ONLINE ONLY

Evaluation of upper airway obstruction in Class II

children with uid-mechanical simulation
Tomonori Iwasaki,a Issei Saitoh,b Yoshihiko Takemoto,a Emi Inada,a Ryuzo Kanomi,c Haruaki Hayasaki,d
and Youichi Yamasakie
Kagoshima, Himeji, and Niigata, Japan

Introduction: The purpose of this study was to test the null hypothesis that dolichofacial and brachyfacial
children with Class II malocclusion do not differ in upper airway obstruction. Furthermore, the ability of uidmechanical simulation to detect airway obstruction within the limitations of simulation was examined.
Methods: Forty subjects from 7 to 11 years of age with Class II malocclusion participated and were divided
into 2 groups, dolichofacial and brachyfacial, based on their Frankfort mandibular plane angles. Cone-beam
computed tomography images supplied the shape of the entire airway. Two measures of respiratory function,
air velocity and pressure, were simulated by using 3-dimensional images of the airway. The images and
simulations were compared between the 2 facial types. Results: The size of the upper airway did not differ statistically between facial types; however, the simulated maximal pressure and velocity of the dolichofacial type
were signicantly higher than those of the brachyfacial type. Conclusions: Airway obstruction differs with the
Frankfort mandibular plane angle, even though the depth and cross-sectional area of the airway do not. The
uid-mechanical simulation system developed in this study detected differences in airway obstruction that
were not apparent from morphologic studies. (Am J Orthod Dentofacial Orthop 2011;139:e135-e145)

pper airway narrowing is implicated in the development of obstructive sleep apnea (OSA).1 The
importance of this obstruction during childhood
is increasingly recognized.2 Children with OSA often
have excessive daytime sleepiness, hyperactivity, attention decit disorder, poor hearing, physical debilitation,
and failure to thrive.3 Accordingly, much attention has
been paid to the inuence of maxillofacial form on

a
Research associate, Developmental Medicine, Health Research Course, Graduate
School of Medical and Dental Sciences, Kagoshima University, Kagoshima,
Japan.
b
Lecturer, Developmental Medicine, Health Research Course, Graduate School of
Medical and Dental Sciences, Kagoshima University, Kagoshima, Japan.
c
Private practice, Himeji, Japan.
d
Professor and chairman, Division of Pediatric Dentistry, Department of Oral
Health Science, Course of Oral Life Science, Graduate School of Medical and
Dental Sciences, Niigata University, Niigata, Japan.
e
Professor and chairman, Developmental Medicine, Health Research Course,
Graduate School of Medical and Dental Sciences, Kagoshima University,
Kagoshima, Japan.
The rst author invented the uid-mechanical simulation; Kagoshima University
holds the know-how, and specic licensees are assigned the rights to manufacture and distribute it.
Supported by KAKENHI from Japan Society for the Promotion of Science (no.
19592360).
Reprint requests to: Tomonori Iwasaki, Graduate School of Medical and Dental
Sciences, Kagoshima University, 8-35-1, Sakuragaoka Kagoshima-City, Kagoshima, 890-8544, Japan; e-mail, yamame@dent.kagoshima-u.ac.jp.
Submitted, April 2010; revised and accepted, August 2010.
0889-5406/$36.00
Copyright 2011 by the American Association of Orthodontists.
doi:10.1016/j.ajodo.2010.08.014

respiratory function during growth.4 Some studies

have suggested that Class II malocclusion is associated
with mouth breathing.5,6 In other studies, a vertical
growth pattern, with obstruction of the upper and lower
pharyngeal airways, has been associated with mouth
breathing.7-12 Comparing subjects with normal occlusion
and Class II malocclusion, Kerr13 found a slight correlation
between the nasopharyngeal airway (NA) and dentofacial
structures when the nasal functions were normal. In contrast, Freitas et al14 found the NA to be closely associated
with vertical maxillofacial growth when comparing dentofacial structures between Class II children with and without
excessive vertical growth.
Some studies concluded that mouth breathing inuences maxillofacial growth,5-12 but others found no
relationship.13,15,16 The different conclusions might be
related to inaccurate evaluation of airway size with
2-dimensional lateral cephalograms.17 To better evaluate the relationship between the respiratory function
and airway morphology, we propose using uidmechanical simulation (FMS) to evaluate the ventilation
condition of the whole upper airway.
The purpose of this study was to clarify the relationship between upper airway obstruction and vertical
maxillofacial growth by using FMS. Because the dolichofacial type represents vertical maxillofacial growth and
the brachyfacial type represents horizontal growth,
a comparison between the 2 can clarify the relationship
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Iwasaki et al

