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CA Aboudara D Hatcher IL Nielsen A Miller

A three-dimensional evaluation of the upper airway in adolescents

Authors' affiliations: C.A. Aboudara, D. Hatcher, I.L. Nielsen, A. Miller, Department of Growth and Development, University of California, Division of Orthodontics, San Francisco, CA, USA Correspondence to: CA Aboudara Univesity of California, San Francisco Department of Growth and Development Division of Orthodontics 707 Parnassus San Francisco CA 94143, USA Tel.: +1 650 328 2860 E-mail: cabouda@itsa.ucsf.edu

Abstract Authors Aboudara CA, Hatcher D, Nielsen IL, Miller A The link between the facial growth and airway function has been a subject of controversy in orthodontics for many years. This study investigates how well lateral cephalometric headlms depict three-dimensional upper airway structures. Subjects are 11 normal adolescent children, ages 716 years old. Airway information over the same anatomic area in the nasopharynx is compared between lateral cephalometric headlms and threedimensional cone beam computed tomography (CT) scans. Intra-subject proportion of airway volume to area shows moderate variability. CT airway volume shows more variability than corresponding headlm airway area. Key words: upper airway; orthodontic; three-dimensional; cone beam computed tomography; NewTom

Introduction
Airway contributes to overall facial development. Research has shown children undergoing adenoidectomy had larger total and anterior face heights, more retrognathic mandibles, and steeper mandibular planes compared with controls. Children who switched back to nose breathing showed some correction towards the controls through decreasing mandibular plane angles, proclination of the incisors, and widening of the upper arch. Girls in the sample showed signicantly more horizontally growing mandibles over this period (14). Studies of articially induced nasal occlusion in monkeys have found different neuromuscular patterns of adaptation with lowered mandibular posture, increased

To cite this article: Orthod Craniofacial Res 6 (Suppl. 1), 2003; 173175 Aboudara CA, Hatcher D, Nielsen IL, Miller A: A three-dimensional evaluation of the upper airway in adolescents Copyright Blackwell Munksgaard 2003 ISSN 1741-2420

Aboudara et al. 3-D adolescent airway comparison

posterior dental eruption, and forward tongue postures that resolved once obstructions were removed (5, 6). Currently during orthodontic diagnosis and treatment planning, information on the airway is charted. Enlarged tonsils and breathing patterns are often noted on clinical examination. Adenoids are subjectively quantied from examination of the two-dimensional lateral cephalometric headlm, but there have been few studies on the three-dimensional airway of adolescents. This pilot study is a retrospective cross-sectional chart review which evaluates the two-dimensional airway from lateral headlms and the three-dimensional airway structure from computed tomography (CT) scans.

Lateral cephalometric X-rays

All lms taken with Instrumentarium Orthopantomograph OP100 (Instrumentarium Imaging, Tuusala, Finland). All structures assumed at midline with magnication of 9.8%. Films scanned at 300 dpi for analysis in 3-D Doctor (Able Software Corp., Lexington, MA, USA).

Materials and methods

Inclusion criteria

Children aged 517 years presenting for orthodontic, oral pathology, or temporomandibular disorders diagnostic imaging. Required lateral cephalometric headlm and conical CT scan at the same time point.
Exclusion criteria

Craniofacial anomalies, previous orthognathic surgery, history of tonsillectomy or adenoidectomy, subjects with postural orthodontic appliances (Table 1).

Fig. 1. Region of interest.

Table 2. Numeric results CT volume Table 1. Pilot patient data Patient 1 2 3 4 5 6 7 8 9 10 11 Age 16 years 1 month 12 years 8 months 15 years 11 months 9 years 10 months 14 years 6 months 12 years 0 month 7 years 7 months 13 years 8 months 12 years 6 months 9 years 9 months 14 years 6 months Sex F M F F F F F F F F M Referral TMJ TMJ TMJ TMJ TMJ TMJ Impacted nos 6 and 10 TMJ TMJ TMJ TMJ Patient 1 2 3 4 5 6 7 8 9 10 11 Mean SD (mm ) 2561.6 1749.3 4180.7 3821.0 4499.8 3782.9 2896.0 3246.4 7839.3 2807.2 4921.2 3845.9 1613.5
3

Ceph area (mm ) 320.4 266.7 407.6 327.5 389.1 370.5 224.8 339.1 472.2 324.6 312.2 341.3 67.5
2

Proportion (volume/area) 8.0 6.6 10.3 11.7 11.6 10.2 12.9 9.6 16.6 8.6 15.8 11.1 3.1

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Aboudara et al. 3-D adolescent airway comparison

CT volume (mm3) 8000 Ceph area (mm2)

mm3

Corresponding CT volume to lateral headlm area calculated from serial 1 mm axial sections. Variable threshold segmentation used. Intra-subject proportions of airway volume to area are compared (Fig. 1).

Results (see Table 2 and Fig. 2)

2000

mm2

0 1000

Fig. 2. Individual subject volume and area of nasopharyngeal airway. Cone beam CT scans

Intra-subject proportion of airway volume to area shows moderate variability. Airway volume shows more variability than airway area. There may be airway information that is not accurately depicted on the lateral headlm. More analysis with a larger sample size is needed.

Scans taken on NewTom-9000 developed by Quantitative Radiology, Verona, Italy. Scan acquired in a 512 512 format. Voxel size is 0.28 mm in x, y and z planes of space. Digital imaging les exported in DICOM (Digital Imaging and Communications in Medicine) format for analysis in 3-D Doctor (Able Software Corp.).
Region of interest

References
1. Linder-Aronson S. Effects of adenoidectomy on dentition and nasopharynx. Trans Eur Orthodontic Society 1972:17786. 2. Linder-Aronson S, Woodside DG, Lundstrom A. Mandibular growth direction following adenoidectomy. Am J Orthod 1986;89:27384. 3. Linder-Aronson S, Woodside DG, Hellsing E, Emerson W. Normalization of incisor position after adenoidectomy. Am J Orthod Dentofacial Orthop 1993;103:41227. 4. Woodside DG, Linder-Aronson S, McWilliam J. Mandibular and maxillary growth after changed mode of breathing. Am J Orthod Dentofacial Orthop 1991;100:118. 5. Miller AJ, Vargervik K, Chierici G. Experimentally induced neuromuscular changes during and after nasal airway obstruction. Am J Orthod 1984;85:38592. 6. Vargervik K, Miller AJ, Chierici G, Harvold E, Tomer BS. Morphologic response to changes in neuromuscular patterns experimentally induced by altered modes of respiration. Am J Orthod 1984;85:11524. 7. 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;24:26376.

Conical CT scans are taken in the supine position. Previous research: signicant differences in airway measurements below the hard palate from lateral headlms taken in an upright and supine position (7). Comparison airway measurements will concentrate in the nasopharynx superior to the hard palate. Boundaries: 1) axial reconstruction plane through posterior nasal spine; 2) plane perpendicular to the former at PNS to height of the pterygomaxillary ssure; 3) posterior pharyngeal wall.

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