ORIGINAL ARTICLE

Pharyngeal airway characterization in adolescents

related to facial skeletal pattern: A preliminary
study
^ nio Carlos de Oliveira Ruellas,c
L
ıgia Vieira Claudino,a Claudia Trindade Mattos,b Anto
c
and Eduardo Franzotti Sant’ Anna
Rio de Janeiro, Brazil

Introduction: The objective of this study was to characterize the volume and the morphology of the pharyngeal
airway in adolescent subjects, relating them to their facial skeletal pattern. Methods: Fifty-four subjects who had
cone-beam computed tomography were divided into 3 groups—skeletal Class I, Class II, and Class III—
according to their ANB angles. The volumes of the upper pharyngeal portion and nasopharynx, and the
volume and morphology of the lower pharyngeal portion and its subdivisions (velopharynx, oropharynx, and
hypopharynx) were assessed with software (version 11.5; Dolphin Imaging & Management Solutions,
Chatsworth, Calif). The results were compared with the Kruskal-Wallis and the Dunn multiple comparison
tests to identify intergroup differences. Correlations between variables assessed were tested by the
Spearman correlation coefficient. Correlations between the logarithms of airway volumes and the ANB angle
values were tested as continuous variables with linear regression, considering the sexes as subgroups.
Results: The minimum areas in the Class II group (112.9 6 42.9, 126.9 6 45.9, and 142.1 6 83.5 mm2)
were significantly smaller than in Class III group (186.62 6 83.2, 234.5 6 104.9, and 231.1 6 111.4 mm2) for
the lower pharyngeal portion, the velopharynx, and the oropharynx, respectively, and significantly smaller
than the Class I group for the velopharynx (201.8 6 94.7 mm2). The Class II group had a statistically significant
different morphology than did the Class I and Class III groups in the velopharynx. There was a tendency to de-
creased airway volume with increased ANB angle in the lower pharyngeal portion, velopharynx, and oropharynx.
In the upper pharyngeal portion, nasopharynx, and hypopharynx, there seemed to be no association between
the airway volume and the skeletal pattern. Conclusions: The Class II subjects had smaller minimum
and mean areas (lower pharyngeal portion, velopharynx, and oropharynx) than did the Class III group and
significantly less uniform velopharynx morphology than did the Class I and Class III groups. A negative corre-
lation was observed between the ANB value and airway volume in the lower pharyngeal portion and the
velopharynx (both sexes) and in the oropharynx (just in male subjects). (Am J Orthod Dentofacial Orthop
2013;143:799-809)

