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A quantitative assessment of respiratory patterns and

their effects on dentofacial development

Article Outline
• Abstract
• Materials and methods
○ Sample
○ Orthodontic assessment
○ Cephalometric analysis
○ Measurements of breathing
 Nasal power and nasal airway resistance
 Head-out body plethysmograph
○ Statistical analysis
• Results
○ Plethysmograph measurements
 Verification studies
 Percent mouth breathing
○ Nasal power and nasal airway resistance
 Verification studies
 Relationship to percent mouth breathing
○ Perception of breathing mode
○ Dental and skeletal relationships
• Discussion
• Acknowledgements
• References
• Copyright
Abstract
The purpose of this study was to assess the effects of quantitatively determined breathing
patterns on dentofacial development in growing children. Forty-nine subjects ranging in age
from 10 to 16 years participated in the breathing pattern assessment portion of this project.
Oral, nasal, and total airflow were measured at separate times by means of a head-out body
plethysmograph technique and the values were compared with the subjects' and parents'
subjective perceptions of their breathing modes. These breathing pattern measurements also
were compared to nasal airway resistance and nasal power. Temporal variation and cyclic
respiration, which may play important roles in quantitative evaluations of childrens'
breathing patterns, also were addressed. In addition, objective assessments of possible
associations between dentofacial structure and respiration were made on 45 of these
children. Most subjects' exhibited was either an oronasal or a completely nasal respiratory
pattern. However, significant variation in breathing measures was evident among a number
of subjects whose breathing was measured twice on the same day and on different days. No
significant correlations were found between objectively measured and subjectively
determined impressions of respiratory patterns. In addition, there was no association
between nasal airway resistance or nasal power and plethysmograph recordings of percent
of mouth breathing. Comparisons of measured breathing modes and dentofacial
characteristics revealed a weak tendency among mouth breathers toward a Class II skeletal
pattern and retroclination of maxillary and mandibular incisors. In contrast, subjective
perception of mouth breathing was associated with increased anterior facial height and
greater mandibular plane angles. Nasal power and resistance were not correlated with either
dental or skeletal variables. This study presents evidence that determination of respiratory
pattern is a complex issue for which methods must be refined and performed longitudinally.
(AM J ORTHOD DENTOFAC ORTHOP 1990;98:523-32.)

Animal and human studies have demonstrated some relationship between nasal airway
function and dentofacial form. Longitudinal investigations in primates by Harvold1, 2 and
Miller3, 4 have revealed that mouth breathing can influence lip, tongue, and mandibular
positions and lead to marked variation in skeletal and dental morphology. Linder-Aronson's
studies5, 6, 7, 8 on human subjects with enlarged lymphoidal tissues also have suggested a
relationship between respiratory pattern and dentofacial form. Skeletal differences were
described in the vertical, transverse, and anteroposterior planes of space. Bresolin9, 10 noted
distinguishing features in mouth-breathing subjects with allergies, including increased
anterior facial height, larger gonial angle, narrower maxillary arch, deeper palatal height,
and a more retrognathic profile. Trask11 described similar findings for allergic and non-
allergic siblings.
Despite these findings, the effects of breathing pattern on facial form are still subject to
debate. Quantitative analysis of respiratory mode has been an obvious methodologic
difficulty in most studies. Efforts have been based on subjective opinions of breathing
patterns or on indirect physiologic measurements taken at one time. Quantifying the
proportions of oral and nasal breathing at repeated intervals is a prerequisite to any
conclusion regarding the effects of respiratory function on facial form. The purpose of this
project was to achieve quantitative evidence with respect to breathing patterns in growing
children to evaluate the influences of these patterns on dentofacial development. Airflow
measurements for the oral and nasal components of respiration were obtained by a head-out
body plethysmograph technique on two separate visits. The values were compared with
those obtained by three different methods of assessing respiratory pattern: subjective
perception of breathing mode and measurement of nasal airway resistance and nasal power.
Associations between dentofacial structure and the various measures of respiratory function
were analyzed. The importance of temporal variation in respiration also was considered in
the analysis of breathing pattern.
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Materials and methods
Sample
Forty-nine children, 18 boys (36.7%) and 31 girls (63.3%), participated in the first
measurement of breathing patterns. Thirty-six of these subjects were willing to return to be
studied a second time on a separate day. The subjects were between the ages of 10 and 16
years, with an average age of 13 years 1 month. The subjects were selected according to
age and interest in participation. Their cephalometric radiographs were analyzed to evaluate
possible associations between facial structure and respiration. Four of the subjects were
eliminated from this part of the study because they did not fulfill one or more of the
additional criteria: (1) white origin; (2) no pacifier or thumb-sucking habits beyond 5 years
of age; and (3) no history of facial trauma.
Because of restrictions on radiographic exposure, the sample included both patients without
prior orthodontic treatment and those in an early phase of treatment. Twelve (24.5%) had
received no orthodontic treatment, 16 (32.7%) were in an early phase such as being treated
with space-maintaining appliances or headgear, and 21 (42.9%) were wearing standard
edgewise appliances during an early alignment period. The sample included both extraction
and nonextraction cases, but patients with prior maxillary expansion were excluded. This
information was obtained from patient records and clinical examination.
In addition, each subject, along with his or her parent(s), was asked to fill out a brief
questionnaire concerning their subjective impressions of the participant's breathing pattern.
One subject was unable to give an opinion.
Orthodontic assessment
Examination of radiographs and models of patients was performed by one investigator (N.
U.) to identify the following variables:
1.Number and type of teeth (deciduous or permanent)

