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1 university of copenhgen Københvns Universitet Risk fctors for smll phryngel irwy dimensions in preorthodontic children Anndrjh, Seerone; Dudhi, Rhib; Sndhm, Andrew; Sonnesen, Liselotte Published in: Angle Orthodontist DOI: / Publiction dte: 2017 Document Version Publisher's PDF, lso known s Version of record Cittion for published version (APA): Anndrjh, S., Dudhi, R., Sndhm, A., & Sonnesen, L. (2017). Risk fctors for smll phryngel irwy dimensions in preorthodontic children: A three-dimensionl study. Angle Orthodontist, 87(1), Downlod dte: 29. dec
2 Originl Article Risk fctors for smll phryngel irwy dimensions in preorthodontic children: A three-dimensionl study Seerone Anndrjh ; Rhib Dudhi b ; Andrew Sndhm c ; Liselotte Sonnesen d ABSTRACT Objective: To nlyze which prmeters, gthered from stndrd orthodontic dignostic mteril, were most relevnt for identifying smll phryngel irwy dimensions in preorthodontic children. Mterils nd Methods: The smple ws composed of 105 cone bem computed tomogrphy scns of helthy preorthodontic children (44 boys, 61 girls; men ge, yers). Airwy volume nd miniml cross-sectionl re were three-dimensionlly ssessed. Cephlometric fetures nd skeletl mturity were ssessed on generted two-dimensionl cephlogrms. Associtions were nlyzed nd djusted for ge, gender, nd skeletl mturity by multiple regression nlyses. Results: Airwy volume nd miniml cross-sectionl re were significntly smller in prepubertl children (P,.001, P,.05, respectively) nd positively ssocited with ge (P,.001, P,.01, respectively). After djustment of ge, skeletl mturity nd gender significnt ssocitions were found between phryngel irwy dimensions nd crniofcil morphology. Airwy volume ws positively ssocited with mxillry nd mndibulr width (P,.01; P,.001, respectively) nd nterior fce height (P,.05; P,.05, respectively). Miniml cross-sectionl re ws positively ssocited with mxillry nd mndibulr width (P,.01; P,.001, respectively) nd negtively ssocited with sgittl jw reltionship (AnPg, P,.05). Mndibulr width nd ge were the most relevnt fctors for irwy volume (r 2 ¼ 0.36). Mndibulr width nd sgittl jw reltionship were the most relevnt fctors for miniml cross-sectionl re (r 2 ¼ 0.16). Conclusion: Phryngel irwy dimensions were significntly ssocited with ge, skeletl mturity, nd crniofcil morphology in ll three plnes. Children with reduced mndibulr width nd incresed sgittl jw reltionship re prticulrly t risk of hving smll phryngel irwy dimensions. (Angle Orthod. 2017;87: ) KEY WORDS: Phryngel irwy; Children INTRODUCTION Privte Prctice, Adelide, South Austrli, Austrli. b Privte Prctice, Brisbne, Queenslnd, Austrli. c Adjunct Professor nd Director of Postgrdute Progrm, Deprtment of Orthodontics, College of Medicine nd Dentistry, Jmes Cook University, Cirns, Austrli. d Associte Professor nd Director of Postgrdute Progrm, Section of Orthodontics, Deprtment of Odontology, Fculty of Helth nd Medicl Sciences, University of Copenhgen, Denmrk. Corresponding uthor: Dr Liselotte Sonnesen, Section of Orthodontics, Deprtment of Odontology, Fculty of Helth nd Medicl Sciences, University of Copenhgen, 20 Nørre Alle, DK Copenhgen N, Denmrk (e-mil: lson@sund.ku.dk) Accepted: April Submitted: Jnury Published Online: June 15, 2016 Ó 2017 by The EH Angle Eduction nd Reserch Foundtion, Inc. Incresed interest in upper irwy dimensions nd morphology during the pst few decdes cn be ttributed to the pprecition tht upper irwy configurtion is ssocited with sleep disordered brething (SDB) s well s its generl reltionship to crniofcil morphology. 1,2 Erly dignosis of SDB, or potentil ssocitions of SDB, is essentil to encourge norml fcil development. 3,4 Reduced phryngel dimensions estblished erly in life could potentilly predispose to lter development of SDB or even obstructive sleep pne (OSA) becuse soft tissue chnges relted to ging, obesity, or genetic bckground further reduce orophryngel ptency. 5 Crniofcil morphology hs been ssocited with the upper irwy in children. In the sgittl dimension 138 DOI: /