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Fig 1. Lateral cephalograms reconstructed from CT data of a dolichofacial child (left) and a brachyfacial
child (right). FMA, Frankfort mandibular plane angle.

between upper airway obstruction and vertical maxillofacial growth. The tested null hypothesis was that
dolichofacial and brachyfacial children with Class II
malocclusion do not differ in their degrees of upper
airway obstruction. Furthermore, the ability of FMS to
detect upper airway obstruction within its limitations
was examined.
MATERIAL AND METHODS

Forty patients, who visited an orthodontic ofce in

Himeji, Japan, for treatment for Class II malocclusion,
participated in this study. The subjects were divided
into 2 groups according to their Frankfort mandibular
plane angle (FMA): dolichofacial Class II malocclusion
patients (FMA, .35 ) and brachyfacial Class II malocclusion patients (FMA, \25 ) (Fig 1). The dolicofacial
and brachyfacial groups consisted of 7 boys and 13 girls
(average age, 9.5 6 1.0 years) and 10 boys and 10 girls
(average age, 9.4 6 1.2 years), respectively.
Because the volume of the airway is inuenced by
head posture, craniocervical inclinations of all subjects
were examined to ensure that their inclinations were between 90 and 110 .18 The craniocervical inclinations
were calculated as the angle between the nasion-sella
line and a line through Cv2ig and Cv2ip; Cv2ig is the
tangent point at the superior posterior extremity of the
odontoid process of the second cervical vertebra, and
Cv2ip is the most inferior posterior point on the body
of the second cervical vertebra (Fig 2).
Clinically, mouth breathing was dened as a pneumatic ow from the mouth during quiet breathing. We
dened the following respiratory patterns that might
inuence maxillofacial form: (1) obstructive mouth
breathing, an obstructive mouth breather breathes
through the mouth because of an obstruction in the

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Fig 2. Diagram showing measurement of craniocervial

inclination as the angle between the nasion-sella line
and a line through Cv2ig and Cv2ip. Cv2ig is the tangent
point at the superior posterior extremity of the odontoid
process of the second cervical vertebra. Cv2ip is the
most inferior posterior point on the body of the second
cervical vertebra.

airway; (2) habitual mouth breathing without obstruction, a habitual mouth breather breathes through the
mouth even though there is no obstruction in their airway; and (3) nasal breathing with open-mouth posture.
Each subject was seated in a chair with his or her
Frankfort horizontal plane parallel to the oor. A
cone-beam computed tomograph (CB MercuRay,

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Fig 3. FMS analysis of the upper airway: A, CBCT used in this study; B, extracted upper airway image,
C, FMS; D, evaluation of upper airway ventilation.

Hitachi Medical, Tokyo, Japan) was set to maximum 120

kV, maximum 15 mA, and exposure time of 9.6 seconds.
Data were sent directly to a personal computer and
stored in digital imaging and communications in
medicine (DICOM) format (Fig 3). Before the computed
tomography (CT) scans, the parents of the patients
were fully informed of the purpose and the risk of CT
scans. The study was reviewed and approved by the ethics
committee of the Kagoshima University Graduate School
of Medical and Dental Sciences, Kagoshima, Japan.
A 3-dimensional (3D) coordinate system and a 3D
image were constructed with a medical image analyzing
system (ImagnosisVE, Kobe, Japan). The origin of the 3D
coordinate system was the midpoint between the left
and right porions. This origin and the left and right orbitales dened the standard horizontal plane. A frontal
plane was constructed through both orbitale points perpendicular to the Frankfort horizontal plane. A sagittal
plane was constructed through both orbitale midpoints
and perpendicular to the horizontal and frontal planes.19
From these constructed cephalometric images, the anteroposterior positions of both the maxilla and the mandible were evaluated with SNA angle, SNB angle, ANB
angle, FMA, overjet, and overbite (Table I).
Airway cross-sectional parameters, including crosssectional area (CSA) and depth (anteroposterior direction), were measured at the NA and oropharyngeal
airway (OA) (Fig 4). These parameters for the sizes of
the NA and the OA were based on a previous report.19
The NA cross-section was dened as lying in a horizontal
plane along the narrowest part of the nasopharynx in the
constructed lateral cephalometric image (Fig 4, A). The
OA cross-section was dened as lying in the horizontal
plane through the midpoint of the bilateral gonion
(Fig 4, B).
Our method simulates turbulent ow to estimate virtual airow patterns in the upper airway (Fig 3). Volume
rendering software (INTAGE Volume Editor, CYBERNET,

