Breathing mode influence on craniofacial development and head posture

J Pedia (Rio J). 2018;94(2):123---130 www.jped.com.b ORIGINAL ARTICLE B ea hing mode in luence on c anio acial de elopmen and head pos u e夽 Annel Chambi-Rocha∗, MaEugenia Cab e a-Domínguez, An onia Domínguez-Reyes Uni e sidad de Se illa, Facul ad de Odon ología, Se ille, Spain Recei ed 6 Janua y 2017; accep ed 6 Ap il 2017 A ailable online 14 Augus 2017 KEYWORDS B ea hing; C anio acial de elopmen ; Head pos u e; Child en Abs ac Objec i e: The incidence o abno mal b ea hing and i s consequences on c anio acial de el- opmen is inc easing, and is no limi ed o child en wi h adenoid aces. The objec i e o his s udy was o e alua e he cephalome ic di e ences in c anio acial s uc u es and head pos u e be ween nasal b ea hing and o al b ea hing child en and eenage s wi h a no mal acial g ow h pa e n. Me hod: Nine y-eigh 7---16 yea -old pa ien s wi h a no mal acial g ow h pa e n we e clinically and adiog aphically e alua ed. They we e classi ied as ei he nasal b ea hing o o al b ea hing pa ien s acco ding o he p edominan mode o b ea hing h ough clinical and his o ical e al- ua ion, and b ea hing espi a o y a e p edomina ion as quan i ied by an ai low senso . They we e di ided in wo age g oups (G1: 7---9) (G2: 10---16) o accoun o no mal age- ela ed acial g ow h. Resul s: O al b ea hing child en (8.0 ± 0.7 yea s) showed less nasopha yngeal c oss-sec ional dimension (MPP) (p = 0.030), whe eas o he s uc u es we e simila o hei nasal b ea hing coun e pa s (7.6 ± 0.9 yea s). Howe e , o al b ea hing eenage s (12.3 ± 2.0 yea s) exhibi ed a g ea e pala e leng h (ANS-PNS) (p = 0.049), a highe e ical dimension in he lowe an e- io ace (Xi-ANS-Pm) (p = 0.015), and a lowe posi ion o he hyoid bone wi h espec o he mandibula plane (H-MP) (p = 0.017) han hei nasal b ea hing coun e pa s (12.5 ± 1.9 yea s). No s a is ically signi ican di e ences we e ound in head pos u e. Conclusion: E en in indi iduals wi h a no mal acial g ow h pa e n, when compa ed wi h nasal b ea hing indi iduals, o al b ea hing child en p esen di e ences in ai way dimensions. Among adolescen s, hese dissimila i ies include s uc u es in he acial de elopmen and hyoid bone posi ion. © 2017 Sociedade B asilei a de Pedia ia. Published by Else ie Edi o a L da. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/ 4.0/). 夽Please ci e his a icle as: Chambi-Rocha A, Cab e a-Domínguez ME, Domínguez-Reyes A. B ea hing mode in luence on c anio acial de elopmen and head pos u e. J Pedia (Rio J). 2018;94:123---130. ∗Co esponding au ho . E-mails: [email p o ec ed], [email p o ec ed] (A. Chambi-Rocha). h ps://doi.o g/10.1016/j.jped.2017.05.007 0021-7557/© 2017 Sociedade B asilei a de Pedia ia. Published by Else ie Edi o a L da. This is an open access a icle unde he CC BY-NC-ND license (h p://c ea i ecommons.o g/licenses/by-nc-nd/4.0/). 124 Chambi-Rocha A e al. PALAVRAS-CHAVE Respi ac¸ão; Desen ol imen o c anio acial; Pos u a da cabec¸a; C ianc¸as In luência do modo de espi ac¸ão sob e o desen ol imen o c anio acial a e pos u a da cabec¸a Resumo Obje i o: A incidência da espi ac¸ão ano mal e de suas consequências no desen ol imen o c anio acial aumen a e não é limi ada a c ianc¸as com ácies adenoideanas. O obje i o des e es udo oi a alia as di e enc¸as ce alomé icas nas es u u as c anio aciais e na pos u a da cabec¸a en e c ianc¸as e adolescen es com espi ac¸ão nasal e espi ac¸ão bucal com pad ão de c escimen o acial no mal. Mé odo: 98 pacien es com idades en e 7-16 anos com pad ão de c escimen