ORIGINAL ARTICLE

Three-dimensional analysis of the airway with

cone-beam computed tomography
Scott Stratemann,a John C. Huang,b Koutaro Maki,c David Hatcher,d and Arthur J. Millere
New Braunfels, Tex, San Francisco, Calif, and Tokyo, Japan

Introduction: In this study, using a cone-beam computed tomography system, we evaluated the airways of 30
adults. Methods: The shapes of the 3-dimensional volume of the airway were analyzed and compared among
the subjects by using surface superimposition software techniques. Results: The airway had the greatest
variability in the hypopharynx, in the region below the epiglottis, and above the vocal folds. Moderate variation
was apparent at the nares, behind the soft palate, and at the base of the tongue. Conservation of form was seen
at the central portion of the nasal airway surrounding the inferior turbinate. Conclusions: The potential for com-
paring the shape of the airway among subjects is possible. (Am J Orthod Dentofacial Orthop 2011;140:607-15)

M
any studies in orthodontics have focused on
the airway and its potential importance to
modifying the development of the craniofacial
region. Much of this research has studied how the airway
is implicated in developing abnormally long vertical
facial dimensions.1-3 Orthodontists have also been
actively involved in evaluating the airway and treating
subjects with particular types of sleep apnea.4-6 With
the advent of low-radiation, rapid computed tomogra-
phy (CT) scanning,7-11 the potential for orthodontists
to assess craniofacial growth in 3 dimensions is now
available,12,13 and with that analysis is the capability
of evaluating the complete airway.14,15
Determining the airway from images generated by
cone-beam CT (CBCT) includes defining the most effec-
tive anatomic landmarks. Many previous studies have
evaluated the airway by using 2-dimensional cephalo-
metric analyses. Tourn
e16 showed that the bony naso-
pharynx extends from hormion (the most dorsal
contact point of the vomer on the body of the sphenoid)
a
Private practice, New Braunfels, Tex.
b
Associate clinical professor, Division of Orthodontics, Department of Orofacial
Sciences, School of Dentistry, University of California at San Francisco.
c
Professor and chair, Department of Orthodontics, Showa University, Tokyo,
Japan.
d
Associate clinical professor, Diagnostic Digital Imaging, Sacramento, Calif.
e
Professor, Division of Orthodontics, Department of Orofacial Sciences, School of
Dentistry, University of California at San Francisco.
The authors report no commercial, proprietary, or financial interest in the prod-
ucts or companies described in this article.
Reprint requests to: Arthur J. Miller, Division of Orthodontics, Department of
Orofacial Sciences, School of Dentistry, University of California at San Francisco,
San Francisco, CA, 94143-0438; e-mail, art.miller@ucsf.edu.
Submitted, January 2010; revised and accepted, December 2010.
0889-5406/$36.00
Copyright Ó 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.12.019
to the level of the hard palate and foramen magnum. The
pharynx’s structural volume increases by approximately
80% during growth.17 Transverse pharyngeal growth
at the pterygoid hamulus is completed at 2 years of
age.18 Choanal width increases about 23% by maturity
with remodeling at the pterygoid laminae.17 The sagittal
diameter of the nasopharynx, measured from the poste-
rior nasal spine to basion, increases only 9% because of
the influence of cranial base flexure (angle formed by
sella to nasion to basion), since an acute angle leads to
more vertical pharyngeal development.19 Hormion is
displaced dorsally, increasing the length of the roof of
the nasal cavity, but the posterior nasal spine has an
even greater dorsal displacement.20,21 The vomer’s
dorsal border and the clivus become upright, and the
concurrent descent of the posterior nasal spine and
basion with age tends to reduce the angle of the
nasopharyngeal roof, but this might be cancelled with
bone apposition at the pharyngeal aspect of the clivus.
This growth counters the contribution of the growth
of the spheno-occipital synchondrosis to nasopharyn-
geal depth, and probably contributes to most of the in-
crease in pharyngeal depth. The vertebral body of the
atlas might better represent the true posterior limit of
the anteroposterior dimension of the pharynx, but the
growth effects are similar. The contribution of apposi-
tion at the posterior palatine border is minimized relative
to growth at the transpalatal suture and the tuberosities.
This backward growth effect is compensated by second-
ary maxillary anterior displacement from cranial base
growth. The main growth direction of the pharynx is
vertical, with downward movement of the palate and
primarily vertical growth at the spheno-occipital syn-
chondrosis. Growth at these areas increases the height
607
608
of the bony nasopharynx by 38% during childhood,17
and this dimension accounts for most of the increase
in pharyngeal capacity, continuing until 13 years of
age (female) or 18 years of age (male).22
Adenoid vegetation is the most frequently cited cause
of airway obstruction.16 The lymphoid tissue increases
rapidly in size during infancy, slows thereafter, peaks be-