T
he upper airway is a structure responsible for one
of the main vital functions in the human organ-
ism—breathing. The interest in studying the upper
airway has always been present in orthodontics, and 1
From the Department of Orthodontics, Universidade Federal do Rio de Janeiro,
Rio de Janeiro, Brazil.
a
b
PhD student.
Substitute professor.
c
Associate professor.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Eduardo Franzotti Sant’ Anna, Avenida Professor Rodolpho
Paulo Rocco, 325 llha do Fund~ao, Rio de Janeiro, RJ, CEP: 21941-617, Brazil;
e-mail, eduardo.franzotti@gmail.com.
Submitted, May 2012; revised and accepted, January 2013.
0889-5406/$36.00
Copyright Ó 2013 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2013.01.015
main objective is to clarify the relationship between
pharynx structures and craniofacial complex growth
and development.1-4
Obstructive processes of morphologic, physiologic, or
pathologic nature, such as hypertrophy of adenoids and
tonsils, chronic and allergic rhinitis, irritant environmen-
tal factors, infections, congenital nasal deformities,
nasal traumas, polyps, and tumors, are predisposing fac-
tors to a blocked upper airway. When that happens,
a functional imbalance results in an oral breathing pat-
tern that can alter facial morphology and dental arch
forms, generating a malocclusion.2,5,6
Considering the functional matrix theory proposed
by Moss,7 the association of respiratory and masticatory
functions and swallowing might act on craniofacial
development.
799
800
The literature is controversial when it comes to the
possible associations among respiratory function, facial
morphology, and occlusion. The ways in which variation
in the airflow can influence growth and development are
not completely elucidated. These questions remain un-
answered because of methodologic limitations related
to, among other factors, the multifactorial etiology of
malocclusion, the limitations in the cephalometric
method, and the lack of longitudinal studies assessing
the airway.8,9
Many studies have assessed the relationship between
craniofacial morphology and the pharyngeal airway in
cephalometric radiographs.10-14 However, lateral
teleradiographs are limited because they reproduce
a 3-dimensional structure in a 2-dimensional way that
does not allow the assessment of cross-sectional areas
and volumes of these structures.15,16
Techniques that allow the precise diagnosis of
changes in the upper airway considering their morphol-
ogy and volume are fundamental to ensure normal
development of the craniofacial complex in growing
subjects and the choice of an adequate treatment
plan.17,18
Although it might expose patients to higher levels of
radiation than isolated customary orthodontic digital ra-
diography,19 cone-beam computed tomography (CBCT)
uses a significantly reduced radiation dose compared
with medical computed tomography machines and is
equivalent to traditional dental imaging methods such
as a full-mouth series.20,21 CBCT has the advantage of
resulting images with good accuracy.16,18,22,23 Specific
softwares and their tools make it possible to obtain
highly reliable measurements of osseous structures and
facial characteristics, as well as to assess soft tissues in
3 dimensions, including measurements of the
oropharynx for volume, morphology, and minimum
axial area. Many studies have been developed in this
area.24-32
Guijarro-Mart
ınez and Swennen33 published a sys-
tematic review concerning the CBCT analysis of the up-
per airway and included 46 clinically or technically
relevant articles from 382 articles from 1968 to 2010
found in PubMed (National Library of Medicine, NCBI).
The results indicate that the 3-dimensional analysis of
the upper airway by using CBCT can be accurate and re-
liable, although important aspects still need to be eluci-
dated.
The aim of this study was to characterize through
CBCT and 3-dimensional image reconstruction software
the volumes of the upper pharyngeal portion and
nasopharynx, and the volume, minimum axial area,
and morphology of the lower pharyngeal portion
and its subdivisions—velopharynx, oropharynx, and
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Claudino et al
hypopharynx—in adolescent subjects, relating them to
their facial skeletal patterns.
MATERIAL AND METHODS
This project was approved by the research ethics
committee of the Institute of Collective Health Studies
from the Universidade Federal do Rio de Janeiro in
Brazil. All patients signed a consent form allowing the
use of their orthodontic records.
A sample calculation was performed based on the
mean standard deviation from a previous study.31 A
sample size of at least 17 patients would be necessary
in each group to detect differences of 65 mm2 in the
minimum axial area and of 2500 mm3 in the oropharynx
volume, with a test power of 0.80 (a 5 0.05). The for-
mula used was described by Pandis.34
The sample was composed of 54 CBCT scans, re-
quested as part of the initial records needed for diagnosis
and planning of patients starting their orthodontic
treatment in the orthodontic clinics of the postgraduate
program in our school of dentistry. All CBCT scans used
so far as orthodontic records in this university were per-
formed on 1 device (i-CAT; Imaging Sciences Interna-
tional, Hatfield, Pa) according to a standard protocol
(120 kV, 5 mA, 13 3 17-cm field of view, 0.4-mm voxel,
and 20-second scanning time). The CBCT scans were
made with each subject sitting in a vertical position,
and with the Frankfort horizontal plane parallel to the
ground and in maximum intercuspation.
The CBCT scans of patients in the sample were se-
lected from the sequential initial records from the clinics.
The following inclusion criteria were used in sample se-
lection: DICOM file, no previous orthodontic treatment
or other treatment that might interfere with the natural
course of maxillomandibular growth and development,
good health conditions, no airway pathology, cranio-
cervical inclination between 90 and 110 (since head
posture might interfere with airway volume),35 CBCT
image including the whole fourth cervical vertebra, no
severe hyperdivergence (FMA angle, 19 -30 ), and age
