ONLINE ONLY

Oropharyngeal airway in children with

Class III malocclusion evaluated by cone-beam
computed tomography
Tomonori Iwasaki,a Haruaki Hayasaki,b Yoshihiko Takemoto,c Ryuzo Kanomi,d and Youichi Yamasakie
Kagoshima and Himeji, Japan

Introduction: Upper airway size is increasingly recognized as an important factor in malocclusion. However,
children with Class III malocclusion are somewhat neglected compared with those with a Class II skeletal pat-
tern. Therefore, the purpose of this study was to establish the characteristic shape of the oropharyngeal airway
(OA) in children with Class III malocclusion. Methods: The sample comprised 45 children (average age, 8.6 6
1.0 years) divided into 2 groups: 25 with Class I and 20 with Class III malocclusions. OA size of each group was
evaluated by cone-beam computed tomography. Cluster analysis, based on OA shape, redivided the subjects
into wide, square, and long types. The distributions of Class I and Class III subjects were compared among the
types. Results: The Class III group showed statistically larger OA area and width compared with the Class I
group. Area was positively correlated with Class III severity. The square type included 84% of the Class I mal-
occlusions but only 30% of the Class III malocclusions, indicating that the OA in Class III malocclusion tends to
be flat. Conclusions: The Class III malocclusion is associated with a large and flat OA compared with the Class
I malocclusion. (Am J Orthod Dentofacial Orthop 2009;136:318.e1-318.e9)

A
bnormal growth of the tissues of the upper air-
way can make the airway narrower and prone
to obstructive sleep apnea (OSA).1 The impor-
tance of this obstruction in the development of many
childhood problems is increasingly recognized.1-4
OSA in children is associated with excessive daytime
sleepiness, hyperactivity, attention deficit disorder,
poor hearing, physical debilitation, and failure to
thrive.3 Accordingly, much attention has been paid to
a
Research associate, Developmental Medicine, Health Research Course,
Graduate School of Medical and Dental Sciences, Kagoshima University,
Kagoshima, Japan.
b
Assistant professor, Developmental Medicine, Health Research Course,
Graduate School of Medical and Dental Sciences, Kagoshima University,
Kagoshima, Japan.
c
Postgraduate student, Developmental Medicine, Health Research Course,
Graduate School of Medical and Dental Sciences, Kagoshima University,
Kagoshima, Japan.
d
Private practice, Himeji, Japan.
e
Professor and chairman, Developmental Medicine, Health Research Course,
Graduate School of Medical and Dental Sciences, Kagoshima University,
Kagoshima, Japan.
Supported in part by the Japanese Society for the Promotion of Science (nos.
18791563, 19390532, 19592357, and 19592360).
The authors report no commercial, proprietary, or financial interest in the
products or companies described in this article.
Reprint requests to: Tomonori Iwasaki, Field of Developmental Medicine,
Health Research Course, Graduate School of Medical and Dental Sciences,
Kagoshima University, 8-35-1, Sakuragaoka Kagoshima-City, Kagoshima,
890-8544, Japan; e-mail, yamame@dentb.hal.kagoshima-u.ac.jp.
Submitted, July 2008; revised and accepted, February 2009.
0889-5406/$36.00
Copyright Ó 2009 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2009.02.017
the relationship between respiratory function and facial
morphology in orthodontics.4 Several articles have ana-
lyzed the morphology of the upper airway from lateral
cephalograms.4,5 Class II patients have a narrower ante-
roposterior pharyngeal dimension, and this narrowing is
specifically noted in the nasopharynx at the level of the
hard palate and in the oropharynx at the level of the tip
of the soft palate and the mandible.5 Class II Division 1
malocclusion is associated with a narrower upper air-
way even without retrognathia.6 However, the relation-
ship between facial morphology and the morphology of
the upper airway in children with Class III malocclusion
has not been previously described.
Previous analyses5,6 established cephalometric
norms for the upper airway7 by using lateral cephalo-
grams, based on the high reproducibility of its dimen-
sions.8 Nevertheless, because the left-right length
(width) of the upper airway is not visible, its precise
size cannot be estimated from a lateral cephalogram
alone.
Accordingly, the purpose of this study was to carry
out a systematic evaluation of the oropharyngeal air-
way (OA) in children with a Class III malocclusion
by using cone-beam computed tomography (CBCT)
and 3-dimensional (3D) image reconstruction soft-
ware. OA size (ie, cross-sectional area [CSA]), length,
and width in the horizontal plane of children with
Class III malocclusion were measured and compared
with children with Class I malocclusion. The null
318.e1
318.e2 Iwasaki et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2009

Fig 1. Three-dimensional image of a skull from CBCT. The standard coordinate system was estab-
lished by using orbitale and porion (blue lines). The OA was measured in a transverse plane that
passed through gonion (red line).