fore adolescence, and declines in the adult. Some evi-
dence from cephalometric studies suggests that the
adenoids increase during the preschool and primary
grade years and then involute during preadolescence
and adolescence.22,23 Lymphoid tissue does facilitate
velopharyngeal closure but can result in blockage of
the airway.1 The absolute size of the adenoids is not as
important as the relative space that the mass occupies
in the nasopharynx.24 Adenoid obstruction appears to
be most common among children with a long face and
small nasopharynx.1,25 Persons with the long-face syn-
drome have smaller nasopharyngeal cavities than those
with a square face, so that even a small increase in
adenoid bulk could easily cause airway obstruction.
When the airway is threatened to a sufficient degree
or at another level than the oropharynx, the postural ad-
aptation of tongue and hyoid will fail to cope, with
purely nasal respiration becoming an oronasal breathing
pattern, with compensations including parting of the
lips, a drop in the mandibular rest position,26 lower1 or
more forward tongue position,27 and extension of the
head and neck.27,28
Measurement of nasal obstruction has included
evaluating cross-sectional area, peak nasal flow, nasal
resistance, and respiratory mode (identifies nasal/oral
airflow ratio). Direct measurement of the ratio of oral
to nasal airflow is an objective measure of respiratory
function.29-31
Warren et al32 constructed a model of the upper air-
way with a variable nasopharyngeal isthmus and a vari-
able oral port to determine the effects of airway size and
shape on the aerodynamics of simulated breathing, and
to develop a theoretical basis for predicting when
breathing mode will change from nasal to predomi-
nantly oral. Several theoretical predictions resulted
from their model. A nasal airway cross-sectional area
less than 0.4 cm2 might represent an inadequate airway
in adults, and mouth breathing would be expected. The
amount of adenoid obstruction must be great to affect
airway resistance. If airway resistance in the nose were
high, large adenoids would be a serious airway problem
and induce mouth breathing. When nasal airway resis-
tance is high ($4.5 cm H2O/L/s), the mouth will open
about 0.4 to 0.6 cm2, shifting a significant amount of
air orally and reducing airway resistance to a normal
level. If morphologic changes are caused by airway
November 2011  Vol 140  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Stratemann et al
impairment, other factors such as a large tongue, large
tonsils, or a long, draping velum, could be significant
contributing factors.
These studies can now be complemented by 3-
dimensional (3D) evaluation of the airway in a subject
seeking orthodontic treatment. Many techniques are ef-
fective in evaluating the airway volume and include cine-
magnetic resonance imaging,33,34 magnetic resonance
imaging,34,35 spiral CT,36,37 and optical coherence
tomography.38 In this article, we propose 1 method using
CBCT to compare the 3D airway among subjects.39-41
MATERIAL AND METHODS
CBCT data sets acquired from 30 patients were used
in this study. Some scans of patients with pathologic
conditions were included, with 4 being evaluated for
temporomandibular disorders, 1 with a pneumocoele
of the right maxillary antrum, and 1 with an odonto-
genic cyst surrounding an impacted mandibular third
molar. Scans of subjects with developmental conditions
such as impacted teeth and orofacial clefts (1 subject)
were permitted. Selection to homogenize the sample
with respect to age, sex, and ethnicity was not specifi-
cally performed. The sample included 13 male and 17
female subjects with an average age of 22 years 8
months 6 12 years 1 month (median, 19 years 2
months). Most were white (17), followed by Asian (6),
Hispanic (5), and African American (2). The most
common reasons for referral for the CBCT scan were im-
pacted teeth (10 subjects) and temporomandibular joint
or temporomandibular disorder evaluation (8 subjects).
CBCT data was acquired from 2 systems: the NewTom
QR DVT 9000 (Aperio, Sarasota, Fla) in a private radiology
laboratory in Sacramento, California, and the CB Mercu-
Ray (Hitachi Medico Technology, Tokyo, Japan) at the
Division of Orthodontics, University of California at San
Francisco.42,43 The patient is supine in the NewTom and
upright with the CB MercuRay; this could modify the
shape of the airway.36,41 However, the primary purpose
of this study was to demonstrate the variability in airway
shape and the methods to compare these shapes.
The entire airway as a single unit was threshold-
segmented by using the CT numbers of each voxel and
edited by hand with each transverse slice to remove
any visible extraneous scatter, artifacts, or background,
similar to the method described by Meehan et al.44 For
areas with widely different thresholds, a combination
of threshold segmentation and manual slice editing
was used to obtain refined surfaces with minimal arti-
facts. The segmentation process involved using the
sculpt tool of CBWorks (CBWorks 1.0; CyberMed Inc.,
Seoul, Korea) to narrow the scan into a volume of interest
including only the structure that was to be segmented.
Stratemann et al 609

