Cephalometric assessment in obstructive sleep apnea

Nonglak Pracharktam, DDS, MSD, a Suchitra Nelson, PhD, b Mark G. Hans, DDS, MSD, ° B. Holly Broadbent, DDS, a Susan Redline, MD, MPH, e Carl Rosenberg, MD,' and Kingman P. Strohl, MD g

Cleveland, Ohio
It is reported that some specific craniofacial characteristics are associated with obstructive sleep apnea syndrome (OSAS). To test this finding, the present study developed and assessed the feasibility of a craniofacial index score (CIS) in differentiating patients with OSAS from habitual snorers. Anthropometric measurements and lateral head radiographs were obtained on 24 male and 4 female patients with OSAS who had physician-diagnosed OSAS (respiratory disturbance index (RDI) >20), and 25 male and 5 female habitual snorers (RDI <20). Thirteen cephalometric and four anthropometric measurements were used in a discriminant model to construct the CIS. The model was able to correctly classify 82.1% of the OSAS group and 86.7% of the snoring group. In addition, variables that were related to the soft tissues, hyoid bone to mandibular plane, Body Mass Index, and soft palate length had the highest predictive value. These findings indicate that a CIS constructed from cephalometric and anthropometric measurements can be used to identify subjects with and without OSAS. (AM J ORTHOD DENTOFACORTHOP 1996;109:410-9.)

O b s t r u c t i v e sleep apnea syndrome (OSAS) has received increased recognition in several medical fields because of multisystem complications asso ciated with the syndrome and the high prevalence of the syndrome in the adult population? Obstructive sleep apnea syndrome is characterized by a constellation of signs and symptoms related to arterial oxygen desaturation and sleep fragmentation caused by pharyngeal obstructions during sleep. ~ Although OSAS has been recognized for some time as a significant clinical illness, its predisposing factors and origin are still debated. Anatomic aberration of the pharyngeal airway and/or neurogenic failure to preserve the patency of the pharyngeal airway during sleep are the two most common theories regarding the origin of the syndrome? Craniofacial anatomic
Based in part on a thesis submitted by Dr. Pracharktam in partial fulfillment of the degree of master of science in dentistry, Case Western Reserve University. aGraduate, Department of Orthodontics, School of Dentistry, Case Western Reserve University, Ohio; currently a research fellow at Harvard School of Dental Medicine. bResearch Associate, Department of Orthodontics, School of Dentistry, Case Western Reserve University. CAssistant Professor and Graduate Program Director, Department of Orthodontics, School of Dentistry, Case Western Reserve University, Ohio. dClinical Professor, Department of Orthodontics, and Director, Bolton Brush Growth Center, School of Dentistry, Case Western Reserve University, Ohio. eAssistant Professor of Medicine and Co-Director, Sleep Disorders Center, Cleveland Veteran Administration Hospital, Case Western Reserve University. fAssistant Professor of Neurology, University Hospitals. gProfessor of Medicine and Chief of Division of Pulmonary and Critical Care Medicine, University Hospitals. 8/1/61080

abnormalities related to structural narrowing of the upper airway have been reported in patients with O S A S . 4-24 However, the relationships between nasorespiratory function and facial structure are still being explored in contemporary research studies. The effects of airway obstruction on facial growth have been debated in the orthodontic field for many years. Some clinicians and researchers contend that airway impairment alters facial and dental growth. 25-29 In contrast, other investigators have reported no correlation between craniofacial growth and nasal resistance. 3°-31 The scope of this argument has largely been limited to the growing child. As interest in OSAS increases, future debate concerning respiratory behavior and dentofacial development will likely expand to include the adult population. Cephalometry has been used extensively in the fields of orthodontics and anthropology to record craniofacial form. Recently, it has been also suggested that cephalometry could be an adjunctive procedure for assessing craniofacial patterns associated with OSAS.1°24 Bacon and his colleagues 1° used cephalometric variables in a step-wise discriminant analysis to classify 43 subjects with OSAS and 40 dental students. The four cephalometric variables that entered the discriminant model were soft palate length, sagittal dimension of upper face, anterior cranial base length, and lower face height. By using these four variables they were able to correctly classify 93% of the study population. However, their model did not include age or weight, which are known to play an important role


