differences
between 2 facial architectures. Therefore, it is not
possible to infer about airway size changes or etio-
logic factors.
Interest has also been focused on uvuloglosso-
pharyngeal dimensions because of a potential rela-
tionship between size and structure of upper airway
and sleep-induced breathing disturbances.32 Shelton
et al35 stated that although several researchers
affirmed that malocclusion can produce obstructive
sleep apnea, most subjects with sleep problems have
no recognizable anatomic malformation. This study
hypothesized that the occurrence of sleep problems is
related to the size of the region enclosed by the
mandible. Zucconi et al36 showed a significant dec-
rease in sagittal dimensions of the mandibular bone
in habitual snorer subjects. As mentioned before, the
performed study was established with healthy
subjects, and any correlations between sleep-induced
breathing disturbances and skeletal class II or class
III could be done. However, the authors discussed
the above studies with the purpose of highlighting
the importance of the pharyngeal structure assess-
ment during the orthodontic/orthognathic surgery
diagnosis and treatment planning, as well as the
sleep breathing investigation. They also suggest that
more 3-D investigations of these subjects are
necessary.
The nasopharyngeal volume and cross-section
area were also analyzed in this present study, and
they were found as not affected by the ANB angle,
suggesting that the breathing capacity of these 2
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Copyright @ 2008 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
November 2008
different facial architectures was correlated. Kerr7
studied patients with skeletal class II and stated that
when the nasal functions were normal, the relation-
ship between changes in pharyngeal area and
dentofacial dimensions are weak. On the other
hand, Ceylan and Oktay8 reported that the oropha-
ryngeal airway area became smaller with the
increase of the ANB angle. In this performed
investigation, the nasal cavity width showed statis-
tical significance between the 2 groups, whereas the
anterior and posterior nasal cavity height did not.
The correlation of these findings with volume and
area means, which did not show statistical signifi-
cance, suggested that total nasal capacity is inde-
pendent of ANB patterns. Similarly, retropalatal and
retroglossal volume and area were not correlated
with malocclusion type.
Pharyngeal dimensions were affected by sex. In
the retrognathic group, retroglossal width mean and
posterior nasal cavity height mean were larger in
males than in female subgroup. In prognathic group,
although linear and angular measures means were
not significant, the retropalatal volume and retro-
glossal volume and area were larger in males. These
findings are in disagreement with Ceylan and Oktay,8
Solow et al,19 Linder-Aronson and Woodside21 which
suggest that sex differences in the pharyngeal dimen-
sions are not present.
According to all aspects observed and discussed
in this present study, the authors concluded that the
comparison of upper airway space in normal nasal
breathing patients suggested no statistical difference
between skeletal pattern of classes II and III. Because
it was not possible to identify in the literature similar
methodology, the authors believe that more resear-
ches need to be done exploring 3-D craniofacial
analyses of patients without pharyngeal problems.
REFERENCES
1. Schlenker WL, Jennings BD, Jeiroudi MT, et al. The effects of
chronic absence of active nasal respiration on the growth of the
skull: a pilot study. Am J Orthod Dentofacial Orthop 2000;117:
706Y713
2. Tourne LP. The long face syndrome and impairment of the
nasopharyngeal airway. Angle Orthod 1990;60:167Y176
3. Joseph AA, Elbaum J, Cisneros GJ, et al. A cephalometric
comparative study of the soft tissue airway dimensions in
persons with hyperdivergent and normodivergent facial
patterns. J Oral Maxillofac Surg 1998;56:135Y139
4. Subtelny JD. The significance of adenoid tissue in orthodontia.
Angle Orthod 1954;24:59Y69
5. McNamara JA Jr. Influence of respiratory pattern on craniofa-
cial growth. Angle Orthod 1981;51:269Y300
6. Bresolin D, Shapiro PA, Shapiro G, et al. Mouth breathing in
allergic children: its relationship to dentofacial development.
Am J Orthod 1983;8:334Y340
 UPPER AIRWAY SPACE IN SKELETAL CLASS II AND III PATIENTS / Alves et al
7. Kerr WJS. The nasopharynx, face height, and overbite. Angle
Orthod 1985;55:31Y36
8. Ceylan I, Oktay H. A study on the pharyngeal size in different
skeletal patterns. Am J Orthod Dentofacial Orthop 1995;108:69Y75
9. Lopatiene K, Babarskas A. Malocclusion and upper airway
obstruction. Medicina 2002;38:277Y283
10. Moss ML. The functional matrix: functional cranial compo-
nents. In: Kraus BS, ed. Vistus in orthodontics. Philadelphia, PA:
Lea and Febiger, 1962:85Y90
11. Weider DJ, Baker GL, Salvatoriello FW. Dental malocclusion
and upper airway obstruction, and otolaryngologist’s perspec-
tive. Int J Pediatr Otorhinolaryngol 2003;67:323Y331
12. Ricketts RM. The interdependence of the nasal and oral
capsules. In: McNamara JS Jr, ed. Nasorespiratory function
and craniofacial growth. Monograph No. 9, Craniofacial
growth series, Center for Human Growth and Development,
The University of Michigan. Ann Arbor, MI: University of
Michigan, 1979
13. Martin O, Muelas L, Viñas MJ. Nasopharyngeal cephalometric
study of ideal occlusions. Am J Orthod Dentofacial Orthop 2006;
130:436.e1Y436.e9
14. Samman N, Mohammadi H, Xia J. Cephalometric norms for the
upper airway in a healthy Hong Kong Chinese population.