Fig 2. Measurements of the nasopharyngeal airway (NA) and the OA (OA): S, CSA; D, depth; and W,
width. The width of OA was measured at the narrowest part of the entire depth. Wmax was measured
at the greatest width of the OA.

hypothesis was that Class III and Class I children do
not differ in upper airway size.
MATERIAL AND METHODS
A total of 45 patients, who visited Kanomi Or-
thodontic & Pediatric Dental Clinic (Himeji-City,
Hyogo-Prefecture, Japan) for orthodontic treatment,
participated in this study. The subjects were divided
into 2 groups according to occlusion: (1) Class I maloc-
clusion patients had a positive overjet of 2 to 4 mm,
a Class I deciduous or permanent canine relationship,
and a Class I permanent molar relationship; and (2)
Class III malocclusion patients had a negative overjet,
a Class III deciduous or permanent canine relationship,
and a Class III permanent molar relationship. The Class
I and Class III groups included 13 boys and 12 girls
(average age, 8.8 6 1.0 years) and 12 boys and 8 girls
(average age, 8.4 6 1.0 years), respectively. Because
the volume of the airway is influenced by head posture,
American Journal of Orthodontics and Dentofacial Orthopedics Iwasaki et al 318.e3
Volume 136, Number 3

Fig 3. Volume measurement of the upper airway and intraoral airway space: A, upper airway volume
was measured between the hard palate and the base of the epiglottis; B, computer-generated
extraction of upper airway (left) and intraoral airway space (right).

Table I. Cephalometric measurements of the anteropos- A 3D coordinate system and 3D image were constructed
terior position of the maxilla and the mandible with a medical image analyzing system (ImagnosisVE,
Imagnosis, Kobe, Japan).
Class I group Class III group
(n 5 25) (n 5 20)
The origin of the 3D coordinate system was the
midpoint between the left and right porions. This origin
Mean SD Mean SD P and left and right orbitale defined the standard horizon-
Overjet (mm) 2.82 1.15 –2.28 0.99 \0.001* tal plane. A frontal plane was constructed through both
ANB ( ) 3.56 1.97 0.40 1.45 \0.001* orbitale points and perpendicular to the horizontal plane
AF-BF (mm) 5.60 2.60 1.00 3.04 \0.001* (Fig 1). The sagittal plane was constructed through both
Wits (mm) 1.23 1.78 4.85 1.56 \0.001* orbitale midpoints and perpendicular to the horizontal
APDI ( ) 79.90 3.50 87.60 4.51 \0.001*
and frontal planes.
AF-BF, The distance between perpendiculars drawn from A-point and From this cephalometric image, the anteroposterior
B-point onto the Frankfort horizontal plane; APDI, the facial angle 6 positions of both the maxilla and the mandible were eval-
the A-B plane angle and again 6 the Frankfort-palatal plane angle. uated with the ANB angle,10 AF-BF (the distance be-
*Statistically significant at P \0.01.
tween perpendiculars drawn from A-point and B-point
onto the Frankfort horizontal plane),11 Wits appraisal,12
the craniocervical inclinations of all subjects were ex- and APDI angle (the facial angle 6 the A-B plane angle
amined to ensure that their inclinations were between and again 6 the Frankfort-palatal plane angle).13
90 and 110 .9 The study was reviewed and approved In addition, the intraoral airway space and degree of
by the Ethics Committee of the Kagoshima University hyperplasia of the palatine tonsils were measured.
Graduate School of Medical and Dental Sciences, Ka- Airway cross-sectional measurements included
goshima, Japan. CSA, depth (anteroposterior direction), and width
Each subject was seated in a chair with his or her (left-right direction). The CSAs of the nasopharyngeal
Frankfort horizontal plane parallel to the floor. A and oropharyngeal airways were defined as shown in
CBCT device (CB MercuRay, Hitachi Medical, Tokyo, Figure 2. Three parameters for the size of the nasopha-
Japan) was set to maximum 120 kV, maximum 15 mA, ryngeal and oropharyngeal airways were determined
and exposure time of 9.6 seconds. The data were sent di- based on previous reports.14 The nasopharyngeal airway
rectly to a personal computer and stored in digital imag- cross-section was measured along a horizontal plane at
ing and communications in medicine format (DICOM). the airway’s narrowest part on the cephalometric image.
318.e4 Iwasaki et al American Journal of Orthodontics and Dentofacial Orthopedics
September 2009