2.Right and left first molar and canine relationships (Angle classification)

3.Open bite (defined from the cephalometric radiograph as space between maxillary and
mandibular incisal edges with reference to the occlusal plane)

4.Posterior crossbite

5.Maxillary and mandibular intermolar widths (as defined by the distance between the
mesiolingual cusp tips of the right and left first permanent molars)

Cephalometric analysis
The cephalometric radiographs were obtained from patient records. Each subject's
pretreatment radiograph was analyzed. The subjects' names were covered, and each was
randomly assigned a code number that was used throughout the study. Tracings of each
film were made by the primary author (N. U.) on 0.003-inch matte acetate with an 0.5 mm
pencil. Fifteen landmarks were identified (Fig. 1), and 19 cephalometric relationships were
measured (Table I).

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• Fig. 1.
Cephalometric landmarks.


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Intraexaminer reliability was determined by a random selection of 10 cephalograms that
were retraced and remeasured. Pearson product moment correlation coefficients, ranging
from r = 0.83 to 0.99, were calculated for each measurement.
Measurements of breathing
Nasal power and nasal airway resistance
Nasal power is commonly defined as the rate of energy required to move air through the
nose.12 Nasal airway resistance is the ratio of the air pressure differential across the
nasopharynx over the rate of nasal airflow.13 Resistance is derived from the relationship
between pressure and nasal airflow at one specific flow rate during the respiratory cycle.
Nasal power, however, provides an estimate over a continuous time interval, yielding a
more precise and reproducible assessment of nasal airway obstruction.12 Posterior
rhinomanometry was employed to measure both nasal power and nasal airway resistance.
The rhinomanometer consisted of an airtight face mask that covered the nose. Two
catheters measured the pressure drop between the mouth and the nose. One was placed in
the posterior oropharynx with a tight lip seal; the second was connected to the well-adapted
nasal mask. A pneumotachograph (Fleisch No. 2) also was attached to the face mask to
measure nasal airflow. The rhinomanometer was connected to a microcomputer, which
calculated nasal power and resistance from the pressure and flow signals. Nasal airway
resistance was computed as the reciprocal of the slope of the curve at zero flow from
pressure plotted against airflow. Nasal power was calculated by integrating the pressure-
flow curves over three consistent respiratory cycles. The subject was instructed on its use
and asked to breathe through the nose to establish a regular breathing pattern. An average
of three measurements was computed for inspiration and expiration immediately before and
directly after the head-out body plethysmograph portion of the experiment.
Head-out body plethysmograph
Mode of respiration was assessed by the head-out body plethysmograph shown in Fig. 2.