3 PHARYNGEAL AIRWAY DIMENSIONS IN CHILDREN 139 ssessed by the sgittl jw reltionship, it ws generlly found tht ptients with Clss 3 skeletl pttern hve greter irwy volume thn skeletl Clss 1, which is greter thn skeletl Clss However, this difference ws not lwys sttisticlly significnt between the groups 7 or between skeletl Clss 1 nd Clss 3. 6 The miniml cross-sectionl re ws lso found to be greter in skeletl clss 1 ptients thn in Clss 2 ptients, 8,9 nd even greter in Clss 3 ptients. 8 Differences in upper irwy morphology hve been described in individuls with Clss 2 skeletl pttern exhibiting more of bckwrd orienttion of the irwy to the Frnkfort horizontl (FH) plne when compred with skeletl Clss 3 individuls who hd more verticl orienttion. 7 Clss 3 skeletl ptients were lso found to hve more flt-shped irwy when compred with Clss 1 individuls who hd more squre orophryngel irwy. 12 However, other studies found no significnt differences between skeletl ptterns (Clsses 1, 2, or 3) nd upper irwy dimensions. 13 Reserch into ssocitions between the verticl nd trnsverse crniofcil dimensions nd the threedimensionl upper irwy in children is limited. Correltions hve been reported between upper irwy dimensions nd nterior nd posterior fce heights. 7,11 Di Crlo et l. 13 found no ssocitions between upper irwy dimensions nd crniofcil fetures in the verticl, trnsverse, or sgittl dimensions. However, unlike the other studies, the ptients were scnned in the supine position nd cephlometriclly ssessed three-dimensionlly, nd young dults were included in the smple. Three-dimensionl ssessments of the upper irwy with ge 14,15 hs shown tht irwy dimensions consistently increse until bout 20 yers of ge. After slight decrese, irwy volume considerbly decreses fter 50 yers of ge nd miniml crosssectionl re fter 30 yers of ge. Although the wlls of the upper irwy re constructed of soft tissue structures tht influence luminl size, the crniofcil osseous structures determine the generl size of the upper irwys. 16 Therefore, it could be ssumed tht skeletl mturity is closely ssocited with upper irwy dimensions in children. However, this reltionship hs not been previously ssessed. Prior to orthodontic tretment, mny of the fctors ssocited with phryngel irwy dimensions re lredy obtined nd nlyzed. Study csts nd orthopntomogrms re obtined for the evlution of the dentition nd occlusion, nd lterl nd frontl rdiogrphs re obtined for the evlution of the crniofcil morphology. Explortive studies in which the prticipnts re their own controls hve previously been published in the orthodontic literture. 17,18 Becuse the phryngel irwy is not regulrly three-dimensionlly ssessed in orthodontic clinics, it is relevnt to exmine which fctors re most relevnt for phryngel irwy dimensions bsed on lredy existing dignostic mteril. The present study focuses on phryngel irwy dimensions in reltion to crniofcil morphology, morphologicl occlusion, ge, gender, nd skeletl mturity in children before orthodontic tretment. The im of the study ws to nlyze which prmeters from stndrd orthodontic dignostic mteril were most relevnt for phryngel irwy dimensions in preorthodontic children. MATERIALS AND METHODS The study ws pproved by the institutionl review bord of n estblished university in Queenslnd, Austrli (H5115). Cone bem computed tomogrphy (CBCT) scns were obtined from n existing dtbse of ptients tht ttended privte prctice in Victori, Austrli, for orthodontic tretment from 2011 to Before they were entered into the dtbse, ll CBCT imges were nonymized. Sex, ge, nd morphologicl occlusion ccording to Angle s clssifiction were lso obtined from the dtbse. These were cross-checked