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CBCT analysis of pharyngeal airway volume and

comparison of airway volume among patients with
skeletal Class I, Class II, and Class III malocclusion:
A retrospective study

Mandovi Nath, Junaid Ahmed, Ravikiran Ongole, Ceena Denny & Nandita
Shenoy

To cite this article: Mandovi Nath, Junaid Ahmed, Ravikiran Ongole, Ceena Denny & Nandita
Shenoy (2019): CBCT analysis of pharyngeal airway volume and comparison of airway volume
among patients with skeletal Class I, Class II, and Class III malocclusion: A retrospective study,
CRANIO®, DOI: 10.1080/08869634.2019.1652993

To link to this article: https://doi.org/10.1080/08869634.2019.1652993

Published online: 12 Aug 2019.

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CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
https://doi.org/10.1080/08869634.2019.1652993

SLEEP PATHOPHYSIOLOGY

CBCT analysis of pharyngeal airway volume and comparison of airway volume

among patients with skeletal Class I, Class II, and Class III malocclusion:
A retrospective study
Mandovi Nath MDS , Junaid Ahmed MDS , Ravikiran Ongole MDS , Ceena Denny MDS
and Nandita Shenoy MDS
Department of Oral Medicine and Radiology, Manipal College of Dental Sciences, Mangalore, Manipal Academy of Higher Education
(MAHE), Manipal, Karnataka, India

ABSTRACT KEYWORDS
Objective: To study the influence of skeletal malocclusion on the oropharyngeal airway volume Oropharyngeal airway; CBCT;
and the difference in the airway volume among gender and the different types of skeletal skeletal malocclusion;
malocclusion. maxillofacial radiologist;
obstructive sleep apnea
Methods: A retrospective analysis of 180 full-field of view (FOV) CBCT scans (55 in Class 1, 55 in
Class II, and 70 in Class III) were assessed to measure the oropharyngeal airway volume, ANB
angle, SNB angle, and Wits appraisal. The values were compared among different skeletal
malocclusions and were correlated to gender.
Result: There was a significant result in terms of oropharyngeal airway volume among different
types of skeletal malocclusion and ANB angle, SNB angle, and Wits appraisal among males and
females.
Conclusion: CBCT is a cheaper, more convenient option than polysomnography (PSG) when
assessing airways, and thus, a maxillofacial radiologist is importantly placed in the assessment of
the retropalatal and retroglossal volume of the oropharyngeal airway.

Introduction
Airway space is defined as the region in anatomy that
includes airway structures from above the plica vocalis to
its two openings, the nose and the mouth. These struc-
tures are responsible for conduction and regulation of air
and prevention of external irritation. A standard pharyn-
geal airway improves nasal respiration and is considered
important in the growth and development of craniofacial
structures; it is made up of several anatomic subsites,
including the tonsillar complexes, the soft palate, base of
the tongue, and the pharyngeal wall [1–3].
Hindrance of the pharyngeal airway occurs due to
obstructive processes and can be physiological, patho-
logical, or morphological in nature, due to an altered
craniofacial morphology. Variation in dentoskeletal
growth leads to an obstruction of the upper airway
and development of deleterious habits like mouth
breathing, which eventually leads to an altered pattern
of craniofacial growth and dental malocclusion. In due
course, these patients end up with a high prevalence of
Class II and Class III malocclusion [4–7]. In addition
to a mouth breathing habit, a restricted pharyngeal
airway can induce obstructive sleep apnea syndrome
(OSAS) [4,5]. Disturbances during the development of
jawbones can cause skeletal malocclusion, leading to
dysfunctions, such as breathing obstruction, dental
deformities, teeth crowding, trismus, bruxism, diges-
tion disturbances, and mastication difficulties [8–10].
Treatment modalities, like rapid palatal expansion,
increase nasopharyngeal airway size, leading to an
improvement in respiratory function, especially in
patients who present with breathing obstruction.
Dental surgeons have an important role in the eva-
luation and treatment of patients with restricted oro-
pharyngeal airways. Oral appliances have been used,
with promising results, since initial descriptions of
their effectiveness in the 1980s. The practice para-
meters for the use of an oral appliance by a dentist
were initially published in the year 1995 [11,12].
There are several techniques employed presently for
the diagnosis of OSA. In-laboratory polysomnography
(PSG) is considered to be the gold standard method