courtesy of Drs. with customized software developed for twodimensional morphologic analysis of anatomy (GeoCalc. model 4700 Scanner or Edentrace II. as well as head/facial form. and relative comparison of maxillary length with mandibular length (Figs. and loud snoring were recruited from a local sleep laboratory.). the pulse oximeter showed no evidence of repetitive episodes of desaturation indicating a lack of substantial apneic activity. 2). patients swallowed a tablespoon of barium sulfate esophageal cream (Esophotrast.05) in the duplicate measurements (see Table IV). All subjects received continuous positive air pressure treatment.American Journal of Orthodontics and Dentofacial Orthopedics Volume 109. and cephalometric measurements were described in our previous study? 3 Additional cephalometric variables used in the present study are presented in Table I and Fig. episodes of obstructed breathing during sleep. ramus width relative to the middle cranial fossa.) by the same investigator (N. obtained with a polygraph (Grass Model 78 Research Polysomnograph. Wis. 33 Centric occlusion was used to minimize variability in mandibular and soft tissue measurements often associated with rest position. Inc. We had the patient respond to the x-ray technician by raising the index finger as radiographs were taken to indicate that the patient was awake and not swallowing. and without swallowing. The patients were asked to first distribute the cream within the oral cavity using the tongue for 10 seconds. lasting at least 10 seconds. Recordings were . 4 P r a c h a r k t a m et aL 411 in developing OSAS. 32 Cephalograms were obtained with the teeth together in centric occlusion as previously described. 501 plus. 3-4) Errors in landmark identification and digitizing method were estimated by examining duplicate tracings of 25% of the lateral head films (n = 15 pairs). arterial saturation assessed by finger pulse oximeter (Nellcor N-200 Pulse Oximeter.. at the end of the expiration phase. Twenty-six subjects underwent a standard polysomnographic study for either half a night or 1 night and had a respiratory disturbance index (apnea and hypopnea per hour) greater than 20. The counterpart analysis of Enlow 3s was used to analyze cranial fossa alignment. Natural head posture was found by having the patient look into his own pupils reflected in a mirror located at eye level. In addition. Pa. Eden Prairie. Mass. and submental and tibial electromyography.) for 2 nights. The reliability of a subject's MATERIALS AND METHODS Study population Twenty-four male and four female white patients with OSAS and with a clinical history of excessive daytime sleepiness. body mass index (kg/m2). Seven of the control subjects were evaluated for abnormal sleep-breathing conditions with a portable home monitor (Edentec Monitoring System. Calif. and sleep stages evaluated by electroencephalography. Standard overnight polysomnography included: oronasal airflow measured with thermister. or a 2% or greater decrease in oxygen saturation accompanied by an arousal. Fort Washington. A respiratory event (apnea or hypopnea) was defined as a cessation or discernible reduction in airflow.). John Blank and Robert Mensforth. the lateral cephalogram was taken using natural head posture. and had repetitive episodes of arterial oxygen desaturation more than 4% from baseline with the cumulative percentages of time spent at normal saturation below 90%. Twenty-five male and five female white habitual snorers composed the control group.P.). respiratory effort assessed by surface chest wall and abdominal electromyography. Nellcor Inc. Minn. All 17 subjects with sleep studies had a respiratory disturbance index of less than 20 and a lack of clinical symptoms of OSAS. reference lines. Two subjects were evaluated by their physician who used oxygen saturation monitoring (Criticare Pulse Oximeter model no. electrooculography. electrocardiography. Thirteen of the control subjects were evaluated with oxygen saturation monitoring (Criticare Pulse Oximeter model #501 plus) for 2 nights. Verification o f cephalometric variables that predict craniofacial a n a t o m i c risks associated with O S A S m a y impact b o t h the diagnosis and the t r e a t m e n t of these patients. None of these subjects had a clinical history of active daytime sleepiness. The respiratory disturbance index (RDI) was calculated by the total sum of apneas and hypopneas divided by total sleep time. Anthropometric and cephalometric data collection Anthropometric data included sex. Cleveland State University). Milwaukee.. Grass Instrument Co.). All cephalometric landmarks were located and digitized (Summagraphics. and none had a uvulopharyngopalatoplasty or other surgical treatment before cephalometric radiographs were taken. No. To further minimize variations in soft tissues. Definition of landmarks. Roer Pharmaceutical Corp. T h e p u r p o s e of this study was to determine the feasibility of using a specific set of cephalometric and a n t h r o p o m e t r i c variables to classify persons into a snoring and an O S A S g r o u p with a derived craniofacial index score (CIS) that included age and weight in the discriminant function. Reliability was fairly accurate with paired t tests indicating no significant differences (p < 0. age. The relationship between skeletal and soft tissue components was determined by the ratio of the tongue area to the intermaxillary space in the sagittal plane as previously reported by Vig and Cohen 34 (Fig.. 1. To clarify the outline of the oropharyngeal soft tissues.). Standard overnight polysomnographic study was performed on 10 subjects in the control group to evaluate heavy snoring and to rule out OSAS. Classification of head forms and facial types was performed according to Montagu. then the patient was asked to swallow the remaining cream. Criticare Corp. and associated with either a 4% or greater decrease in oxygen saturation..