from 13 to 20 years. The inclination between the palatal
plane and the sella-nasion plane was measured to
characterize the sample. To take the initial angular
measurements necessary to confirm the inclusion criteria
and distribute the subjects among the groups (ANB
and FMA angles, and cranio-cervical inclination), 2-
dimensional lateral cephalometric radiographs were
created (ray-sum technique) from the CBCT scans in
the software (version 11.5; Dolphin Imaging & Manage-
ment Solutions, Chatsworth, Calif), and measurements
were made by an experienced operator (L.V.C.). The
subjects were then divided into 3 groups considering
the relationship between the maxilla and the mandible
Claudino et al
Table I. Descriptive statistics of age and cephalomet-
ric characteristics of patients in all groups, classified
according to ANB angles
Class I (n 5 17) Class II (n 5 20) Class III (n 5 17)
Mean (SD) Mean (SD) Mean (SD)
Age (y) 15.62 (2.17) 16.83 (2.74) 16.28 (1.74)
FMA ( ) 24.51 (2.37) 25.73 (4.07) 24.05 (3.52)
ANB ( ) 2.18 (0.76) 5.55 (2.00) 2.05 (2.52)
PP-SN ( ) 6.64 (3.89)a 8.7 (3.21)a 9.83 (3.18)a
Different superscript letters mean statistically significant difference
(same line).
PP-SN, Angle between the palatal plane and the sella-nasion line.
(ANB angle): Class I (1 #ANB #3 ), Class II (ANB .3 ),
and Class III (ANB\1 ).31 Fewer Class I and Class III sub-
jects met all inclusion criteria than Class II patients. To
maintain the sample size calculated and make the
groups more even, random subjects were excluded
from the Class II group using initials and sex. No numeric
parameters were considered.
The groups were divided in the following way: Class I
(17 patients, 12 female and 5 male), Class II (20 patients,
10 female and 10 male), and Class III (17 patients, 11 fe-
male and 6 male). The mean age of the sample was 16.28
years (SD, 2.30 years) and the mean FMA angle was
24.82 (SD, 3.45 ). The mean inclination between the
palatal plane and the sella-nasion plane was 8.40 (SD,
3.60 ). Specific age and cephalometric characteristics
for each group are described in Table I.
The direct measurements selected for the dimensional
assessment of the pharyngeal airway in this study were (1)
upper pharyngeal portion, nasopharynx, lower pharyn-
geal portion, velopharynx, oropharynx, and hypopharynx
volume; (2) lower pharyngeal portion, velopharynx, oro-
pharynx, and hypopharynx minimum axial area; (3) lower
pharyngeal portion total length and upper length; and (4)
velopharynx, oropharynx, and hypopharynx total length.
All measurements were made with Dolphin Imaging
software. The volumes and minimum axial areas were
measured with the tool for airway volume calculation
in the 3-dimensional mode of the software in the 25
(standard) threshold values. The limits for each portion
of interest were defined in the sagittal slice, and the soft-
ware automatically calculated the total volume and the
most constricted airway area (minimum axial area) in
the region previously set out.
The limits adopted for the upper pharyngeal portion
were those proposed by El and Palomo.27 The lower limit
was defined by the palatal plane, which is the line pass-
ing by the anterior nasal spine and posterior nasal spine,
extended to the pharyngeal posterior wall. The upper
limit was defined as a slice before the nasal septum
merges with the pharyngeal posterior wall (Fig 1).
American Journal of Orthodontics and Dentofacial Orthopedics
801
The lower limit of the nasopharynx segment was the
palatal plane; its upper limit was defined in the sagittal
view as the line uniting the posterior nasal spine and
the So (middle point of the sella-basion line) points,18
and its posterior limit was defined in the sagittal view
as a line approximately perpendicular to the palatal
plane that intersects the So point (Fig 2).
The lower pharyngeal portion’s upper limit was the
palatal plane extended to the posterior pharyngeal
wall, and the lower limit was the plane parallel to the pal-
atal plane that intersected the lower and most anterior
point in the fourth cervical vertebra (Fig 3). The location
of the minimum axial area in the lower pharyngeal por-
tion was determined using the ratio proposed by Van
Holsbeke et al36 between the upper airway length (dis-
tance from the upper limit to the minimum axial area)
and the total airway length (Fig 3). The position ratio
can be described as follows: location 5 upper airway
length/total airway length.
The 3 segments assessed in the lower pharyngeal
portion—velopharynx, oropharynx, and hypopharynx—
were delimited by 4 cross-sectional planes, constructed
with previously determined points. The upper limit of
the velopharynx was the palatal plane, and the lower
limit was a plane parallel to the palatal plane that in-
tersected the uvula (Fig 4, A). The upper limit of the
oropharynx segment was the lower limit of velophar-
ynx, and its lower limit was a plane parallel to the pal-
atal plane intersecting the upper point of the epiglottis
(Fig 4, B). The upper limit of the hypopharynx was the
lower limit of the oropharynx, and its lower limit was
a plane parallel to the palatal plane intersecting the
lower and most anterior point of the fourth cervical
vertebra (Fig 4, C).
Once volume, minimum axial area, and total length
of the lower pharyngeal portion, velopharynx, orophar-
ynx, and hypopharynx were obtained, the mean area
of each segment was calculated using the following ra-
tio: mean area 5 volume/total airway length.
The morphologic characterizations of the lower pha-
ryngeal portion, velopharynx, oropharynx, and hypo-
pharynx were possible by calculation of the following
ratio for each segment: morphology 5 minimum area/
mean area.36 This ratio shows whether the area distribu-
tion along the upper airway was uniform or irregular.
Statistical analysis
All measurements were repeated in 40% of the CBCT
scans after a 2-week interval. Calibration of the operator
was tested with the intraclass correlation coefficient.
A descriptive analysis, including means and standard
deviations, was performed for all quantitative variables.
The Kolmogorov-Smirnov test was applied to assess the
June 2013  Vol 143  Issue 6
802 Claudino et al