o acial no mal o am a aliados de o ma clínica e adiológica. Eles o am classi icados como pacien es com espi ac¸ão nasal ou espi ac¸ão bucal de aco do com a p edominância do modo de espi ac¸ão po meio da a aliac¸ão clínica e his ó ica e da p edominância da equência espi a ó ia con o me quali icado po um senso de luxo de a . Os pacien es o am di ididos em duas aixas e á ias (G1: 7 a 9) (G2: 10 a 16) pa a con abiliza o c escimen o no mal acial elacionado à idade. Resul ados: As c ianc¸as com espi ac¸ão bucal (8,0 ± 0,7 anos de idade) mos a am meno dimensão ans e sal naso a íngea (MPP) (p = 0,030), ao passo que ou as es u u as o am semelhan es a seus pa es com espi ac¸ão nasal (7,6 ± 0,9 anos de idade). Con udo, os ado- lescen es com espi ac¸ão bucal (12,3 ± 2,0 anos de idade) mos a am maio comp imen o do pala o (espinha nasal an e io -espinha nasal pos e io (ENA-ENP)) (p = 0,049), maio dimensão e ical na meno ace an e io (Xi-ENA-Pm) (p = 0,015) e meno posic¸ão do osso hioide a espei o do plano mandibula (H-PM) (p = 0,017) que seus pa es com espi ac¸ão nasal (12,5 ± 1,9 anos de idade). Não o am cons a adas di e enc¸as es a is icamen e signi ica i as na pos u a da cabec¸a. Conclusão: Mesmo em indi íduos com pad ão de c escimen o acial no mal, em compa ac¸ão a indi íduos com espi ac¸ão nasal, as c ianc¸as com espi ac¸ão bucal ap esen am di e enc¸as nas dimensões das ias aé eas. En e os adolescen es, essas dissimila idades incluem es u u as no desen ol imen o acial e na posic¸ão do osso hioide. © 2017 Sociedade B asilei a de Pedia ia. Publicado po Else ie Edi o a L da. Es e ´ e um a igo Open Access sob uma licenc¸a CC BY-NC-ND (h p://c ea i ecommons.o g/licenses/by-nc-nd/4. 0/). In oduc ion Physiological b ea hing is o en a ec ed by ana omic o unc ional p oblems, causing he espi a o y cycle o be ini ia ed no only h ough he nose bu also h ough he mou h.1,2 Compa ed o nasal b ea hing (NB) child en, o al b ea hing (OB) child en a e a highe isk o es less sleep, diapho esis and enu esis a nigh , and, in some cases, e en sleep apnea synd ome. The low-quali y sleep ma e ializes as day ime sleepiness, i i abili y, and headaches3likely o nega i ely impac academic pe o mance. Fu he , he p es- ence o hyponasal speech o speech al e a ions4inc eases he likelihood o being classi ied wi h a lea ning disabili y. In ac , many o hese child en a e misdiagnosed wi h a en- ion de ici hype ac i i y diso de (ADHD) and some imes e oneously medica ed.5 Se e al s udies pos ula e ha OB child en exhibi cha - ac e is ics o he ypical adenoid acies: a dec ease in he acial p ogna hism, a small nose and nos ils, a sho uppe lip, and an open mou h pos u e which may be he sou ce o a backwa d and downwa d o a ion o he mandible ha causes an inc ease in he e ical de elopmen o he lowe an e io ace and a na owe an e opos e io uppe ai way dimension.1,6---8 These pa ien s’ muscle imbalance, owing o an ana omic econdi ion, may lead o c anio-ce ical hype - ex ension and kypho ic pos u e.9,10 The e a e also epo s o di e en ypes o malocclusion, such as open bi es, an e io and/o pos e io c ossbi es, class II malocclusion,11 con- s ic ed pala es, and gummy smiles esul ing in una ac i e acial ea u es.5In addi ion, OB child en o en su e om ch onic gingi i is, pe iodon i is, candida in ec ions,12 den- al e osion, and ca i ies.13 Due o he di icul y o b ea hing and chewing simul aneously o ex ended pe iods, mas i- ca o y e iciency dec eases.14 This, in u n, leads o OB child en’s p e e ence o so and o en imes non-nu i ious oods ha inc ease he