3. and histograms were plotted to insure a normal distribution. Conventional linear and angular eephalometric measurements and additional soft tissue measurements (see Table I). Means and standard deviations were calculated for all continuous independent variables. ratio of the cranial index to facial index. Relative comparison of cumulative maxillary length from Ar to A point with cumulative mandibular length from Ar to B point is also demonstrated. Definition of the anterior intermaxillary space height (AntrMxHt)..) mandibular effect. as This diagram shows effects of rotational alignment of subject's own MCF compared with neutral MCF on corresponding maxillary and mandibular placement.34 Fig. and body mass index (kg/m2). age. natural head position tested randomly by selecting 14 subjects and recording the natural head position before and after taking the radiograph. Fig. and intermaxillary area was previously described by Vig and Cohen. American Journal of Orthodontics and Dentofacial Orthopedics April 1996 C2tg ~ Fig.412 P r a c h a r k t a m et al. Counterpart analysis.05). Counterpart analysis. Diagram shows protrusive ( . 2. Ratio of tongue area to intermaxillary area. Equality of .3s This diagram shows comparison of horizontal dimension of MCF with width of ramus. also revealed no significant difference (p <_ 0. 4. Sex was coded as a dichotomous variable. 1. Fig. Statistical analysis The independent variables measured on a continuous scale included the following: 22 anatomic variables derived from the lateral head radiographs. head posture. intermaxillary space length (InMxLth). Clockwise (+) alignment is shown. posterior maxillary space height (PostrMxHt).

Journal of Orthodontics and Dentofacial Orthopedics Volume 109. 3. Soft palate length. Angle between the Frankfort horizontal line and the extracranial horizontal line obtained by a fluid level device with a metalic line.001). Length of the tongue measured from tongue tip (tt) to epiglottis base (Eb). a step-wise procedure was also computed to determine whether some variables were more important in differentiating between the two groups. All computations were performed with the Statistical Package (SPSS Inc. the final variables were chosen in accordance with results of published literature. t h e differe n c e s w e r e statistically significant only for t h e hyoid b o n e p o s i t i o n a n d c r a n i o c e r v i c a l angle. No.1 _+ 3. Distance between the most superior-posterior point of the soft palate and posterior pharyngeal wall. Polys o m n o g r a p h i c m o n i t o r i n g of t h e O S A S g r o u p d e m o n s t r a t e d m o d e r a t e to severe a p n e a ( m e a n R D I = 52.002. Linear correlation was computed for the 22 cephalometric variables to assess interdependency among variables. C o m p a r i s o n o f t h e 22 c e p h a l o m e t r i c a n a t o m i c v a r i a b l e s a r e p r e s e n t e d in T a b l e IV. t h e b o d y m a s s i n d e x ( B M I ) o f t h e subjects with O S A S was significantly g r e a t e r t h a n t h e c o n t r o l g r o u p (p _ 0.S N . measured along a line parallel to B-Go. Significant d i f f e r e n c e b e t w e e n g r o u p s was n o t e d for hyoid b o n e p o s i t i o n r e l a t i v e to t h e m a n d i b u l a r p l a n e ( H . A s e x p e c t e d . The CIS was defined as the midpoint of the mean function scores of the two groups.American . Tongue length.59). Further. 2. Superior posterior airway space. Subjects with O S A S also h a d m o r e o b t u s e c r a n i o c e r v i c a l angles ( < C 2 C 4 . all the final predictor variables were included in the model. < C2C4-SN < 2C-SN Soft tissues P-PNS Phw-Psp T1 Head posture FH-Hor Ratio CI/FI TflnMx area RESULTS the means between the two groups was compared with t tests (equal variance). 