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• Fig. 2.
Schematic diagram of the head-out body plethysmograph.
This system measures airflow during respiration. It is a noninvasive procedure in which
each subject is placed into an airtight box with his or her head out. An airtight seal is
maintained by means of a pliable sheet of rubber-dam material that is held in place around
the neck with a tubular sandbag. Without information about our purpose, the participant
was instructed to breathe normally for 10 minutes through a rubber mouthpiece.
Total airflow from the subject was measured by the displacement of air in the airtight box
caused by the relative movements of the thoracic cage and abdomen. The amount of oral
flow could be compared with total airflow. A mouthpiece was connected to a
pneumotachograph, which measured oral airflow and translated the measurements into an
electronic signal. Both oral and total flow signals were recorded on X-Y axes every 30
seconds for 10 minutes. When the total flow equaled the orally respired flow, the X-Y
graph plotted a signal of approximately 45°. Deviation from this angle indicated nasal
airflow. During the last three measurements, nose clips were used to induce total oral
breathing. The value thus obtained was used as the baseline at which oral breathing
represented total respiratory airflow. Thus the percent of mouth breathing could
subsequently be calculated.
Statistical analysis
Pearson correlation coefficients were calculated to identify temporal variation and to verify
all breathing measurements. Sex, age, number of previous measurements, time of day, and
perception of breathing mode were analyzed separately. Means and variances for percent of
mouth breathing were compared with subjective perceptions of breathing modes. A t test
was performed to ascertain whether the subjective assessments of respiratory patterns
differed significantly from the quantitative measurements of their breathing modes. Pearson
correlation coefficients were computed to determine whether there was a relationship
between nasal power or nasal resistance and the percent of mouth breathing. Scatter
diagrams were plotted for nasal power, nasal airway resistance, and percent of mouth
breathing to determine whether there were threshold levels at which mouth breathing
became the predominant mode of respiration. Multiple linear regression analysis was used
to assess differences in skeletal and continuous dental parameters. Discrete dental variables
were analyzed with the X2-test by dividing the groups into those identified as ≤ 10% or >
10% mouth breathing. Covariables were adjusted for age and sex. The significance level for
all tests was accepted at p ≤ 0.05.
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Results
Plethysmograph measurements
Verification studies
Verification of the measurements for percent of mouth breathing, nasal power, and nasal
airway resistance was obtained by remeasuring 27 randomly selected subjects. Periods of
20 to 60 minutes were allowed between measurements. Pearson correlation coefficients for
the plethysmograph's recording of percent of mouth breathing at the two different times
were computed and are found in Table II.


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Although the univariate or overall correlation was strong, the mouth breathing of 6 of the
27 subjects varied more than 15% on the same day (from 16.2% to 63.9%), accounting for
the large variation seen. In addition, the sample was divided according to sex, percent of
mouth breathing measured, and the subject's perceptions of respiratory pattern to ascertain
whether these variables had been influential in the plethysmographic measurements. The
variability between measurements was not influenced by perception of breathing mode. It
appeared that female subjects and those who registered less than 10% mouth breathing had
significantly stronger correlations and may have had less variation in breathing modes.
However, it should be noted that one male subject significantly affected the correlation
coefficient. When the value for this one subject was eliminated, no statistically significant
difference was evident between the sexes.
The total variation in the measurements for percent of mouth breathing could have been due
either to differences in two sets of measurements for the same individual at different times,
or to variations between different subjects. The intraclass correlation was calculated to
assess the contribution of variation from these two separate sources. The correlation was
0.885, demonstrating that the variation in the two measurements for one particular subject
was not great. However, the variation among different subjects accounted for a high
proportion of the total variation.
Percent mouth breathing
The oral component of respiration varied between 0% for nose breathers to 100% for total
mouth breathers. The results for the first measurement were plotted according to the
subjective perceptions of breathing patterns and can be seen in Fig. 3.