Table I. Maxillofacial form and incisor relationship

Dolichofacial type
(n 5 20)
SNA ( )
SNB ( )
ANB ( )
FMA ( )
Overjet (mm)
Overbite (mm)

Mean
80.48
72.83
7.65
36.22
7.35
4.40

SD
3.01
3.12
1.57
2.07
2.46
1.79

Brachyfacial type
(n 5 20)
Mean
82.15
75.03
7.13
21.78
7.60
5.30

SD
3.46
3.38
1.19
2.19
2.60
1.87

P value
0.149
0.035
0.314
\0.001*
0.883
0.102

*Statistically signicant at P \0.01.

Tokyo, Japan) was used to create the 3D images of the

shape of the upper airway. Because the airway is void
space surrounded by hard and soft tissues, inversion of
the 3D rendered image is required; this converts a negative value to a positive value, and vice versa. Inversion
removes the hard and soft tissues from the image and
displays only the upper airway. Subsequently, threshold
values were adjusted to eliminate imaging artifacts and
to rene the selected airway region. By using an appropriate smoothing algorithm with a moving average, the
3D model was converted to a smooth model without
losing the patient-specic character of the upper airway
shape.20 The rendered volume data was in a 512 3 512
matrix with a voxel size of 0.377 mm. The 3D cone-beam
CT (CBCT) images for the airway model were exported to
computational uid-dynamic software (PHOENICS,
CHAM-Japan, Tokyo, Japan) in stereolithographic
format. The construction of the 3D model takes about
15 minutes.
Airway resistance is greater during expiration than
inspiration during quiet breathing.21 Accordingly, each
voxel on the plane of the hypopharynx was considered
part of the ow inlet, whereas each voxel at the entrance
of each nostril was considered part of the ow outlet.22

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Fig 4. Measurement of cross-sections in the NA and the OA: A, NA cross-section is dened as a horizontal plane at the airways narrowest part in the reconstructed lateral cephalometric image; B, OA
cross-section is dened as the horizontal plane through the midpoint of bilateral gonion. CSA,
Cross-sectional area; D, depth.

Fig 5. Airway images of a brachyfacial child, representing a normal ventilation condition: A, morphologic airway images (right lateral, front, and superior views) extracted from a CBCT image; B, FMS
analysis of the same airway in the sagittal plane (left, pressure analysis; right, velocity analysis). In
A, no stenosis was found in either the pharynx or the bilateral nasal cavity. In B, both the maximal pressure and velocity were relatively low, and no abrupt change of pressure or velocity was found.

The air was assumed to be a newtonian, homogeneous,

and incompressible uid.23 Elliptic-staggered equations
and the continuity equation were used in the study.24
The following boundary conditions were set to the
model: (1) the air ow perpendicular to the lower pharyngeal plane had a velocity of 200 mL per second,25
(2) the wall surface was nonslip, and (3) the simulation
was repeated 1000 times to calculate the mean values.
Convergence was judged by monitoring the magnitude
of the absolute residual sources of mass and momentum,
normalized by the respective inlet uxes. The iteration
was continued until all residuals fell below 0.2%. With
our system, the FMS analysis takes about 6 hours.
The results of the FMS are shown as pressure and
velocity. The maximum pressure and the maximum velocity of the upper airway were calculated to evaluate

