International Journal of Pediatric Otorhinolaryngology (2005) 69, 311317

www.elsevier.com/locate/ijporl

Cephalometric assessment of the mandibular

growth pattern in mouth-breathing children
Juliana B.R. Sousaa, Wilma T. Anselmo-Limab,*, Fabiana C.P. Valerab,
Aline J. Gallegob, Miriam A.N. Matsumotoa
a

o Preto Dental School,

Department of Preventive and Social Pediatric Dentistry, Ribeira
o Paulo (FORP-USP), Brazil
University of Sa
b
Department of Ophthalmology, Otorhinolaryngology and Head and Neck Surgery,
o Preto, University of Sa
o Paulo, Brazil
Faculty of Medicine of Ribeira
Received 18 February 2004; received in revised form 11 October 2004; accepted 13 October 2004

KEYWORDS
Cephalometry;
Mouth breathing;
Adenoids;
Palatine tonsils

Summary
Objective: At the present time, it is generally accepted that chronic mouth breathing
influences craniofacial growth and development. The objective of this study was to
determine the position of the jaw, its growth direction and morphology, and the facial
proportions of children with two different etiological factors of mouth breathing, at
different age groups.
Materials and methods: Four groups of mouth breathing children were analyzed by
cephalometry. Two groups, ages ranging from 3 to 6 and 7 to 10 years, with respiratory
obstruction due to isolated adenoid hypertrophy (AH), and two groups, ages ranging
from 3 to 6 and 7 to 10 years, due to adenotonsillar hypertrophy (ATH).
Results: No significant differences were observed between mouth breathing children
caused either by AH or by ATH in any of the age groups. Only the linear ArGo
measurement was significantly larger in children with ATH with 7 years or more.
Conclusions: The results suggest that the influence of mouth breathing on mandibular
growth is poorly related to the etiological factors analyzed. The single difference
observed was the lower posterior facial height in children of 7 years of age or more,
which was higher in those with ATH than in those with AH.
# 2004 Elsevier Ireland Ltd. All rights reserved.

1. Introduction

* Corresponding author. Present address: Av. Bandeirantes,

3.900Monte Alegre, CEP, 14049-900 Ribeira
o Preto, SP, Brazil.
E-mail address: ramancio@fmrp.usp.br
(Wilma T. Anselmo-Lima).

Normal craniofacial development and adequate

occlusion depend on various factors. The genetic
factors are of great influence on the constitution
of the facial and occlusal pattern of an individual
[5]. It is believed, however, that functions of the

0165-5876/$ see front matter # 2004 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.ijporl.2004.10.010

312

stomatognathic apparatus also play an important role

in craniofacial and occlusal development [27,16].
Normal respiratory activity influences the development of craniofacial structures [4,29], favoring
their harmonious growth and development by adequately interacting with mastication and swallowing
[15].
The presence of any obstacle in the respiratory
system, especially in the nasal and pharyngeal
regions, causes respiratory obstruction and forces
the patient to breathe through the mouth [7]. Mouth
breathing may be due to anatomical predisposition
or may be caused by several pathologies, such as
palatine and pharyngeal tonsils hypertrophy, septal
deviation, allergic rhinitis and nasal turbinate
hypertrophy, among others [23].
Mouth breathing leads to a new posture in order
to compensate the decrease in nasal airflow and to
allow respiration [9]. The changes include a lower
position of the mandible, and an anterior or a lower
position of the tongue, usually associated with lower
orofacial muscles tonicity [25]. As a result, there is
disharmony in the growth and development of orofacial structures, including narrowing of the
maxilla, lower development of the mandible,
alterations in the position of the head in relation
to the neck, protrusion of the upper incisors and
distal position of the mandible in relation to the
maxilla, for example [19].
Adenoid hypertrophy (AH) isfrequently citedasone
of the main causes of respiratory obstruction
[13,14,18]. AH causes the development of mouth
breathing, which in turn, produces alterations on
the morphology and growth direction of the jaw.
However, there are still some doubts concerning
whether additional hypertrophy of the palatine
tonsils results in more significant mandibular changes.
Thus, it is necessary to study if the consequences of
adenotonsillar hypertrophy (ATH) are identical of
those due to AH. It is also important to determine if
the changes occur before or after the first facial spurt.
The objective of this study was to determine the
position of the jaw in the vertical and anteroposterior planes, its growth direction and morphology, and
the facial proportions of children with mouth
breathing at different age groups (36 and 710
years) caused by two different etiological factors,
i.e., isolated adenoid hypertrophy or adenotonsillar
hypertrophy.