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• Fig. 3.
First-visit plethysmograph measurements plotted according to subjects' or parents'
perceptions of breathing pattern. Percent of mouth breathing was calculated as the
mean of a 10-minute recording on the head-out body plethysmograph.
sixteen subjects (32.7%) registered as total nose breathers, while only two (4.3%) registered
as 100% mouth breathers. Most subjects used an oronasal breathing pattern in the range of
40% to 80%. No one measured between 5% and 40% oronasal breathing for either the first
or the second visit.
The correlation between breathing patterns on different days was less strong than the
correlation between patterns on the same day. Ten of the 36 subjects measured on the
second visit registered a variation from the first day of greater than 15%. Five of these 10
switched from complete nasal breathing to predominantly mouth breathing, and 2 changed
from oral breathing to total nasal respiration. In addition, female subjects had significantly
less variation than male subjects. Perceptions, time of day, and season did not appear to
have significant influences on the temporal variation in percent of mouth breathing.
The evident variation made it difficult to categorize subjects as mouth breathers or nose
breathers. Therefore, measurements from the first visit, the second visit, and an average of
these two values were all used for statistical comparisons requiring classification of
breathing patterns. Findings were reported only if significant relationships were identified
for all three of these separate classifications of breathing pattern.
Nasal power and nasal airway resistance
Verification studies
The verification measurements for nasal power and nasal airway resistance were divided
according to those taken before and after the plethysmograph portion of the experiment that
was performed on the same day. Two subjects were unable to perform the breathing
exercise required by the procedure. Lack of patency between the pharynx and the oral
cavity from contraction of the pharyngeal musculature in persons who were unable to
complete the procedure have been described in previous research.14 The small mean
differences between readings and the strong correlation coefficients for nasal power (r =
0.91) and nasal airway resistance (r = 0.99) of expiration values taken after the
plethysmograph led us to use these measures in analyzing relationships between percent of
mouth breathing and dental and skeletal variables.
Relationship to percent mouth breathing
The Pearson correlation coefficients were calculated and scatterplots were derived for
measured percent of mouth breathing and nasal power/nasal airway resistance. No
statistically significant correlation, threshold level, or apparent relationship could be found
between plethysmograph measurements of oral breathing and either the degree of nasal
resistance or the amount of work required to breathe through the nose (Fig. 4).


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• Fig. 4.
First-visit plethysmograph measures (as percent of mouth breathing) plotted against
nasal power (in milliwatts).
Perception of breathing mode
Information provided by the subjects or their parents was used for comparisons between
measured and perceived breathing patterns. Both an estimation of percent of nasal and oral
breathing and a categorization of patients as nose or mouth breathers were requested. A t
test was performed to determine whether the perceived breathing pattern was significantly
different from the quantitatively measured breathing pattern (Fig. 3), nasal power, or nasal
airway resistance. There was no evidence that a subject's or a parent's impression of
breathing mode had any statistically significant relationship to any of these objective
assessments of respiratory function.
Dental and skeletal relationships
The variability in the dental parameters examined could not be explained by the percent of
mouth breathing measured. Angle classification and presence or absence of either crossbite
or anterior open bite were not explained significantly by respiratory mode. Also, no
relationship was found between maxillary or mandibular intermolar width and measured
percent of oral breathing. Age and sex did not affect these results.
As subjects increased the degree of mouth breathing, there was a weak but significant
tendency toward a Class II skeletal pattern and retroclined maxillary and mandibular
incisors. Significant findings for the multiple linear regression analysis comparing
cephalometric measurements and percent of mouth breathing are shown on Table III.


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The r2 values give the percentage of the variation seen in the cephalometric measurements
that was explained by mouth breathing after adjustment for age and sex. ANB was
correlated most strongly with mouth breathing. Thirty-eight percent of the 0.41° increase in
ANB was explained by a 10% increase in mouth breathing. The maxillary and mandibular
incisor positions also were affected significantly. With every 10% increase in mouth
breathing, maxillary and mandibular incisors decreased 1.0° for 1 SN and 1̄ MP,
respectively. In the vertical plane, no relationships were found to be statistically significant
after adjustments had been made for age and sex.
Estimated perception of mouth breathing by parents and subjects also was used to classify
individuals. As with the plethysmograph breathing measurements, no statistically
significant dental relationships were found. Significant cephalometric results are shown in
Table IV.