Fig 1. Limits of the upper pharyngeal portion: A, determination of the last axial slice before the nasal
septum fuses with the pharyngeal posterior wall; B, the reflection of that slice in the sagittal plane de-
fines the upper limit, and the palatal plane determines the lower limit.

values were tested as continuous variables using linear

regression, with the sexes as subgroups.

Fig 2. Nasopharynx limits: the lower limit is the palatal
plane (pp) extended to the posterior pharyngeal wall,
and the upper limit is the line uniting PNS and So (middle
point in the Ba-S line).
normality of the data. No significant sex-related differ-
ences were found; therefore, the data were combined.
The Kruskal-Wallis test was used to verify whether there
were statistically significant differences (P \0.05)
among the groups. The Dunn multiple comparison test
was then used to identify where these differences were.
Correlations among the variables were tested by the
Spearman correlation coefficient. The P values were ad-
justed for multiple comparisons. Correlations between
the logarithms of airway volumes and the ANB angle
RESULTS
The intraclass correlation coefficient results were
higher than 0.95 for all variables assessed; this con-
firmed the operator’s calibration.
The Kruskal-Wallis nonparametric test was applied
for all variables, since the distribution of some variables
was not normal. Comparisons among mean values of all
groups for all dimensional variables (except for volumes)
assessed for each airway segment are given in Tables II
through V.
In the lower pharyngeal portion, the Class II group
had a significantly smaller (P \0.007) upper length
than did the Class I group. The most constricted area
was in the middle portion (50% of the total length) in
the Class II group. The Class II group also showed signif-
icantly smaller (P \0.007) minimum airway area and
mean area than did the Class III group (Table II).
All groups showed variations in lower pharyngeal
portion morphology, characterized by a less uniform dis-
tribution of the airway area along the length of this
structure. However, no statistically significant difference
was found (Table II).
The Class II group had significantly smaller (P \0.01)
velopharynx minimum axial area and mean area, and
a greater morphologic variation than did the Class I
and Class III groups (Table III).
In the oropharynx segment, the Class II group showed
significantly smaller minimum axial area and mean area
than did the Class III group (Table IV).