with the CBCT scns nd clinicl reports. The inclusion criteri were (1) helthy children between 8 to 16 yers of ge; (2) biting in centric occlusion; nd (3) complete imging of the crnil bse, mxill, mndible, the first four cervicl vertebre (C1 C4), nd the ssocited irwy. The exclusion criteri were (1) previous orthodontic tretment nd/or orthognthic surgery, (2) previous deno-tonsillectomy, (3) known syndroml conditions, (4) presence of pthology detectble long the upper irwy, (5) history of obstructive sleep pne, (6) movement rtefct, nd (7) swllowing during scn cquisition. This resulted in the finl smple of 105 scns (Figure 1). The smple consisted of 61 girls (58.1%) nd 44 boys (41.9%) with men ge of 10.7 (62.4) yers. Scn Protocol All imges were tken by the sme opertor with the sme i-cat Next Genertion CBCT mchine (Imging Sciences Interntionl, Htfield, P). The following prmeters were used: 120 kv, 5 ma, 0.3-mm voxel resolution, 8.9-second scn time, 13 cm (height) 3 16 cm (dimeter) scn volume. Ptients were seted nd restrined with hedrest nd hed strp, but no chin rest to llow Frnkfurt horizontl to be positioned prllel to the floor. Ptients were instructed to close into centric occlusion, relx their tongue nd lips, brethe gently, nd not swllow or move during the cquisition. All CBCTs were reviewed by dento-
4 140 ANANDARAJAH, DUDHIA, SANDHAM, SONNESEN Figure 2. Illustrtion of mrgins for delinetions of the upper irwy (htched). 1. Coronl plne orbitle of both sides were on the sme horizontl plne. 2. Sgittl plne Frnkfort plne ws horizontl. 3. Axil plne line through the crist glli nd the bsion ws verticl. The upper irwy volume nd miniml crosssectionl re were ssessed three-dimensionlly nd mesured ccording to Anndrjh et l. 19 (Figure 2; Tble 1). Crniofcil Morphology Assessment Figure 1. Flowchrt of finl smple size. Crniofcil morphology ws digitlly ssessed on utomticlly constructed two-dimensionl lterl nd posteronterior cephlogrms with no mgnifiction. Stndrd crniofcil mesurements were mde of the crnil bse, mxill, nd mndible ccording to Björk 20,21 nd Yoon et l., 22 with reference points, lines, nd ngles ccording to Solow nd Tllgren 23 nd Yoon et l. 22 (Figure 3, Tble 2). mxillofcil rdiologist (Dr. Dudhi) to ensure tht ll inclusion nd exclusion criteri were met. Imge Preprtion nd Airwy Assessment The Digitl Imging nd Communictions in Medicine (DICOM) dt were processed using Dolphin Imging softwre (version 11.5; Dolphin Imging nd Mngement Solutions, Chtsworth, Clif). Imges were nlyzed under the sme lighting conditions nd by the sme investigtor s previously described. 19 This method ws found to be relible nd reproducible. To stndrdize mesurements the skull ws reoriented in ll three plnes using the following guidelines: 19 Figure 3. Illustrtions of reference points nd lines (dotted) describing crniofcil morphology on lterl (A) nd postero-nterior (B) cephlogrms. 22,23
5 PHARYNGEAL AIRWAY DIMENSIONS IN CHILDREN 141 Tble 1. Antomicl nd Technicl Limits of the Upper Airwy Limit Antomicl Technicl Superior Hrd nd soft plte The line pssing from the pltl plne (ANS to PNS) extending to the posterior wll of the phrynx Inferior Vllecul (plne of hyoid bone; Line pssing from the ntero-superior edge of C4 to menton bse of the epiglottis) Anterior Circumvllte ppille nd the Line pssing from the soft plte to menton orophryngel isthmus Posterior Respective phryngel wlls Posterior wll of the phrynx Lterl Respective phryngel wlls Respective phryngel wlls ANS indictes nterior nsl spine; PNS, posterior nsl spine. Skeletl Mturity Assessment Skeletl mturity ws digitlly ssessed on constructed two-dimensionl lterl cephlogrms by the Cervicl Vertebrl Mturtion index ccording to Bccetti et l. 24 nd ctegorized s prepubertl, pubertl, nd postpubertl ccording to Pheln et l. 25 Relibility A totl of 25 scns were rndomly selected for ech vrible nd remesured 2 weeks fter the initil mesurement. The method error for the irwy volume nd miniml cross-sectionl re hs been previously reported by the uthors (1.90% nd 0.49%, respectively). 