Methods of Evaluation of Airway

Rajeev
kumar Mishra
2/15/2013
Department of Orthodontics and Dentofacial
Deformities, Centre for Dental Education and
Research, All India Institute of Medical Sciences
Methods of evaluation of airway and its
role in orthodontics
Contents
Introduction
Anatomy
Methods of evaluation
Orthodontic consideration
Adenoid facies
Variations in airway
Effect of treatment
Obstructive sleep apnoea

2/15/2013
Introduction
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From the late 1800s until now, the relationship between
pharyngeal structures and dentofacial pattern has been
intensively researched

Meyer in 1872 reported thinned nose, flattened from side
to side, and the nostrils collapsed and narrow in patients
suffering from obstruction of nasopharyngeal cavity.

According to the functional-matrix hypothesis proposed by
Moss, soft-tissue units guide the hard tissues to an extent
2/15/2013
Deformities,
Centre for Dental Education and Research,
All India Institute of Medical Sciences

Some authors claim that patients with deficient respiratory
functions present with so called adenoid facies (Ricketts,
1968)

However, there is still a dispute whether this relationship
between craniofacial morphology and respiratory function
causes dentofacial anomalies ( Leech, 1958,Vig ,1998)

It is a general belief that the upper airway structures play a
significant role over the development of craniofacial complex(El &
Palamo, 2011)

There exists a close relationship between the pharynx and the
dentofacial structures, a mutual interaction is expected to occur
between the pharyngeal structures and the dentofacial pattern, and
therefore justifies orthodontic interest.(Ceylan et al)

2/15/2013
Department of Orthodontics and Dentofacial Deformities,
Centre for Dental Education and Research, All India
Institute of Medical Sciences
ANATOMY
2/15/2013
2/15/2013
Methods of evaluation of
Airway

Lateral Cephalogram
Dynamic MRI
CT/CBCT
Polysomnography
Acoustic reflection test
Fluoroscopy
Nasopharyngoscopy
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Lateral cephalogram

Two dimensional image but useful in evaluation of airway

Recorded at the end of expiration and not at deglutition

2/15/2013

Lateral head film studies of the airway have included both
linear and area measurements based on specific
cephalometric landmarks and subjective classification of
airway restriction based on an ordinal scale

Linear measurement are considered unreliable and area
measurement more meaningful in airway evaluation
2/15/2013
Deformities, Centre for Dental Education and Research,

A number of reference measurements are attributed to the
airway and several studies have attempted to establish
normal values for some of these
2/15/2013
McNamara (1984)
Upper pharynx-point on the posterior outline of the soft
palate to the closest point on the posterior pharyngeal
wall.(measurements of less than 5 mm are of concern).

Lower pharynx -intersection of the posterior border of the
tongue and the inferior border of the mandible to the
closest point on the posterior pharyngeal wall. (average
values, 10-12 mm). Any value over 15-16 mm is of
concern

2/15/2013
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Cervical axis(od-C5c)
Odontoid tangent
Pterygoid vertical
1 Anterior cranial base
2 Posterior cranial base
3 Effective cranial base length
4 Length of palate(floor of nasal
cavity)
5 Posterior height of nasal cavity(S-
PNS)
6 Vertical diameter of choanal
opening(ho-PNS)
7 Length of pharyngeal clivus(ba ho)
8 Length of floor of nasopharynx(AA
to PNS)
9 Depth of nasopharynx(Ba-PNS)
10 Effective length of maxilla(TMJ to
ANS)
11 Upper anterior facial height
Some important linear measurements used in radiographic
cephalometric studies of upper airway
2/15/2013

1

Saddle angle(N-S-ba)

2

SNA

3

Angle between palatal plane and
Cranial base

4

The angle of nasopharyngeal
depth and included angle of ba-
S-PNS

5

The angle of nasopharynx and
included angle of PNS-ba-S

6

The angle of roof of
nasopharynx and include angle
ba -ho-PNS

7

Craniocervical angle
Basic cephalometric
analysis for OSA patient
2/15/2013
Deformities,
PAS Distance between posterior
pharyngeal wall and base of
tongue measured on line B-
Go
11
mm
PNS-
P
Length of soft palate 35
mm
MPH Distance of hyoid bone
measure don perpendicular
from MP to anterior superior
point of hyoid bone
15
SAS Distance from pharyngeal wall
to maximum convexity of soft
palate
15-
20
MAS Minimum anteroposterior
airway space in lower pharynx
9-
11
G width of soft palate 8
Limitations
Two dimensional representation of a three dimensional
structure
Differences in magnifications
Superimposition of the bilateral craniofacial structures
Low reproducibility as a result of difficulties in landmark
identification
No information about lateral structures
Cannot be performed dynamically
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Deformities,
Nasopharyngoscopy
Widely available
Easy to perform
No radiation
Can be performed in the sitting
and supine positions
Imaging during wakefulness and
sleep
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Deformities,
Limitations
lnvasive
Evaluates only airway lumen, not surrounding soft tissue
structures
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Deformities,