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Vertical relationships, including anterior facial height and mandibular plane, were most
affected. As perceived mouth breathing increased by 10%, SN-MP increased by +0.70° and
PP-MP by +0.80°; 13:0% of this variation in cephalometric values was explained by mouth
breathing in the cases involving increased SNMP and in 21.5% of the variation with
increased PP-MP. Anterior facial height, as measured by N-Me, also increased by 0.70 mm
with every 10% increase in perceived mouth breathing. There were no significant findings
with respect to the anteroposterior plane or incisor position.
Analyses of the associations between dentofacial variables and nasal airway resistance, as
well as nasal power, were also performed. No statistically significant dental or
cephalometric relationships were found.
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Discussion
The results of this study revealed that the plethysmograph measurements of the oral and
nasal components of breathing, as well as the subjective perception of respiratory pattern,
could not be associated with either nasal power or nasal airway resistance. In the past, nasal
power has been examined infrequently in studies assessing respiratory activity and its
effects on facial development. In one study, Trask11 reported greater nasal power readings
for mouth-breathing siblings with allergies, compared with their nonallergic siblings.
Unfortunately, although nasal power appears to be a more sensitive measure of estimating
nasal obstruction,12 studies using nasal resistance as the criterion for assessing respiratory
activity have been more popular in determining relationships between dentofacial variables
and breathing pattern.15, 16, 17 In agreement with our findings, Hartgerink and Vig17 have
reported a lack of association between nasal resistance and respiratory pattern when 38
orthodontic patients were compared with a group of 24 control subjects between the ages of
8 and 14. On the other hand, in a study of 100 adult subjects, Warren18 reports that airway
impairment and obligatory mouth breathing occur at a threshold of 4.9 cm H2O/L/sec of
nasal airway resistance, which corresponds to a nasal cross-sectional area of 0.4 cm.2
Although the sample in our study came from a much younger population, there was no
threshold level at which nasal resistance was associated with quantitatively assessed mouth
breathing and therefore no demonstrable relationship between them. Consideration,
however, must be given to the disparate samples with respect to remaining facial and nasal
growth, atrophy of lymphoidal tissues, and other age-related factors. These variables may
have influences on nasal airway function, making comparisons difficult between the two
study groups.
The measurement of nasal airway resistance itself should be examined. Warren18 states
that as a nasal airway is impaired, resistance increases. The body responds with obligate
mouth breathing, thereby reducing the degree of resistance. This measurement represents
the cross-sectional area of the nasal cavities and does not appear to reveal directly a
person's pattern of breathing. Direct measurements of oral and nasal components of
respiration have been accomplished by Gurley and Vig19 and by Keall and Vig.20 The
simultaneous nasal and oral respirometric technique, or SNORT, is capable of separating
nasal and oral airflow through a system of valves, transducers, and flow meters to make
recordings.
In the present investigation, respiratory patterns were obtained by direct measurement of
oral and total airflow with the head-out body plethysmograph. A significant degree of
variation was evident in some children whose breathing was measured twice within 1 hour.
However, the variation in measurements obtained by this system was similar to that in a
report on the inductive plethysmographic technique described by Warren et al.21 The
device used assessed nasal and tidal air volume without enclosing the subject in an airtight
box. Although the validation methods were different, the intraclass correlations to assess
variation within subjects ranged between 0.760 and 0.929 for Warren's technique and 0.885
for our study. Despite the apparent strong correlations between the head-out body and
inductive plethysmograph techniques, these methods must be received with caution because
of the possibility for individual variations that a summary correlation statistic cannot reveal.
Our evaluation of the breathing modes of growing children measured on different days
showed variations that may be attributed to inherent fluctuations in respiratory activity.
Nasal breathing cycles, which have a 3-hour average periodicity with a range of 1 to several
hours, have been found to occur in 80% of adults.22, 23 The patency measured in each
nostril varies, and yet the total resistance remains constant. Children, however, do not
maintain uniform conductivity from alternating nasal patency.24 Instead, nasal passage
obstruction is random in nature and will fluctuate throughout the day with periods of
congestion. Van Cauwenberge and Deleye24 reported that the duration of the cycle in
children averages 57 minutes, although this will vary immensely on an individual basis.
This recognized cyclic nature of respiration could explain the numerous “switchers” that
alternated from total nasal breathing to complete oral respiration and, conversely, on
separate visits. The variation in measurements recorded on the same day within an hour
also could be a product of the nasal breathing cycle.
The possibility that the variation measured in our study might be a result of the method
itself cannot be discounted. Although the plethysmograph is noninvasive, awareness that
the airway is being assessed is an inherent difficulty in any evaluation. Attempts to breathe
normally with a mouthpiece in place easily could influence a person to increase the oral
component of breathing. This has been suggested in a recent study by Hairfield and
associates.25 Adult subjects had greater oral airflow during respiration when plastic tubing
was placed in the mouth. An inverse relationship was found between the degree of mouth
breathing and the distribution of airflow through the nose. Although this suggests the
possibility of technique-induced breathing patterns, there are several reasons not to consider
the plethysmograph measurements as entirely invalid. First, it is notable in this study that
half of those whose breathing varied more than 15% on the same day also had high
variations when measured on two separate days. This finding supports a theory of more
profound cyclic respiration in certain persons. In addition, the correlation between
measurements taken within an hour was significantly stronger than the correlation between
measurements recorded on separate days. Furthermore, the plethysmograph values were
taken over a 10-minute period and were averaged over this entire interval to adjust for the
possibility of fluctuations or spurious measurements caused by postural adaptations to the
measuring device. Despite these findings and precautions, it appears that both inherent
respiratory fluctuations and difficulties in technique, as well as nasal power and nasal
airway resistance, may contribute to variations in plethysmograph measures.
Measures for percent of mouth breathing in this study revealed that the subjects were either
total nasal breathers or combined oral and nasal breathers. Only two subjects measured