19 For ech of the crniofcil mesurements, no systemtic error ws found nd the method error Tble 2. Reference Points, Lines, nd Angles According to Solow nd Tllgren (1976) 23 nd Yoon et l. (2004) 22 Lndmrk Abbrevition Definition Points Sell S The centre of sell turcic, the upper limit of which is defined s the line joining the tuberculum nd the dorsum sell Nsion N The most nterior point of the fronto-nsl suture Bsion B The most postero-inferior point on the clivus A point A The most posterior point on the nterior contour of the mxillry lveolr rch B point B The most posterior point on the nterior contour of the mndibulr lveolr rch Pogonion Pg The most nterior point on the mid-sgittl mndibulr symphysis Anterior nsl spine ANS The pex of the nterior nsl spine Posterior nsl spine PNS The tip of the posterior nsl spine Menton Me The most inferior point on the mid-sgittl mndibulr symphysis Gonion (lt ceph ) Go The most postero-inferior point on the ngle of the mndible, indicted by bisection of the RL to ML Gonion (PA ceph ) Go nd Go The most lterl point on the convex mrgin on the ngle of the mndible Articulre Ar The intersection between the externl contour of the crnil bse nd the dorsl contour of the condylr hed or neck Mxillry notch Mx nd Mx The intersection of the zygomtic buttress nd outline of the tuberosity Upper 6 occlusl U6o The mesio-buccl cusp tip of the mxillry molr Lower 6 occlusl L6o The mesio-buccl cusp tip of the mndibulr molr U1 incisl tip U1i The mid-point of the incisl edge of the most prominent upper centrl incisor L1 incisl tip L1i The mid-point of the incisl edge of the most prominent lower centrl incisor Lines Overjet OJ The length difference between U1i nd L1i s mesured long the Mx occlusl line Overbite OB The overlp difference between U1i nd L1i s mesured perpendiculr to the Mx occlusl line Mxillry occlusl line OLs The line pssing through U6o nd U1i Nsion-sell line NSL The line pssing through N nd S Nsl line NL The line pssing through ANS nd PNS Mndibulr line ML The tngent to the lower border of the mndible through Me Rml line RL The tngent to the posterior border of the mndible through Ar Pltl width Mx -Mx The distnce between Mx nd Mx Mndibulr width Go -Go The distnce between Go nd Go Angles Gonil ngle Go The ngle formed between RL nd ML Bet ngle b The ngle formed between ML nd constructed line from Ar to the intersection between ML nd perpendiculr line to it through Pg lt ceph indictes lterl cephlogrm; PA ceph, postero-nterior cephlogrm.
6 142 ANANDARAJAH, DUDHIA, SANDHAM, SONNESEN Tble 3. Descriptive nd Numericl Dt Dimension or shpe Minimum Mximum Men Stndrd Devition Upper irwy dimensions Volume, mm Miniml cross-sectionl re, mm Crniofcil morphology Incisl reltionships Overjet, mm Overbite, mm Crnil bse ngle SNB, degrees Sgittl crniofcil dimension SNA, degrees SNB, degrees SNPg, degrees ANB, degrees ANPg, degrees Verticl crniofcil dimension SN-NL, degrees SN-MP, degrees MMP, degrees ANS-Me, mm N-ANS, mm N-Me, mm LAFH, % S-B, mm S-PNS, mm S-Go, mm Trnsverse crniofcil dimension Mx -Mx, mm Go -Go, mm Mndibulr shpe Gonil ngle, degrees b-ngle, degrees rnged from 0.13% to 9.37%. The relibility coefficient rnged from 0.94 to Sttistics The normlity of distribution ws ssessed by prmeters of skewness nd kurtosis nd Shpiro- Wilks W-tests. The irwy volume nd miniml crosssectionl re differed modertely from the norml distribution nd were trnsformed logrithmiclly. The smple ws screened for outliers by boxplots of ech vrible. No outliers were found. Associtions between irwy dimensions nd the continuous vribles were ssessed by the Spermn correltion nlysis. Associtions between irwy dimensions nd ctegoricl