progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

Available online at www.sciencedirect.com

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

Original article

Comparision of orofacial airway dimensions in subject with

different breathing pattern
Faruk I. Ucar a , Tancan Uysal b,
a
b

Research Assistant, Department of Orthodontics, Faculty of Dentistry, Erciyes University, Kayseri, Turkey
Professor and Head, Department of Orthodontics, Faculty of Dentistry, Izmir Katip Celebi University, Izmir, Turkey

a r t i c l e

i n f o

a b s t r a c t

Article history:

Objective: To test the null hypothesis that there is no signicant difference in the craniofa-

Received 17 November 2011

cial morphology and orofacial airway dimensions between mouth breathing (MB) and nasal

Accepted 9 February 2012

breathing (NB) subjects.

Keywords:

12.81.5 years; range: 12.015.2 years) and 33 NB subjects (mean 13.91.3 years; age range:

Airway obstruction

12.215.8 years) with Class I occlusion were examined. Totally, 34 measurements (27 cranio-

Materials and methods: Lateral cephalometric radiographs of 34 MB subjects (mean age:

Craniofacial morphology

facial and 7 orofacial airway) were evaluated. Group differences were statistically evaluated

Mouth breathing

by independent samples t-test at p < 0.05 levels.

Orthodontics

Results: Statistical comparisons showed that SNA (p < 0.01), ANB (p < 0.01), A to N perp

Respiration

(p < 0.05), convexity (p < 0.05), IMPA (p < 0.05) and overbite (p < 0.05) measurements were signicantly lower in MB group when compared to NB group. However, SN-MP (p < 0.01) and
PP-GoGn (p < 0.01) from angular measurements and S-N (p < 0.05) and anterior facial height
(p < 0.05) from linear measurements were signicantly higher in MB subjects. Among orofacial airway measurements, only upper posterior airway space was found signicantly
higher(p < 0.001) in MB than NB subjects.
Conclusions: The null hypothesis was rejected. Mouth breathing affects craniofacial morphology and orofacial airway dimensions.
2012 Published by Elsevier Srl. on behalf of Societ Italiana di Ortodonzia SIDO.

1.

Introduction

Nasal obstruction, chronic allergic rhinitis, hypertrophic adenoids decrease the nasal breathing (NB) and compensation of
this situation by mouth breathing (MB) might be essential.1
Respiratory airway function inuences the facial morphology
and craniofacial functions.2 The breathing pattern may inuence the development of the transverse relationship, resulting
in the development of posterior crossbite and also MB can

affect the form of the jaw or cause malocclusions.3 MB may

lead to adenoid face which is characterized by a narrow upper
dental arch, retroclined mandibular incisors, an incompetent
lip seal, a steep mandibular plane angle and increased anterior
facial height46
MB has a multifactorial etiology including physical obstructions, hypertrophic adenoids, tonsils, nasal polyps, nasal
septum deviations, chronic allergic rhinitis,7 sinusitis, hypertrophic chonca and hypertrophic pharyngeal tonsils.4 MB is
clinically characterized by postural open bite, shorter upper

Fakltesi, Ortodonti Anabilim Dal, Cigli, IZMIR.

Corresponding author. Izmir Katip Celebi niversitesi, Dis Hekimligi
E-mail address: tancanuysal@yahoo.com (T. Uysal).
1723-7785/$ see front matter 2012 Published by Elsevier Srl. on behalf of Societ Italiana di Ortodonzia SIDO.
doi:10.1016/j.pio.2012.02.005

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

lip, protrusive upper incisive teeth, decient maxilla,2 narrow

and V-shaped maxillary arch, deep palate vault and posterior
cross bite,3 increased lower face height, retroclined mandibular incisors, incompetent lip seal.46 Chronic MB causes
unfavorable dentofacial development during growth period of
a child resulting in several morphological disorders.6,8
MB demonstrated considerable backward and downward
rotation of the mandible, increased overjet, increase in the
mandible plane angle, a higher palatal plane compared to
NB. Abnormal lip-to-tongue anterior oral seal was signicantly more frequent in the MB than in the NB. In pediatric
patients, naso-respiratory obstruction with mouth breathing
during critical growth periods in children has a higher tendency for clockwise rotation of the growing mandible, with a
disproportionate increase in anterior lower vertical face height
and decreased posterior facial height.9
Pharyngeal size is very important for all subjects and especially for the patient with obstructive sleep apnea (OSA). The
size of the nasopharynx may be of particular importance in
determining whether the mode of breathing is predominantly
nasal or oral. The orthodontist should contribute to the initial diagnosis of many nasopharyngeal obstructions that can
result in a predisposition to MB.
The aim of this study was to compare the craniofacial morphology and orofacial airway dimensions in Class I, MB and
NB subjects. For this purpose, the null hypothesis assumed
that there is no signicant difference in the craniofacial morphology and orofacial airway dimensions between MB and NB
subjects.

