The Saudi Dental Journal (2012) 24, 135–141

King Saud University

The Saudi Dental Journal

www.ksu.edu.sa
www.sciencedirect.com

ORIGINAL ARTICLE

Comparison of craniofacial morphology, head posture

and hyoid bone position with different breathing patterns
Faruk Izzet Ucar a, Abdullah Ekizer a, Tancan Uysal b,*

a
Erciyes University, Faculty of Dentistry, Department of Orthodontics, Kayseri, Turkey
b
Izmir Katip Celebi University, Faculty of Dentistry, Department of Orthodontics, Izmir, Turkey

Received 15 February 2012; revised 26 June 2012; accepted 21 August 2012

Available online 11 September 2012

KEYWORDS Abstract Objectives: The aim of this study was to evaluate differences in craniofacial morphol-
Mouth breathing; ogy, head posture and hyoid bone position between mouth breathing (MB) and nasal breathing
Craniofacial morphology; (NB) patients.
Hyoid bone Methods: Mouth breathing patients comprised 34 skeletal Class I subjects with a mean age of
12.8 ± 1.5 years (range: 12.0–15.2 years). Thirty-two subjects with skeletal Class I relationship were
included in the NB group (mean 13.5 ± 1.3 years; range: 12.2–14.8 years). Twenty-seven measure-
ments (15 angular and 12 linear) were used for the craniofacial analysis. Additionally, 12 measure-
ments were evaluated for head posture (eight measurements) and hyoid bone position (four
measurements). Student’s t-test was used for the statistical analysis. Probability values <0.05 were
accepted as significant.
Results: Statistical comparisons showed that sagittal measurements including SNA (p < 0.01),
ANB (p < 0.01), A to N perp (p < 0.05), convexity (p < 0.05), IMPA (p < 0.05) and overbite
(p < 0.05) measurements were found to be lower in MB patients compared to NB. Vertical mea-
surements including SN-MP (p < 0.01) and PP-GoGn (p < 0.01), S-N (p <0.05) and anterior
facial height (p < 0.05) were significantly higher in MB patients, while the odontoid proses and pal-
atal plane angle (OPT-PP) was greater and true vertical line and palatal plane angle (Vert-PP) was
smaller in MB patients compared to NB group (p < 0.05 for both). No statistically significant dif-
ferences were found regarding the hyoid bone position between both groups.
Conclusions: The maxilla was more retrognathic in MB patients. Additionally, the palatal plane
had a posterior rotation in MB patients. However, no significant differences were found in the
hyoid bone position between MB and NB patients.
ª 2012 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.

* Corresponding author. Address: Izmir Katip Celebi University,

Disß Hekimliği Fakültesi, Ortodonti Anabilim Dalı, Izmir, Turkey. 1. Introduction
E-mail address: [email protected] (T. Uysal).
Peer review under responsibility of King Saud University. Nasal obstruction, chronic allergic rhinitis and hypertrophic
adenoids decrease capacity for nasal breathing (NB) and com-
pensating for this by mouth breathing (MB) might be neces-
sary (Oulis et al., 1994). Respiratory airway function
Production and hosting by Elsevier
influences facial morphology and both craniofacial (Gungor
1013-9052 ª 2012 King Saud University. Production and hosting by Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.sdentj.2012.08.001
136 F.I. Ucar et al.