Table II. Mean measurements of the upper airway

Class I group (n 5 25) Class III group (n 5 20)

Mean SD Mean SD P

Nasopharyngeal airway
CSA (mm2) 181.12 64.57 182.77 64.89 0.993
Depth (mm) 8.27 2.65 9.57 3.64 0.173
Width (mm) 26.80 3.84 25.79 3.36 0.360
Oropharyngeal airway
CSA (mm2) 119.18 48.09 168.56 54.40 0.002†
Depth (mm) 10.68 2.52 13.58 3.16 0.001†
Width (mm) 14.97 3.98 18.40 4.47 0.021*
Width difference 3.33 2.17 6.09 3.72 0.008†
Upper airway volume (mm3) 6260.15 3010.03 7326.89 2593.40 0.295
Intraoral airway (mm3) 702.02 1289.18 2101.51 2148.17 0.016*

*Statistically significant at P \0.05; †Statistically significant at P \0.01.

Table III. Correlations among the OA measurements of Table IV. Correlations between the anteroposterior posi-
the Class I and Class III groups tion of the maxilla and the mandible and the OA mea-
surements of the Class III group (n 5 20)
Depth (P) Width (P)
ANB (P) AF-BF (P) Wits (P) APDI (P)
Class I group CSA 0.471 (0.018)* 0.570 (0.003)†
(n 5 25) Depth — –0.234 (.261) CSA –0.529 –0.515 0.173 0.584
Class III group CSA 0.219 (0.355) 0.536 (0.015)* (0.016)* (0.020)* (0.465) (0.007)†
(n 5 20) Depth — –0.406 (0.076) Depth –0.253 –0.26 0.085 0.343
† (0.281) (0.269) (0.722) (0.139)
*Statistically significant at P \0.05; Statistically significant at
Width –0.017 0.03 0.095 0.009
P \0.01.
(0.944) (0.900) (0.691) (0.970)

AF-BF, The distance between perpendiculars drawn from A-point and

The OA cross-section was measured along a horizontal
plane passing through the midpoint of bilateral gonion.
Volume-rendering software (INTAGE Volume Edi-
tor, KGT, Tokyo, Japan) was used to create 3D images
and evaluate the volumes of the upper airway and intrao-
ral airway space. The volume data were in a 512 3 512
matrix with a voxel size of 0.377 mm. A Hounsfield unit
range of –1024 to –300 was interpreted to be air. The
upper airway volumes from nasal plane to the base of
epiglottis plane and the intraoral airway space were
measured15 (Fig 3).
The difference between the greatest width and the
narrowest width of the OA was examined to evaluate
changes in airway form produced by hyperplasia of
the palatine tonsils (Fig 2).
Statistical analysis
T tests were used to compare (1) the anteroposte-
rior position of the maxilla and the mandible; (2) the
size of the upper airway (volume, CSA, width, depth);
(3) intraoral airway space, and (4) degree of
hyperplasia of the palatine tonsils between the Class
I and Class III groups. The Pearson product-moment
B-point onto the Frankfort horizontal plane; APDI, the facial angle 6
the A-B plane angle and again 6 the Frankfort-palatal plane angle.
*Statistically significant at P \0.05; †Statistically significant at
P \0.01.
correlation coefficients were calculated to evaluate
the relationships among CSA, depth, and width of
the OA, and correlations between the size of the OA
and the anteroposterior position of the maxilla and
the mandible in the Class III group. A cluster analysis
(group average method) was carried out based on the
shape of the OA after the size parameters of the air-
way were standardized from 0 to 1. According to the
resulting dendrogram, the subjects could be divided
into 3 types of shapes. The Scheffé test was performed
among the 3 groups for the anteroposterior position of
the maxilla and the mandible and the size of OA. In
addition, the Fisher exact test clarified the distribution
of shape types in the 2 malocclusion groups. P \0.05
was considered statistically significant.
The reliability of the measurements (intraoperator
repeatability) was assessed first by repeated tracings
(landmark identification) and then by digitization of
the same lateral cephalograms. To assess the error in
American Journal of Orthodontics and Dentofacial Orthopedics Iwasaki et al 318.e5
Volume 136, Number 3