3). Vertical position of the hyoid relative to a line which is perpendicular to pterygomaxillary vertical line (PM) and passes sphenoethmoidal junction (SE). Ratio of the cranial index to the facial index. First. Vertical position of the hyoid relative to the mandibular plane. A d d i t i o n a l c e p h a l o m e t r i c v a r i a b l e s u s e d in t h e p r e s e n t s t u d y Variables Hard tissues Interpretation MCF Ram/MCF ArA-ArB H-MP H-Ver Neck Middle cranial fossa and posterior maxillary relative alignment (Fig. T h e d e m o g r a p h i c a n d a n t h r o p o m e t r i c d a t a for t h e subjects involved in t h e study a r e p r e s e n t e d in T a b l e s II a n d III. s h o w e d s o m e t r e n d s t o w a r d d i f f e r e n c e b e t w e e n t h e O S A S a n d s n o r i n g groups.) for the Social Sciences (SPSS-PC + for windows). T h e c o n t r o l s w h o u n d e r w e n t polysomnographic monitoring had a mean RDI of 5. For the discriminant model. 4 Pracharktam et al. with Bonferroni's correction was used to determine statistical significance.M E p -< 0. A craniocervical angle formed by a line from the most posterior-inferior point of the second cervical vertebra (C2) to the forth cervical vertebra (C4) and S-N plane.92 t h a t r e p r e s e n t e d a p n e i c activity within t h e n o r m a l range. The efficiency of the discriminant model was assessed by examining the eigenvalues (ratio of the between-groups variability to within-groups sums of squares) 36 and the canonical correlation (degree of association between the discriminant scores and the groups)? 6 A large value of both is associated with a good discriminant function. the discriminant function that best classified the subjects was used to calculate the CIS. A craniocervical angle formed by a line from C2 to C2 tangent (C2tg) and S-N plane.002) t h a n t h e snorers. Relative comparison of cumulative maxillary length with cumulative mandibular length measured along the reference line Fig. Because of the high number of comparison tests of the means of the two groups.. A l t h o u g h m a n y c e p h a l o m e t r i c variables. a p value of less than 0. 413 Table I. It was decided that a subset of the 22 cephalometric variables would be chosen if several variables were very highly correlated with each other (p -< 0. Chicago. L i n e a r c o r r e l a t i o n c o m p u t e d for e x a m i n i n g t h e i n t e r r e l a t i o n s h i p s a m o n g t h e 22 a n a t o m i c m e a s u r e m e n t s i n d i c a t e d t h a t t h e r e was s o m e level o f r e d u n d a n c y in using all o f t h e s e v a r i a b l e s in t h e discrimi- . 4). Ill.001). In addition. p a r t i c u l a r l y soft tissue m e a s u r e ments. Finally.92 _+ 27. p _< 0. Ratio between tongue area to intermaxillary area Fig. Ramus width relative to middle cranial fossa horizontal dimension (Fig. two main methods of variable selection were used.001).

6). The discriminant function included 13 cephalometric ( < BaSN. BMI and the soft palate length (P-PNS) were selected in the model.84 4.3 nant model.o) 20 46.3 7. These variables reflected.3%) snoring subjects (Table VI and Fig. Demographic and anthropometric data of the study population Snore Var~b/es Male:Female Age BMI (kg/m 2) CI/FI Head positiona RDI OSAS SD 14.92 Mean 25:5 49.9%) OSAS subjects and 25 of the 30 (83. recorded from a fluid level device.9 Euryprosopic ( < 84. Table III.002. The CIS computed from this model was 0. On the basis of this score. the 22 anatomic variables were reduced to 13 predictor variables that were in accordance with previously published results. Percentage distribution of the head forms and facial forms Head forms Brachycephalic Groups Snorer (%) OSAS (%) Facial forms Dolichocephalic ( <-75.15 3. ***p -< 0.7 10. Variable selection terminates when there are no more variables that meet the selection criteria. **for 26 subjects.36 42. the first variable that entered the model was H-MP. BMI.56 27.2 Mesocephalic (76-80. However. Accordingly. BMI.3% in the snorers group were correctly classified.98 52.3 42.08 5.414 Pracharktam et aL American Journal of Orthodontics and Dentofacial Orthopedics April 1996 Table II.7 89.29 4. However.39) of total variance of the discriminant score was attributable to between-group variability.34 0. and P-PNS).59 p Value 0. approximately 52% (canonical correlation.84 3. only three variables met the selection criteria.380 - *For 17 subjects. the model was able to correctly classify 23 of the 28 OSAS subjects (82. MCF.7 (>_81.9) 16. CI/FI.0) 86. T-l) and 4 