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Claudino et al 803

Fig 3. Lower pharyngeal portion limits and measurements: A, Upper limit, palatal plane (ANS-PNS line)
extended to the pharyngeal posterior wall, and lower limit, plane parallel to the palatal plane (pp) inter-
secting the lower and most anterior point in the fourth cervical vertebra (C4); the horizontal white line
represents the most constricted axial area (minimum axial area) within these limits; Ul, Upper length;
Tl, total length. B, Axial view of the minimum axial area determined by the software within these limits.

Fig 4. Limits used in the lower pharyngeal portion segments: A, velopharynx upper limit, palatal plane
(pp), and lower limit, plane parallel to the palatal plane intersecting the uvula (U); B, oropharynx upper
limit, plane parallel to the palatal plane intersecting the uvula (U), and lower limit, plane parallel to the
palatal plane intersecting the upper point in the epiglottis (EP); C, hypopharynx upper limit, plane par-
allel to the palatal plane intersecting the upper point in the epiglottis (EP), and lower limit, plane parallel
to the palatal plane intersecting the lower and most anterior point in the fourth cervical vertebra (C4).

No statistically significant differences were observed
in the hypopharynx segment in any assessed measure-
ments (Table V).
The correlation analysis between airway volumes and
the variables FMA, age, and sex, and the correlation
analysis between the palatal plane to sella-nasion and
ANB angles are shown in Table VI. No variable had a cor-
relation with airway volumes.
The plots of the correlations between airway volumes
and ANB angle (Fig 5) showed a tendency in male

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804 Claudino et al

Table II. Intergroup comparison of LPP dimensional measurements and morphology

Class I (n 5 17) Class II (n 5 20) Class III (n 5 17)
Mean (SD) Mean (SD) Mean (SD)
LPP total length (mm) 66.7 (7.0)a 67.0 (7.8)a 70.22 (5.4)a
LPP upper length (mm) 50.8 (14.5)a 31.30 (15.2)b 46.81 (17.65)a,b
LPP minimum area (mm2) 132.45 (48.5)a,b 112.9 (42.9)a 186.62 (83.2)b
LPP mean area (mm2) 205.38 (68.7)a,b 211.8 (52.9)a 299.93 (93.16)b
Minimum area location (Ul/Tl) 0.7 (0.2)a 0.5 (0.2)b 0.6 (0.3)a,b
LPP morphology (Amin/Amean) 0.5 (0.1)a 0.5 (0.1)a 0.6 (0.1)a
Different superscript letters mean statistically significant difference (same line).
LPP, Lower pharyngeal portion; Ul, upper airway length; Tl, total airway length; Amin/Amean, minimum area/mean area.

Table III. Intergroup comparison of VP dimensional measurements and morphology

Class I (n 5 17) Class II (n 5 20) Class III (n 5 17)
Mean (SD) Mean (SD) Mean (SD)
VP length (mm) 29.5 (4.9)a 28.7 (4.1)a 31.5 (3.7)a
VP minimum area (mm2) 201.8 (94.7)a 126.9 (45.9)b 234.5 (104.9)a
VP mean area (mm2) 291.0 (93.6)a 218.8 (87.8)b 327.9 (112.0)a
VP morphology (Amin/Amean) 0.7 (0.1)a 0.6 (0.1)b 0.7 (0.2)a
Different superscript letters mean statistically significant difference (same line).
VP, Velopharynx; Amin/Amean, minimum area/mean area.

Table IV. Intergroup comparison of OP dimensional measurements and morphology

Class I (n 5 17) Class II (n 5 20) Class III (n 5 17)
Mean (SD) Mean (SD) Mean (SD)
OP length (mm) 18.56 (3.9)a 14.73 (5.4)a 16.0 (5.8)a
OP minimum area (mm2) 160.2 (62.6)a,b 142.1 (83.5)a 231.1 (111.4)b
OP mean area (mm2) 210.9 (86.9)a,b 195.1 (85.3)a 283.4 (124.1)b
OP morphology (Amin/Amean) 0.76 (0.1)a 0.7 (0.1)a 0.8 (0.1)a
Different superscript letters mean statistically significant difference (same line).
OP, Oropharynx; Amin/Amean, minimum area/mean area.