2. Patients and methods

A total of 117 mouth breathing children of both
sexes, ranging in age from 3 to 10 years, were all
subjected to an otorhinolaryngological evaluation

J.B.R. Sousa et al.

for the diagnosis and determination of the etiology

of mouth breathing. The evaluation included
anamnesis and complete otorhinolaryngological
examination with mouth examination, flexible
nasoendoscopy and otoscopy. The data were
recorded on pre-elaborated protocols.
Palatine tonsil hypertrophy was classified by
mouth examination according to the criteria of
Brodsky and Kock [2] as follows: grade 0tonsils
limited to the tonsillar fossa; grade 1tonsils occupying up to 25% of the space between the anterior
pillars in the oropharynx; grade 2tonsils occupying
2550% of the space between the anterior pillars;
grade 3tonsils occupying 5075% of the space
between the anterior pillars; and grade 4tonsils
occupying 75100% of the space between the anterior pillars.
Adenoids were assessed by lateral cephalometric
radiography according to the method of Cohen and
Konak [3] and by flexible nasoendoscopy. Radiographic analysis consisted of the comparison
between soft palate thickness 1 cm below its insertion on the hard palate and thickness of the air
passage between the soft palate and the adenoid
shadow. Nasoendoscopic assessment evaluated the
percentage that adenoids obstructed the choanae.
Adenoids were grouped into:
 small: when the air column was equal to or larger
than the thickness of the soft palate at the X-ray,
or adenoid was less than 50% of choana at nasoendoscopy;
 medium: when the air column was reduced but
still wider than half the thickness of the soft
palate at the X-ray, or adenoid was higher than
50% but less than 70% of choana at nasoendoscopy;
 large: when the narrowing corresponded to half of
the thickness of the soft palate or less at the Xray, or adenoid was higher than 70% of choana at
nasoendoscopy.
When X-ray results were not in accordance to
nasoendoscopic findings, the latter were considered
to the study. Only children with medium or large
adenoids and consequent predominant mouth breathing were selected.
After otorhinolaryngological evaluation, the children were divided into two groups for the diagnosis
and determination of the etiology of mouth breathing: group Amouth breathing children due to AH
(Brodsky and Kock scale grades 02) and group B
mouth breathing children due to ATH (Brodsky and
Kock scale grades 3 and 4). Children using an orthodontic apparatus and children with craniofacial
syndromes were excluded from the study since

Cephalometric assessment of the mandibular growth pattern in mouth-breathing children

these factors directly influence the development of

the facial pattern.
The two groups were then subdivided according
to the age of the children (36 and 710 years),
before (A1 and B1) and after (A2 and B2) the first
craniofacial spurt.
After otorhinolaryngological diagnosis, all patients
were subjected to an orthodontic evaluation with
anamnesis, clinical examination and cephalometric
analysis. Based on the lateral cephalometric radiographs, the following angular and linear cephalometric measurements were obtained (Fig. 1):
SNB angle: determined by the intersection between
the sella-nasion (SN) and nasion-supramental (NB)
lines. This angle expresses the degree of protrusion
or retrusion of the mandible in relation to the
cranial base.
ANB angle: determined by the intersection between
the nasion-subspinal (NA) and nasion-supramental
lines and corresponding to the difference between
the SNA and SNB angles. This angle determines the
anteroposterior relationship between the maxilla
and mandible.
SNGoGn angle: determined by the intersection of
the mandibular plane (GoGn) with the SN line. This
angle expresses the degree of inclination of the
mandible in relation to the anterior cranial base.
SNGn angle: determined by the intersection
between the SN and SGn lines. This angle indicates
the direction of mandibular growth.
SNPg angle: determined by the intersection
between the SN and nasion-pogonion lines. This
angle indicates basal mandibular prognathism.