February 2011  Vol 139  Issue 2

the ventilatory condition. In addition, detection of

obstructions in the upper airway is shown in Figures 5
through 8. A previous study showed upper airway
obstruction when the resistance was above 5.0 cm of
water per liter per second, and that the pressure (upper
airway resistance ow) in children with nasal breathing
difculty is greater than 100 Pa (1 Pa j 0.01 cm of
water) with an inow of 200 mL per second.26 The place
where the 3D images from the CBCT were completely
perforated was considered obstructed. An obstruction
in the upper airway was also indicated by an abrupt
pressure decrease and high velocity in the FMS.
Statistical analysis

For each measurement, either an unpaired t test

or a Mann-Whitney U test was used to detect

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Fig 6. Airway images of a dolichofacial child, representing obstruction in the nasal cavity only: A, morphologic airway images (right lateral, front, and superior views) extracted from a CBCT image; B, FMS
analysis of the same airway in the sagittal plane (left, pressure analysis; right, velocity analysis). In A,
no stenosis was found in either the pharynx or the bilateral nasal cavity. In B, the pressure decreased
abruptly, and the velocity was high, indicating an obstruction in the nasal cavity, although its morphology seemed normal (red arrow).

Fig 7. Airway images of a dolichofacial child, representing obstructions in both the nasopharynx and
the nasal cavity: A, morphologic airway images (right lateral, front, and superior views) extracted from
a CBCT image; B, FMS analysis of the same airway in the sagittal plane (left, pressure analysis; right,
velocity analysis). In A, stenosis by the hypertrophied adenoid and complete perforation of the right nasal cavity were found (yellow arrows). In B, because the pressure decreases abruptly around the adenoids, and the velocity was so high, the existence of an obstruction could be diagnosed (yellow
arrows). Similar ndings were present at the left nasal cavity. This could not be determined from the
morphology alone (red arrows).

between-group differences, depending on the data

distribution. The criterion for an obstruction was
a maximal pressure of more than 100 Pa, and the frequency of obstruction was compared between facial
types by using the Fisher exact test. For all tests,
P \0.05 was considered statistically signicant.
The reliability of the measurements (intraoperator repeatability) was assessed rst by repeated tracings (landmark identication) and then by digitization of the same
lateral cephalograms. To assess the error in landmark
identication, 10 randomly selected lateral cephalogram
images from the 40 were traced and digitized twice by
the same operator (T.I.) within 1 week.

Calculations were also performed independently for

each digitization, the differences between paired linear
measurements were calculated, and Dahlbergs error
(double determination method) was computed.27 The
measurement errors for the cephalometric images
ranged from 0.433 to 0.487 mm (mean error, 0.460
mm) and from 0.387 to 0.559 (mean error, 0.502 ), indicating that these errors were negligible. The method
errors were 1.67 mm2 and 0.44 mm for cross-sectional
area and depth for the NA, respectively, and 1.56 mm2
and 0.14 mm for the OA, respectively. According to all
repeated analyses, the method error was considered
negligible.

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Fig 8. Airway images of a dolichofacial child, representing obstructions in both the oropharynx and the
nasal cavity: A, morphologic images (right lateral, front, and superior views) of the airway extracted
from a CBCT image; B, FMS analysis of the same airway in the sagittal plane (left, pressure analysis;
right, velocity analysis). In A, stenosis by hyperplasia of the palatine tonsil was present (yellow arrows).
In B, the pressure suddenly decreased around the palatine tonsil, and the velocity was also high. The
location of the obstructions coincided on both the FMS and the morphologic observation (yellow arrows). However, the obstruction at the right nasal cavity could only be observed by FMS (red arrows).