2.

Materials and methods

The Regional Ethical Committee on Research of the Erciyes

University, Faculty of Dentistry, approved this study.
In the present study, 155 MB and 50 NB Class I subjects were
evaluated and 34 MB and 33 NB patients were selected by the
following sample selection criteria: subjects were between 1216 years of age, skeletal Class I relationship according to ANB
angle. Subjects were permanent dentition and no history of
previous orthodontic or functional orthopedic treatment. Subjects with history of nasal respiratory complex surgery, allergic
or acute rhinitis, visual, vestibular, equilibrium, swallowing
disorders and facial or spinal abnormalities and severe sleeping disorders with moderate and severe AHI index (15-30 and
greater than 30) were excluded from the study.
Sixty-seven pretreatment cephalometric radiographs of
these Class I patients formed the sample for this study taken
by a standard technique at the relaxed position of tongue
and perioral muscles. Patients were divided into two groups
according to respiration pattern: MB children used as experimental group and NB children used as control group.
All patients had Class I skeletal relationship (ANB:
2.2o 1.5o and 2.9o 0.9o in MB group and NB group, respectively). To participate in the study written informed consents
were given by the parents of the patients.
Evaluation of the breathing pattern was adapted from the
study by Cuccia et al.10 Most subjects in MB group showed
a diaphragmatic mode of inhalation under expansion of the
thorax and a reduced mobility of the nostrils suggesting a

211

reduced patency of the upper airway. MB was shown by water

vapor condensed on the surface of a mirror placed outside the
mouth.
MB group comprised 16 boys and 18 girls (mean age
12.81.5 years; range: 12.015.2 years). On clinical examination MB patients showed lip incompetence, dry lips at rest,
dental crowding in the upper arch, adenoidal face and
reduced maxillary transverse dimension with unilateral or
bilateral cross bite. These factors were considered for the diagnosis of MB in agreement with Moyers criteria.11
NB group comprised 8 boys and 25 girls (mean age 13.91.3
years; range: 12.215.8 years). This group was chosen at random from a group of children according to inclusion criteria,
who had various orthodontic problems, but who did not have
a past history or any clinical signs of MB.

2.1.

Cephalometric Measurements

Lateral cephalometric radiographs were taken with Instrumentarum Cephalometer (Ortoceph OC100, Tuusula, Finland).
All subjects were positioned in the cephalostat with the sagittal plane at a right angle to the path of the x-rays, the
Frankfort plane was parallel to the horizontal, the teeth were
in centric occlusion, and the lips were lightly closed. All radiographs were taken with the same machine and magnication
(110%; 1-1.1).
All radiographs were traced manually. Whole measurements were recorded by a single author (F.I.U.) and were
reviewed twice by other investigator for accurate landmark
identication. Tracings were transferred to computer in JPEG
format by the same resolution and scanner. Orofacial airway
areas were obtained with the same resolution. Orofacial airway areas were separated into three parts showed in Figure 5.
Each part was painted and calculated the number of pixels
separately in histogram section on the Adobe Photoshop CS5
trial version (Adobe, California, USA) and converted to mm2 .
Landmarks and reference lines used for orofacial airway dimensions were shown in Figure 1 and craniofacial
measurements were shown in Figures 24. Fifteen angular
(Figs. 2 and 3) and 12 linear (Fig. 4) measurements were used
for the evaluation of craniofacial morphology. Additionally,
seven measurements were used to evaluate orofacial airway
dimensions (Figs. 5 and 6).

2.2.