and Turkkahraman, 2009) and cervical functions (Huggare Erciyes, with a Class I skeletal relationship (ANB:
and Laine-Alava, 1997; McNamara, 1981). The breathing pat- 2.2 ± 1.5 and 2.9 ± 0.9 in MB and NB, respectively).
tern may influence the development of the transverse relation- Prior to their participation in the study, written informed con-
ship between the maxilla mandible, resulting in the sent forms were signed by the parents of the patients.
development of a posterior cross bite (Rubin, 1980). MB can Patients were divided into two groups according to their
affect the form of the jaw or cause malocclusions (Hartsook, breathing pattern as follows: Group I, MB children as the
1946), and it has been shown to lead to the so-called ‘‘adenoid experimental group and Group II, NB children used as the
face’’, which is characterized by a narrow upper dental arch, control group. Group I comprised 16 boys and 18 girls (mean
retroclined mandibular incisors, an incompetent lip seal, a age, 12.8 ± 1.5 years; range: 12.0–15.2 years). On clinical
steep mandibular plane angle and increased anterior facial examination, MB patients showed lip incompetence, dry lips
height (Lessa et al., 2005; Peltomäki, 2007; Linder-Aronson, at rest, dental crowding in the upper arch, an ‘adenoidal face’
1970). Ricketts (1968) suggested that head extension represents (Fig. 1) and a reduced maxillary transverse dimension with a
a functional response in MB patients to compensate for nasal unilateral or bilateral cross bite. These factors were consistent
obstruction. with the diagnosis of MB according to Moyers’ criteria (1973).
MB has been reported to cause changes in human head The evaluation of the breathing pattern was adapted from the
posture (Cuccia et al., 2008). The treatment of hypertrophic study by Cuccia et al. (2008). MB was demonstrated by the
adenoids (Linder-Aronson, 1970) and nasal obstruction (Vig presence of condensed water vapor on the surface of a mirror
et al., 1980) with a nasal clip has been shown to alter head pos- placed in front of the mouth Figs. 2–4).
ture. Children with MB who have enlarged tonsils can develop Group II (NB-control) comprised eight boys and 24 girls
the extension of their head posture and the low position of hyoid (mean 13.5 ± 1.3 years; age range: 12.2–14.8 years). This
bone position (Behlfelt et al., 1990a,b). However, some authors group was chosen at random from a group of children accord-
have concluded that the hyoid position is maintained in a stable ing to inclusion criteria (Table 1) with various orthodontic
position in children with MB (Bibby, 1984; Ferraz et al., 2007). problems, but who did not have a past history or any clinical
MB is associated with a low tongue posture and the absence signs of MB.
of a contact surface between the tongue and soft palate; this
latter factor was termed ‘‘posterior oral incompetence’’ by Bal- 2.1. Craniofacial measurements
lard (1951). This problem is caused by enlarged adenoid tissue
that reduces the airway space and leads to postural adapta- Twenty-seven measurements (15 angular and 12 linear) (Figs. 2
tions at the level of the oropharynx. The hyoid bone drops and 3) were used for craniofacial analysis (Table 2). Addition-
in relation to the mandible, and creates a relatively constant ally, 12 measurements were evaluated to assess head posture
air-space diameter in the anteroposterior direction. This neu- (eight measurements) and the hyoid bone (four measurements)
romuscular recruitment may cause changes in the mandibular Fig. 4, as described in Table 2.
resting position and neck extension (Tourné, 1991). Thus, the
breathing pattern could represent a major factor that underlies 2.2. Statistical analysis
the hyoid bone position (Graber, 1978).
The impact of MB in dentofacial growth remains unclear
All statistical analyses were performed using the Statistical
(Warren, 1990). The aim of this study was to evaluate differ-
Package for Social Sciences v.13.0 (SPSS Inc., Chicago, Illi-
ences in craniofacial morphology, head posture and hyoid
nois, USA). The normality test of Shapiro–Wilks and Levene’s
bone position between MB and NB patients. The null hypoth-
variance homogeneity test was applied to the data. The data
esis assumed that there were no significant differences in the
were found to be normally distributed, and there was homoge-
craniofacial morphology, head posture and hyoid bone posi-
neity of variance between the groups. Arithmetic mean and
tion between MB and NB children.
standard deviation values were calculated for each measure-
ment. Group differences were analyzed with Student’s t-test.
2. Materials and methods To determine the errors associated with radiographic mea-
surements, 15 radiographs were selected at random. Their trac-
This study was approved by the Regional Ethics Committee on ings and measurements were repeated 8 weeks after the first
Research of the Faculty of Dentistry, Erciyes University. A measurements. A paired sample t-test was applied to the first
power analysis established by G*Power Ver. 3.0.10. (Franz and second measurements, and the differences between the
Faul, Universität Kiel, Germany) software, based on 1:1 ratio measurements were insignificant (0.849). Correlation analysis
between groups with a sample size of 33 patients would give applied to the same measurements showed the highest r-value
more than 80% power to detect significant differences with (0.988) for the overbite and the lowest r-value (0.867) for ser-
an effect size of 0.33 [to detect a clinically meaningful differ- vical vertebra and sella-nasion plane angle (CVT-SN) and insi-
ence of 1 mm (±3 mm) for the distance of the A to N perp] cor mandibular plane angle (IMPA) measurements.
between two groups and at a significance level of a = 0.05. Probability values less than 0.05 were accepted as significant.
In the present study, 155 MB and 50 NB skeletal Class I
subjects were evaluated and 34 MB and 32 NB patients were 3. Results
selected by the sample selection criteria presented in Table 1.
Sixty-seven pretreatment cephalometric radiographs of Class The descriptive statistics and statistical comparisons of angular
I patients taken by a standard technique formed the sample and linear craniofacial measurements are shown in Table 3.
for this study. All children were admitted for orthodontic Statistically significant differences were found between Group
treatment to the Department of Orthodontics, University of I and Group II in 10 out of 27 measurements. SNA (p < 0.01),
Mouth breathing and craniofacial morphology 137