possibili y o malocclusions and ca i ies. Published e idence is inconclusi e, in pa , because g ow h pa e ns ha e no been aken in o accoun , as ce - ain physical cha ac e is ics a e sha ed by subjec s wi h a p edominan e ical g ow h pa e n, who, in u n, a e mo e likely o be OB child en.15 In addi ion, dec eased adenoids and occlusal ma u a ion ha e no been used as classi ica ion pa ame e s when compa ing ac oss subjec s.8Mo eo e , di - e en diagnos ic ools ha e been used o classi y b ea hing modes. The main objec i e o his esea ch was o e alua e he cephalome ic di e ences in c anio acial s uc u es (i.e., he o m and posi ion o he maxilla, mandible, uppe ai - way, and hyoid bone) and head pos u e be ween NB and OB child en and eenage s wi h a no mal acial g ow h pa e n, using a measu able diagnos ic ool o b ea hing mode and a igo ous selec ion c i e ia o pa ien s. I is hypo hesized ha he e a e ana omic di e ences in c anio acial s uc u es in B ea hing mode in luence on c anio acial de elopmen 125 OB compa ed o NB child en and eenage s, e en in pa ien s wi h a no mal acial g ow h pa e n. Me hod Pa icipan s Pa icipan s we e ec ui ed a andom du ing a ou ine clinic isi a he College o In eg a ed Child Den is y a Se ille Uni e si y. Inclusion c i e ia we e as ollows: whi e boys and gi ls be ween 7 and 16 yea s o age; no mal g ow h pa e n appea ance; ee o any neu ologic o congeni al al e a ions, gene ic synd omes, c anio acial mal o ma ions, se e e sys emic disease, espi a o y alle gies, obs uc i e sleep apnea synd ome (OSAS), o as hma. Exclusion c i e ia: any uppe ai way su ge y, o hodon ic o o hopedic p oce- du es, p olonged use o a paci ie (mo e han six mon hs) and/o baby bo le (mo e han wo yea s), any habi s like lip o inge sucking, o an e iden an e io ongue posi- ion. O he 187 child en (11.3 ± 0.2 yea s, 58.3% gi ls and 41.7% boys) e alua ed o eligibili y, 98 me he inclusion c i e ia. Fo all pa ien s, one pa en and/o legal gua dian signed he in o med consen o m. The s udy and i s p o- ocol we e app o ed by he Resea ch E hics Commi ee o he Vi gen Maca ena-Vi gen del Rocio Uni e si y Hospi als (Se ille, Spain). Measu es No mal acial g ow h pa e n was con i med by c anial and acial index and cephalome ic pa ame e s (FP-MP) (n = 68◦± 3.5◦) o exclude child en wi h a g ow h pa e n p edisposi ion. The c anial index measu es ans e se and an e opos e io diame e s o he skull based on he ollow- ing o mula: maximum ans e se diame e × 100/maximum an e opos e io diame e . The sco es a e ca ego ized as ollows: dolichocephalic (<76), mesocephalic (76---81), o b achycephalic (>81). The acial index measu es e ical and ans e se pa ame e s o he acies. The heigh o he ace is de e mined s a ing on he supe cilia plane ( he line uni - ing he eyeb ows) and measu ing e ically o he gna hion poin (i.e., he lowes poin o he so chin). The wid h o he ace is measu ed based on he bizygoma ic wid h as ollows: maximum e ical diame e × 100/maximum ans- e se diame e . The sco es classi y acies as: b achy acial (<97), meso acial (97---104), o dolicho acial (>104).16 B ea hing mode (o al s. nasal) was assessed by an Ai low Senso o e-Heal h Pla o m, designed by Cooking Hacks (Libelium®, Libelium Comunicaciones Dis ibuidas S.L, Za agoza, Spain). The senso measu ed he nasal espi a o y equency accu a ely by de ec ing empe a u e changes in he ai low. This de ice consis s o a se o wo p ongs placed in he nos ils and secu ed by a lexible h ead ha i s behind he ea s. B ea hing is measu ed by he senso s loca ed inside he p ongs. Two measu