Statistical Analysis

All statistical analyses were performed using the Statistical

Package for Social Sciences 13.0 (SPSS Inc., Chicago, Illinois, USA). A power analysis established by G*Power Ver.
3.0.10. (Franz Faul, Universitt Kiel, Germany) software, based
on 1:1 ratio between groups, sample size of 33 patients would
give more than 80% power to detect signicant differences
with 0.30 effect size [to detect a clinically meaningful difference of 1 mm (1.5 mm) for the distance of the A to N perp.]
between two groups and at = 0.05 signicance level.
The normality test of ShapiroWilks and Levenes variance homogeneity test were applied to the data. The data
were found normally distributed, and there was homogeneity
of variance between the groups. Arithmetic mean and standard deviation values were calculated for each measurement.

212

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

Fig. 1 Landmarks and reference lines used for orofacial

airway space: Pt (Pterygoid point), the posterior point of the
pterygopalatine fossa; ANS (anterior nasal spine), Anterior
point of the maxilla; PNS (posterior nasal spine), Posterior
point of the palatine bone; Me (Menton), the inferior point
of the symphysis; H1, intersection between posterior border
of tongue and hyoid bone; H2, the most anterior point of
the hyoid bone; T, the most anterior point of the outline of
tongue; Palatal plane, a line passing through ANS and PNS.

Fig. 2 1) SNA: inward angle toward the cranium between

the NA line and the SN plane, 2) SNB: inward angle toward
the cranium between the NB line and the SN plane, 3) ANB:
angle between the NA and NB lines, obtained by subtracting
SNB from SNA, 4) SN-Ar: inward angle toward the cranium
between the S-Ar line and the SN plane, 5) Articular angle:
inward angle between the S-Ar line and the Ar-Go line,
6) Gonial/Jaw Angle: inward angle toward the cranium
between the Ar-Go line and the mandibular plane (MP).

Group differences were statistically evaluated by independent

samples t-test.
To determine the errors associated with radiographic measurements, 15 radiographs were selected randomly. Their
tracings and measurements were repeated 8 weeks after the
rst measurements. A paired sample t-test was applied to the
rst and second measurements, and the differences between
the measurements were insignicant. Correlation analysis
applied to the same measurements showed the highest r value
(0.973) for the overjet and the lowest r value (0.876) for tongue
gap and S-N measurements.
Probability values less than 0.05 were accepted as
signicant.

(SN-MP) and maxilla mandibular angle (PP-GoGn) were signicantly increased in the MB group (p < 0.01). Besides, S-N
(p < 0.05) and anterior facial height (p < 0.05) from linear measurements were signicantly higher in MB group than NB
group.
Descriptive data for the variables expressing the orofacial
airway dimensions are also given for the MB and NB groups in
Table 2. According to statistical analysis, only the upper posterior airway space decreased signicantly (p < 0.001) in MB
subjects. As a result, this part of the null hypothesis was also
rejected.

3.

Radiographic examination of nasopharyngeal obstruction

provides limited information on 3D airway dimensions
according to Wang et al.12 and Cohen et al.13 On the other
hand, it has been shown that cephalometric lms are reliable
records in airway measurements when compared to computer tomography (CT) and cephalometric lms.14,15 Aboudara
et al.15 showed that there is a signicant positive relationship between nasopharyngeal airway size on cephalometric
lms and its true volumetric size from a cone beam computed tomography (CBCT) scan in adolescents. Malkoc et al.16

Results

Descriptive statistics and statistical comparisons of angular

and linear craniofacial measurements are shown in Table 1.
Statistically signicant differences were found between MB
group and NB group in eleven of 28 measurements.
SNA (p < 0.01), ANB (p < 0.01), A to N perp (p < 0.05),
convexity (p < 0.05), IMPA (p < 0.05) and overbite (p < 0.05) measurements were found signicantly lower; but the angular
relationship of the sella-nasion to the mandibular plane

4.