vribles were nlyzed by nlysis of vrince, followed by post hoc Bonferroni tests. Ech of the significnt ssocitions ws then tested for the effect of gender, ge, nd skeletl mturity by liner regression nlysis. The most relevnt vribles for irwy dimensions were nlyzed by liner regression nlysis. All sttisticl nlyses were performed using SPSS for Windows version 22.0 (IBM Corp., Armonk, NY) nd considered significnt t P,.05. RESULTS Of the study popultion, 54.3% ws in the prepubertl stge of skeletl mturity, 29.5% ws in the pubertl stge, nd 16.2% ws in the postpubertl stge. The morphologicl occlusion ccording to Angle s clssifiction included 36.2% clss 1, 56.2% clss 2, nd 6.7% clss 3. The men vlues for the upper irwy nd crniofcil morphology re presented in Tble 3. Airwy volume nd miniml cross-sectionl re were significntly smller in prepubertl children when compred with pubertl children (P,.001, P,.05, respectively; Figures 4 nd 5) nd positively ssocited with ge (P,.001, P,.01, respectively). Gender nd molr occlusion were not significntly ssocited with irwy volume or miniml cross-sectionl re. After djusting for ge, skeletl mturity, nd gender, significnt positive ssocitions were found between irwy volume nd crniofcil morphology: mxillry nd mndibulr width (Mx -Mx, P,.01; Go -Go, P,.001; Tble 4) nd nterior fce height (N-Me, P,.05; N-ANS, P,.05; Tble 4). Miniml cross-sectionl re ws positively ssocited with mxillry nd mndibulr width (Mx -Mx, P,.01; Go -Go, P,
7 PHARYNGEAL AIRWAY DIMENSIONS IN CHILDREN 143 Figure 4. Airwy volume in reltion to skeletl mturity. NS, not significnt. 1 ¼ prepubertl, 2 ¼ pubertl, 3 ¼ postpubertl. * P.05; ** P.01; *** P ; Tble 5) nd negtively ssocited with sgittl jw reltionship (AnPg, P,.05; Tble 5). No other significnt ssocitions were found. For irwy volume, the most relevnt vribles were mndibulr width nd ge (r 2 ¼ 0.36; Tble 6). Mndibulr width nd sgittl jw reltionship were the most relevnt fctors for miniml cross-sectionl re (r 2 ¼ 0.16; Tble 6). DISCUSSION Dimensions of helthy phryngel irwy re influenced by growth, 14 16,26,27 ntomicl, 6 13 postur- Figure 5. Airwy miniml cross-sectionl re in reltion to skeletl mturity. 1 ¼ prepubertl, 2 ¼ pubertl, 3 ¼ postpubertl. NS, not significnt. * P.05; ** P.01; *** P.001.
8 144 ANANDARAJAH, DUDHIA, SANDHAM, SONNESEN Tble 4. Significnt Associtions Between Airwy Volume nd Gender, Age, Skeletl Mturity, Crniofcil Fetures, nd Occlusion After Adjustment of Gender, Age, nd Skeletl Mturity Vrible Correltion Coefficient, r P Vlue Verticl crniofcil dimension N-Me, mm b N-ANS, mm b Trnsverse crniofcil dimension Mx -Mx b Go -Go b N-Me indictes the distnce between N nd Me; N-ANS, the distnce between N nd ANS; Mx -Mx, the distnce between Mx nd Mx; Go -Go, the distnce between Go nd Go. b Also significnt for the effect of ge. l, nd mechnicl fctors. 32,33 Therefore, it is importnt to perform multifctoril nlyses of the upper irwys. Becuse growth-relted nd ntomicl fctors re routinely ssessed from stndrd orthodontic mteril, it is cliniclly relevnt to investigte which of these prmeters re relevnt to phryngel irwy dimensions. In the present study, no significnt differences in irwy dimensions were found between molr clsses 1, 2, nd 3. This is supported by other studies 34,35 possibly becuse ny mlocclusion cn exist on ny underlying skeletl pttern s result of the dentolveolr compenstory mechnism. 36 It is osseous nd soft tissue structures tht frme the irwy tht determine its size nd morphology. 8,16 There ws no sttisticlly significnt gender difference in irwy dimensions, which is lso in greement with previous findings. 6 8,11 However, one study found tht boys not only hd longer nd lrger irwy thn girls but lso experienced quicker increse in dimensions fter 11 yers of ge. 15 During ctive growth, upper irwy dimensions increse s ws demonstrted in the present study. Growth nd development of the upper irwy is influenced by chnges in the bony frmework until mturity is reched. 