Table 1 Adopted criteria for sample selection.

Inclusion criteria Exclusion criteria
Age between 12–16 years Age under 12 or older 16 years
Skeletal Class I relationship Skeletal Class II/III relationship
Permanent dentition Mixed/deciduous dentition
Lack of orthodontic treatment and/or Young people had been under orthodontic
maxillary functional orthopedic treatment treatment
No history of nasal respiratory complex Previous history of nasal respiratory complex
surgery surgery
No vestibular or equilibrium problems Vestibular or equilibrium problems
No visual, hearing or swallowing disorders, Visual, hearing or swallowing disorders, and
and facial or spinal abnormalities (i.e., facial or spinal abnormalities (i.e., torticollis,
torticollis, scoliosis, or kyphosis) scoliosis, or kyphosis)
No caries Extensive carious lesions.
Enough sharpness and contrast for a good Radiographs without sharpness and contrast
visualization of the bone structures on for a good visualization of the bone
radiographs structures
No allergic or acute rhinitis Allergic or acute rhinitis
No sleeping disorders with mild apnea Severe sleeping disorders with moderate and
hypoapnea index (AHI) (5–15) severe apnea hypoapnea index (AHI)(15–30
and greater than 30)

Figure 1 Typical case example from the mouth breathing group.

ANB (p < 0.01), A to N perp (p < 0.05), convexity

(p < 0.05), IMPA (p < 0.05) and overbite (p < 0.05) measure- Figure 2 (1) SNA angle (SNA), (2) SNB angle (SNB), (3) ANB
ments were found to have smaller values; but SN-MP angle (ANB), (4) Saddle/Sella angle (SN-Ar), (5) Articular angle,
(p < 0.01) and PP-GoGn (p < 0.01) from angular measure- (6) Gonial/Jaw angle (Ar-Go/MP), (7) SN plane to mandibular
ments, and S-N (p < 0.05) and anterior facial height plane angle (SN-MP), (8) Palatal-Mand angle (PP-GoGn), (9) Y-
(p < 0.05) from linear measurements were higher in Group I Axis, (10) SN-NPog, (11) NA-Apog (convexity), (12) FMA, (13)
than Group II. Thus, this part of the null hypothesis was FMIA, (14) IMPA, (15) Mand Plane to Occ Plane (MP-OP).
rejected.
Descriptive data for the variables that described head pos-
ture and hyoid bone are given for the MB and control group in 4. Discussion
Table 4. According to the statistical analysis, the OPT-PP mea-
surement was significantly higher and the Vert-PP measure- MB alters the balance between the intra-oral and extra-oral
ment was lower in MB patients compared to the controls neuromuscular regions. MB changes the muscle forces exerted
(p < 0.05 for both). No significant difference was found for by the tongue, cheeks, and lips upon the maxillary arch
the other head posture measurements. According to the results (Cuccia et al., 2008). In MB patients, it is generally expected
regarding head posture, the null hypothesis regarding head that a narrow maxillary arch with a high palatal vault will
posture was also rejected. be found, associated with a posterior cross bite, a Class II or
No statistically significant differences were found for the III dental malocclusion, and an anterior open bite (Rubin,
hyoid bone position between the two groups, and consequently 1980; Hartsook, 1946; Lessa et al., 2005; Peltomäki, 2007;
this part of the null hypothesis was accepted. Linder-Aronson, 1970). The head is generally extended to
138 F.I. Ucar et al.