subjects toward greater volumes than in females, except
for the nasopharynx, where there was no difference. In
the lower pharyngeal portion, velopharynx, and oro-
pharynx, the linear regression coefficient (R2) was more
consistent; the greater the ANB angle, the smaller the
airway volume. In the oropharynx, this was significant
only in male subjects. In the upper pharyngeal portion,
nasopharynx, and hypopharynx, there seemed to be no
association between airway volume and skeletal pattern.
DISCUSSION
The main objective of this study was to assess the vol-
umes of the upper pharyngeal portion and nasopharynx
and the volumes, the minimum axial areas, and the mor-
phology of the lower pharyngeal portion and its seg-
ments (velopharynx, oropharynx, and hypopharynx)
using CBCT scans of 13- to 20-year-old subjects divided
into Class I, Class II, and Class III groups according to
their ANB angles.
The Dolphin Imaging software we used is user
friendly and provides quick upper airway segmenta-
tion—good segmentation sensitivity that can be checked
in 2-dimensional slices (axial, coronal, and sagittal)—and
minimum cross-sectional area analysis. It is considerably
more accurate than or similar to other softwares in upper
airway assessments.27,37 Its disadvantages include cost,
lack of tools to adjust or correct the segmentation in
2-dimensional slices, and threshold interval units that
are not comparable with other imaging softwares.37
Many studies have been performed to assess the rela-
tionship between upper airway and dentomaxillofacial
morphology using CBCT.25,26,30,31,38 Nevertheless,
most of these studies assessed only airway segments
that do not necessarily represent the complete upper
portion of this complex structure. The assessment of
the entire upper airway is necessary to establish
a correct diagnosis.28 We were concerned with determi-
nation of the anatomic limits of the upper airway and its

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Claudino et al 805

Table V. Intergroup comparison of HP dimensional measurements and morphology

Class I (n 5 17) Class II (n 5 20) Classs III (n 5 17)
Mean (SD) Mean (SD) Mean (SD)
HP length (mm) 19.2 (5.4)a 21.8 (5.1)a 22.3 (5.2)a
HP minimum area (mm2) 147.4 (51.9)a 149.6 (53.0)a 206.5 (93.0)a
HP mean area (mm2) 224.1 (59.2)a 235.4 (69.9)a 283.9 (80.7)a
HP morphology (Amin/Amean) 0.6 (0.1)a 0.6 (0.1)a 0.7 (0.1)a
Different superscript letters mean statistically significant difference (same line).
HP, Hypopharynx; Amin/Amean, minimum area/mean area.