16 Consequently, it could be ssumed tht skeletl mturity is closely ssocited Tble 5. Significnt Associtions Between Airwy Miniml Cross- Sectionl Are nd Gender, Age, Skeletl Mturity, Crniofcil Fetures, nd Occlusion After Adjustment of Gender, Age, nd Skeletl Mturity Vrible Correltion Coefficient, r P Vlue Sgittl crniofcil dimension ANPg b Trnsverse crniofcil dimension Mx -Mx b Go -Go ANPg indictes the ngle between A, N nd Pg; Mx -Mx, the distnce between Mx nd Mx; Go -Go, the distnce between Go nd Go. b Also significnt for the effect of ge. Tble 6. Most Relevnt Fctors Associted With Upper Airwy Dimensions Fctor Correltion Coefficient, r P Vlue Volume Go -Go Age.007 Miniml cross-sectionl irwy ANPg Go -Go.001 ANPg indictes the ngle between A, N nd Pg; Go -Go, the distnce between Go nd Go. with upper irwy dimensions during this period. However, ssessment of this reltionship is limited. The dimensionl irwy chnges in reltion to skeletl mturity observed in the present study could reflect growth-relted chnges of bony structures surrounding the phryngel irwys. Vrious studies found significnt ssocitions with sgittl crniofcil dimensions nd upper irwy dimensions with regrd to volume nd miniml crosssectionl re. 6,8 11 In generl, irwy dimensions were negtively correlted to the sgittl jw reltionship, for exmple, s result of mndibulr retrognthism, nd positively correlted to mndibulr prognthism. Therefore, it ws found tht skeletl clss 3 ptients hd greter irwy volume thn clss 1, which ws greter thn skeletl clss 2 ptients However, this difference ws not lwys sttisticlly significnt between the groups 7 or between clss 1 nd clss 3. 6 Conflicting results hve been reported regrding miniml cross-sectionl re nd sgittl crniofcil dimension; some studies hve found n ssocition, 8,9 wheres others hve not. 37 In greement with most previous studies, the present study found tht the sgittl jw reltionship remined significntly negtively ssocited to miniml cross-sectionl re when tested for the effects of ge, gender, nd skeletl mturity. This suggests tht the lrger the sgittl jw reltionship, the smller the irwy dimensions. In reltion to verticl crniofcil dimensions, nterior fce height ws previously found to be significntly ssocited with upper irwy dimensions. 7,11 This is in greement with the present study. However, the ssocition remined sttisticlly significnt with only irwy volume fter the correction for ge, gender, nd skeletl mturity. In the present study, ssocitions were found between irwy dimensions nd the width of the mxill nd mndible. However, Di Crlo et l. 13 found no ssocitions between the phryngel irwy nd trnsverse dimension. This discrepncy could possibly be explined by the popultion smple being older in the Di Crlo el l. study. 14
9 PHARYNGEAL AIRWAY DIMENSIONS IN CHILDREN 145 In the present study, mndibulr width nd ge were the most relevnt fctors for irwy volume. The most relevnt fctors for the miniml cross-sectionl re were mndibulr width nd sgittl jw reltionship. Previously, ge nd verticl nd sgittl crniofcil morphology hve been ssocited with phryngel irwy dimensions s single fctors, 6,7,9 15 but the combintions of ge with mndibulr width nd sgittl jw reltionship with mndibulr width hve not been previously reported for preorthodontic children. The results my be vluble for orthodontic dignosis nd tretment plnning of children, especilly those with compromised phryngel irwy dimensions. Future studies could ssess the contribution of other fctors tht potentilly influence irwy dimensions, including functionl fctors. CONCLUSIONS Phryngel irwy dimensions were significntly ssocited with ge, skeletl mturity, nd crniofcil morphology in ll three plnes. Children with reduced mndibulr width nd incresed sgittl jw reltionship