CONTACT Junaid Ahmed junaid.ahmed@manipal.edu Department of Oral Medicine and Radiology, Manipal College of Dental Sciences,
Mangalore, Manipal Academy of Higher Education (MAHE), Manipal, Karnataka 576104, India
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/ycra.
© 2019 Taylor & Francis Group, LLC
2 M. NATH ET AL.

that can help in diagnosing sleep-disordered breathing. Materials and methods

The apnea-hypopnea index (AHI) is another method
The current study was conducted in the Department of
that helps in determining the severity of OSA.
Oral Medicine and Radiology, Manipal College of
Pharyngeal critical closing pressure (Pcrit) is another
Dental Sciences (MCODS), Mangalore and was
technique that can be used to quantify collapsibility of
approved by the Ethical committee of the Institution
the upper airway during sleep. However, this technique
(Institutional Ethics committee Protocol Ref No-16104
is time-consuming and requires skilled personnel to
dated 20/09/2016).A statistician was consulted, and
analyze and collect the data. Cephalometric radio-
considering the power of the study to be 80%, it was
graphs provide limited information, as only two-
advised to include 180 patient scans from the preado-
dimensional changes are conveyed for a structure that
lescent and adolescent age group who had reported to
is three-dimensional, and hence, the complexity and
the hospital for orthodontic treatment. After evaluating
size of the airway cannot be completely ascertained
the inclusion and exclusion criteria among the 180
[13]. Recently, there has been an increase in the num-
patients, they were further divided into 55 cases in
ber of reliable and simple studies on the development
Class I, 55 cases in Class II, and 70 cases in Class III.
of 3D imaging to estimate the extent of collapse of the
The study was retrospective, cross-sectional in design,
airway. The airway extending from the tip of the nose
and the scans were obtained from the existing CBCT
to the superior end of the trachea can be visualized on
database in the department during the period of
conventional computed tomography (CT) and cone
December 2016 to July 2018. The patients were sub-
beam CT (CBCT) scans [12].
jected to the full field of view (FOV) CBCT scans
The dawn of CBCT has provided clinicians an oppor-
(200 mm x 170 mm) for orthodontic assessment.
tunity to assess the volumetric regions and cross-sectional
A Planmeca Promax 3D Mid unit (Planmeca Oy,
areas simultaneously with respect to the oropharyngeal
Helsinki, Finland) CBCT machine was used for record-
airway in multiple planes, i.e., coronal, sagittal, and axial.
ing the scans with the parameters of 90kV, 8mA, 40
The quantification of the oropharyngeal airway and assess-
ms, with a slice thickness of 0.4 mm. Romexis software
ment of 3D morphology by CBCT scans provides a better
version 4.6.2 was used to assess the scans. Patient scans
substitute for the conventional 2D assessment and provides
with an adequate resolution and with skeletal Class I,
a precise analysis in all three anatomical planes [14–18].
Class II, and Class III malocclusion were included for
Currently, assessment of the oropharyngeal airway is
the study. Detailed information regarding facial asym-
a routine orthodontic procedure. An orthodontist,
metry, deformities such as cleft lip and palate, history
along with a maxillofacial radiologist, plays a vital
of orthodontic treatment, trauma, and history of upper
role in the diagnosis of airway obstruction since they
respiratory infections was obtained from the patient’s
are well-equipped to diagnose early signs of impending
past medical records. Patients with these findings were
oropharyngeal obstruction in full-volume CBCT
excluded from the study. The patients satisfying three
images. In the present study, an attempt was made to
out of the following four criteria were classified as
understand the differences in oropharyngeal airway
skeletal Class I, Class II, and Class III (Table 1):
volume and its quantitative analysis among patients
1) SNB angle
grouped under skeletal Class I, II, and III malocclusion
using CBCT. Any difference in the oropharyngeal air- ● SNB: formed by lines joining from point S and
way pattern in relation to gender was also assessed. point B up to point N. The mean is 80º (skeletal