Table. Airway landmarks

Landmark Description Bilateral point
NarAM Anteromedial vertex of the impression of the naris Yes
NarPM Posteromedial vertex of the impression of the naris Yes
NarL Lateral vertex of the impression of the naris Yes
NasA Most medioinferior point on the reflex of the anterior nasal airway Yes
ConPS Posterosuperior aspect of impression of inferior nasal concha Yes
ConPI Posteroinferior aspect of impression of inferior nasal concha Yes
IAM-S Most superior point on impression of internal auditory meatus Yes
IAM-I Most inferior point on impression of internal auditory meatus Yes
FR-S Most superior point on the base of the impression of Rosenm€ uller’s fossa Yes
FR-I Most inferior point on the base of the impression of Rosenm€ uller’s fossa Yes
FR-D Most dorsosuperior point at the height of the impression of Rosenm€ uller’s fossa Yes
PW-C Greatest convexity on the impression of the lateral aspect of the posterior pharyngeal wall Yes
PA Most lateroinferior point at the junction of the impressions of the soft palate and anterior pharyngeal wall Yes
BT Most lateroinferior aspect of the impression of the base of the tongue Yes
EJ-L Most lateroinferior point on the impression of the esophageal junction Yes
EJ-C Most inferior point at the central aspect of the impression of the esophageal junction No
VF-L Most posterolateral point on impression of vocal folds Yes
VF-A Most anteroventral point on impression of vocal folds Yes
Ad Most dorsosuperior point on impression of adenoid tonsil No