anthropometric (age.52) of total variance of discriminant score was attributable to differences between the groups when all anthropometric and cephalometric predictor variables were included in the model.000"** 0.7%) (Table VI and Fig. Therefore inclusion of anthropometric and soft and hard craniofacial cephalometric variables improved the discriminant function to a considerable extent. RAM/MCF.86 13.10" I Mean 24:4 47. or were related to. T-area. 9) 13. These three variables alone were successful in classifying 19 of the 28 (67.81 0. When the step-wise method was used. P-PNS.1 I [ Leptoprosopic I ( > 90. Discriminant analysis was used to predict group membership for new cases.72. the clas- . The other method forces all the predictor variables into the model. Phw-Psp. f = 0. "Head position relative to the extracranial horizontal line. At subsequent steps. r ~ = 0.533 0. r = 0. The step-wise variable selection model examines each variable and selects those with the highest predictive value. H-MR InMxLth. With this model.797 0. The limitation of this method is that variables with low individual discriminant power may be ignored even though they may have high discriminant power when considered as part of a group. 67.6 Mesoprosopic (85-89.92"* SD 12. 5). an index was first constructed from anthropometric and cephalometric variables.63. T/InMx.1%) and 26 of the 30 snoring subjects (86.85 5. In addition. 9) 63.03505 (Table V). the present study examined another option for selecting variables for the index. DISCUSSION In an attempt to test the validity of using cephalometric radiographs to identify patients at risk for OSAS.49 0. head post) variables in the first model. Because of this limitation. findings from the present study indicated that approximately 39% (canonical correlation in the stepwise procedure r = 0. PNS-Ba.60 31.91 0. For the step-wise procedure.07 4. the soft tissues (H-MP. A-PNS. 9) 3. < C2C4-SN.9% in the OSAS group and 83.

American Journal of Orthodontics and Dentofacial Orthopedics Volume 109. With cluster analysis the patients with OSAS were subdivided into two groups. Further.. All-groups stacked histogram: summary of classification by including all predictor variables. They concluded that in patients with a high AI/low BMI ratio and moderate obesity. 4 Pracharktam et al. can be found in the report of Tsuchiya and coworkers. In the first group.1% correctly classified in the OSAS group and 86. . and craniofacial and demographic data. based on the origin of the disease. the effectiveness of this model was proved with a higher eigenvalue and canonical correlation. a steep mandibular plane.7% in the snoring group. the severity of OSAS.. and an inferoanterior position of the hyoid bone. They found when the BMI is low. They have further stated that when BMI increases. 6. One group had a high apnea index (AI) and low BMI.il 0iscriminant I~10SAS • SNO~ Scores Fig. with 82. In contrast. 5. 415 6 == LL i 4" 3' 2' 1' 0 • • OSAS SNORERS Discriminant Scores Fig. l. Each subgroup was. All-groups stacked histogram: summary of classification by step-wise method. and the other group had low AI and high BMI. evaluated with craniofacial and demographic data by means of multiple regression analysis. Some studies have suggested that there may be subgroups of patients with OSAS based on interrelated anatomic and functional factors. the RDI appears to be less dependent on the cephalometric results.21 used eephalography to study the relationship between abnormal upper airway anatomy and body mass in 157 OSAS patients. the severity of airway collapse. Further support for the hy- pothesis that patients with OSAS may belong to at least two subgroups. sification rate increased when we forced all the predictor variables into the equation. appears associated with abnormal craniofacial cephalometric findings. No. a high AI was related to a large skeletal anteroposterior discrepancy. as assessed by the RDI.= They proposed the existence of OSAS subtypes based on the degree of obesity.li°l.i. then. particularly in obese patients with a BMI greater than 30. Partinen et al. a high AI was associated with a large tongue and a small upper airway in the latter group.