Muller maneuver, performed during the procedure, may
provide insight into the location of upper airway closure by
potentially simulating obstructive apnoeas
2/15/2013
Deformities,
Fluoroscopy
Advantages
Provides dynamic airway
imaging during wakefulness
Can also be performed during
sleep
Limitations
Significant radiation exposure
Poor sensitivity
Not capable of cross sectional
imaging
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Acoustic Reflection
Technique based on analyzing reflected sound waves from the
respiratory system, which provides a calculation of the upper
airway area as a function of distance from the incisors (mouth)
Advantages
Noninvasive
No associated radiation
Easily repeated
Dynamic imaging ,can determine location of obstruction
Determine effect of mandibular advancement and protrusion on
airway
Can be done in an orthodontic clinic

2/15/2013
Deformities,
Limitations
Primarily used as a research tool; clinical usefulness has not been
adequately assessed

Technique is performed through the mouth, which alters upper airway
anatomy

Does not provide high resolution anatomical representation of the
airway or soft tissue structures
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Deformities,
Polysomnography
Multi-parametric test
Gold standard for diagnosis of apnoea
Electroencephalogram
Electrooculogram
Electromyogram
Electrocardiogram
Respiratory flow
Pulse oxymetry
Provides apnoeahypnoea index
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Deformities,
Magnetic Resonance Imaging
Since the shape of upper respiratory tract continuously
changes with the respiratory movement, conventional MRI
lacks sufficient temporal resolution to diagnose the severity
of obstruction

Dynamic MRI provides excellent temporal resolution to
define dynamic changes of the upper airway, requires no
exposure to ionizing radiation and provides a pharyngeal
airway view on the sagittal plane
2/15/2013
Accurate assessment of upper airway cross-sectional area and
volume

Excellent airway, soft tissue and fat resolution

Direct sagittal, coronal, and axial images without radiation,
therefore studies can be performed and repeated during
wakefulness and sleep

Three dimensional reconstruction of soft tissue structures (tongue,
soft palate, lateral parapharyngeal fat pads, lateral pharyngeal
walls) and airway
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Technique not widely available

Expensive

Weight limitation of approximately 300 pounds

Claustrophobia is a problem

Cannot be performed in patients with ferromagnetic clips or
pacemakers
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Computed Tomography

Excellent airway and bony resolution

Accurate assessment of upper airway cross-sectional area and
volume

Three dimensional reconstruction of craniofacial structures and
airway

2/15/2013
Deformities,
Limitations
High radiation exposure

High cost

Poor resolution for upper airway adipose tissue at least
compared with MR imaging
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Cone Beam CT
Low radiation exposure

Possible to visualize sites of interest by adjusting the image
orientation and rotation

Different gray-level intensities that allow visualization of soft tissue
as well as hard tissue with different tissue densities

Low cost
2/15/2013
Deformities,

Scans are converted to DICOM image

Image analyzed with special software
2/15/2013
Deformities,
Mimics (Materialise, Leuven, Belgium),

ITK-Snap

OsiriX (Pixmeo, Geneva, Switzerland)

Dolphin3D (Dolphin Imaging & Management Solutions,
Chatsworth, Calif)

InVivo Dental (Anatomage, San Jose, Calif)

Ondemand3D (CyberMed, Seoul, Korea)
2/15/2013

Segmentation
Manual
Semiautomatic
Image thresholding
Static
Dynamic
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Anterior
boundary
Posterior
boundary
Superior
boundary
Inferior
boundary
Nasopharynx Line extending from
sella (S) to the
posterior
nasal spine (PNS)
Line extending from
S to
the tip of the
odontoid
process
Line extending from
the PNS to tip of
the
odontoid process
Oropharynx Line extending from
the
posterior nasal
spine (PNS)
to the base of the
epiglottis
Line extending from
the
tip of the odontoid
process
to the posterior-
superior
border of CV 4
Line extending from
the PNS to the tip
of the odontoid
process
Line extending from
the
base of the
epiglottis
to the posterior-
superior
border of CV 4
Hypopharynx Line extending from
the
base of the
epiglottis
to the inferior
border
of the symphysis
Line extending from
the
posterior-superior
corner
of CV 4 to the
posteriorinferior
corner of CV 4
Line extending from
the
base of the
epiglottis
to the posterior-
superior
corner of CV 4
Line extending
from the
posterior-inferior
corner of
CV 4 to the
inferior border
of the symphysis
Smith T, Ghoneima A, Stewart K, Liu S, Eckert G, Halum S, Kula K.
Threedimensional computed tomography analysis of airway volume changes after rapid maxillary expansion. Am J Orthod Dentofacial
Orthop. 2012 May;141(5):618-26