significant negative correlations between the lower

Table VI. Spearman correlation coefficients between pharyngeal portion and the velopharynx volumes and
airway volumes and the variables FMA, age, and sex, the ANB angle (Fig 5).
and between the palatal plane to sella-nasion and Our sample included subjects with an FMA angle
ANB angles from 19 to 30 . Therefore, no subject with severe man-
ANB FMA Age Sex* dibular hypodivergency or hyperdivergency was in-
PP-SN 0.045 - - - cluded in the sample, because this aspect can influence
UPP volume - 0.151 0.197 0.077 airway dimensions, as described by Joseph et al.45 These
LPP volume - 0.050 0.229 0.299 authors observed greater pharyngeal anteroposterior
NP volume - 0.107 0.356 0.094
narrowing in hyperdivergent subjects at the levels of
VP volume - 0.011 0.185 0.260
OP volume - 0.183 0.052 0.404 the hard palate and the oropharynx, the soft-palate
HP volume - 0.023 0.162 0.178 tip, and the mandible. Ucar and Uysal14 reached similar
conclusions when comparing craniofacial dimensions
P \0.002 is statistically significant (adjusted for multiple compari-
sons).
and airway and tongue width in healthy Class I subjects
PP-SN, Angle between the palatal plane and the sella-nasion line; with different vertical growth patterns. They observed
UPP, upper pharyngeal portion; LPP, lower pharyngeal portion; smaller nasopharynx airway dimensions in hyperdiver-
NP, nasopharynx; VP, velopharynx; OP, oropharynx; HP, hypophar- gent subjects compared with hypodivergent and normo-
ynx. divergent subjects. In our study, no correlation was
*Number 1 was adopted for the male sex and number 2 for the fe-
male sex.
found between airway volume and FMA angle (Table
VI); this is probably because subjects with a severe diver-
subdivisions in segments that could be more susceptible gence were eliminated from the sample. These findings
to morphologic changes in Class I, Class II, and Class III agree with the results of El and Palomo31 in normodiver-
subjects. Additionally, the assessment of the whole up- gent subjects (FMA angle, 19 -31 ). No correlation was
per airway, represented by the lower pharyngeal portion, observed between the inclination of the palatal plane
was considered necessary. The lower pharyngeal portion and the ANB angle (Table VI).
limits used in this study are wider than those frequently The age range in this study was selected to observe
used and described in the literature. airway differences in growing adolescents with different
The sample division into Class I, Class II, and Class III skeletal patterns. According to Schendel et al,17 airway
skeletal patterns according to the ANB angle was chosen dimensions increase until age 20 years; after this, mod-
because this is one of the most used criteria in the deter- erate stability is observed. No statistically significant dif-
mination of the anteroposterior relationship between ferences were observed in the upper pharyngeal portion
the maxilla and the mandible.14,28,31,39 Nevertheless, and the nasopharynx volume among our groups. Never-
this angle might be influenced by the anteroposterior theless, a slight tendency of increase was observed with
position of nasion relative to Points A and B, among an increase of ANB angles (Fig 5, A and B). These results
other factors, and some authors have suggested that might be explained by the difficulty in the assessment of
the diagnosis of such discrepancies must be based on the upper pharyngeal portion volume in areas where na-
more than 1 anteroposterior appraisal.28,40-42 Despite sal conchae presented a more complex anatomy. This
its limitation, the ANB angle was used alone because difficulty was also reported by El and Palomo.31 How-
the use of 2 criteria to eliminate such limitations is not ever, they did not find a statistically significant smaller
always coincident. Many studies have demonstrated volume in this region in their Class II subjects.
negative correlations between the oropharynx volume Some studies have demonstrated that the parameters
and the ANB angle.31,43,44 Our study showed used to determine pharyngeal airway dimensions, such

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806 Claudino et al

Fig 5. Plots showing the linear regression analyses between the logarithms of airway volume and the
ANB angle values tested as continuous variables, with the sexes as subgroups. The blue circles repre-
sent males, and the green circles represent females. The black line represents the mean correlation of
the entire sample. The blue and green lines represent the mean correlations for male and female sub-
jects, respectively. Segments analyzed: A, upper pharyngeal portion; B, nasopharynx; C, lower pharyn-
geal portion; D, velopharynx; E, oropharynx; F, hypopharynx. *P \0.05; **P \0.01; ***P \0.001.