pharyngeal airway in patients with unobstructed airways and

normal breathing function (Hellsing, 1989), but this compensa-
tory mechanism is insufficient to alter the breathing pattern
(Huggare and Laine-Alava, 1997).
It has been recognized that mandibular posture as it relates
to the craniomaxillary complex is influenced by both proprio-
ceptive intra- and extra-oral forces. Accommodative posture
influences the load in several joints of the craniovertebral re-
gion, which results in unfavorable dentofacial and craniofacial
growth (Darnell, 1983). The purpose of the present study was
to evaluate the craniofacial morphology, hyoid bone position
and head posture in MB and NB patients.
In this study, respiration types were evaluated according to
the study of Cuccia et al. (2008), but for an objective evalua-
tion of breathing mode, rhinomanometry was used to deter-
mine the degree of MB (Linder-Aronson, 1970).
Furthermore, clinical evaluations might be insufficient and
the degree of nasorespiratory obstruction may need to be iden-
tified and quantified (Vig, 1998).
Figure 3 (1) A point to Nasion perpendicular (A to N perp), (2) All patients were selected for skeletal classification accord-
Pogonion to Nasion perpendicular (Pog to N perp), (3) S-N: ing to the ANB angle. Only Class I patients with a normal ver-
distance between sella and nasion point, (4) Posterior Cranial Base tical growth pattern were included in the study sample. Thus,
(S-Ar), (5) Ramus Height (Ar-Go), (6) Mandibular Body Length this study differed from previous studies as a standard and
(Go-Gn), (7) Nasion-Gonion Length (N-Go), (8) Y-Axis Length homogenous group of patients was used, divided into two
(S-Gn), (9) Posterior Facial Height (S-Go), (10) Anterior Facial groups only according to their breathing pattern.
Height (Na-Me). When the maxillary sagittal skeletal relationship is evalu-
ated, reduced SNA and A to N perp measurements in MB pa-
tients were determined. These values indicate a tendency for
maxillary deficiency, which was consistent with the findings
of Seto et al. (2001). However, Lowe et al. (1996) reported that
the maxillary position did not show any major difference in
MB patients compared to the control subjects. However, they
also found that the maxillary skeletal position is retrognathic
in the anteroposterior direction.
In the current study, we found that vertical measurements
(PP-GoGn, SN-MP and anterior facial height) were higher
in MB patients, which was consistent with the findings of pre-
vious studies (Hellsing et al., 1987). Patients in the MB group
are likely to present with increased mandibular inclination,
characterized by decreased posterior facial height and in-
creased lower anterior facial height. These measurements sug-
gest that respiratory function influences craniofacial
development (Lessa et al., 2005). These skeletal measurements
indicate a tendency for MB children to present with a dolicho-
cephalic skeletal pattern. Frasson et al. (2006) found no differ-
ence between NB and MB patients when facial vertical
patterns were assessed. Their study included an assessment
of the FMA, SN-GoGn and Y-axis angle values, and they ob-
Figure 4 (1) CVT-SN:angle between the CVT line and SN plane, served no significant alterations between the MB and NB
(2) OPT-SN:angle between the OPT line and SN plane, (3) CVT- groups in terms of posterior facial height measurements. We
Hor: angle between the CVT line and horizontal line, (4) OPT- found higher values for SN-MP, PP-GoGn and anterior facial
Hor: angle between the OPT line and horizontal line, (5) CVT-PP: height (N-Me) in MB patients but no significant differences in
angle between the CVT line and palatal plane, (6) OPT-PP: angle posterior facial height between groups.
between the OPT line and palatal plane, (7) H-MP: distance to the Pirilä-Parkkinen et al. (2010) stated that nocturnal sleeping
H point measured perpendicular to the mandibular plane (MP), disorders cause larger craniocervical angles (NSL–CVT and
(8) H-Me: distance between the H point and menton, (9) H-MP: NSL–OPT), but their patients had a mean age of 7.3 years
angle between the H-menton line and mandibular plane, (10) H- and a Class II skeletal pattern. In this age period, growth
C4: distance between the H point and most inferior/posterior and development are still continuing and can further influence
point on the fourth cervical vertebra corpus. the craniocervical angles. Cuccia et al. (2008) suggested that a
stable breathing pattern has not been established in growing
compensate for the smaller airway space. It is important to no- patients and the natural head posture might be altered in
tice that head extension increases the sagittal extension of the MB patients. The MB and NB children in the current study
Mouth breathing and craniofacial morphology 139