RESULTS

The depth of the NA in the dolichofacial type (6.96 6

2.83 mm) did not differ signicantly from that of the
brachyfacial type (8.67 6 2.65 mm) (Table II). The
cross-sectional area of the NA in the dolichofacial type
(159.96 6 72.17 mm2) was signicantly smaller in the
brachyfacial type (213.45 6 64.22 mm2). The depth
and cross-sectional area of the OA did not differ significantly between types.
Plotting of the maximum pressures and maximum
velocities showed that 4 of the dolichofacial children
had exceptionally large values (Table III), creating a nonnormal distribution. Therefore, in our comparisons
between the 2 groups, these 4 children were dropped
from the analysis. With the remaining chidren, the
maximal pressures were 93.11 6 58.11 Pa and 49.16
6 35.96 Pa for the dolichofacial and the brachyfacial
children, respectively, and the corresponding maximum
velocities were 10.99 6 4.24 m per second and 7.54 6
3.19 m per second, respectively. For both measures,
the dolichofacial children had signicantly higher values
(P \0.02). If the 4 excluded dolichofacial children had
been added to the analysis, the differences between
the 2 groups would have been even greater.
The incidence of upper airway obstruction in the dolichofacial children was 60%. This percentage increased
to 85% in children with habitual mouth breathing. In
contrast, only 10% of the brachyfacial children had
this obstruction (Table IV). The incidences of obstruction
for each part of the upper airway were 92.9% in the nasal
cavity, 14.3% in the nasopharynx, 14.3% in the oropharynx, and 21.4% in the hypopharynx (Fig 9). These

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Table II. Measurement of the upper airway

Dolichofacial type
(n 5 20)
Mean
Nasopharyngeal airway
Depth (mm)
6.96
159.96
CSA (mm2)
Oropharyngeal airway
Depth (mm)
10.09
117.67
CSA (mm2)

SD

Brachyfacial
type (n 5 20)
Mean

SD

P value

2.83
8.67 2.65 0.102
72.17 213.45 64.22 0.033*
2.51 10.46 2.17 0.820
57.09 149.39 63.55 0.127

*Statistically signicant at P \0.05.

percentages sum to more than 100% because some children had obstructions at more than 1 site. The patterns
of upper airway obstruction site were 50.0% in the nasal
cavity only, 14.3% in the nasal cavity and nasopharynx,
14.3% in the nasal cavity and oropharynx, 14.3% in the
nasal cavity and hypopharynx, and 7.1% in the hypopharynx only (Table V).
DISCUSSION

The main purpose of this study was to examine the

relationship between upper airway obstruction and vertical maxillofacial growth. Many studies have indicated
that respiratory function affects maxillofacial form during growth. However, none could prove a direct relationship because simultaneous measurements of respiratory
function, including air velocity and pressure, and the
morphology of the entire airway are difcult. Accordingly, our method simulated respiratory function based
on precise morphologic data.

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Table III. Individual upper airway ventilation conditions

Dolichofacial type (n 5 18)
Patient
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
Mean
SD
P

Maximum pressure (Pa)

12.2
28.9
36.5
39.6
47.5
52.2
81.4
93.6
114.5
137.6
157.3
157.8
167.2
177.2
277.1
334.7
394.3
410.8

151.12
125.38
0.002*

Maximum velocity (m/sec)

3.2
5.5
6.3
7.0
11.0
11.5
10.4
13.6
14.3
15.8
13.3
13.0
10.6
18.3
27.4
27.7
32.1
36.2

15.39
9.44
0.001*

Brachyfacial type (n 5 20)

Patient
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Maximum pressure (Pa)

11.0
16.4
16.4
20.9
22.0
24.4
24.9
26.7
28.8
37.6
41.3
48.8
50.4
59.1
62.5
65.9
67.3
90.5
127.3
140.9
49.15
35.97

Maximum velocity (m/sec)

7.0
4.2
4.7
4.6
4.4
4.7
4.9
6.7
5.5
7.2
6.3
5.6
9.4
9.4
10.1
6.4
8.8
13.9
12.4
14.6
7.53
3.19

, Complete obstruction.
*Statistically signicant at P \0.01 vs brachyfacial type.

Freitas et al,14 in their cephalometric study, concluded that the depth of the NA of vertical-growth Class
II children (9.56 6 2.19 mm; n 5 20) was signicantly
smaller than that of children with normal growth
(12.61 6 3.61 mm; n 5 20). Their values were larger
than ours because of differences in age, anamnesis,
and measuring points.
Upper airway size (depth and cross-sectional area)
has been measured in children with Class I and Class III
malocclusion by using 3D CT.19 However, a comparison
of dolichofacial and brachyfacial children with Class II
malocclusion has not been previously reported. We
found no signicant depth differences between the 2
facial types in the NA. The cross-sectional area of the
NA in the dolichofacial type was signicantly smaller
than in the brachyfacial type. These results suggest
that the cross-sectional area of the NA might be related
to vertical maxillofacial growth. However, both a previous study19 and this study showed high variability of
the cross-sectional areas of the NA in all facial types.
Therefore, the cross-sectional area of the NA is not a conclusive factor for the maxillofacial type.
Both maximal pressure and maximum velocity of the
upper airway were higher in the dolichofacial type than
in the brachyfacial type. In addition, the simulated