re prticulrly t risk of hving smll phryngel irwy dimensions. The results my prove vluble in dignosis nd orthodontics tretment plnning, especilly in children with compromised phryngel irwy dimensions. ACKNOWLEDGMENT The study ws funded by the Austrlin Society of Orthodontists Foundtion for Reserch nd Eduction s prt of thesis for the degree of Doctor of Clinicl Dentistry (Orthodontics). REFERENCES 1. Guijrro-Mrtínez R, Swennen GRJ. Cone-bem computerized tomogrphy imging nd nlysis of the upper irwy: systemtic review of the literture. Int J Orl Mxillofc Surg. 2011;40: Flores-Mir C, Koryem M, Heo G, Witmns M, Mjor MP, Mjor PW. Crniofcil morphologicl chrcteristics in children with obstructive sleep pne syndrome systemtic review nd met-nlysis. J Am Dent Assoc. 2013;144: Aboudr C, Nielsen I, Hung JC, Mki K, Miller AJ, Htcher D. Comprison of irwy spce with conventionl lterl hedfilms nd 3-dimensionl reconstruction from cone-bem computed tomogrphy. Am J Orthod Dentofc Orthop. 2009;135: Peltomäki T. The effect of mode of brething on crniofcil growth revisited. Eur J Orthod. 2007;29: Mrtin SE, Mthur R, Mrshll I, Dougls NJ. The effect of ge, sex, obesity nd posture on upper irwy size. Eur Respir J. 1997;10: El H, Plomo JM. Airwy volume for different dentofcil skeletl ptterns. Am J Orthod Dentofc Orthop. 2011;139:e511 e Oh K-M, Hong J-S, Kim Y-J, Cevidnes LSH, Prk Y-H. Three-dimensionl nlysis of phryngel irwy form in children with nteroposterior fcil ptterns. Angle Orthod. 2011;81: Zheng ZH, Ymguchi T, Kurihr A, Li HF, Mki K. Threedimensionl evlution of upper irwy in ptients with different nteroposterior skeletl ptterns. Orthod Crniofc Res. 2014;17: Alves JM, Frnzotti ES, Brtieri C, Nunes LKF, Nojim LI, Ruells ACO. Evlution of phryngel irwy spce mongst different skeletl ptterns. Int J Orl Mxillofc Surg. 2012;41: El H, Plomo JM. An irwy study of different mxillry nd mndibulr sgittl positions. Eur J Orthod. 2013;35: Kim Y, Hong J, Hwng Y, Prk Y. Three-dimensionl nlysis of phryngel irwy in predolescent children with different nteroposterior skeletl ptterns. Am J Orthod Dentofc Orthop. 2010;137:306.e e Iwski T, Hyski H, Tkemoto Y, Knomi R, Ymski Y. Orophryngel irwy in children with clss iii mlocclusion evluted by cone-bem computed tomogrphy. Am J Orthod Dentofc Orthop. 2009;136:318.e e Di Crlo G, Polimeni A, Melsen B, Cttneo P. The reltionship between upper irwys nd crniofcil morphology studied in 3D. A CBCT study. Orthod Crniofc Res. 2015;18: Schendel SA, Jcobson R, Khlessi S. Airwy growth nd development: computerized 3-dimensionl nlysis. J Orl Mxillofc Surg. 2012;70: Ching CC, Jeffres MN, Miller A, Htcher DC. Threedimensionl irwy evlution in 387 subjects from one university orthodontic clinic using cone bem computed tomogrphy. Angle Orthod. 2012;82: Tourné LP. Growth of the phrynx nd its physiologic implictions. Am J Orthod Dentofc Orthop. 1991;99: Sonnesen L, Bkke M. Molr bite force in reltion to occlusion, crniofcil dimensions, nd hed posture in pre-orthodontic children. Eur J Orthod. 2005;27: Andersen MK, Sonnesen L. Risk fctors for low molr bite force in dult orthodontic ptients. Eur J Orthod. 2013;35: Anndrjh S, Abdll Y, Dudhi R, Sonnesen L. A proposl of new upper irwy mrgins in children ssessed by cone bem CT. Dentomxillofc Rdiol. 2015;44: Björk A. The fce in profile: n nthropologicl x-ry investigtion on Swedish children nd conscripts. Sven Tndlk Tidskr. 1947;40: Björk A. The reltionship of the jws to the crnium. Introduction to Orthodontics. New York, NY: McGrw-Hill; 1960: Yoon Y-J, Perkiomki MR, Tllents RH, et l. Trnsverse crniofcil fetures nd their genetic predisposition in fmilies with nonsyndromic unilterl cleft lip nd plte. Cleft Plte Crniofc J. 2004;41: Solow B, Tllgren A. Hed posture nd crniofcil morphology. Am J Phys Anthropol. 1976;44:
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