Table 2 Description of the measurements used in the study.

Craniofacial analysis
Angular measurement
SNA angle (SNA): inward angle toward the cranium between the NA line and the SN plane
SNB angle (SNB): inward angle toward the cranium between the NB line and the SN plane
ANB angle (ANB): angle between the NA and NB lines, obtained by subtracting SNB from SNA
Saddle/sella angle (SN-Ar): inward angle toward the cranium between the S-Ar line and the SN plane
Articular angle: inward angle between the S-Ar line and the Ar-Go line
Gonial/jaw angle (Ar-Go/MP): inward angle toward the cranium between the Ar-Go line and the mandibular plane (MP)
SN plane to mandibular plane angle (SN-MP): angle between the SN plane and the MP
Palatal–mand angle (PP-GoGn): angle between the PP plane and the MP
Y-Axis: inward angle toward the cranium between the S-Gn line and the SN plane
SN-NPog: inward angle toward the cranium between the N-Pog line and the SN plane
NA-Apog (convexity): inward angle between the NA line and the APog line
FMA: angle between the frankfurt horizontal plane and the MP
FMIA: angle between the frankfurt horizontal plane and the mandibular incisor axis
IMPA: angle between the MP and the mandibular incisor axis
Mand plane to Occ plane (MP-OP): angle between the MP and occlusal plane (OP)
Linear measurements
A point to nasion perpendicular (A to N perp): distance between A point and N perpendicular line measured perpendicular to N perpendicular
line
Pogonion to nasion perpendicular (Pog to N perp): distance between pogonion and N perpendicular line measured from the perpendicular to N
perpendicular line
S-N: distance between sella and nasion point
Posterior cranial base (S-Ar): distance between sella and articular
Ramus height (Ar-Go): distance between articular and gonion
Mandibular body length (Go-Gn): distance between gonion and gnathion
Nasion–gonion length (N-Go): distance between nasion and gonion
Y-Axis length (S-Gn): distance between sella and gnathion
Posterior facial height (S-Go): distance between sella and gonion
Anterior facial height (Na-Me): distance between nasion and menton
Overjet: distance between labial surfaces of the upper and lower incisors
Overbite: distance between the upper and lower incisor margins
Head posture and hyoid bone
Vert-SN: inward angle toward the cranium between the true vertical line and sella-nasion (SN) plane
Vert-PP: inward angle between the true vertical line and palatal plane (PP)
CVT-SN: angle between the CVT line (an extended line from posterior extremity of the odontoid process of the second cervical vertebra to and
the most inferior/posterior point on the fourth cervical vertebra corpus) and SN plane
OPT-SN: angle between the OPT line (connecting the tangent point at the superior, posterior extremity of the odontoid process of the second
cervical vertebra and the most inferior/posterior point on the second cervical vertebra corpus) and SN plane
CVT-Hor: angle between the CVT line and horizontal line (Perpendicular to true vertical line)
OPT-Hor: angle between the OPT line and horizontal line
CVT-PP: angle between the CVT line and palatal plane (PP)
OPT-PP: angle between the OPT line and palatal plane (PP)
H-MP: distance to the H point (most superior and anterior point on the body of the hyoid bone) measured perpendicular to the mandibular
plane (MP)
H-Me: distance between the H point and menton
H-MP: angle between the H-menton line and mandibular plane (MP)
H-C4: distance between the H point and most inferior/posterior point on the fourth cervical vertebra corpus