Other authors have also reported a similar relationship between hyoid bone position and apnea severity.75 494.63 3.045 0.94 6.963 0.94 4. With the step-wise procedure.06 6.70 7.20 56.65 5. the present study found that hyoid bone position (H-MP) was the most important predictor variable in the discriminant function.10 0.46 51.64 7.8166 0.004 0.04 128.28 44.81 5.54 3.95 73.976 0.992 Soft tissue Phw-Psp P-PNS Tongue length Tongue area Ratio AntrMxHt PostrMxHt InMxLth T/InMx area ***p -< 0.865 0.93 7. Discriminant functions evaluated at group means Method 1 (All predictor variables) Group 1 Group 2 CIS .52 42.71 41.10 .14 0.63 4.46 8.002.17 7.77 6. 1~'14"21-22However.006 0.36 81.54 4629. 5F) Mean Cranial base MCF < BaSN OSAS (24M.31 4.36 6.960 0.73 3.93 90.0.989 Maxilla < SNA <ArN-PM A-PNS PNS-Ba Mandible Ram/MCF < SNB ArA-ArB 0.42 47.760 0. In contrast.363 0.02 73.93 6.323 0. American Journal of Orthodontics and Dentofacial Orthopedics April 1996 Table IV.05 9.083 0.002*** 0.504 0.96 3. 0.610 0.931 0.92 4.992 Neck < C2C4-SN < C2-SN Head posture FH-Hor 0.010 0.639 0.49 84.35 128.51 3.79 79.75 56.03505 Method 2 (Step-wise) . the position of the hyoid bone is subject to a high degree of variation because of physiologic adaptation and changes of the head position.057 0.52 4. 4F) Mean SD SD p value Reliability (Re) 0.80 78.0.943 Table V.89 2.01 4.43 9.45 24.416 Pracharktam et al.94 132.30 6.41 0.34 3.05 84.47 4.81 51.7622 0.79 5.79 81.23 5.9814 1.06 3.24 3.62 46.0515 0.09 0.12 .967 Hyoid H-MP H ver 0.86 81.39 100.47 456.988 0.69 0.01 125.08 0.64 2.38 46.39 105.18 4.0272 skeletal abnormalities may be more important etiologic factors.988 0.91 4269. Comparison of means of cephalometric variables between OSAS and snoring groups using t tests Snore (25M.0.23 114. Cephalometric radiographs of the subjects were obtained .66 6.0.10 4.78 4. 37 Recently published reports support the contention that low hyoid bone position is a compensory response to airway obstruction and not a predisposing f a c t o r .36 9.310 0.013 0. atypical soft tissue structures (a large tongue and/or soft palate possibly related to obesity) may result in a small upper airway in patients with a low AI and high BMI.14 4.33 1.59 7.19 18.576 0.54 107.66 2. We have elected to include both BMI and age in the CIS to allow the index to be generalized to a larger population.000"** 0.985 0.008 0. 3s'39 Solow and associates 39 assessed the effect of airway obstruction on the posture of the head and the cervical column in patients with OSAS.02 7. These findings may indicate that our CIS may be more effective in identifying OSAS sufferers who have low BMI because craniofacial anatomy may be a more important predisposing factor in this subgroup.016 0.50 6.84 3.

Surprisingly. Bench 41 also reported physiologic adaptation behavior of the hyoid bone. However. it could be transformed to the true vertical reference as used in Solow's study. cephalometry has been introduced primarily to study awake subjects. 4° He concluded that adult nasopharyngeal depth dimensions are established in early life. there might be some sample selection bias due to differential diagnostic tests used in the present study. Thus. It is important to emphasize that cephalometric radiographs provide only a two-dimensional static image.2) 25 (83. No. Classification results of both methods of variable selection (all predictor variables and Step-wise method) Actual group Snoring OSAS Eigenvalue 1 Canonical correlation 2 Number of cases 30 28 Percent correctly classified All predictor (1. Greater variability in structural abnormalities may have been demonstrated if a larger and more heterogeneous group of patients with OSAS was studied. Although in the present study. they postulated that these changes might be physiologic adaptations to maintain an adequate airway. it must be kept in mind that such observations do not prove the existence of a causal relationship between craniofacial anatomy and OSAS. Information derived from a lateral head radiograph cannot be extrapolated to the threedimensional anatomic structures. the pharynx increases its capacity predominantly by a vertical expansion at the lower level.0687 0. thus. this measurement may still be an important cephalometric indicator of the presence of OSAS. They found that the patients with OSAS showed markedly larger craniocervical angulation ( < C2-SN) than reference data found in their previous study of normal healthy adults. He described a dramatic descent of the hyoid in the late stages of development.3%) 19 (67. Interestingly. Although published studies that use computerized