Discussion

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

Fig. 3 7)SN-MP: angle between the SN plane and the

MP, 8) PP-GoGn: angle between the PP plane and the MP,
9) Y-Axis: inward angle toward the cranium between the SGn line and the SN plane, 10) SN-NPog: inward angle toward
the cranium between the N-Pog line and the SN plane,
11) NA-Apog: inward angle between the NA line and the
APog line, 12) FMA: angle between the frankfurt horizontal
plane and the MP, 13) FMIA: angle between the frankfurt
horizontal plane and the mandibular incisor axis, 14) IMPA:
angle between the MP and the mandibular incisor axis,
15) MP-OP: angle between the MP and occlusal plane (OP).

found that cephalometric lms were reliable and reproducible

records to determine and evaluate the airway dimensions.
In the current study all patients were selected for skeletal
classication, according to ANB angle. Only skeletal Class I
patients were included to the study sample.
Thus, standard and homogenous group of patients were
used in the present study, which is different from the other
studies, and these patients were separated into two groups
according to breathing pattern. Wits appraisal might be used
for the sample selection but occlusal plane could be inuenced
by dental problems such as deep bite, open bite or supra- or
infra-eruption of molars.17,18 However, during sample selection we did not comprised a balanced group regarding to
gender distribution for NB group. Because gender-related size
difference can inuence differences in linear measurements
between groups, the different gender distribution should be
carefully considered.
When maxillary sagittal skeletal relationship is evaluated,
reduced SNA and A to N perp. measurements in MB patients
could be determined. These values indicate a tendency for
maxillary deciency which is consistent with the ndings by
Seto et al.19 But, Lowe et al.20 reported that the position of

213

Fig. 4 1)A to N perp: distance between

A point and N perpendicular line measured perpendicular
to N perpendicular line, 2) Pog to N perp: distance between
pogonion and N perpendicular line measured from
the perpendicular to N perpendicular line, 3) S-N: distance
between sella and nasion point, 4) S-Ar: distance between
sella and articular 5) Ar-Go: distance between articular and
gonion, 6) Go-Gn: distance between gonion and gnathion,
7) N-Go: distance between nasion and gonion, 8) S-Gn: distance between sella and gnathion, 9) Posterior Facial Height
(S-Go): distance between sella and gonion, 10) Anterior
Facial Heigh (Na-Me): distance between nasion and menton.

the maxilla did not show any important discrepancy in MB

patients when compared to the NB subjects, however, they
also found that the maxillary skeletal position is retrognathic
in antero-posterior direction.
In children with nasal obstruction, there was a posterior rotation of the mandible. MB group is likely to present
increased mandibular inclination, characterized by decreased
posterior facial height and increased lower anterior facial
height. These measurements give rise to think respiratory
function inuences the craniofacial development. Lessa et al.4
found no differences in gonial angle between the MB and NB
children. They evaluated 6 to 10 years aged children which
have potential growth.4 In the present study our samples had
higher age range and dentofacial growth and development
was almost completed.
In general, the MB subjects had longer faces and their
mandibles had more obtuse gonial angles, resulting in a
vertical growth pattern.21,22 On the contrary, we found no statistically signicant different gonial angles between the MB
and NB patients. Angular measurements of vertical skeletal
relationships were signicantly different between groups. The

214

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

Fig. 5 1) Nasopharyngeal airway space (mm2 ): formed by

palatal plane, Pt-PNS line and posterior nasopharyngeal
wall, 2) Palatal tongue space (mm2): space between tongue
and palate from the line perpendicular to the palatal
planeat the incisive foramen to the line perpendicular to
the palatal plane at the PNS, 3) Tongue space (mm2): area
formed by superior and posterior border of tongue and T,
Me, H1 and H2.

Fig. 6 4) Upper PAS (mm): Point of intersection of line from

soft palate center perpendicular to posterior pharyngeal
wall and posterior pharyngeal wall, 5) Lower PAS (mm):
Distance of mandibular plane intersection between the
posterior pharyngeal wall and tongue posterior wall,
6) Tonsil size (mm): the wider line which is parallel to the
Frankfort horizontal plane on palatal tonsil, 7) Tongue
gap (mm): line perpendicular to the palatal plane from the
center of palatal plane to the tongue.

angular relationship of the sella-nasion to the mandibular

plane (SN-MP) and maxilla mandibular angle (PP-GoGn) were
signicantly increased in the MB group (Table 1). Anterior
facial height was larger in MB subjects and this result agrees
with the literature.2023
Frasson et al.24 found no difference between NB and MB
patients when facial vertical patterns are assessed. Their
study was represented by the values: SN-MP, FMA, and Y axis
angle. Frasson et al.24 also found that signicant differences
were not seen between MB and NB groups for posterior facial
height measurement. We found higher SN-MP, PP-GoGn, anterior facial height in MB group, but no statistically signicant
alteration in posterior facial height between the MB and NB
groups. In their study, Class I patients were included according
to dental classication
Mouth breathers have to open their mouths and maintain an oral airway. Three changes in posture are needed
to accomplish this: lowering the mandible, positioning the
tongue downward and forward, and extending the head.
These postural changes could affect dentofacial growth and
development.25,26 In the current study we found increased
anterior facial height in MB group; but no differences was
found in tongue space and palatal tongue space between the
groups.