100% oral respiration. Therefore, the term mouth breathing should be reconsidered. Pure
mouth breathing appears to be unusual. From these and other findings,26, 27 oronasal
breathing seems more common. This theory is in agreement with that of Hartgerink and
Vig,17, 28 who also demonstrated that 100% mouth breathing occurred infrequently. The
absence of measurements between 5% and 40% mouth breathing also is notable. Perhaps a
threshold exists after which oronasal breathing varies on a continuum. No absolute
definition of mouth breathing can be described; only an arbitrary designation could be
postulated with the present level of knowledge.
In this study, an increase in the oral component of respiration was associated weakly with a
skeletal Class II pattern and retroclination of maxillary and mandibular incisors. Although
the correlation was statistically significant, its clinical importance is questionable because
of the degree of association measured. However, previous reports have shown similar
findings. Freng29 studied 11 patients with restricted nasal respiratory function due to
choanal atresia. Sagittal differences were affected significantly. Retrognathia of both the
maxilla and the mandible were observed, while vertical facial dimensions were similar for
both control subjects and patients. Linder-Aronson6 has reported that children with nasal
obstruction from enlarged adenoidal tissue are characterized not only by a more
retrognathic profile and retroclined maxillary and mandibular incisors but also by
distinctive vertical facial features. Increased total and lower anterior facial heights, as well
as steeper mandibular planes, typified children with nasopharyngeal obstruction. In
contrast, Hartgerink and Vig17 examined vertical relationships and found no association
with an objective measurement of percent of nasal respiration. Solow et al.30 studied 24
children with no history of nasal obstruction. Mandibular retrognathia and retroclination of
the maxillary incisors were found in association with obstructed nasopharyngeal airway,
defined radiographically and rhinomanometrically. Despite these findings in previous
studies, comparisons are difficult to make. Classifications of subjects as mouth breathers
and nasal breathers were dissimilar. Associations were made between very different
samples, so interpretation must be made with this fact in mind.
Our findings also indicated a lack of association between either nasal power or nasal airway
resistance and dentofacial characteristics. In a study by Trask et al.,11 no relationship was
found between nasal power and facial form (Trask, 1989 personal communication). Watson
et al.15 examined 51 subjects to compare nasal airway resistance and sagittal skeletal
dimensions. No relationships were determined between nasal resistance and the
cephalometric parameters analyzed. In a report by Vig et al.,16 28 adult subjects were
grouped according to vertical facial proportions and lip competency. Values for nasal
resistance were measured and found to be unrelated to facial morphology. Similarly,
Hartgerink and Vig17 have reported no significant relationships between vertical facial
characteristics and the degree of nasal airway obstruction measured by resistance. These
conclusions are consistent with our finding that nasal airway resistance was not associated
with respiratory pattern. Nasal respiration in children appears to exist despite varying
degrees of resistance.
In our report, vertical relationships were found to be related weakly to the subject's/parent's
impression of breathing mode. As the degree of perceived mouth breathing increased,
anterior facial height and mandibular plane steepness also increased. Subjective opinion as
a source of information for determination of nasorespiratory condition has been employed
in past studies.6, 10, 11 Previous findings of increased vertical dimensions are in agreement
with the results of this report. However, objectively measured respiratory activity did not
correlate with subjective perception in this study. Those who perceived themselves as
mouth breathers often based their assessments on open-mouth posture. One can speculate
that posture may largely influence vertical facial relationships. Yet Vig28 argues that there
is a minimal level of muscular activity for posture. A greater threshold is required to
maintain muscular balance for respiration. This larger degree of muscular control may be
responsible for variations in dentofacial morphology seen in mouth breathers, which may
not be attributed to the weaker neuromuscular requirements of posture only. Another
possibility may be that some subjects develop a habitual open position after an earlier
period of actual mouth breathing, despite presently measured nasal respiration. Perhaps,
then, those who were measured as nasal breathers in this study had been oronasal breathers
at one time when influences on dentofacial form were strongest. This theory might allow an
understanding of the variations in vertical facial dimensions seen in this and other studies
with regard to classifications of individuals by perceived respiratory pattern. The period in
which facial development can be most readily influenced by respiratory mode cannot be
addressed in a cross-sectional study.
This investigation made initial efforts to assess respiratory patterns objectively and to
evaluate influences on dentofacial morphology in children from an orthodontic population.
Variations in sagittal relationships and retroclination of incisors were partially explained by
plethysmograph measurements with respect to percent of mouth breathing. In contrast,
subjective perceptions of respiratory patterns were associated mildly with increases in
vertical facial structure. In both objective and subjective assessments of respiratory
patterns, associations with dentofacial variables were not adequate to warrant strong
generalizations about causal relationships. In addition, nasal power and nasal airway
resistance could not be correlated with either subjectively determined or objectively
measured oral respiration, or with dentofacial characteristics. From this study, it is clear
that the classification of individuals according to respiratory pattern is a complex issue.
Furthermore, although the effects of mouth breathing on dentofacial morphology were
statistically significant, the magnitude of the variations explained by oral respiration were
not great. Stronger correlations and a more thorough analysis of respiratory patterns may be
required to support decisions for clinical intervention. Questions also remain as to the
timing of the possible effects of respiratory mode on dentofacial form. If the period during
which influences are strongest were known, intervention could be timed to have its greatest
value. Finally, longitudinal evaluations involving objective assessment of breathing pattern
are crucial and deserve further research.
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Acknowledgements
We gratefully acknowledge the technical assistance of Garrett Hayashi, Quentin Hanley,
and Viviana Rebellodo, as well as the statistical assistance of Dr. Timothy DeRouen and
Lloyd Mancl.
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References
1. Harvold EP, Vargervik K, Chierici G. Primate experiments on oral respiration.
AM J ORTHOD. 1973;63:494–508
○ View In Article
○ Full-Text PDF (5031 KB)
○ CrossRef