Fig 4. Dendrogram of the 3 airway shapes obtained by cluster analysis.

Fig 5. Examples of 3 airway-shape types. W, Width; D, depth. In the wide type, W . D; in the square
type, W 5 D; in the long type, W \ D.

landmark identification, 10 randomly selected lateral
cephalograms from the 45 were traced and digitized
twice by the same operator (T.I.) a week later. A paired
t test detected no statistically significant differences.
Correlations between the first and second measurements
ranged from 0.975 to 0.999 (P \0.001, df 5 8). Calcu-
lations were also performed independently for each dig-
itization, the differences between paired linear
measurements were calculated, and error according to
Dahlberg’s method16 (double determination method)
was computed. The resulting errors were 1.37 mm2
for CSA, 0.34 mm for depth, and 0.53 mm for width
of the nasopharyngeal airway. For the OA, the errors
were 1.69 mm2 for CSA, 0.15 mm for depth, and 0.54
mm for width. The error for airway volume was
162.48 mm3. According to all repeated analyses, the
method error was considered negligible.
RESULTS
The cephalometric anteroposterior position of the
maxilla and mandible, and the OA measurements of
318.e6 Iwasaki et al
Table V. Subject distributions based on airway shape
Wide type Square type Long type
Class I group (n 5 25) 3 21
Class III group (n 5 20) 11 6 3
Total 14 27
Fisher exact test: df 5 2; chi-square 5 14.18; P \0.01.
the Class I and the Class III groups are compared in
Table I. The mandible of the Class III group was located
more anteriorly than in the Class I group.
The size of the nasopharyngeal airway and the upper
airway volume of the Class III group did not differ sig-
nificantly from those of the Class I group (Table II).
However, the size of the OA of the Class III group
was significantly larger than that of the Class I group.
The CSA of the Class I group (119.18 mm2) was 71%
that of the Class III group (168.56 mm2). The intraoral
airway space of the Class III group (2101.52 mm3) was
significantly larger than that of the Class I group (702.03
mm3), indicating a lower tongue position; the difference
between the maximum and minimum oropharyngeal
widths was significantly greater in the Class III group
(6.09 mm) than in the Class I group (3.33 mm), indicat-
ing greater hyperplasia of the palatine tonsils.
The 2 groups also differed in how the OA measure-
ments were correlated. The oropharyngeal CSA was
significantly correlated with both depth and width in
the Class I group (Table III) but with width only in the
Class III group.
Table IV shows the correlations between the antero-
posterior positions of the maxilla and mandible with 3
measurements of the OA in the Class III group. Depth
and width did not show significant correlations with
cephalometric parameters; however, the CSA had mod-
erate correlations with all but the Wits appraisal. ANB
and AF-BF were negatively correlated to CSA, and
APDI showed the only significant positive correlation.
The subjects were divided into 3 groups—wide,
square, and long—according to the shape of their OAs
by the cluster analysis (Figs 4 and 5). This number of
groups was determined by considering the number of sub-
jects. Based on this analysis, 21 of 25 (84%) of the Class I
subjects were the square type, and 11 of 20 (55%) of Class
III subjects were the wide type (Table V). This distribu-
tion of the subjects was statistically significant according
to the Fisher exact test (P \0.01).
When the cephalometric parameters were compared
among the 3 shape types, significant differences were
found, especially between the wide and square types
(Table VI). The group differences of the 3 size dimen-
sions were significant except for CSA and width
American Journal of Orthodontics and Dentofacial Orthopedics
September 2009
between the square and long types. The wide type had
the largest CSA (198.58 mm2), and the long type’s
CSA was only 67% (132.75 mm2), whereas the square
1 type’s CSA was just 53% (105.70 mm2) of the wide
type. The anteroposterior position of the maxilla and
4 the mandible were significantly different only between
the wide and square types.
DISCUSSION
The main purpose of this study was to establish the
characteristics of the OA in children with Class III mal-
occlusion with CBCT. Upper airway shape has been of
interest for more than 30 years because of its connection
with OSA in young children, and studies have included
clinical observations,17 anatomy,18 flow mechanics,19
and ventilation control.20 That children with OSA
have narrower pharyngeal airways compared with con-
trol children during wakefulness21 and sedation22 has
been shown by cephalometry,23 acoustic reflection,21
endoscopy,24 and magnetic resonance imaging.25-27
Aboudara et al28 found much larger interindividual
variations of the volume and area of the upper airway in
cephalograms than with computed tomography (CT).
CBCT can better assess the cross-sectional dimensions
of the airway space than conventional 2-dimensional radi-
ography. The drawing of airway circumferences and cal-
culation of cross-sectional areas by computer also greatly
reduces operator-dependent bias.
Because of the relatively small sample in this study,
boys and girls were analyzed together. Abu Allhaija
et al29 found no sex differences in pharyngeal dimen-
sions between 45 girls and 45 boys (Class I, Class II,
and Class III groups of 15 patients each; ages, 14-17
years), and their findings agree with other reports that
suggest no sex differences in the pharyngeal dimensions
of prepubertal children.30-33
The CSA of the upper airway has been measured in
children with respiratory obstruction with 3D CT.29-34
However, norms for the upper airway in healthy children
have not been previously reported. After evaluating up-
per airway volume and CSAs of the nasopharyngeal and
oropharyngeal airways, we found that the oropharyngeal
CSA is a characteristic of Class III children (Table II).
Thus, about the oropharyngeal airway which was a char-
acteristic of Class III, size and form of the CSA were
examined.
Peh et al35 used CT to compare the CSAs of adult
OSA patients in the supine position with matched con-
trols. They found that the size of the OA of the Class I
group was smaller (119.18 6 48.09 mm2, n 5 25) than
that of normal adults (173.0 6 97.6 mm2, n 5 25),
who were closer to the Class III group (168.56 6 54.4
American Journal of Orthodontics and Dentofacial Orthopedics Iwasaki et al 318.e7
Volume 136, Number 3