emen s we e aken a di e en imes o a oid punc ual subs an ial luc ua ions ha could a ec esul s. Pa ien s unde wen a comple e clinical examina ion, and hei clinical his o y and da a we e collec ed h ough a pa en ques ionnai e. Based on his in o ma ion, pa icipan s we e classi ied as ei he OB o NB pa ien s. OB child en we e de ined by a lowe nasal espi a o y equency (unde 17 b ea hs pe minu e) as measu ed by he s a and based on pa en al epo s ha epo p edominan b ea hing h ough he mou h, showing an open mou h pos u e du ing he day and/o while sleeping (change om an up igh o a supine posi ion may cause a change in espi a o y mode).1Mo eo e , i he child en equen ly exhibi ed h ee o mo e o hese symp oms, hey we e included: sno ing, wheezing, d ooling on he pillow, waking up du ing he nigh gasping o ai , o ge ing up i ed in he mo ning. Child en we e classi ied as nasal b ea he s i hey had a high nasal espi a o y equency (abo e 18 b ea hs pe minu e), a closed mou h du ing he day and nigh , and he p e iously desc ibed symp oms we e absen . The classi ica ion was suppo ed by an o ola yngologis by means o hinomanome y. La e al adiog aphs we e aken s anding wi h he body elaxed and wi h a na u al head posi ion (sel -balance posi ion)17 by X- ay equipmen Planmeca P omax (Planmeca Oy), a he Facul y o Den is y o Se ille Uni e si y. The cephalos a was placed wi hou adding any p essu e, so as o no a ec he child’s pos u e. T adi ional cephalo- me ic landma ks we e hand- aced and digi al adiog aphs we e impo ed in o a comme cially a ailable so wa e sys- em (O ho TP®, Vime ca e Mic oLab, Vime ca e, I aly) and analyzed again. The cephalome ic pa ame e s we e chosen based on p e ious publica ions6,17---19 (Figs. 1 and 2). How- e e , new measu emen s we e added o ai way dimensions: • USP: Dis ance o a poin o so pala e (5 mm unde o he uppe poin o he so pala e) (USP) o he ho izon al coun e poin on he pos e io pha yngeal wall pa allel o he F ank u ho izon al plane (FHP). • IT: Dis ance o he pos e io and in e io poin o onsil (T) (5 mm uppe o he down poin o he onsil) o ho izon al coun e poin on pos e io pha yngeal wall pa allel o he FHP. • MPP: Dis ance o he in e sec ion poin s on an e io and pos e io pha yngeal wall o he middle o he USP and IT pa allel o he FHP. • MPp: Dis ance o he in e sec ion poin s on an e io and pos e io pha yngeal wall o he mandibula plane (MP) pa allel o he FHP. • C3P: Dis ance be ween pos e io pha yngeal om he mos an e io and in e io poin on he co pus o he hi d ce ical e eb a (C3) and an e io pha yngeal (P) pa allel o he FHP. To de ec e o s in landma k iden i ica ion and mea- su emen s, wen y andomly selec ed la e al cephalome ic adiog aphs we e measu ed and compa ed by he same in es iga o wo weeks la e . Finally, pa ien s we e di ided in o wo age g oups (G1 = 7 --- 9 yea s) (7.8 ± 0.5 yea s) and (G2 = 10---16 yea s) (12.3 ± 1.0 yea s) o h ee main easons: (1) o a oid con using b ea hing mode in luence on c anio acial de el- opmen wi h no mal changes in g ow h; (2) o accoun o he p ocess o occlusal ma u a ion----associa ed wi h changes in he e ical dimension o he ace----based on he a ia ion in he e up ion o pe manen ee h o eplace mixed den i- ion; and (3) o accoun o he dec ease o adenoids ha s a s be ween he ages o 7 and 10, which widens he di - e ences in nasopha yngeal dimensions. In child en younge 126 Chambi-Rocha A e al. OPT-SN CTV-SN S FC 1413 6 8 Fhp PNS Xi Go MP Gn 1 B Pm FP AANS 10 12 H 2 9 5 11 4 7 N Figu e 1 Cephalome ic landma ks, angles, and e e ence planes. G ow h pa e n: 1. FP-MP