2. Harvold EP, Tomer BS, Vargervik K, Chierici G. Primate experiments on oral


respiration. AM J ORTHOD. 1981;79:359–372
○ View In Article
○ Abstract
○ Full-Text PDF (4025 KB)
○ CrossRef

3. Miller AJ, Vargervik K. Neuromuscular adaptation in experimentally induced


oral respiration in the rhesus monkey (Macaca mulatta). Arch Oral Biol.
1980;25:579–589
○ View In Article
○ MEDLINE
○ CrossRef

4. Miller AJ, Vargervik K, Chierici G. Sequential neuromuscular changes in rhesus


monkeys during the initial adaptation to oral respiration. AM J ORTHOD.
1982;81:99–107
○ View In Article
○ Abstract
○ Full-Text PDF (2136 KB)
○ CrossRef

5. Linder-Aronson S, Backstrom A. A comparison between mouth and nose


breathers with respect to occlusal and facial dimensions. Odont Rev.
1960;2:343–376
○ View In Article

6. Linder-Aronson S. Adenoids: their effect on mode of breathing and nasal


airflow and their relationship to characteristics of the facial skeleton and
dentition. Acta Otolaryngol (Stockh). 1970;265(suppl):5–132
○ View In Article
7. Linder-Aronson S. Effects of adenoidectomy on dentition and nasopharynx. AM
J ORTHOD. 1974;65:1–15
○ View In Article
○ Abstract
○ Full-Text PDF (1042 KB)
○ CrossRef

8. Linder-Aronson S. Nasorespiratory function and craniofacial growth. In:


Nasorespiratory function and craniofacial growth. McNamara JA editors.
Monograph 9. Ann Arbor: Center for Human Growth and Development, University
of Michigan; 1979; 1979
○ View In Article

9. Bresolin D, Shapiro G&, Shapiro PA, Chapko MK, Dassel S. Mouthbreathing in


allergic children: Its relationship to dentofacial development. AM J ORTHOD.
1983;83:334–340
○ View In Article
○ Abstract
○ Full-Text PDF (748 KB)
○ CrossRef

10. Bresolin D, Shapiro GG, Shapiro PA, Chapko MK, Dassel S. Facial
characteristics of allergic mouthbreathers versus nonallergic nasal breathers.
Pediatrics. 1984;73:622–625
○ View In Article
○ MEDLINE