Table VI.Comparison of anteroposterior positions of the maxilla and the mandible, and the OA size parameters of the 3
shape types
Post-hoc

Wide Square Long Scheffé test

(n 5 14) (n 5 27) (n 5 4) ANOVA
Mean (SD) Mean (SD) Mean (SD) P Wide vs square Long Square vs long

ANB ( ) 0.72 (1.94) 3.22 (2.08) 1.25 (2.50) 0.002* \0.05† 0.9 0.221
AF-BF (mm) 1.46 (2.76) 5.26 (3.20) 1.30 (4.11) 0.001* \0.05† 0.995 0.074
Wits (mm) 4.23 (1.80) 1.76 (2.23) 4.02 (3.41) 0.003* \0.05† 0.986 0.174
APDI ( ) 86.84 (5.18) 80.60 (4.09) 86.25 (6.29) 0.006* \0.05† 0.975 0.094
CSA (mm2) 198.58 (44.68) 105.70 (30.68) 132.75 (24.52) \0.001* \0.05† \0.05† 0.385
Depth (mm) 13.07 (1.52) 10.12 (1.87) 19.12 (1.53) \0.001* \0.05† \0.05† \0.05†
Width (mm) 16.64 (4.21) 10.49 (4.06) 7.22 (2.37) \0.001* \0.05† \0.05† 0.328

AF-BF, The distance between perpendiculars drawn from A-point and B-point onto the Frankfort horizontal plane; APDI, the facial angle 6 the A-B
plane angle and again 6 the Frankfort-palatal plane angle.
*Statistically significant at P \0.01; †Statistically significant at P \0.05.