Table 1. Age and gender correlation with distribution of subjects in Class I, II and III.
Mean / count Standard Deviation / percentage
SEX MALE MOLAR/CANINE RELATION CLASS I AGE 20.50 1.68
CLASS II AGE 21.29 2.08
CLASS III AGE 20.21 1.84
FEMALE MOLAR/CANINE RELATION CLASS I AGE 22.05 4.55
CLASS II AGE 21.11 2.38
CLASS III AGE 21.76 2.98
MOLAR/CANINE RELATION CLASS I AGE 21.04 3.05
CLASS II AGE 21.16 2.28
CLASS III AGE 21.11 2.67
MOLAR/CANINE RELATION CLASS I SEX MALE 36 65.5%
FEMALE 19 34.5%
CLASS II SEX MALE 17 30.9%
FEMALE 38 69.1%
CLASS III SEX MALE 29 41.4%
FEMALE 41 58.6%
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
Class I). Angles less than 80º were taken as skele-
tal Class II and angles greater than 80º as skeletal
Class III.
2) ANB angle
● ANB: formed by lines joining from point A and
point B up to point N. It indicates whether the
skeletal relationship between the maxilla and
mandible is a normal skeletal Class I (+2º), skele-
tal Class II (+4º or more), or skeletal Class III (0
or negative) relationship.
3) Wits appraisal
● This analysis calls for drawing an occlusal plane
through the overlapping cusps of molars and pre-
molars. Perpendicular lines connecting A point
and B point to the occlusal plane were drawn
and labeled as AO and BO. The distance between
AO and BO was measured and categorized as
skeletal Class I (0 to 2 mm), skeletal Class II
(greater than 2 mm), and skeletal Class III (less
than 1 mm).
4) Molar relation between maxillary and mandibular
first molar or canine relation (in case of absence of
maxillary and mandibular first molars).
The oropharyngeal airway was outlined in the sagittal
plane as follows (Figure 1):
● Superior border of the oropharynx as the horizontal
plane passing through the posterior nasal spine.
● Inferior border of the oropharynx as the plane
passing through the most superior part of the
epiglottis.
● A horizontal line passing through the tip of the
uvula dividing the oropharynx into a lower retro-
glossal (RG) and an upper retropalatal (RP) com-
partment. The volume of the airway was
measured using the airway measuring tool present
in the Romexis software.
The parameters measured were airway volume (mm3)
and average surface cross-sectional area for both retro-
glossal and retropalatal compartments (Figure 2 a-d).
The CBCT scans were used to create a virtual cepha-
logram, and ANB, SNB, Wits appraisal, and molar
relationship were recorded (Figure 3). The skeletal
class malocclusion was calculated by a maxillofacial
radiologist and later verified by an orthodontist.
A flowchart was created to explain the methodology
of the study (Figure 4).
3
Figure 1. Marking of the oropharyngeal region in sagittal plane. RP:
retropalatal compartment: RG: retroglossal compartment.
Significant results
Seventy-three of the 180 patients examined had
a discrepancy in values between ANB angle and Wits
appraisal in determination of the type of skeletal mal-
occlusion. A total of 40 male patients were diagnosed
with Class I malocclusion, of whom 4 were excluded
since they did not fulfill the criteria for inclusion. The
remaining 36 males were analyzed using Pearson’s
correlation. The correlation between the parameters
ANB angle and retropalatal volume showed an inverse
correlation and was significant, with a p-value of 0.024.
The correlation between the parameters ANB angle &
retropalatal cross-sectional area showed an inverse cor-
relation and was significant, with a p-value of 0.024.
The correlation between the parameters SNB angle &
retroglossal compartment volume showed a direct cor-
relation and was significant, with a p-value of 0.049.
The correlation between the parameters SNB angle &
retroglossal compartment cross-sectional area showed
a direct correlation and was significant, with a p-value
of 0.013 (Figure 5).
A total of 20 male patients were diagnosed with
Class II malocclusion, of whom 3 were excluded since
they did not fulfill the criteria for inclusion. The
remaining 17 males were analyzed using Pearson’s
correlation. The correlation between the parameters
ANB angle & retropalatal compartment cross-
sectional area among males with Class II malocclusion
showed an inverse correlation and was significant, with
a p-value of 0.045. The correlation between the
4 M. NATH ET AL.