Threshold segmentation tools were used to isolate the
osseous structures and the airway space from the data.
Details in this approach have previously been pub-
lished.42,43,45 After segmentation, the resulting set of
masks (highlighted areas representing each structure of
interest in each image slice of the CBCT scan) was
rendered into a shaded surface mesh in the CBWorks’
Shaded Surface Display tool. The 30 resulting surface
meshes were exported from CBWorks in a Virtual
Reality Modeling Language (.vrl) format into Amira
software (version 3.1, Mercury Computer Systems,
Berlin, Germany) for further analysis.
Due to limitations in the ability of the software to
solve the problem of comparing nonhomeomorphic sur-
faces (surfaces that do not correspond in topology and
cannot be transformed into one another by continuous
and invertible mapping) or numbers of nodes (each voxel
comprising the surface becomes a node in a tetrahedral
mesh in which each voxel is connected to its 3 nearest
neighbors), a reference structure was selected for indi-
rect comparison of the individual surfaces. The reference
surface consisted of 1 surface model of 1 patient, who
was considered average as determined from a lateral
view. The reference surface was nonrigidly transformed
into each individual surface to provide a set of 30 sur-
faces of identical topology with the same number of no-
des. The nonrigid transformation was completed by
embedding 27 landmarks in each airway by using the
Amira landmark tool (Table). Landmarks were embedded
pairwise in the arbitrary reference and in each individual
structure. The Amira landmarksurfacewarp tool was set
in a rigid transformation method to align the surfaces
based on the embedded landmarks. Individual surfaces
were then enlarged or compressed uniformly in the x-,
y-, and z- dimensions by hand with the Amira transform
editor dialog to scale each surface to the same size as the
arbitrary reference surface.
Once the surfaces were aligned and scaled, a subset
of 7 landmarks was used to identify the mathematically
“most average” surface and to rank the remaining sur-
faces relative to it. Because the objects were now of sim-
ilar alignment and size, the remaining differences in the
surfaces were primarily related to differences in shape.
To simplify the analytic calculations, these 7 landmarks,
representing the basic form of each structure, were de-
fined and used with all 30 forms including 4 shapes
that did not extend fully rostrally and caudally. The x,
y, and z coordinates of the 7 landmarks (Ad, left and
right NasA, ConPS, ConPI, IAM-S, PA, and BT; Table)
and the rectangular coordinate values were used.
By averaging the coordinate data for each data set,
the centroid of each coordinate set was determined
(Fig 1). Mean centroid coordinates were determined by
averaging the coordinate values of the individual cen-
troids. All data sets were centered at a common centroid
located at the origin by subtracting the individual cen-
troid coordinates from each landmark’s coordinates.
The distance for each landmark of each set to its corre-
sponding centroid was then calculated. The average
distance of all landmark points in each set to the cen-
troid was determined to be the centroid size of the
data set. If scaling was correct, the data sets should be
of identical centroid size. Manual scaling was generally
within 3% to 5% of the calculated mean centroid size.
Therefore, a correction factor (ratio of the mean centroid
size to the individual centroid size) was applied to the

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610 Stratemann et al

Fig 2. The root mean square (RMS) error of each data

Fig 1. Seven landmarks used to define the most average set of 30 patients is ranked with the least error to the
surface-rendered airway after the surfaces had been most error (% on vertical scale) from the mean coordinate
aligned and scaled. Small spheres in each cluster repre- values of the reference surface.
sent individual landmarks for each of the 30 patients, with
the larger sphere in the clump representing the mean of
all these landmarks. The largest sphere in the center
among the clusters represents the zero centroid for all 7
landmarks.

coordinate values of each data set to scale all sets per-

fectly to a common centroid size. These steps of aligning
the individual coordinate systems about a common
centroid and scaling them to a common centroid size
constituted a Procrustes transformation of the coordi-
nate data.
The root mean square error of each data set relative
to the set of average landmark coordinates was deter-
mined. Root mean square error provides a way to deter-
mine how well the mean coordinate values fit each data
set and provides part of the information necessary to
rank the surfaces. Because root mean square error is
always positively signed, arranging data sets from least
to greatest root mean square errors orders each set in
increasing distance from the mean but does not indicate
whether each set is smaller or larger than the mean or
average landmark coordinates (Fig 2). To give a sign to
each root mean square rank, the average x, y, and z
coordinates for each landmark were subtracted from
each landmark coordinate. The signs of the difference
for each component of each coordinate were recorded
as more than 0 (assigned a value of 1) or less than
0 (assigned a value of 1). The sign of the sum of the
landmark x, y, and z component differences was set to
be the sign of the root mean square error. The signed
root mean square errors were then ranked from 1 to
30 (Fig 3). The data set with the smallest root mean
square error was the reference surface for the surface-
warping procedure.
Fig 3. The root mean square (RMS) error of each data
set is ranked as inside or outside ( or 1) the mean ref-
erence surface as the signed ranked airway root mean
square error. The vertical axis indicates the percentage
difference from the mean surface coordinates.
For the surface warping, models of each surface ho-
meomorphic to the reference surface were created by
nonrigid transformations of the reference surface. In
this process, the same set of 27 landmarks was embed-
ded in each airway as was used in the alignment to the
arbitrary reference surface by using the Amira landmark
tool. These settings were chosen because they yielded
the visually best overall fidelity to the initial individual
surface of the warped reference surface over other avail-
able combinations of the same settings and over a Book-
stein transformation, which maintains the fidelity of the
corresponding point pairs in the warping procedure but
lacked the degree of overall fidelity observed in the flow