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Claudino et al
as volume, minimum cross-sectional area, length, and
form, are correlated with obstructive sleep apnea syn-
drome and its gravity.46-49 The probability of its
development increases with minimum cross-sectional
area narrowing, which is considered severe when it is
smaller than 52 mm2, intermediate when it is between
52 and 110 mm2, and less severe if it is above 110
mm2.50 Our Class II subjects had significantly smaller
lower pharyngeal portions, velopharynx and oropharynx
minimum axial areas and mean areas than did the Class
III group, and a mean lower pharyngeal portion mini-
mum axial area of 112.9 mm2. One subject in the Class
II group even had a minimum axial area smaller than
52 mm2, which is considered severe. This finding led to
the conclusion that Class II subjects are more susceptible
to the development of obstructive sleep apnea syndrome
than are patients with different skeletal patterns.
Additionally, studies show that most obstructive
sleep apnea subjects’ airway constriction occurs at the
level of the oropharynx, near the occlusal plane.36,51 In
this study, the Class II group had smaller minimum
axial areas, which were located in the oropharynx
segment.
The upper airway morphology is also described in the
literature as a parameter that can predict the chance of
obstructions developing in these structures.36,46 In our
study, the morphology was characterized by the ratio
between the minimum axial area and the mean axial
area, and it was considered more irregular if the value
obtained from the ratio was lower. When this ratio in
the lower pharyngeal portion was compared among
the groups, all groups had irregularities in airway
morphology as shown by the morphology values
(Table II), and no statistically significant difference was
found among the groups. Nevertheless, the velopharynx
segment was more sensitive to morphologic changes,
and the Class II group had a less uniform area distribu-
tion compared with the Class I and Class III groups
(Table III).
Another fact from this study was that subjects with
higher ANB values had smaller lower pharyngeal por-
tions and velopharynx volumes and velopharynx mini-
mum axial areas compared with the other groups.
Alves et al39 reached similar conclusions when evaluat-
ing the dimensions of the pharyngeal airway space in
50 awake, upright children with different anteroposte-
rior skeletal patterns using CBTC. The patients were di-
vided into 2 groups according to their ANB angles
(group I, 2 # ANB # 5 ; group II, ANB . 5 ). Those au-
thors concluded that the pharyngeal airway space was
statistically larger in group I than in group II, indicating
that the dimensions of the pharyngeal airway space are
affected by different anteroposterior skeletal patterns.
American Journal of Orthodontics and Dentofacial Orthopedics
807
Additionally, our results show that when a negative
correlation was found between airway volume and
ANB angle (lower pharyngeal portion and velopharynx),
a difference between the sexes was notable, although
this difference was not enough to trigger a significant
correlation between airway volume and sex. Male sub-
jects had greater airway volumes than did females; this
is similar to the results of Shigeta et al,24 who found
larger airway volumes in men than in women. When
we considered the whole lower pharyngeal portion,
this difference seemed to decrease with higher ANB
values, which meant that men and women with severe
skeletal Class II problems have no great differences in
lower pharyngeal portion volumes. Specifically in the ve-
lopharynx segment, the difference between the sexes
persisted no matter what the ANB value.
Therefore, orthodontists must be aware that specific
dimensional characteristics such as a greater constriction
might be associated with the skeletal pattern. Dimen-
sional airway assessments of the upper airway that in-
clude 3- and 2-dimensional measurements such as
those we used in this study are relevant information
for the orthodontic diagnosis and treatment plan. Con-
sidering this information, an orthodontist must define
the best treatment for each patient, avoiding treatments
that could compromise airway dimensions in those who
are already prone to have smaller dimensions in this
structure.
These findings should be considered with caution,
since this was a preliminary study. The small sample
size did not allow an adequate statistical appreciation
of the differences between the sexes. Based on these re-
sults, we intend to evaluate a larger sample and to adopt
the lower limit of the oropharynx, since the hypopharynx
showed no differences between the groups for any vari-
able. That will simplify sample selection, since many pa-
tients were excluded from this study because they did
not have the lower limit adopted (fourth cervical verte-
bra) in the tomographic image.
The comparison between Class I and Class III subjects
showed similar airway dimensions, confirmed by the fact
that no statistically significant difference was found in
any measurement between these groups. The Class II
group, however, had statistically significant smaller di-
mensions in many segments compared with the other
2 groups, especially the Class III group; this was similar
to the findings of El and Palomo.31
Longitudinal studies of airway changes in subjects
with different skeletal patterns in specific craniofacial
growth and development periods should be performed
to elucidate detailed knowledge on the relationship be-
tween upper airway morphology and function and cra-
niomaxillofacial characteristics.
June 2013  Vol 143  Issue 6
808
CONCLUSIONS
Based on the results from this study, the following
conclusions can be inferred.
1. Class II subjects have smaller minimum and mean
areas in the lower pharyngeal portion, and the velo-
pharynx and oropharynx segments than do Class III
subjects.
2. No dimensional differences were observed among
the groups in the hypopharynx segment.
3. The velopharynx segment was more sensitive to air-
way morphologic changes, and the Class II group
had the greatest irregularity in this region.
4. No statistically significant difference in airway di-
mensions was observed between the Class I and
Class III groups.
5. A negative correlation was observed between ANB
value and airway volume in the lower pharyngeal
portion and the velopharynx (both sexes) and in
the oropharynx only in male subjects.
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