Angle o med by acial plane (N-Pg) and mandibula plane (Gn-Go). Facial plane is o med by nasion (N) and pgonion (Pg). Mandibula plane is o med by gna ion (Gn) and gonion (Go); acial heigh : 2. FCNA Angle o med by acial cen e poin (FC) and line FC-nasion (N) and line FC-subspinale (A); 3. Xi-ANS-Pm Angle o med by cen e o he amus poin (Xi) and line Xi-an e io nasal spine (ANS) and Xi-sup apogonion (Pm); Maxilla: 4. SNA Angle o med by skull base line (SN) and line N-subspinale (A). Skull base is a plane om sella (S) o nasion (N); 5. ANS-PNS Dis ance om an e io nasal spine (ANS) o pos e io nasal spine (PNS); 6. ANS-PNS- FhP Angle o med by pala al plane (ANS-PNS) and F ank u plane (FhP). F ank u plane is o med by o bi ale (O ) and ponion (Po); Mandible: 7. SNB Angle o med by skull base line (SN) and line N-sup amen ale (B); 8. MP-FhP Angle o med by mandibula plane (MP) and F ank u plane (FhP); 9. Go-FC Dis- ance om gonion (Go) o he acial cen e (FC); 10. Xi-Pm Dis ance om Xi o sup apogonion (Pm); Maxilla-Mandible: 11. ANB Angle o med by subspinale (A) and nasion (N) line and line N-sup amen ale (B); Hyoid bone: 12. H-MP Dis ance om he mos an e io and supe io poin o hyoid bone (H) pe pendicula o mandibula plane (MP); C anioce ical Pos u e: 13. OPT-SN Angle o med by (SN) and odon oides (OPT). OPT is o med by a line h ough he pos e o-supe io poin and pos e o-in e io poin o odon oides; 14. CVT-SN Angle o med by (SN) and ce - ical (CVT). CVT is o med by a line h ough he pos e o-supe io poin and pos e o-in e io poin o he ou ce ical. han 7 yea s old, adenoids a e s ill physiologically p esen in a conside able olume in NB and OB child en; he e o e, i may di icul o ind di e ences in he adenoids zone.20 S a is ical analyses Da a we e analyzed using desc ip i e s a is ical me hods. Quan i a i e a iables we e desc ibed wi h means and s anda d de ia ions, and di e ences we e es ed o signi icance wi h S uden ’s - es o independen samples. Di e ences in non-pa ame ic a iables we e es ed o signi icance wi h he Mann---Whi ney U es o independen FhP S S0 2 3 MPP PNS IT C3P MPP USP 4 5 6 7 P V-Ad Ad1 Ad2 Ba 1 Figu e 2 Ai way dimensions. Nasopha ynx: 1. Ad1-Ba Dis- ance o (ad1) o basion (Ba); Ad1 is he in e sec ion poin o pos e io pha yngeal wall and he line om pos e io nasal spine (PNS) o basion (Ba); 2. ad2-S0Dis ance o (ad2) o (S0). Ad2 is he in e sec ion poin o pos e io pha yngeal wall and he line om he midpoin (S0) o he line om sella (S) o basion (Ba) o pos e io nasal spine (PNS); 3. P V-Ad Dis ance o (P V) poin o adenoid (Ad). P V is a e ical line pe pendicula o FhP passing h ough he mos pos e io poin o he ossa p e igomaxila . P V poin is loca ed 5 mm uppe o PNS. O opha ynx: 4. USP Dis ance o a poin o so pala e (5 mm unde o he uppe poin o So Pala e) (USP) o he ho izon al coun e poin on he pos e io pha yngeal wall pa allel o F ank u Plane (FhP). 5. MPP Dis ance o he in e sec ion poin s on an e io and pos- e io pha yngeal wall o he middle o (USP) and (IT) pa allel o FhP. 6. IT Dis ance o he pos e io and in e io poin o onsil (T) (5 mm uppe o he down poin o he onsil) o ho izon al coun e poin on pos e io pha yngeal wall pa allel o FhP. 7. MPPDis ance o he in e sec ion poin s on an e io and pos e- io pha yngeal wall o he mandibula plane (MP) pa allel o FhP; Hypopha ynx: 8. C3P Dis ance be ween pos e io pha yn- geal since he mos an e io and in e io poin on he co pus o he hi d ce ical e eb a (C3) and an e io pha yngeal. samples. S a is ical signi icance was se a wo-sided p < 0.05. Bon e oni co ec ion was used as