had a mean age of 12.8 and 13.5 years, respectively, with a (Behlfelt et al., 1990a,b; Huggare and Laine-Alava, 1997) in
Class I skeletal relationship. order to increase the airway measurements (Warren, 1990)
The present main finding was that MB patients have in- and the oropharyngeal permeability (Ricketts, 1968). Behlfelt
creased OPT-PP and reduced Vert-PP angles compared with et al. (1990a,b) found that extended head posture is associated
the control group. Cuccia et al. (2008) found that a reduction with a low hyoid bone posture and MB. We cannot conclude
of cervical lordosis and increased extension of the atlanto- from this current study that an extended craniocervical head
occipital joint maintained the Frankfort horizontal plane. posture occurs with nasorespiratory obstruction, due to the
Their cohort included growing children and a natural head absence of data regarding nasal airflow resistance.
posture may develop after maxillofacial growth and develop- In mouth breathers, one might expect a different head pos-
ment is complete. ture to be adopted to facilitate breathing, especially where MB
Several studies have shown that MB is associated with head is due to an obstructed nasopharynx; however, Bibby (1984)
posture variation and increased craniocervical extension indicated that, this was not reflected in the position of the
140 F.I. Ucar et al.

Table 3 Descriptive statistics and statistical comparisons of angular and linear craniofacial measurements in mouth breathing and
nasal breathing children.
Craniofacial analysis Mouth breathing (n = 34) Nasal breathing (n = 32) Sig.
Angular measurement () Mean SD Mean SD
SNA 78,503 3,287 80,415 2,709 **
SNB 76,303 3,217 77,418 2,511 NS
ANB 2,209 1,572 2,997 0.931 **
SN-Ar 124,944 6,261 125,221 5,704 NS
Articular angle 140,882 6,911 139,976 6,730 NS
Ar-Go/MP 128,691 8,223 126,939 5,332 NS
SN-MP 35,156 4,570 31,939 2,144 **
PP-GoGn 27,335 6,118 23,324 3,756 **
Y-Axis 70,797 3,141 69,961 2,237 NS
SN-Npog 77,179 2,733 78,145 2,481 NS
NA-Apog 2,729 4,008 5,061 3,348 *
FMA 27,032 5,747 24,945 3,805 NS
FMIA 63,779 7,682 61,885 6,005 NS
IMPA 88,926 6,015 92,755 5,892 *
MP-OP 18,765 4,403 18,424 3,796 NS
Linear measurements (mm)
A to N perp 1,191 2,955 0.373 2,919 *
Pog to N perp 4,779 6,174 -3,712 5,063 NS
S-N 68,815 4,836 65,964 4,594 *
S-Ar 37,088 4,274 35,848 3,985 NS
Ar-Go 45,274 4,356 46,588 4,232 NS
Go-Gn 76.19 8,389 72.5 6,777 NS
N-Go 113,009 8,602 110,024 7,271 NS
S-Gn 126,406 10,312 122,348 9,450 NS
Posterior facial height 75,076 6,090 75,127 5,653 NS
Anterior facial height 118,971 9,918 114,058 8,577 *
Overjet 2,938 32,074 3,236 1,234 NS
Overbite 0.335 25,650 1,400 1,244 *