Figure 2. Measuring the volume of the oropharyngeal region in sagittal plane using an airway measuring tool.
a) Measurement of airway volume in retropalatal section b) Measurement of airway volume in retroglossal section c) 3D volumetric assessment of
retropalatal oropharyngeal area using “airway measurement tool” in Planmeca Romexis® software d) 3D volumetric assessment of retroglossal
oropharyngeal area using “airway measurement tool” in Planmeca Romexis® software

parameters SNB angle & retropalatal compartment
cross-sectional area among males with Class II maloc-
clusion showed a direct correlation and was significant,
with a p-value of 0.048 (Figure 6).
Thirty patients were diagnosed with Class III mal-
occlusion, of whom 1 male patient was excluded since
he did not fulfill the criteria for inclusion, and the
remaining 29 were analyzed using Pearson’s correla-
tion. The correlation between the parameters ANB
angle & retroglossal compartment volume showed
a direct correlation and was significant, with a p-value
of 0.011. The correlation between the parameters ANB
angle & retroglossal compartment cross-section area
showed an inverse correlation and was significant,
with a p-value of 0.034. The correlation between the
parameters SNB angle & retroglossal compartment
volume showed direct correlation and was significant,
with a p-value of 0.019. The correlation between the
parameters Wits appraisal & retropalatal compartment
cross-sectional area showed an inverse correlation and
was significant, with a p-value of 0.023 (Figure 7).
Among female patients, the correlation of ANB
angle, SNB angle, and Wits appraisal with retroglossal
compartment volume, retroglossal compartment cross-
sectional area, retropalatal compartment volume and
retropalatal compartment cross-sectional area diag-
nosed with Class I and Class III skeletal malocclusion
revealed statistically non-significant results.
A significant value could be obtained only among
female patients diagnosed with Class II malocclusion
between Wits appraisal & retropalatal compartment
volume, which showed a direct correlation and was
significant, with a p-value of 0.013.
A total of 40 female patients, of whom 2 were excluded
since they did not fulfill the criteria for inclusion, were
diagnosed with Class II malocclusion, and the remaining
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 5

Figure 3. Images of virtual cephalometry created from cone beam computed tomography (CBCT) volumes of patients for
assessment of skeletal malocclusion.
3a) Measurement of SNB angle; 3b) Measurement of ANB angle; 3c) Measurement of Wits appraisal. A – Point A (or ss, subspinale) – the point at
the deepest midline concavity on the maxilla between the anterior nasal spine and prosthion. N – Nasion – the most anterior point of the
frontonasal suture in the median plane. B – Point B (supramentale) – the point at the deepest midline concavity on the mandibular symphysis. S –
Sella – this is the point representing the midpoint of the pituitary fossa (sella turcica)