Although MB patients may caused some skeletal discrepancies including postural open bite, decient maxilla,
narrow and V-shaped maxillary arch, and posterior cross bite,
increased lower face height, nasopharyngeal airway space
was not evaluated in their studies.2 We found that only
upper posterior airway space reduced in MB subjects compared to NB patients. When examining the upper airway eld,
no differences found between the groups. Linder-Aronson27
maintained this result and concluded the sagittal depth of the
nasopharynx is less in the MB subject and they recommended
that the angular height of the nasopharynx appears to be a
suitable selective factor among different respiratory groups.
When examining the lower posterior airway space, we found
no differences between MB and NB patients.
Pae and Lowe28 studied in OSA patients and demonstrated
that the tongue shape variations in OSA patients may be different from normal by eigenshape analysisa relatively novel
morphometric tool and they analyzed tongue shape in OSA
patients in supine position. They did not examine tongue size.
Determining a tongue is not easy because its anatomy does
not provide landmark points in the cephalometric lms. In
the current study, all cephalometric lms were taken in relax
position of tongue and perioral muscles to get standardization. This study examined the tongue space via the shape of

215

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

Table 1 Descriptive statistics and statistical comparisons of angular and linear craniofacial measurements in mouth
breathing and nasal breathing subjects.
Mouth Breathing

Nasal Breathing
Mean

Sig.

Airway measurements

Mean

SD

SD

Angular Measurement (degree)

SNA
SNB
ANB
SN-Ar
Articular angle
Ar-Go/MP
SN-MP
PP-GoGn
Y-Axis
SN-Npog
NA-Apog
FMA
FMIA
IMPA
MP-OP

79.000
76.303
2.209
124.944
140.882
128.691
35.156
27.335
70.797
77.179
2.729
27.032
63.779
88.926
18.765

3.287
3.217
1.572
6.261
6.911
8.223
4.570
6.118
3.141
2.733
4.008
5.747
7.682
6.015
4.403

80.515
77.418
3.097
125.221
139.976
126.939
31.939
23.324
69.961
78.145
5.061
24.945
61.885
92.755
18.424

2.709
2.511
1.096
5.704
6.730
5.332
2.144
3.756
2.237
2.481
3.348
3.805
6.005
5.892
3.796

**
NS
**
NS
NS
NS
**
**
NS
NS
*
NS
NS
*
NS

Linear Measurements (mm)

A to N perp
Pog to N perp
S-N
S-Ar
Ar-Go
Go-Gn
N-Go
S-Gn
Posterior Facial Height
Anterior Facial Height
Overjet
Overbite

-1.191
-4.779
68.815
37.088
45.274
76.190
113.009
126.406
75.076
118.971
2.938
0.335

2.955
6.174
4.836
4.274
4.356
8.389
8.602
10.312
6.090
9.918
3.207
2.565

0.373
-3.712
65.964
35.848
46.588
72.500
110.024
122.348
75.127
114.058
3.236
1.400

2.919
5.063
4.594
3.985
4.232
6.777
7.271
9.450
5.653
8.577
1.234
1.244

*
NS
*
NS
NS
NS
NS
NS
NS
*
NS
*

* p<0.05, ** p<0.01, NS: Statistically not signicant, SD: Standard deviation.

Table 2 Descriptive statistics and statistical comparisons of orofacial airway measurements in mouth breathing and
nasal breathing children.
Airway measurements

Nasopharyngeal airway space (mm2 )

Palatal tongue space (mm2 )
Tongue space (mm2 )
Upper posterior airway space (mm)
Lower posterior airway space (mm)
Tonsil size (mm)
Tongue gap (mm)

Mouth Breathing

Nasal Breathing

Mean

SD

Mean

SD

3.856
3.952
33.019
9.630
10.382
14.150
10.544

1.225
1.119
5.473
3.026
3.684
2.091
3.949

4.316
3.662
35.292
12.240
9.940
14.150
8.864

1.058
1.078
3.964
2.815
2.706
2.266
3.005

Sig.