Table 4 Descriptive statistics and statistical comparisons of head posture and hyoid bone measurements in mouth breathing and
nasal breathing children.
Head posture and hyoid bone Mouth breathing (n = 34) Nasal breathing (n = 32) Mean difference Sig.
Mean SD Mean SD
Vert-SN 81,876 3,309 83,006 2,664 0.129 NS
Vert-PP 89,674 3,957 91,609 3,677 0.042 *
CVT-SN 105,838 6,772 104,318 5,825 0.329 NS
OPT-SN 100,824 7,325 98,318 6,126 0.134 NS
CVT-Hor 95,309 6,160 94,636 5,936 0.651 NS
OPT-Hor 90,368 6,195 88,606 6,250 0.251 NS
CVT-PP 97,191 7,620 95,333 4,484 0.23 NS
OPT-PP 93,632 7,079 90,273 6,216 0.043 *
H-MP 15,265 5,609 14,121 3,988 0.341 NS
H-Me 42,324 9,237 44,061 4,981 0.344 NS
H-MP 20,765 6,651 18,788 6,204 0.213 NS
H-C4 51,029 4,523 52,091 3,964 0.311 NS

hyoid. We found that the hyoid bone is maintained in a stable no effect on the hyoid bone position during rest, which indi-
position, probably in order to protect the proper airway ratios, cates that there is no permanent alteration in skeletal morphol-
and it was not influenced by the respiratory pattern. This find- ogy due to MB as far as the hyoid bone and its relation to the
ing has been supported by other investigators (Bibby, 1984; mandible are concerned.
Ferraz et al., 2007). However, some studies have found that This study was limited as the measurements were based on
the hyoid bone is located in a lower position in MB patients two-dimensional cephalometric radiographs. To overcome this
(Ozbek et al., 1998). According to the present data, MB has weakness, all radiographs were taken by the same technician
Mouth breathing and craniofacial morphology 141