38 were analyzed using Pearson’s correlation. The corre-
lation between the parameters Wits appraisal & retro-
palatal compartment volume showed a direct correlation
and was significant, with a p-value of 0.013 (Figure 8).
Discussion
The methods used for the analysis of oropharyngeal
airway patency include conventional radiology, nasal
endoscopy, 3D CT & CBCT, and magnetic resonance
imaging. The maximum accuracy, however, can be
achieved by a more accurate analysis using 3D images.
Various studies have been conducted on the assess-
ment of the airway and, conjointly, the correlation
with various soft tissue profiles, skeletal malocclusion,
age, and gender-related changes among numerous eth-
nic groups and populations [19,20]. The present study
aimed to evaluate the oropharyngeal airway among the
different types of skeletal malocclusion besides the
influence of other parameters like SNA angle, ANB
angle, and WITS appraisal on the airway and its corre-
lation with gender.
Several studies have tested the accuracy and
dependability of CBCT and have confirmed its poten-
tial in comparison to multiple detector row computed
tomography (MDCT) for analysis of the oropharyn-
geal airway. CBCT gives data concerning not only the
dimension of the airway, but it also additionally pro-
vides information on the depth of the airway [21].
In their study, Zamora, et al. [22] found
a distinction among various skeletal malocclusions
and ANB angle and also a discrepancy in values
between ANB angle and Wits appraisal in the diagnosis
of various types of skeletal malocclusion. These find-
ings were consistent with the current study, in which
73 of the 180 patients had a discrepancy in values
6 M. NATH ET AL.
Figure 4. Flowchart explaining the structure of the study.
between ANB angle and Wits appraisal in the diagnosis
of different types of malocclusion.
Baccetti et al. [23], who conducted a study to under-
stand the variations in cephalometric measurements
among Class III malocclusion individuals, concluded
that ANB was greater in males in comparison to
females. This was in accordance with the current
study, which revealed a considerably higher ANB
value among males with Class III malocclusion with
a significant ‘p’ value result.
Ceylan and Oktay reported that changes in the ANB
angle affected not only the nasopharyngeal airway size,
but additionally, the oropharyngeal area, which was
reduced in subjects with an increased ANB angle
[24]. They observed that ANB angle and oropharyngeal
airway volumes are inversely correlated. This was in
accordance to the findings of the current study,
wherein the airway compartment was largest in Class
III, followed by Class I and Class II, respectively, and
inversely, the ANB angle was maximum in Class II
individuals, followed by Class I and Class III.
Bhattacharya et al. [25], in their study, concluded
that Class III malocclusion has a higher SNB angle
compared to Class II and Class I malocclusion. The
current study revealed similar results, with a higher
value of SNB angle for Class III patients, followed by
Class I and Class II patients, with a significant ‘p’
value.
Several studies have also been conducted wherein
the cervical position in various types of skeletal mal-
occlusion has been suggested as a potential etiological
factor that can affect the breathing pattern and con-
tribute to the development of sleep apnea [26–29].
However, since the current study was retrospective in
nature, no such changes were recorded in cervical
posture among the patients.
Al-Jabaa and Aldrees [30] found a higher value of
Wits appraisal for Class I patients. Roth [31], in his
study, observed an overlap in Wits appraisal measure-
ments among Class I, Class II, and Class III patients. In
the present study, a higher value of Wits appraisal was
found for Class II, followed by Class I and Class III.
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 7

Figure 5. Correlation of ANB angle, SNB angle, Wits appraisal with retroglossal compartment volume, retroglossal compartment
cross-sectional area, retropalatal compartment volume, and retropalatal compartment cross-sectional area among male patients
diagnosed with Class I malocclusion.

However, the higher values did not correspond to
a significant ‘p’ value. Wits appraisal is purely
a dental correlation and denotes the occlusal relation-
ship to the base of the skull, and various factors like
crowding, missing teeth, and size of teeth can cause
alteration in its value. The patients in the studies men-
tioned had anterior crowding, and hence, there was
a discrepancy in Wits appraisal values. In the present
study, no such discrepancy was noted in the values
since there was absence of any crowding, missing
teeth, or alteration in size of the teeth.
Jayaratne and Zwahlen [32], in their study, observed
a considerably higher value for the oropharyngeal airway
(retropalatal and retroglossal compartment) volumes
among Class III subjects when compared to Class II
individuals, which was similar to the findings in the
current study, which showed higher values for orophar-
yngeal airway volume, with a significant ‘p’ value.
8 M. NATH ET AL.

Figure 6. Correlation of ANB angle, SNB angle, Wits appraisal with retroglossal compartment volume, retroglossal compartment
cross-sectional area, retropalatal compartment volume, and retropalatal compartment cross-sectional area among male patients
diagnosed with Class II malocclusion.