313

ArGoGoMe: determined by the intersection

between the ArGo and GoMe lines. This angle measures the opening between the gonial and mandibular angle.
NMe: linear measurement determined by the
union of the nasion and mental points corresponding
to the total anterior facial height.
NANS: linear measurement determined by the
union of the nasion and anterior nasal spine points
corresponding to the upper anterior facial height.
ANSMe: linear measurement determined by the
union of the anterior nasal spine and mental points
corresponding to the lower anterior facial height.
SGo: linear measurement determined by the union
of the sella and gonial points corresponding to the
total posterior facial height.
ArGn: linear measurement determined by the
union of the articular and gnathion points corresponding to the length of the mandible.
GoGn: linear measurement determined by the
union of the gonial and gnathion points corresponding to the mandibular plane (Steiner).
ArGo: linear measurement determined by the
union of the articular and gonial points corresponding to the lower posterior facial height.
The cephalometric data were concentrated in a
table and subjected to statistical analysis for the
determination of differences in the morphology and
growth pattern of the mandible, facial proportions
and the position of the mandible in the vertical and
anteroposterior planes. The influence of age on the
groups studied was also assessed statistically.
This study has been approved by local Ethical
Committee and Institutional Review Board (process
number 2002.1.59.58.0).

3. Results

Fig. 1 Cephalogram illustrating the angular and linear

cephalometric measurements.

The study groups included 30 children with AH in

Group A1, with ages ranging from 3 to 6.9 years
(mean age 4.74), and 29 children in Group A2,
with ages ranging from 7 to 10.1 years (mean age
8.22).
Also, 28 children with ATH in Group B1, with ages
ranging from 3.3 to 6.8 years (mean age 5.46), and
29 children in Group B2, with ages ranging from 7 to
10.9 years (mean age 7.95), were studied.
The comparison between the mean and standard
deviation of the cephalometric measurements
obtained for the four groups are shown in Tables 1
and 2. Table 1 shows the mean and standard deviation of cephalometric measurements obtained for
groups A1 and B1 (younger than 7 years). The Student t-test did not reveal significant differences in

314

J.B.R. Sousa et al.

Table 1 Comparison of cephalometric measurements obtained for children aged 36 years between children with
adenoid hypertrophy only (group A1) and children with adenoid and palatine tonsil hypertrophy (group B1)
Cephalometric measure

Group A1
Mean

Angular (degree)
ANB
SNB
SNGoGn
SNGn
SNPg
ArGoGoMe
Linear (mm)
NMe
NANS
ANSMe
SGo
ArGn
GoGn
ArGo

Group B1
S.D.

t-test

Mean

S.D.

t calculated

6.63
76.37
37.13
69.73
75.38
134.82

2.54
3.06
4.17
3.60
3.46
5.50

6.53
76.08
38.32
70.00
74.85
135.61

2.27
3.52
4.94
3.94
3.49
3.75

0.164
0.338
0.343
0.276
0.594
0.668*

0.870
0.736
0.733
0.784
0.555
0.513

99.65
42.35
60.40
59.33
85.78
61.35
33.90

4.60
3.62
3.46
3.97
11.77
4.05
3.31

99.31
42.10
60.87
59.55
87.15
59.76
34.24

5.37
2.81
3.76
3.92
4.87
4.58
2.50

0.268
0.306
0.509
0.213
0.594
1.438
0.456

0.790
0.761
0.613
0.832
0.555
0.156
0.650

Data are reported as means and standard deviation (S.D.)

*
Student t-test for differences between means with unequal variances (F-test for difference between variances F29;30 (calculated) = 1.919 and p = 0.040).

the mean measurements between the two subgroups, which means that for these groups, there
was no difference in cephalometric measurements.
Table 2 shows statistical data for children aged 7
years or older. Again, no significant differences
in cephalometric measurements were observed
between the two subgroups, except for the mean
ArGo measurement, which was significantly larger
in group B2 than in group A2 (difference of 2.24 mm
and p < 0.05).