N.S
N.S
N.S
***
N.S
N.S
N.S

*** p<0.001, NS: Statistically not signicant, SD: Standard deviation.

the tongue outline to demonstrate differences between MB

patients and NB subjects and we did not nd any differences
in tongue space between the groups.

5.

Conclusions

Within the limitations of this cross-sectional study, following

conclusions can be drawn:
According to craniofacial measurements, maxillary skeletal base is positioned posteriorly and this affects facial
convexity in MB patients when compared to NB control

sample. In general, vertical measurements are higher and

lower incisors were retroclined in MB group.
Upper posterior airway dimension was reduced in MB subjects, but nasopharyngeal airway and lower posterior airway
space measurements were not different between MB and NB
patients.
Tongue gap and tongue space were not affected by respiration pattern.

Conict of interest
The authors have reported no conict of interest.

216

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

Acknowledgements
The authors would like to thank King Saud University Visiting
Professor Program for the contributions to the study.

Riassunto
Obiettivo: Vericare lipotesi nulla secondo cui non vi una
differenza signicativa nella morfologia craniofacciale e nelle dimensioni delle vie aeree orofacciali tra respiratori orali e nasali.
Materiali e metodi: Sono state analizzate le radiograe cefalometriche laterali di 34 respiratori orali (et media 12.81.5 anni; range
di et: 12.0-15.2 anni) e di 33 respiratori nasali (et media 13.91.3;
range di et: 12.2-15.8 anni) con occlusione di I classe. In totale sono
state valutate 34 misurazioni (27 delle strutture craniofacciali e 7
delle vie aeree orofacciali). Le differenze tra I gruppi sono state sottoposte ad esame statistico con test t per campioni indipendenti con
livelli di p<0.05.
Risultati: I confronti statistici hanno evidenziato che le misurazioni
dellangolo SNA (p < 0.01), dellANB (p < 0.01), di A rispetto a
N perpendicolare (p < 0.05), della convessit (p < 0.05), del lIMPA
(p < 0.05) e delloverbite (p < 0.05) avevano valori inferiori nel gruppo
dei respiratori orali rispetto ai respiratori nasali. Tuttavia, i valori
di SN-MP (p < 0.01) e PP-GoGn (p < 0.01) ottenuti con misurazioni
angolari e di S-N (p < 0.05) e dellaltezza facciale anteriore (p < 0.05)
calcolati con misurazioni lineari erano signicativamente pi elevati
nei respiratori orali. Tra le misurazioni delle vie aeree orofacciali condotte, solo lo spazio posteriore delle vie aeree superiori risultato
maggiore nei respiratori orali rispetto ai respiratori nasali in maniera
statisticamente signicativa (p < 0.001). Lipotesi nulla relativa alla
differenza stata pertanto invalidata. Lo studio ha evidenziato che
la respirazione orale ha un impatto sulla morfologia cranio-facciale
e sulle dimensioni delle vie aeree orofacciali.

Rsum
Objectif: Vrier lhypothse nulle selon laquelle il ny a aucune diffrence signicative pour ce qui est de la morphologie cranio-faciale
et des dimensions des voies ariennes suprieures orofaciales entre
ceux qui respirent par la bouche et ceux qui respirent par le nez.
Matriels
et
mthodes:
Analyse
des
radiographies
cphalomtriques latrales de 34 sujets qui respirent par la
bouche (ge moyen 12.81.5 ans; tranche dge: 12.0-15.2 ans) et
de 33 sujets qui respirent par le nez (ge moyen 13.91.3; tranche
dge: 12.2-15.8 ans) avec occlusion de classe I. Au total, 34 mesures
ont t values (27 concernant des structures cranio-faciales et 7
concernant des voies ariennes orofaciales). Les diffrences entre
les groupes ont t soumises analyse statistique laide du test t
pour chantillons indpendants avec des niveaux de p <0.05.
Rsultats: Les comparaisons statistiques ont mis en lumire que
les mesures de langle SNA (p < 0.01), ANB (p < 0.01), A par rapport
N perpendiculaire (p <0.05), convexit (p < 0.05), IMPA (p < 0.05)
et overbite (p <0.05) faisaient tat de valeurs infrieures chez le
groupe des sujets qui respirent par la bouche par rapport ceux
qui respirent par le nez. Toutefois, les valeurs de SN-MP (p < 0.01) et
de PP-GoGn (p < 0.01), obtenues laide de mesures angulaires, et
de S-N (p < 0.05) ainsi que de la hauteur faciale antrieure (p < 0.05),
calcules par le biais de mesures linaires, taient remarquablement
plus leves chez les sujets qui respirent par la bouche. Les mesures
des voies ariennes orofaciales ralises ont montr que seulement