November 2011  Vol 140  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Stratemann et al 611

Fig 4. Lateral view of the surface-rendered volumetric airway from each of the 30 subjects ranked by
the signed root mean square error as compared with the reference surface. The spectrum of shapes
proceeds from the smaller, more vertically oriented airway ( root mean square end) to the larger
and more horizontal airway (1root mean square end). RS is the reference surface with which all
other surfaces were compared. The 7 landmarks to determine the ranking were used in all 30 airways
including 4 volumes that are partially abbreviated rostrally and caudally.

transformation method. The reference surface, which
was one of the 30 surfaces, was warped to the remaining
29 surfaces in groups of 5, primarily because of limita-
tions of the computer hardware and software. Groups
for warping were determined by the signed root mean
square rank of the individual surfaces, so that surfaces
1 through 5, 6 through 10, 11 through 15, 16 through
20, 21 through 25, and 26 through 30 were clustered
together. Each group of 5 surfaces was then combined
by weighted surface interpolation to yield a local average
surface. The 6 local average surfaces were then interpo-
lated again to yield the overall average shape.
With the mean surfaces generated, the next step to
make the 3D description of anatomic structures useful
was to add a color map depicting the variability across
each structure in the sample. First, to remove rotational
and translational differences, the warped version of each
surface was aligned to the coordinate system of the over-
all average surface by using the Amira tool, alignsurfa-
ces, which minimized the root mean square distance
between points of the model surface to the correspond-
ing closest points on the reference surface by using the
iterative closest point algorithm. Colors were set from
0 mm (dark blue) to 3 mm (bright red), and the included
portion of the spectrum was divided proportionally.
Color maps were generated for the warped reference sur-
face version of each airway. An interpolation procedure
similar to that performed to create the local average sur-
faces was completed, yielding 6 local color maps applied
to the local average surfaces. The 6 local average

American Journal of Orthodontics and Dentofacial Orthopedics November 2011  Vol 140  Issue 5
612
Fig 5. Frontal view of the airways ranked by signed root mean square error. RS is the reference surface
with which all other surfaces were compared.
surfaces and their color maps were subsequently put
through another interpolation step to produce a surface
representing the overall mean form with an associated
color map describing variations of the surface in the
sample population.
RESULTS
The airways ranked by signed root mean square errors
are shown in lateral (Fig 4) and frontal (Fig 5) views. This
spectrum roughly corresponds to thinking of the airways
as small and more vertical at the minus root mean square
end, and large and more horizontal at the plus root mean
square end. Asymmetries of the airway were particularly
noted in the frontal views. Extreme narrowing or restric-
tions were evident in both the lateral and frontal views of
the airway. The distance color map for the airway was
imposed on the mean surface along with an aligned
and scaled translucent individual airway. For the airway,
constriction of the overall tubular structure was judged
at the nasal airway, nasopharynx, oropharynx, and
November 2011  Vol 140  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Stratemann et al
hypopharynx. The airway components were evaluated
as inside (constricted), similar to, or outside (dilated)
the mean, and assigned respective values of 1, 0, or
1. The airway had the greatest variability in the hypo-
pharynx, in the region below the epiglottis and sur-
rounding the vocal folds (Figs 6 and 7). Moderate
variation was apparent at the nares, behind the soft
palate, and at the base of the tongue. Conservation
was seen at the central portion of the nasal airway
surrounding the inferior turbinate.
DISCUSSION
CBCT is suited to aiding our understanding the upper
airway; all of the intricacies are visible and not hidden in
the shadows of x-ray projections. In addition, surface
data that can be derived from the CT studies can be ma-
nipulated in CT, engineering, and mathematical soft-
ware. These types of programs not only improve
visualization of head and neck anatomy, but also
open orthodontics to the possibilities of integrating
Stratemann et al 613

Fig 6. Six airway color maps, lateral view. Each airway represents a warping of the reference surface
by using groups of 5 surfaces at a time and warping by the signed root mean square rank of the
individual surfaces. Each of these 6 surfaces was combined to yield an overall average shape. The
spectrum ranges from 0 mm (dark blue) to 3 mm (red).