2/15/2013
`

2/15/2013

Nasopharynx morphology is complex, and its volume measurement has
less reliability than does oropharynx volume measurement

El H, Palomo JM. Measuring the airway in 3 dimensions: a reliability and accuracy study. Am J
Orthod Dentofacial Orthop 2010;137: S50.e1-9

Poor soft tissue resolution

More noise and movement artifact

2/15/2013
Orthodontic considerations
Adenoid facies
Term coined by Tomes(1872)

Studies by Linder-Aronsen supported the relationship between
nasal obstruction and craniofcial and dental patterns

Harvold suggested the role of neuromuscular changes

Solow & kreiborg Soft tissue stretch theory
2/15/2013

Clinical features
Excessive lower facial anterior facial height
Incompetent lip posture
Gummy smile
Flattened nose, poorly developed nostrils
Steep mandibular plane
Posterior cross bite
Open mouth posture
Short upper lip and fuller lower lip
Narrow V shaped upper jaw and high narrow palatal vault
Class II skeletal relationship

2/15/2013
Diagnosis
History
Clinical examionation
Assesment of mode of respiration
Water holding test
Mirror condensation test
Cotton wisp test
Cephalometric analysis
Rhinomanometric examination
2/15/2013
Deformities,
Orthodontic implication
Effective orthodontic therapy necessitates elimination of
nasal obstruction
Early intervention
Appliances
2/15/2013
Deformities,
CBCT study of airway in different malocclusion types

Investigator
s
Sample
size
Age Measure
ment
modality
Conclusion
El &
Palamo(201
1)
140(m-70,f-
70)
Class I,Class
II & Class III
14-18 yrs CBCT/IN
vivo
OP volume-Class II <Class I & III
NP
Class II <Class I
Hong et al
(2011)
60
Class I-29
Class III-31
24.1-
27.9
CBCT/In
ViVo
Area of lower pharynx and volume of upper
pharynx greater in Class III than Class I
Yoon-Ji
Kim(2010)
27(m-12,f-15)
Group 1-
2
0
ANB5
0
Group 2-
ANB>5
0

11.92.8 CBCT/IN
Vivo
mean total airway volume of retrognathic
patients was significantly smaller than that
of patients with a normal anteroposterior
skeletal relationship

2/15/2013

2/15/2013
Deformities,
El &
Palamo(20
11)

101(m-57,f-
44)
Class I
Class II
MaxP
Class II Man
R
Class III
max R
Class III
ManP

14-18 CBCT/IN
Vivo

Posterior airway space, area of the most
constricted region at the base of the
tongue (minAx), and OP volume were
significantly higher for the CIIIMandP
group, whereas CIIMandR subjects had
the lowest values. The only significant
difference for the NP volume was
between CI and CIIMandR groups where
a smaller volume for the CIIMandR
group was observed.
Cephalometric studies
INVESTIGATOR SAMPLE Conclusion

Ceylan and Oktay
(1995)
90(M-45,f-45)
oropharynx areas of patients with ANB <1 degree
were larger compared to subjects with ANB >5
degrees

Kirjavainen and
Kirjavainen (2007)

120
Class II div1-40
Class I-80

children with Class II malocclusion had a wider or
similar nasopharynx than the controls but narrower
oropharyngeal (OP) and hypopharyngeal areas
Martin et al(2011) 162
Class I(M-55,F-
36)
Class III(M-33,F-
38)
Upper airway thickness is greater in those with
ideal occlusions than in Class III patients, in
contrast to lower
pharynx dimension, which is greater in Class III
patients
No signicant differences in lower airway
thickness
were found. However, the Class III group showed
a statistically signicant constricted airway at this
region because of reduced aerial thickness and
greater adenoidal tissues
2/15/2013
Deformities,

However some studies have concluded that malocclusion type
does not influence pharyngeal airway width ( de Freitas et al.,
2006; Alves et al., 2008).
2/15/2013
Deformities,
Investigator Sample Method Conclusion
De Freitas et al 80
Male -32
Female -48
Mean age -11.64