11. Trask GM, Shapiro GG, Shapiro PA. The effects of perennial allergic rhinitis on
dental and skeletal development: a comparison of sibling pairs. AM J ORTHOD
DENTOFAC ORTHOP. 1987;92:286–293
○ View In Article
12. Walker S, Shapiro GG, Bierman W, Morgan M, Marshall S, Furukawa C, et al.
Induction of eustachian tube dysfunction with histarnine nasal provocation. J
Allergy Clin Immunol. 1985;76:158–162
○ View In Article
○ MEDLINE
○ CrossRef

13. Warren DW. Aerodynarnic studies of upper airway: implications for growth,
breathing and speech. In: Nasorespiratory function and craniofacial growth.
McNamara JA editors. Monograph 9. Ann Arbor: Center for Human Growth and
Development, University of Michigan; 1979; 1979
○ View In Article

14. Timms DJ, Trenouth MJ. A quantified comparison of craniofacial form with
nasal respiratory function. AM J ORTHOD DENTOFAC ORTHOP. 1988;94:216–
221
○ View In Article

15. Watson RM, Warren DW, Fischer ND. Nasal resistance, skeletal classification,
and mouthbreathing in orthodontic patients. AM J ORTHOD. 1968;54:367–379
○ View In Article
○ Abstract
○ Full-Text PDF (330 KB)
○ CrossRef

16. Vig PS, Sarver DM, Hall DJ, Warren DW. Quantitative evaluation of nasal
airflow in relation to facial morphology. AM J ORTHOD. 1981;79:263–272
○ View In Article
○ Abstract
○ Full-Text PDF (616 KB)
○ CrossRef

17. Hartgerink DV, Vig PS. Lower anterior facial height and lip incompetance do
not predict nasal airway obstruction. Angle Orthod. 1989;59(1):17–23
○ View In Article
○ MEDLINE

18. Warren DW, Hairfield WM, Seaton DL, Hinton VA. The relationship between
nasal airway cross-sectional area and nasal resistance. AM J ORTHOD
DENTOFAC ORTHOP. 1987;92:390–395
○ View In Article

19. Gurley WH, Vig PS. A technique for the simultaneous measurement of nasal
and oral respiration. AM J ORTHOD. 1982;82:33–41
○ View In Article
○ Abstract
○ Full-Text PDF (1751 KB)
○ CrossRef

20. Keall C, Vig PS. An improved technique for the simultaneous measurement of
nasal and oral respiration. AM J ORTHOD DENTOFAC ORTHOP. 1987;91:207–
212
○ View In Article

21. Warren DW, Hinton VA, Hairfield WM. Measurement of nasal and oral
respiration using inductive plethysmography. AM J ORTHOD. 1986;89:480–484
○ View In Article
○ Abstract
○ Full-Text PDF (418 KB)
○ CrossRef

22. Kern EB. Rhinomanometry. Otolaryngol Clin North Am. 1973;6:863–873


○ View In Article
○ MEDLINE

23. Hasegawa M, Kern EB. The human nasal cycle. Mayo Clin Proc. 1977;52:28–34
○ View In Article
○ MEDLINE

24. Van Cauwenberge PB, Deleye L. Nasal cycle in children. Acta Otolaryngol
(Stockh). 1984;110:108–110
○ View In Article

25. Hairfield WM, Warren DW, Dalston ET. Effect of mouth opening on oral/nasal
airflow distribution. J Dent Res. 1989;68:184
○ View In Article

26. Niinimaa V, Cole P, Mintz S, Shepard RS. The switching point from nasal to
oronasal breathing. Respir Physiol. 1980;42:61–71
○ View In Article
○ MEDLINE
○ CrossRef

27. Niinimaa V, Cole P, Mintz S, Shepard RS. Oronasal distribution of respiratory


airflow. Respir Physiol. 1981;43:69–75
○ View In Article
○ MEDLINE
○ CrossRef

28. Vig PS. Respiratory mode and morphological types: some thoughts and
preliminary conclusions. In: Nasorespiratory function and craniofacial growth.
McNamara JA editors. Monograph 9. Ann Arbor: Center for Human Growth and
Development, University of Michigan; 1979; 1979
○ View In Article

29. Freng A. Dentofacial development in long lasting nasal stenosis. Scand J Dent
Res. 1979;87:260–267
○ View In Article
30. Solow B, Siersbæk-Nielsen SS, Greve E. Airway adequacy, head posture, and
craniofacial neurology. AM J ORTHOD. 1984;86:214–223
○ View In Article
○ Abstract
○ Full-Text PDF (929 KB)
○ CrossRef