tomography. Thus. 4 Pracharktam et aL 417 Table VI. The fact the hyoid and. the CIS would have to be validated by using a different group of OSAS and snoring subjects.6446 0. information from cephalometric radiographs cannot be used to identify potential sites of upper airway obstruction during sleep. subjects with OSAS in the present study showed significantly more extended craniocervical angulation ( < C2C4SN) and a tendency toward differences in craniocervical angulation (<C2-SN). was not significantly different from the snoring group. Interestingly. drop considerably in older age groups would compensate for the increase in bulk and would maintain function during growth. despite the problems associated with the assessment of hyoid bone position. the tongue. especially in male subjects. the head. His finding was consistent with Cohen and Vig42who stated that the tongue increases in bulk until maturity and becomes relatively larger in relation to the intermaxillary space with increasing age. Consistent with these findings. the CIS was tested on the same sample that was used to derive the index. A review of growth of the pharynx and its physiologic adaptation was recently presented by Tourne. they found this trend to be more pronounced in males. 39 Thus. So far. and bias introduced by using some of the controls who were potential OSAS cases. In contrast. and cephalography have demonstrated that patients with OSAS have structural narrowing of the upper airway. Ideally.7188 Percent correctly classified Stepwise (1. also recorded from a fluid level device. was maintained in its original orientation in relation to the true vertical.9%) 0. He postulated that a drop in hyoid position relative to the mandible represents an attempt to secure a relatively constant anteroposterior diameter of the airway. Limitations of the study The sample size is still small in the present study. they did not find a significant difference in the craniovertical posture (SN-True Vertical). their visual axis indicated by head posture ( < FH-Hor). magnetic resonance image. In addition. Also.2) 26 (86. this observation may provide support for the postulation that inferior hyoid bone position in patients with OSAS may be a secondary effect because of an attempt to maintain patency of the upper airway Passage.1%) 1.American Journal of Orthodontics and Dentofacial Orthopedics Volume 109. the true horizontal line was used as a reference. thus. Anatomic aberrations associated with OSAS may be the result .7%) 23 (82. and thus the visual axis.6261 in natural head posture.

Inc. Palta M. eds. Berthon-Jones M. CONCLUSIONS These results indicate that a CIS constructed from cephalometric and anthropometric measurements can be used to differentiate habitual snorers with and without apneas. Jamieson A.101:533-42. Am Rev Respir Dis 1983. Soft tissue morphology. Strohl KP.98:1149-58. Bacon WH. Dee P. Upper airway morphology in patients with idio- pathic obstructive sleep apnea. Upper airway morphology in patients with idiopathic obstructive sleep apnea. tongue activity. 14. Laryngoscope 1988. Tsuchiya M. The occurrence of sleep-disordered breathing among middle aged adults.9:469-77. 10. Valuable information has been derived from a number of studies concerning cephalometric assessment in snorers and patients with OSAS. Sleep 1983.93:1199-205. Krogstad O. craniofacial anatomy may be an underlying factor that contributes to the development of clinical illness. Multimodality imaging of the upper airway: MRI. Guilleminault C. Chest 1984. Djupesland G. Cephalometric airway analysis in obstructive sleep apnea syndrome. Sleep and breathing. Laryngoscope 1988. Bryan AC. 16.127: 221-6. 129:355-60. Allen RP. 17. Guilleminault C. 129:355-60. Am Rev Respir Dis 1991. Kalbfieisch .. Djupesland G. Djupesland G. Constructing the CIS is the first step in testing the utility of using cephalometrics as a diagnostic test for OSAS and a larger study is planned to test the validity of the index in the general population. Saunders NA. 1984:299-363. Quera-Salva MA. Given the limitations of the cephalometric technique and the polygenetic basis for OSAS.6:303-11. Am Rev Respir Dis 1984. Gefter WB. 9. Smith PL. Rivlin J. Li D. AM J ORTHOD DENTOFAC ORTHOP 1986. Zamel N.20: 159-62. 15. Young T. Hoffman EA. 25. Fleetham JA.60:115-21. Fluoroscopic and computed tomographic features of the pharyngeal airway in obstructive sleep apnea. 1984: 365-402. Zamel N. Cephalometric analysis in patients with obstructive sleep apnoea syndrome: 2. 13. 23. 8. Saunders NA. 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