McNamara analysis on
lateral cephalogram
No difference ina
airway width of Class
I and Class II subject
Alves et al 60
Male-30
Femle-30
Mean age-17.32-
18.21.2
Spiral computed
tomography
No statistical
difference
between skeletal
pattern of classes II
and III
Variations due to growth pattern
Hyperdivergent patients had a narrower antero-posterior
pharyngeal dimension especially in the nasopharynx at the
level of hard palate and in the oropharynx at the level of the
tip of the soft palate and mandible

Patients with long faces tended to have an extremely narrow
airway, both antero-posteriorly and coronally, when compared
to patients with normal faces(Grauer et al 2009)

2/15/2013
Deformities,
Subjects with Class I and Class II malocclusions and vertical
growth patterns have signicantly narrower upper pharyngeal
airways than those with Class I and Class II malocclusions and
normal growth patterns however growth pattern doesnt
influence volume of lower pharyngeal airway(de Feritas et
al,2006)
2/15/2013
Centre for Dental Education and Research
Trenouth and Timms (1999) who measured the length of
mandible between gonion and menthon and found that
oropharyngeal airway was positively correlated with length of
the mandible.

2/15/2013
Deformities,
Effect of Treatment

Godt et al (2011)evaluated the changes in upper airway width
associated with Class II treatments (headgear vs activator) and
different growth patterns
2/15/2013
Deformities,
Dimensional changes in the pharyngeal area within the
overall context of orthodontic treatment were only minor,
and even the differences noted between various treatment
modalities were small.

However they also noted that pharyngeal width reductions
can occur in the phase of isolated headgear treatment which
may exacerbate any preexisting OSAS or may result in
decompensation of compensated OSAS.

2/15/2013
Extraction vs non-extraction treatment
No statistically significant oropharyngeal airway volume
changes were found between cases treated with the
extraction of four premolars and nonextraction groups.
(Valiathan et al ,2010)

The pharyngeal airway size became narrower after the
treatment in cases treated with extraction of all four
premolars compared to non extraction case(wang et al,2012)
2/15/2013
Deformities,
Centre for Dental Education and Research
Effect of RME /Maxillary protraction
CBCT studies
2/15/2013
Deformities,

Ribeiro et
al

15
Males-8,Females-7
Mean age-7.5 yrs

Bonded Hyrax

RME is able to increase the
transverse width of the nasal cavity,
but it does not have the same effect
in the nasopharynx

Smith et al

20
Males-8,Females-12
Mean Age-12.3 yrs +
1.9 months

Banded hyrax

RME causes significant increase in
nasal cavity volume and nasopharynx
volume
Centre for Dental Education and Research, All India
Institute of Medical Sciences
Investigators Sample
size/averag
e age of
sample
Intervention
Done
Duration Imagig
Modalitie
conclusion
Sayinsu et al,2006 19(12M+7F)/

10.51+1.15 yrs
RPE+face mask 6.78+0.93 mth Lateral
Cephalograp
h
Increase in
Nasopharyngeal
airway,no change in
oropharymgeal airway
Oktay et al, 2008 20(5M+15F)

11.5+1.54 yrs
Face Mask 8+2.5 mth Lateral
Cephalograp
h
Maxillary protraction
caused the upper airway
dimension to increase
Kilinc et al,2008 18(11F+7M)
10.5+0.93
Protraction
headgear
+RPE
6.94+0.56
mth
Lateral
Cephalogram
s
Improved naso and
oropharyngeal airway
dimension
Kaaygisiz et
al,2009
25(11F+14M)
11.32+1.08 yrs
Reverse Head
Gear
6.94+0.91 mth
with follow up
upto 4 yrs
Lateral
Cephalograp
hs
Improved airway
dimension initially which
was maintained in long
term followup
Tiziano Baccetti et
al,2010
22(12F+10M)

8.9+1.5 yrs
Bite block+ face
mask
Lateral
Cephalograp
h
No significant change in
oropharyngeal &
nasopharyngeal airway
2/15/2013
Orthodontic consideration in Obstructive sleep
apnoea
Craniofacial anomalies associated with OSA
Mandibular deficiency-Posterior positioning of tongue
leading to airway obstruction
Maxillary deficiency-approximation of soft palate with
posterior pharyngeal wall
Combination of both

2/15/2013
Deformities,
2/15/2013
Role of Orthodontist in Multidisciplinary team
Analysis of craniofacial anatomy and upper airways

Design and fabrication of appliance for mandibular
advancement

Institute orthodontic treatment during orthognathic
surgery/distraction osteogenesis

Treatment of mandibular deficiency by functional
applainces

Oral appliance therapy
Primary snoring
Mild to moderate OSA not responding to CPAP
Unsuitable for behavior modificaton procedures