Fig 7. Six airway color maps, frontal aspect. The spectrum ranges from 0 mm (dark blue) to 3 mm (red).

sophisticated morphometric methodologies with a phys-
iologic understanding of the fluid dynamics of air pass-
ing through the nose and throat. The segmentation
techniques used in this study allow incorporation of
conventional linear and angular measurements into
graphic, shape-based strategies that help to describe
the features of a patient in the context of overall popu-
lation variation.
Our data suggest that subjects can vary much more in
the hypopharyngeal region than at the oropharynx or
nasopharynx. However, part of this finding might also
depend on the position of the centroid, which was
defined predominantly in the central region of the air-
way and used for registration across subjects. It was ex-
pected that there would be fewer changes in shape close
to the registration center and that greater changes
would be evident farther from the registration site. The
location of the landmarks and whether they represent
peripheral boundaries of the airway and its general shape
can affect the centroid. Although we did not evaluate the
wide variety of problems and issues that can affect the
airway, including subjects with chronic sleep apnea,
this study does demonstrate that the airway has some
variability in shape. We were particularly interested in

American Journal of Orthodontics and Dentofacial Orthopedics November 2011  Vol 140  Issue 5
614
the limits of normal structures for the airway vs subjects
who have an airway obstruction.39,46,47 We believe that
CBCT will provide the tool for orthodontists to
determine whether a patient, particularly a young
patient, has severe enlargement of tissues that impinge
on the airway, and CBCT will also provide a range of
shapes and sizes that will function for normal airways.
The issue also arises as to what a CBCT 3D shape an-
alyzes. CBCT systems differ in the time to scan a subject;
the time will include several inspirations and expirations
that can significantly modify the shape of the airway. In
addition, the airway would modify its shape depending
on whether the patient was lying supine or sitting up-
right. The final airway shape might represent a complex
extrapolation of form over the period of scanning, and
comparison of CBCT scans with other methods that
accurately portray the change in airway during each
breath will be needed. These other methods will include
cine-magnetic resonance imaging,33-35,48 magnetic
resonance imaging,49-51 ultrafast CT,52 CT,53,54 and
endoscopic analysis, including optical coherence
tomography.38
There is some parallel in applications between the
2-dimensional lateral headfilm used to evaluate the air-
way and the CBCT evaluation, in that the lateral full
headfilm is taken quickly during 1 moment in time, but
that shape and dimension of the airway can be poten-
tially diagnostic for certain conditions that include
restriction.39,46,47 In contrast, CBCT can evaluate the
cross-sectional area, the volume, and the 3D form, and
provides a more accurate review of the anatomy than
a 2-dimensional lateral view, since it defines 1 key char-
acteristic that modifies airflow, which relates to the ra-
dius of the cross-sectional area.14,15,41,55 We did not
evaluate the airway cross-sectional area in this study
but have emphasized the differences in 3D form and
the fact that regions of restriction are evident.
CONCLUSIONS
CBCT provides a method to render a 3D volume of the
airway through segmentation of voxels with similar CT
numbers.
Defining landmarks of the airway provided a method
to superimpose 3D rendered surfaces.
Three-dimensional surfaces were aligned and scaled
to the same size by using a reference surface considered
to be an average airway and chosen arbitrarily.
A small number of 7 landmarks were then used to
define how each surface-rendered airway could be
superimposed and compared quantitatively by using
root mean square analysis to rank the images from the
average or reference surface.
November 2011  Vol 140  Issue 5 American Journal of Orthodontics and Dentofacial Orthopedics
Stratemann et al
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