A study performed by Daniel et al. [33], who ana-
lyzed the oropharyngeal airway space among 10 males
and 10 females between the ages of 7 and 11 years,
revealed that the airway dimensions are larger in males
compared to females. However, a study done by El and
Palomo [34] reported no such distinction in gender in
terms of airway volume. In the current study, compar-
ison of the oropharyngeal airway among males and
females revealed a higher value in terms of volume
(retroglossal and retropalatal compartment) among
females when compared to males, with a significant
‘p’ value. This significant finding could be due to
a greater number of female patients (98) being included
in the current study. Also, previous studies have
included males and females within the pre-adolescent
years, in which the growth spurt is more rapid in men
compared to women, as stated by Chuen et al. [35] in
their cohort study of children 7–11 years of age,
wherein they observed that the enlargement of the air-
way post-growth spurt continues at a slower rate in
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE 9

Figure 7. Correlation of ANB angle, SNB angle, Wits appraisal with retroglossal compartment volume, retroglossal compartment
cross-sectional area, retropalatal compartment volume, and retropalatal compartment cross-sectional area among male patients
diagnosed with Class III malocclusion.

men than in women in later years, up to the age of 18.
In the present study, the age bracket considered for the
study was 10–21 years, which is considerably higher
when compared to the previous studies where the age
group included was between 7 and 11 years, and hence,
this could be a possible reason for a larger value of
oropharyngeal airway volume among women when
compared to men.
A study by Lopatienė et al. [36] revealed that
a decrease of the SNB angle by 1º increased the risk
of a 1 mm reduction in the width of the upper
pharynx by 17%. However, there was no significant
change observed in terms of oropharyngeal airway
volume for such patients. This observation was con-
sistent with the present study, where it was observed
that as the SNB angle increased, the airway volume in
both the retropalatal and retroglossal compartment
increased.
The current study correlated numerous aspects of
orthodontic parameters like ANB angle, SNB angle,
10 M. NATH ET AL.

Figure 8. Correlation of ANB angle, SNB angle, Wits appraisal, retroglossal compartment volume, retroglossal compartment cross-
sectional area, retropalatal compartment volume, and retropalatal compartment cross-sectional area among female patients
diagnosed with Class II malocclusion.

and Wits appraisal among skeletal Class I, II, and III
patients and their relationship with oropharyngeal air-
way volume. In the literature, numerous studies have
been conducted to assess the airway using various
methods in different types of skeletal malocclusion.
However, most of these studies are restricted to either
the assessment of the airway during an interventional
treatment or for a specific type of malocclusion. The
following study was aimed at studying the changes in
oropharyngeal airway volume among the adolescent
age bracket group before any intervention and, con-
currently, assessing the influence of various orthodon-
tic parameters on the airway volume and area among
both males and females.
Conclusion
Although PSG is the most commonly used technique
for the identification of the degree of airway obstruc-
tion, the use of CBCT is fast becoming an integral part
 CRANIO®: THE JOURNAL OF CRANIOMANDIBULAR & SLEEP PRACTICE
in the identification of a narrow and constricted air-
way, thanks to an enhanced visualization of the airway
and its relatively lower cost. Information about the
airway in all dimensions of length, width, and height
can be obtained by CBCT images, and maxillofacial
radiologists are strategically placed for the diagnosis
of any obstruction in the oropharynx and assessment
of its volume. CBCT is useful in 3D volumetric assess-
ment of the retropalatal and retroglossal area, and thus,
is an important aid in the treatment of conditions
affecting the airway resulting in debilitating conditions
like OSA.
CBCT is a less time-consuming, cheaper, and more
convenient alternative for the patient when compared
to PSG and can serve as a useful tool in the diagnosis of
OSA. Hence, its progression in the initial stages can be
stalled by early surgical intervention, or if the need be,
through an orthodontic intervention.
Conflict of interest
Authors Dr. Mandovi Nath, Dr. Junaid Ahmed,
Dr. Ravikiran Ongole, Dr. Ceena Denny, Dr. Nandita
Shenoy declare that they have no conflict of interest.
Human and animal rights statement
This article does not contain any studies with human or
animal subjects performed by any of the authors.
Funding
The study has not been funded by any external source.
ORCID
Mandovi Nath MDS http://orcid.org/0000-0003-0730-
9708
Junaid Ahmed MDS http://orcid.org/0000-0001-9419-
0754
Ravikiran Ongole MDS http://orcid.org/0000-0001-7075-
2708
Ceena Denny MDS http://orcid.org/0000-0001-9908-6753
Nandita Shenoy MDS http://orcid.org/0000-0002-4585-
1357
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