4. Discussion
Studies comparing the morphological patterns of
children with mouth breathing differentiated
according to the etiological factor, i.e., AH versus
ATH, are rare in the literature, as are analyses of
facial morphology and of the altered respiratory
patterns caused by voluminous palatine tonsils
[8,17,21,24]. Most investigations published thus
far refer to changes in facial growth resulting from

Table 2 Comparison of cephalometric measurements obtained for children aged 710 years between children with
adenoid hypertrophy only (group A2) and children with adenoid and palatine tonsil hypertrophy (group B2)
Cephalometric measure

Group A2

Group B2

t-test

Mean

S.D.

Mean

S.D.

t calculated

Angular (degree)
ANB
SNB
SNGoGn
SNGn
SNPg
ArGoGoMe

4.64
77.48
37.04
69.48
77.43
132.46

2.18
4.03
4.25
4.25
4.19
5.98

5.50
76.88
39.68
70.57
76.55
132.71

2.16
2.96
3.73
3.05
3.25
4.04

1.476
0.642
0.907
1.101
0.873
0.183*

0.145
0.524
0.368
0.276
0.387
0.855

Linear (mm)
NMe
NANS
ANSMe
SGo
ArGn
GoGn
ArGo

109.86
47.45
65.16
67.00
97.66
69.21
37.30

6.44
3.79
4.56
4.35
6.44
5.43
3.95

111.54
49.13
65.25
67.45
99.00
68.64
39.54

6.64
3.82
4.53
4.27
5.41
4.76
3.96

0.960
1.651
0.074
0.387
0.842
0.418
2.107

0.341
0.104
0.942
0.700
0.403
0.677
0.040

Data are reported as means and standard deviation (S.D.)

*
Student t-test for differences between means with unequal variances (F-test for difference between variances F27;27 (calculated) = 0.871 and p = 0.047).

Cephalometric assessment of the mandibular growth pattern in mouth-breathing children

nasal obstruction without providing a precise diagnosis of the etiological factor of this dysfunction
[1,11,12,28].
In the present study, special attention was
focused on the diagnostic method, determining
the etiological factor of mouth breathing. The diagnosis consisted of anamnesis, complete otorhinolaryngological examination, nasopharynx radiography
and nasoendoscopy for adenoid assessment and
mouth examination for the assessment of the palatine tonsils. Endoscopic examination yields a more
precise diagnosis of AH than X-rays, since it allows
the direct visualization of the size and condition of
the tissue [26]. The direct visualization of the adenoid seems to be extremely important for providing
reliable results. Nonetheless, several studies have
not been concerned with this aspect, and have used
only nasopharynx radiography for the diagnosis
[1,6,18,24]. The specific influence of the AH or
ATH on craniofacial growth remains unknown due
to the lack of reports of the role of these etiological
factors in the determination of the facial morphological pattern.
In the present study, we evaluated mouth-breathing children aged 310 years in order to determine
differences in mandibular growth and morphology.
The facial proportions were also assessed. The evaluations were performed during a period preceding
the maximum pubertal growth spurt. At this time,
bone remodeling processes caused by oral respiration have still not reached their maximum potential.
The knowledge about the influence of etiological
factors on facial development in this age group is
important because appropriate treatment should be
initiated early in such a way that these alterations
can be compensated for by growth itself during the
pubertal period.
Regarding children aged 36 years, statistical
analysis revealed similar cephalometric measurements from the two groups. However, the SNGoGn
angle tended to be wider in the group of children
with ATH. This result suggests a numerical trend
towards a more inclined mandibular plane in this
group as compared to children with AH. It should be
pointed out that this difference was not significant.
The difference in this angle was greater in children
aged 710 years, suggesting an influence of hypertrophied palatine tonsils on the clockwise rotation
of the mandible during growth.
Furthermore, in children aged 710 years, statistical analysis revealed that children with ATH
presented larger ArGo values than children with
AH. This result suggests that children with adenotonsillar hypertrophy have a higher lower posterior
facial height than the children with isolated adenoid
hypertrophy. Moreover, this result indicates a ten-