Fig 6. Examples of tongue position against the palate and OA: A, the wide type has a flat shape and
a lower position of the tongue, resulting in reduced OA; B, the long type has hypertrophic palatine
tonsils. The tongue is positioned more anteriorly to maintain OA.

mm2, n 5 20).30 Ciscar et al2 stated that the maximum
and minimum velopharyngeal area in healthy adults
(n 5 8; ages, 30-50 years) are 121.9 6 7.9 and 103.2 6
10.0 mm2, respectively, based on magnetic resonance
imaging. They also reported maximum and minimum
depths and widths of the same healthy subjects (8.7 6
3.2 to 4.9 6 3.4 mm, and 16.4 6 2.3 to 13.9 6 2.6
mm, respectively). Their results were relatively small
compared with ours because of differences in age, posi-
tion, and projected planes. The depths of our Class III
group were 13.58 mm before enlargement and 14.98
mm after enlargement to match a cephalogram, which
is almost the same as the 15 mm reported by McNa-
mara.36 All measurements of the OA were significantly
larger in our Class III group than in our Class I group.
Although the negative and moderate correlation be-
tween depth and width (Table III) in the Class III group
was not significant (r 5 –0.406, P 5 0.076), the results
still suggest a flat OA shape. In both groups, CSA was
statistically correlated with airway width, making it
a more important contributor to CSA than depth. CSA
tends to be larger in proportion to the severity of the
Class III malocclusion (Table IV). Lopatiene and Babar-
skas37 reported that nasal resistance was correlated to
318.e8 Iwasaki et al
overjet (P 5 0.042), open bite (P 5 0.033), and maxil-
lary crowding (P 5 0.037) of Class II patients aged 7 to
15 years. Accordingly, Class III children might have
less obstruction of the upper airway.
Variation of OA measurements were relatively large
in this study (Table II), but all subjects could be divided
into 3 groups based on airway shape. According to this
division, 84% of the Class I subjects but only 30% of the
Class III subjects were of the square type. In other
words, 70% of the Class III subjects were either of the
wide or the long type, with a flattened OA along either
the anteroposterior axis (55% of the Class III subjects)
or the left-right axis (15% of the Class III subjects)
(Table V). The most interesting finding was the smallest
CSA in the square type (Table VI). These results suggest
that 100 mm2 might be large enough for normal func-
tion in Class I children at this age. A simultaneous func-
tional analysis is needed to confirm this suggestion.
A lower tongue position is considered characteristic
of an anterior crossbite.38-41 However, it is difficult to
quantitatively evaluate the distance between the tongue
and the palate from a lateral image. Therefore, we used
the volume of the oral cavity air space between the pal-
ate and the tongue as a quantitative index of tongue po-
sition. The Class III group had a significantly greater
intraoral airway space than did the Class I group (Table
II), indicating that a low tongue position is a characteris-
tic of Class III children.
Evaluation of hyperplasia of the palatine tonsils is
used for classification of a tonsillar-pharyngeal ratio.42
However, no method for quantitative evaluation of
palatine tonsil hyperplasia by using oropharyngeal
CSA has been previously reported. Therefore, we sug-
gest using the difference between the maximum and
minimum widths to evaluate the degree of hyperplasia
of the palatine tonsils (Fig 2). This difference was
significantly larger in the Class III group than the
Class I group, confirming enlarged tonsils in Class
III children (Table II).
In Class III children, the hypertrophy of the palatine
tonsils and the lower position of the tongue affect both
occlusal relationships and upper airway space.38-41 For
example, the tongue base is 3.0 mm more inferiorly
placed in patients with severe OSA than in those with
mild to moderate OSA.43 Figure 6 shows 2 typical ex-
amples of Class III children, 1 with a wide airway and
the other with a long airway. The wide type has a lower
tongue position, leaving space below the palate (Fig 6,
A). Moyers44 stated that the acquired protracted tongue
posture was usually a transitory result of pharyngitis or
tonsillitis. This might explain the higher tongue position
against the palate in the long type (Fig 6, B), resulting in
more posterior space for the OA.
American Journal of Orthodontics and Dentofacial Orthopedics
September 2009
Our data indicate that Class III patients have larger
OAs, with less possibility of OSA, even though the
shape is not square (ie, flat in an anteroposterior or
left-right direction).
CONCLUSIONS
Children with Class III malocclusion had signifi-
cantly larger OAs compared with those with Class I
malocclusion. Although 84% of children with Class I
malocclusion had a square OA, 70% of the children
with Class III malocclusion had a relatively flat shape,
either left-right (55% wide type) or anteroposterior
(15% long type).
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