lespace postrieur des voies ariennes suprieures sest avr plus

marqu, tout en ayant une signication statistique (p < 0.001) chez
les sujets qui respirent par la bouche par rapport aux sujets qui
respirent par lenez.
Conclusions: Il sensuit donc que lhypothse nulle concernant la
diffrence a t invalide. Ltude a mis en relief que la respiration
par la bouche a un impact sur la morphologie cranio-faciale et sur
les dimensions des voies ariennes orofaciales.

Resumen
Objetivo: Comprobar la hiptesis nula de que no hay diferencia signicativa en la morfologa crneo-facial y las dimensiones de las
vas areas orofaciales entre quienes respiran por la boca y quienes
respiran por la nariz.
Materiales y mtodos: Se analizaron las radiografas cefalomtricas laterales de 34 sujetos que respiran por la boca (edad promedio

12.81.5 anos;
rango de edad: 12.0-15.2 anos)
y de 33 sujetos que
respiran por la nariz (edad promedio 13.91.3; rango de edad: 12.2
con oclusin de clase I. En total, se valoraron 34 mediciones
15.8 anos)
(27 de las estructuras crneo-faciales y 7 de las vas areas orofaciales). Las diferencias entre los grupos se sometieron a anlisis
estadstico por medio de la prueba t para muestras independientes
con niveles de p<0.05.
Resultados: Las comparaciones estadsticas destacaron que las
mediciones del ngulo SNA (p < 0.01), ANB (p < 0.01), A respecto a
N perpendicular (p < 0.05), convexidad (p < 0.05), IMPA (p < 0.05) y
overbite (p < 0.05) experimentaban valores inferiores en el grupo de
sujetos que respiran por la boca con respecto a los sujetos que respiran por la nariz. Sin embargo, los valores de SN-MP (p < 0.01) y de
PP-GoGn (p < 0.01), conseguidos por medio de mediciones angulares,
de S-N (p < 0.05) y de la altura facial anterior (p < 0.05), calculados
con mediciones lineales, resultaban signicativamente ms altos en
los sujetos que respiran por la boca. Entre las mediciones de las vas
areas orofaciales, slo el espacio posterior de las vas areas superiores result ms marcado en los sujetos que respiran por la boca
con respecto a los sujetos que respiran por la nariz, teniendo una
signicacin estadstica (p < 0.001).
Conclusin: De lo anterior se desprende que la hiptesis nula en
cuanto a la diferencia queda invalidada. El estudio ha destacado que
la respiracin por la boca tiene un impacto tanto en la morfologa
crneo-facial como en las dimensiones de las vas areas orofaciales.

references

1. Oulis CJ, Vadiakas GP, Ekonomides J, Dratsa J. The effect of

hyperthophic adenoids and tonsils on the development of
posterior crossbite and oral habits. J Clin Pediatr Dent
1994;18:197201.
2. Gungor AY, Turkkahraman H. Effects of airway problems on
maxillary growth: a review. Eur J Dent 2009;3:2504.
3. Hartsook JT. Mouth breathing as a primary etiologic factor in
the production of malocclusion. J Dent Child 1946;13:914.
4. Lessa FC, Enoki C, Feres MF, Valera FC, Lima WT,
Matsumoto MA. Breathing mode inuence in craniofacial
development. Braz J Otorhinolaryngol 2005;71:15660.
5. Peltomki T. The effect of mode of breathing on craniofacial
growthrevisited. Eur J Orthod 2007;29:4269.
6. Linder-Aronson S. Adenoids. Their effect on mode of
breathing and nasal airow and their relationship to
characteristics of the facial skeleton and the dentition. A

progress in orthodontics 1 3 ( 2 0 1 2 ) 210217

7.

8.

9.

10.
11.
12.