315

dency towards alterations in the mandibular morphology of children with hypertrophied tonsils.
These tonsils, when hypertrophied, could occupy
a huge space in the pharynx. Thus, children protruded their mandible in order to breathe better,
stimulating the growth of mandible and increasing
their lower posterior facial height.
The tendency observed in the present study was
confirmed in the study of Kawashima et al. [10], who
found a retrognathic mandible and increased posterior facial height in preschool children (mean age
of 4.7 years), with more than 75% of the palatine
tonsils being visible upon clinical examination.
Nevertheless, the use of a larger number of
children might have detected other differences,
especially in older children in whom growthmediated dimensional changes would certainly be
more evident.
Trotman et al. [24] obtained more marked results
when analyzing children with enlarged palatine
tonsils and reduced airways due to hypertrophied
adenoids. The skeletal pattern associated with voluminous tonsils was in many aspects opposite to the
pattern associated with reduced sagittal airways.
The reduction in airway size due to hypertrophied
adenoids was characterized by posterior rotation of
the maxilla and mandible in relation to the cranial
base and by a shorter mandibular body. In contrast,
the larger size of the tonsils was characterized by a
more anterior position of the maxilla and mandible
in relation to the cranial base, accompanied by
wider SNA and SNB angles due to the lack of an
increase in the SN dimension. These contrasting
results might be due to differences in the sample
analyzed by these authors and that of the present
study. The former study was conducted on children
aged 313 years, and thus included children who
had already reached the maximal pubertal growth
spurt and whose maximal growth potential had
already manifested. The present study included
children who had not yet entered this growth spurt.
Another relevant factor that might explain the lack
of significant evidence in the study of Trotman et al.
[24] is the considerably larger size of their sample
(207 children) compared to 117 children selected in
the present study. Trotman et al. [24] diagnosed
nasal obstruction based on cephalograms, which
produce a two-dimensional image of nasal airway
and pharyngeal morphology, which is actually threedimensional and anatomically irregular, thus resulting in an empirical analysis according to Oulis et al.
[17]. In the present study, the diagnosis of the
etiology of mouth breathing was made by an otorhinolaryngologist who in addition to clinical and
radiographic examination, used nasofibroscopy,
which permits the direct visualization of the rela-

316

tionship between the adenoid and choanae, ear

tube and palate. This visualization allows a reliable
determination of the content/container relationship and thus provides more precise data than radiography [26]. It should also be taken into account that
the children studied by Trotman et al. [24] represented a selected population of severely affected
patients. Therefore, the conclusions obtained cannot be generalized to other groups of children.
According to Warren [27], induced oral respiration
[20,22] causes exaggerated changes in tongue and
mandible, conditions that might compromise the
reliability of the results considering that the respiratory obstruction affecting most children is not
severe. Thus, it does not result in such marked
alterations. In this respect, the children analyzed
in this study are more representative of the general
population since they represent patients with
predominantly but not necessarily severe oral
respiration.
The facts discussed herein indicate the need for
further studies with the same objective, i.e., to
analyze morphological differences between children with mouth breathing of distinct etiologies.
However, these studies should comprise a larger
number of patients including older children, in
whom dimensional alterations can be more evident,
especially during the maximal pubertal growth
spurt, which probably would permit the detection
of more marked differences.

5. Conclusions
With respect to the position of the jaw in the
vertical and anteroposterior planes, growth direction, mandibular morphology and facial proportions,
no significant differences were observed between
children aged 310 years, except for the linear Ar
Go measurement (lower posterior facial height),
which was significantly larger in children with tonsil
and adenoid hypertrophy than in children with isolated enlarged adenoids in children aged 710
years. This difference could be an initial postural
mandible change observed in older children, in
order to increase the pharynx area.
Therefore, the present study detected little morphological differences between children with adenoid hypertrophy and those with adenoid and tonsils
hypertrophy. Mouth breathing seems to have a similar effect on mandibular growth irrespective of its
etiology. Nevertheless, other studies with higher
samples and with older children will be necessary
in order to understand the effects of different
causes of mouth breathing in facial growth.

J.B.R. Sousa et al.

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