Most of oral appliance work by placing mandible forward
and thus increases the distance between posterior
pharyngeal wall and tongue
2/15/2013
Deformities,
Mandibular advancement device(MAD)
Monoblock appliances
Splint
Acivator
Bionator
Karwetzky activator
Twin block appliances
Removable herbst appliance
Twin block
2/15/2013
Deformities,

Tongue retaining devices

Tongue repositioning manoeuvre with oral shields

Titrable MADS
2/15/2013
Deformities,
Limitations of MADs
Treatment outcome cant be predicted
Acclimatization period is required
Uncertainty about selection of maximum dosage
Potential long term complications irt TMJ and
occlusion
2/15/2013
Deformities,
References
2/15/2013
Deformities,
Kharbanda O P. Orthodontics diagnosis and management of malocclusion and
dentofacial deformities .2
nd
edition.2012
Graber T M,Vanarsdall R L,Vig K W L.Orthodontics current principles and
technique.4
th
edition.2005

El H, Palomo JM. Airway volume for different dentofacial skeletal patterns. Am J

Orthod Dentofacial Orthop. 2011 Jun;139(6):e511-21

El H, Palomo JM. An airway study of different maxillary and mandibular sagittal

positions. Eur J Orthod. 2011 Oct 31. [Epub ahead of print]

Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D. Comparison of

airway space with conventional lateral headfilms and 3-dimensional reconstruction
from cone-beam computed tomography. Am J Orthod Dentofacial Orthop. 2009
Apr;135(4):468-79

2/15/2013

German DS, German J. Cone-beam volumetric imaging: a two-minute drill. J Clin Orthod. 2010
Apr;44(4):253-65

Valiathan M, El H, Hans MG, Palomo MJ. Effects of extraction versus non-extraction treatment on
oropharyngeal airway volume. Angle Orthod. 2010 Nov;80(6):1068-74

Grgl S, Gokce SM, Olmez H, Sagdic D, Ors F. Nasal cavity volume changes after rapid maxillary
expansion in adolescents evaluated with 3-dimensional simulation and modeling programs.Am J
Orthod Dentofacial Orthop. 2011 Nov;140(5):633-40

Ucar FI, Uysal T. Orofacial airway dimensions in subjects with Class I malocclusion and different
growth patterns. Angle Orthod. 2011 May;81(3):460-8

Oh KM, Hong JS, Kim YJ, Cevidanes LS, Park YH. Three-dimensional analysis of pharyngeal airway
form in children with anteroposterior facial patterns. Angle Orthod. 2011 Nov;81(6):1075-82

Hong JS, Oh KM, Kim BR, Kim YJ, Park YH. Three-dimensional analysis of pharyngeal airway volume
in adults with anterior position of the mandible. Am J Orthod Dentofacial Orthop. 2011
Oct;140(4):e161-9.

2/15/2013
Grauer D, Cevidanes LS, Styner MA, Ackerman JL, Proffit WR.
Pharyngeal airway volume and shape from cone-beam computed
tomography: relationship to facial morphology. Am J Orthod Dentofacial
Orthop. 2009 Dec;136(6):805-14
Alves M Jr, Baratieri C, Mattos CT, Brunetto D, Fontes Rda C, Santos JR,
Ruellas AC. Is the airway volume being correctly analyzed? Am J Orthod
Dentofacial Orthop. 2012 May;141(5):657-61
Martin O, Muelas L, Vias MJ. Comparative study of nasopharyngeal
soft-tissue characteristics in patients with Class III malocclusion. Am J
Orthod Dentofacial Orthop. 2011 Feb;139(2):242-51
Oktay H, Ulukaya E. Maxillary protraction appliance effect on the size of
the upper airway passage. Angle Orthod. 2008 Mar;78(2):209-14
El H, Palomo JM. Measuring the airway in 3 dimensions: a reliability and
accuracy study. Am J Orthod Dentofacial Orthop. 2010 Apr;137(4
Suppl):S50.e1-9
Weissheimer A, Menezes LM, Sameshima GT, Enciso R, Pham J, Grauer
D. Imaging software accuracy for 3-dimensional analysis of the upper
airway. Am J Orthod Dentofacial Orthop. 2012 Dec;142(6):801-13

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Rajeev

El H, Palomo JM. Airway volume for different dentofacial skeletal patterns. Am J

El H, Palomo JM. An airway study of different maxillary and mandibular sagittal

Aboudara C, Nielsen I, Huang JC, Maki K, Miller AJ, Hatcher D. Comparison of

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