Hong Kong Med J 2003;9:25Y30
15. Freitas MR, Alcazar NMPV, Janson G, et al. Upper and lower
pharyngeal airways in subjects with Class I and Class II
malocclusions and different growth patterns. Am J Orthod
Dentofacial Orthop 2006;130:742Y745
16. Kirjavainen M, Kirjavainen T. Upper airway dimensions in
Class II malocclusion. Angle Orthod 2007;77:1046Y1053
17. Trenouth MJ, Timms DJ. Relationship of the functional orophar-
ynx to craniofacial morphology. Angle Orthod 1999;69:419Y423
18. Dunn GF, Green LJ, Cunatt JJ. Relationships between variation
of mandibular morphology and variation of nasopharyngeal
airway size in monozygotic twins. Angle Orthod 1973;43:
129Y135
19. Solow B, Siersbaek-Nielsen S, Greve E. Airway adequacy, head
posture, and craniofacial morphology. Am J Orthod 1984;86:
214Y223
20. Mergen DC, Jacobs RM. The size of the nasopharynx associated
with normal occlusion and Class II malocclusions. Angle Orthod
1970;40:342Y346
21. Linder-Aronson S, Woodside DG. The growth in the sagittal
depth of the bony nasopharynx in relation to some other facial
variables. Trans Eur Orthod Soc 1977;69Y83
Copyright @ 2008 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
22. Pracharktam N, Nelson S, Hans MG, et al. Cephalometric
assessment in obstructive sleep apnea. Am J Orthod Dentofacial
Orthop 1996;109:410Y419
23. Fleiss JL. The design and analysis of clinical experiments. New
York: John Wiley & Sons, Columbia University, 1986:432
24. Hack GA, de Mol van Otterloo JJ, Nanda R. Long-term stability
and prediction of soft tissue changes after Lefort I surgery. Am J
Orthod Dentofacial Orthop 1993;104:544Y555
25. Ishikawa H, Nakamura S, Iwasaki H, et al. Seven parameters
describing anteroposterior jaw relationship: postpuberal pre-
diction accuracy and interchangeability. Am J Orthod Dentofacial
Orthop 2000;117:714Y720
26. Johnston CD, Richardson A. Cephalometric changes in adult
pharyngeal morphology. Eur J Orthod 1999;21:357Y362
27. Aboudara CA, Hatcher D, Nielsen IL, et al. A three-dimensional
evaluation of the upper airway in adolescents. Orthod Craniofac
Res 2003;6:173Y175
28. Miles PG, O’Reilly M, Close J. The reliability of upper airway
landmark identification. Aust Orthod J 1995;14:3Y6
29. Ono I, Gunji H, Suda K, et al. Method of preparing an exact-size
model using helical volume scan computed tomography. Plast
Reconstr Surg 1994;93:1363Y1371
30. Lagravère MO, Major PW. Proposed reference point for 3-
dimensional cephalometric analysis with cone-beam computer-
ized tomography. Am J Orthod Dentofacial Orthop 2005;128:
657Y660
31. Lagravère MO, Hansen L, Winfried H, et al. Plane orientation
for standardization in 3-dimensional cephalometric analysis
with computerized tomography imaging. Am J Orthod Dento-
facial Orthop 2006;129:601Y604
32. Allhaija ESA, Al-Khateeb SN. Uvulo-glosso-pharyngeal dimen-
sions in different anteroposterior skeletal patterns. Angle Orthod
2005;76:1012Y1018
33. Leech HL. A clinical analysis of orofacial morphology and
behavior of 500 patients attending an upper respiratory
research clinic. Dent Pract 1958;9:57Y68
34. Gwynne-Evans E, Ballard CF. Discussion of the mouth breather.
Proc R Soc Med 1959;51:279Y285
35. Shelton KE, Gay SB, Hollowell DE, et al. Mandible enclosure of
upper airway and weight in obstructive sleep apnea. Am Rev
Respir Dis 1993;148:195Y200
36. Zucconi M, Ferini-Strambi L, Palazzi S, et al. Craniofacial
cephalometric evaluation in habitual snorers with and without
obstructive sleep apnea. Otolaryngol Head Neck Surg 1993;109:
1007Y1013
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