and the same author (F.I.U.) performed all measurements spinal curvature in 8, 11 and 15-year-old children. Eur. J. Orthod. 9
carefully to ensure they were consistent. Further 3D studies (4), 254–264.
are needed to give a highly precise quantitative analysis. Huggare, J., Laine-Alava, M.T, 1997. Nasorespiratory function and
head posture. Am. J. Orthod. Dentofacial Orthop. 112 (5), 507–
511.
5. Conclusions Lessa, F.C., Enoki, C., Feres, M.F., Valera, F.C., Lima, W.T.,
Matsumoto, M.A., 2005. Breathing mode influence in craniofacial
Within the limitations of this cross-sectional study, the follow- development. Braz. J. Otorhinolaryngol. 71 (2), 156–160.
ing conclusions can be drawn: (i) according to the craniofacial Linder-Aronson, S., 1970. Adenoids. Their effect on mode of
measurements, the maxillary skeletal base is positioned poste- breathing and nasal airflow and their relationship to characteristics
of the facial skeleton and the dentition. A biometric, rhinomano-
riorly in MB patients which affects facial convexity compared
metric and cephalometro-radiographic study on children with and
to a NB control sample. In general, vertical measurements
without adenoids. Acta Otolaryngol. Suppl. 265, 1–132.
were higher and lower incisors were retroclined in the MB Lowe, A.A., Ono, T., Ferguson, K.A., Pae, E.K., Ryan, C.F.,
group; (ii) the palatal plane showed a posterior rotation Fleetham, J.A., 1996. Cephalometric comparisons of craniofacial
according to the second cervical vertebra in the MB group; and upper airway structure by skeletal subtype and gender in
and (iii) the position of the hyoid was stable in patients with patients with obstructive sleep apnea. Am. J. Orthod. Dentofacial
MB. Orthop. 110 (6), 653–664.
McNamara, J.A., 1981. Influence of respiratory pattern on craniofacial
growth. Angle Orthod. 51 (4), 269–300.
References
Moyers, R.E., 1973. Handbook of Orthodontics, third ed. Year Book
Medical Publishers, Chicago, IL, 442.
Ballard, C.F., 1951. The facial musculature and anomalies of the
Oulis, C.J., Vadiakas, G.P., Ekonomides, J., Dratsa, J., 1994. The
dentoalveolar structure. Trans. Eur. Orthod. Soc., 137–148.
effect of hypertrophic adenoids and tonsils on the development of
Behlfelt, K., Linder-Aronson, S., McWilliam, J., Neander, P., Laage-
posterior crossbite and oral habits. J. Clin. Pediatr. Dent. 18 (3),
Hellman, J., 1990a. Cranio-facial morphology in children with and
197–201.
without enlarged tonsils. Eur. J. Orthod. 12 (3), 233–243.
Ozbek, M.M., Miyamoto, K., Lowe, A.A., Fleetham, J.A., 1998.
Behlfelt, K., Linder-Aronson, S., Neander, P., 1990b. Posture of the
Natural head posture, upper airway morphology and obstructive
head, the hyoid bone, and the tongue in children with and without
sleep apnoea severity in adults. Eur. J. Orthod. 20 (2), 133–143.
enlarged tonsils. Eur. J. Orthod. 12 (4), 458–467.
Peltomäki, T., 2007. The effect of mode of breathing on craniofacial
Bibby, R.E., 1984. The hyoid bone position in mouth breathers and
growth – revisited. Eur. J. Orthod. 29 (5), 426–429.
tongue-thrusters. Am. J. Orthod. 85 (5), 431–433.
Pirilä-Parkkinen, K., Löppönen, H., Nieminen, P., Tolonen, U.,
Cuccia, A.M., Lotti, M., Caradonna, D., 2008. Oral breathing and
Pirttiniemi, P., 2010. Cephalometric evaluation of children with
head posture. Angle Orthod. 78 (1), 77–82.
nocturnal sleep-disordered breathing. Eur. J. Orthod. 32 (6), 662–
Darnell, M.W., 1983. A proposed chronology of events for forward
671.
head posture. Cranio 1 (4), 49–54.
Ricketts, R.M., 1968. Respiratory obstruction syndrome. Am. J.
Ferraz, M.J., Nouer, D.F., Teixeira, J.R., Bérzin, F., 2007. Cephalo-
Orthod. 54 (7), 495–503.
metric assessment of the hyoid bone position in oral breathing
Rubin, R.M., 1980. Mode of respiration and facial growth. Am. J.
children. Braz. J. Otorhinolaryngol. 73 (1), 45–50.
Orthod. 78 (5), 504–510.
Frasson, J.M., Magnani, M.B., Nouer, D.F., de Siqueira, V.C.,
Seto, B.H., Gotsopoulos, H., Sims, M.R., Cistulli, P.A., 2001.
Lunardi, N., 2006. Comparative cephalometric study between nasal
Maxillary morphology in obstructive sleep apnoea syndrome.
and predominantly mouth breathers. Braz. J. Otorhinolaryngol. 72
Eur. J. Orthod. 23 (6), 703–714.
(1), 72–81.
Tourné, L.P., 1991. Growth of the pharynx and its physiologic
Graber, L.W., 1978. Hyoid change following orthopedic treatment of
implications. Am. J. Orthod. Dentofacial Orthop. 99 (2), 129–139.
mandibular prognathism. Angle Orthod. 48 (1), 33–38.
Vig, K.W., 1998. Nasal obstruction and facial growth: the strength of
Gungor, A.Y., Turkkahraman, H., 2009. Effects of airway problems
evidence for clinical assumptions. Am. J. Orthod. Dentofacial
on maxillary growth: a review. Eur. J. Dent. 3 (3), 250–254.
Orthop. 113 (6), 603–611.
Hartsook, J.T., 1946. Mouth breathing as a primary etiologic factor in
Vig, P.S., Showfety, K.Y., Phillips, C., 1980. Experimental manipu-
the production of malocclusion. J. Dent. Child. 13 (4), 91–94.
lations of head posture. Am. J. Orthod. 77 (3), 258–268.
Hellsing, E., 1989. Changes in the pharyngeal airway in relation to
Warren, D.W., 1990. Effect of airway obstruction upon facial growth.
extension of the head. Eur. J. Orthod. 11 (4), 359–365.
Otolaryngol. Clin. North Am. 23 (4), 699–712.
Hellsing, E., McWilliam, J., Reigo, T., Spangfort, E., 1987. The
relationship between craniofacial morphology, head posture and