Table IV. Frequency of upper airway obstruction in

children

Dolichofacial type (n 5 20)

Brachyfacial type (n 5 20)

Obstruction
present
12 (60%)
2 (10%)

Obstruction
absent
8* (40%)
18 (90%)

Fisher exact test: df 5 2; chi-square 5 10.989; P \0.003.

*5 of these 8 children had ndings of habitual mouth breathing.

functional values in the dolichofacial type were relatively

more prominent than the morphologic differences. Because conventional morphologic evaluation of the upper
airway is performed along a longer axis and area of the
cross section, it does not precisely reect the airway
cross-section.28 In addition, the upper airway is morphologically evaluated as the lumen of consecutive airway
cross-sections. In contrast, FMS can evaluate upper airway as a lumen with a more complicated cross-sectional
form (Fig 10). Therefore, FMS would be expected to
show greater differences than the morphology alone.
These differences demonstrate the importance of evaluating the entire upper airway when relating respiration
and maxillofacial form.

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Fig 9. Incidence of upper airway obstructions by site.

Table V. Patterns of upper airway obstruction sites

Dolichofacial type
Brachyfacial type
Total (%)

Only nasal
cavity
6
1
7 (50%)

Nasal cavity and

nasopharynx
2
0
2 (14.3%)

In the 4 dolichofacial children with exceptionally

large pressures and velocities, correspondingly large differences were not observed in the size of the upper
airway. Their nasal airway had a complicatedly narrow
cross-section (Fig 11, B), and sudden stenosis of the
oropharyngeal region was observed (Fig 12). In these patients, accurate evaluation of the ventilation condition is
difcult with conventional airway size. In contrast, functional evaluation of the pneumatic ow detects problems in the ventilation condition.
Crouse et al26 reported that nasal airway resistance in
9 to 10 year-old normal children ranges from 3.0 to 5.0
cmH2O/L/s, with a mean of 4.0 cmH2O/L/s. Warren29
reported that the smallest nasal airway cross-section in
normal children is 0.43 cm2, which would result in an
air-ow velocity of 4.65 m per second under a ow of
200 mL per second. Lopatiene and Babarskas6 reported
that nasal airway resistance values in a child without upper airway obstruction or adenoids were 1.4 cmH2O/L/
sec and 5.7 cmH2O/L/sec, respectively. In this study,
airway-resistance values of more than 5.0 cmH2O/L/s
were considered to indicate obstruction with 100 Pa of
pressure at an inow of 200 mL per second.

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Nasal cavity and

oropharynx
2
0
2 (14.3%)

Nasal cavity and

hypopharynx
2
0
2 (14.3%)

Only
hypopharynx
0
1
1 (7.1%)

Based on these reports, the ventilation condition of

brachyfacial children appears to be normal, but that of
dolichofacial children does not. Craniofacial morphology and occlusal patterns in breathing-impaired subjects
are signicantly different from those in normal
subjects.5-12 These differences might relate to vertical
components associated with the long face.
Upper airway obstruction was diagnosed in 60% (12
of 20) of the dolichofacial children. These children might
have been suffering from obstructive mouth breathing.
Fields et al8 reported a higher ratio of mouth breathing in long-face children than in normal children.
Nasal airway resistance in mouth breathers is higher
than that of nasal breathers.30 However, some mouth
breathers might be habitual mouth breathers even
though their nasal resistance is low.31 Children treated
for upper airway obstruction might continue to breathe
partially through the mouth even after the obstruction
has been removed.21 In this study, mouth breathing
without upper airway obstruction was observed in 5 of
8 dolichofacial children. As a result, most of the dolichofacial children (17 of 20) had either obstructive mouth
breathing or habitual mouth breathing.