13.

14.

15.

16.

biometric, rhinomanometric and cephalometro-radiographic

study on children with and without adenoids. Acta
Otolaryngol 1970;265:1132.
Bresolin D, Shapiro PA, Shapiro GG, Chapko MK, Dassel S.
Mouth breathing in allergic children: its relationship to
dentofacial development. Am J Orthod 1983;83:33440.
Shendal SA, Eisenfeld J, Bell WH, Epker NB, Mishelevich DJ.
The long face syndrome: Vertical maxillary excess. Am J
Orthod 1976;70:398408.
Harari D, Redlich M, Miri S, Hamud T, Gross M. The effect of
mouth breathing versus nasal breathing on dentofacial and
craniofacial development in orthodontic patients.
Laryngoscope 2010;120:208993.
Cuccia AM, Lotti M, Caradonna D. Oral breathing and head
posture. Angle Orthod 2008;78:7782.
Moyers RE. Handbook of Orthodontics. 3rd ed. Chicago, IL: Year
Book Medical Publishers; 1973.
Wang D, Clement P, Kaufman L, Derde MP. Fiberoptic
examination of the nasal cavity and nasopharynx in
children. Int J Pediatr Otorhinolaryngol 1992;24:3544.
Cohen LM, Koltai PJ, Scott JR. Lateral cervical radiographs and
adenoid size: do they correlate? Ear Nose Throat J
1992;71:63842.
Cakarne D, Urtane I, Skagers A. Pharyngeal airway sagittal
dimension in patients with Class III skeletal dentofacial
deformity before and after bimaxillary surgery. Stomatologija
2003;5:136.
Aboudara C, Nielsen IB, Huang JC, Maki K, Miller AJ,
Hatcher D. Comparison of airway space with conventional
lateral headlms and 3-dimensional reconstruction from
cone-beam computed tomography. Am J Orthod Dentofacial
Orthop 2009;135:46879.
Malkoc S, Usumez S, Nur M, Donaghy CE. Reproducibility of
airway dimensions and tongue and hyoid positions on lateral
cephalograms. Am J Orthod Dentofacial Orthop 2005;128:5136.

217

17. Bishara SE, Fahl JA, Peterson LC. Longitudinal changes in the
ANB angle and Wits appraisal: clinical implications. Am J
Orthod 1983;84:1339.
SI, Yagc
A, Uysal T. Wits Appraisal in
18. Ramoglu
Cappadocian Turkish Population. J Heal Scien 2009;18:1117.
19. Seto BH, Gotsopoulos H, Sims MR, Cistulli PA. Maxillary
morphology in obstructive sleep apnoea syndrome. Eur J
Orthod 2001;23:70314.
20. Lowe AA, Ono T, Ferguson KA, Pae EK, Ryan CF, Fleetham JA.
Cephalometric comparisons of craniofacial and upper airway
structure by skeletal subtype and gender in patients with
obstructive sleep apnea. Am J Orthod Dentofacial Orthop
1996;110:65364.
21. Weimert T. Airway obstruction in orthodontic practice. J Clin
Orthod 1986;20:96105.
22. Linder-Aronson S, Woodside DG, Hellsing E. Normalization of
incisor position after adenoidectomy. Am J Orthod
1993;103:41227.
23. Rubin RM. The effects of nasal airway obstruction. J Pedod
1983;8:327.
24. Frasson JM, Magnani MB, Nouer DF, de Siqueira VC,
Lunardi N. Comparative cephalometric study between nasal
and predominantly mouth breathers. Braz J Otorhinolaryngol
2006;72:7281.
25. Preston B. The upper airway and craniofacial morphology. In:
Graber TM, Vanarsdall RL, Vig KWL, editors. Orthodontics:
Current Principles and Techniques. St Louis, Mo: Elsevier Mosby;
2005. p. 12836.
26. Proft WR, Fields HW. The etiology of orthodontic problems.
In: Proft WR, Fields HW, editors. Contemporary Orthodontics.
St Louis, Mo: CV Mosby; 1986. p. 1123.
27. Linder-Aronson S. Respiratory function in relation to facial
morphology and the dentition. Br J Orthod 1979;6:5971.
28. Pae EK, Lowe AA. Tongue shape in obstructive sleep apnea
patients. Angle Orthod 1999;69:14750.