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Fig 10. Difference between a conventional morphologic evaluation and the functional evaluation by
FMS. A, CT cross-section images are oriented perpendicular to the upper airway. The form and size
of each upper airway cross-section varies with the location. The upper airway ventilation condition is
conventionally evaluated based on area measurements from selected sections of the entire airway
column (eg, the blue arrow in 1 section of the NA and the red arrow in 1 section of the OA). However,
other regions might also affect upper airway ventilation. B, Diagrammatic representation of the serial
cross-sections used to create the 3D upper airway model. C, The 3D upper airway model (yellow arrow,
pneumatic inlet ow; orange arrow, pneumatic outlet ow). FMS evaluates the upper airway ventilation
condition by including airway dynamics in this model. Therefore, FMS has higher sensitivity and specicity than conventional morphologic evaluation.

Fig 11. Examples of CT sections from the middle of the nasal cavity: A, the nasal cavity cross-section
of a dolichofacial child with low pressure and velocity is comparatively wide; B, the nasal cavity crosssection of a dolichofacial child with exceptionally high pressure and velocity is complicatedly narrow.

The incidence of upper airway obstruction by site has

been reported in adults with OSA.32,33 However, few
studies have examined it in children with malocclusion.
According to Bachar et al,32 the uvulopalantine area
was the most commonly obstructed site (89%) in adults
with OSA, followed by the tongue base, hypopharynx,
and larynx (33% each), and the nose (21%). In another
study of adults, the most commonly obstructed site
was the oropharyngeal region.33 Differences among
studies might arise from (1) different scanning positions
(sitting vs supine), (2) children vs adults, and (3) malocclusion vs OSA. Posture is crucial when recording 3D
airway form with CT. The sitting posture was selected

for our study because it is closer to the normal respiratory

posture than the supine position. This might be a reason
that our ndings differed from studies of adults with
OSA.32,33
Although many believe that narrowing of the NA is
related to vertical maxillofacial growth,7,9,10 others
disagree.13,15,16 In this study, the nasal cavity was the
most commonly obstructed site, observed in all
dolichofacial patients with obstruction. Because the
incidence of obstruction at the nasopharynx was
relatively low in our study, a direct relationship between
NA narrowing and vertical maxillofacial growth could
not be demonstrated.

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Iwasaki et al

e144

Fig 12. Example of an airway image of a dolichofacial child with stenosis of the oropharyngeal region:
A, morphologic airway images (posterior view) extracted from a CBCT image; B, schematic view of the
pneumatic ow of the narrow segment. The sudden stenosis of the oropharyngeal region has an inuence on a highly pneumatic ow, and large pressure and velocity values occur (red arrows, fast pneumatic ow; blue lines, slow pneumatic ow).

Adults with OSA show variable patterns in the location

of obstruction sites and their numbers, and this was also
true for children in our study.32,33 In the children, upper
airway obstructions occurred in the nasal cavity,
nasopharynx, oropharynx, and hypopharynx. However,
half of the patients had an obstruction in the
nasal cavity only. In addition, 42.9% of them had
obstructions in both the nasal cavity and the pharynx.
We introduced here a new method of combining
constructed 3D images of the whole upper airway with
an FMS analysis. This method simulates the magnitude
of air pressure and velocity as it ows out, evaluating
the ventilation condition more precisely than can a morphologic evaluation alone. As shown by our results,
identication of functional obstruction sites in the upper
airway is possible.
Our data suggest that upper airway obstruction
might be a factor in the vertical growth pattern of Class
II dolichofacial children. Previously, detailed evaluation
of the ventilation condition of the upper airway was
too difcult for routine evaluation before the orthodontic treatment of Class II dolichofacial children. With FMS,
detection of obstructions and their locations is possible.
Finding the upper airway obstruction is the rst step in
treating this condition. Resolving an upper airway
obstruction could reduce 1 cause of excessive vertical
maxillofacial growth, leading to better orthodontic
treatment outcomes.

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CONCLUSIONS

Most dolichofacial children with a Class II malocclusion have an obstructed upper airway. Almost half of
these children have several obstructed sites, which can
occur in the nasal cavity, nasopharynx, oropharynx,
and hypopharyx. The FMS system developed in this
study is better able to locate apparent obstructions
than CT imaging alone. Accordingly, this FMS system
might be useful to dentists and otorhinolaryngologists.
We thank Gaylord Throckmorton for reviewing this
article for English usage.
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