he adjus men me hod o main ain he p obabili y o ype I e o below 5% (0.05). Acco dingly, he p- alue o conside s a is ically signi ican di e ences was 0.05/22 = 0.002. S a is ical es s we e pe o med using SPSS (SPSS o Windows, Ve sion 16.0. Chicago, USA). Resul s The a e age espi a o y a e was 18 b ea hs pe minu e; he lowes espi a o y a e de ec ed was 12 b ea hs pe B ea hing mode in luence on c anio acial de elopmen 127 minu e and he highes a e was 25 b ea hs pe minu e. The a e age c anial and acial index sco es we e 79.3 ± 2.4 and 101.5 ± 1.7, espec i ely. Means and s anda d de ia ions o cephalome ic a iables----c anio acial, hyoid posi ion, head pos u e (Table 1), and ai way pa ame e s (Table 2)---- om 56 OB pa ien s (64.6%) and 42 NB pa ien s (35.4%) we e compa ed by age g oup. Acco ding o he la e al cephalome ic anal- ysis, in G1 he ai way dis ance in he egion o he onsils (MPP) was lowe in OB (8.0 ± 0.7 yea s) han NB (7.6 ± 0.9 yea s) (p = 0.03). No s a is ically signi ican di e ences in he ai way we e ound in G2. Howe e , in G2, he lowe an e io acial heigh (Xi-ANS-Pm) and he pala e leng h (ANS-PNS) we e highe in OB (12.3 ± 2.0 yea s) han in NB (12.5 ± 1.9 yea s) (p = 0.015 and p = 0.049, espec i ely). Also, he hyoid bone was loca ed in a lowe posi ion ela i e o he mandibula plane (H-MP) in OB eenage s han NB ones (p = 0.017). Finally, no s a is ically signi ican di e ences we e ound in he head pos u e be ween OB and NB pa ien s in ei he age g oup (Table 2). Discussion P e ious s udies epo ha OB child en ha e a hype di- e gen acial pa e n21---24 and a g ea e lowe an e io acial heigh 6,11 ha i was obse ed in ou esea ch in OB eenage s (G2) wi h a no mal acial pa e n bu no in G1. A g ea e inclina ion o he mandible plane22,23 was obse ed which, oge he wi h a pos e io o a ion o pala al plane,25 migh indica e he e ical di ec ion o mandibu- la g ow h11,26 and he de elopmen o a class II skele al malocclusion.11 Howe e , he OB pa ien s (63.9%) p esen ed class I skele al occlusion. Acco ding o p e ious indings, OB pa ien s’ maxilla and mandible we e mo e e uded in ela ion o hei skull base.23 Ne e heless, Uca e al.25 obse ed ha only he maxilla was mo e e ogna hic, whe eas o he s ound ha only he mandible was mo e e uded.26 The p esen esul s show a low posi ion o he hyoid bone ela i e o he mandibula plane in OB in G2, which suppo s p e ious indings by Cuccia e al.27 Nasopha yngeal sec ional dimensions inc ease wi h he es o body issues du ing he g ow h pe iod, bu he ade- noid issue s a s o diminish be ween he ages o 7 and 10, only o disappea du ing adul hood. The measu emen s o he uppe ai way space we e smalle in OB han in NB child en (G1) in he egion o he onsils (MPP) bu no in G2, suppo ing p e ious wo k.26 The e o e, onsils a e mo e hype ophic in child en han eenage s. This esul could be a ec ed by he possibili y ha G1 pa ien s’ adenoids we e s ill a he onse o hei educ ion, whe eas G2 pa ien s’ adenoids we e al eady sh unken. In addi ion, he new ai - way measu emen s in his s udy could a ec he abili y o compa e, because hey we e pa allel o he F ank u plane (a cons an plane) o a oid inco ec compa a i e esul s based on a a iable plane. Se e al s udies epo OB pa ien s wi h c anio-ce ical hype ex ension,27 whe eby pos u al p oblems a e signi i- can ly mo e common among hese child en.9The p esen esea ch showed a ce ical spine pos u al change in 90.3% o OB bu , as bo h g oups p esen ed high pe cen ages o c anio acial hype ex ension, di e ences we e no s a is i- cally signi ican . I is specula ed ha he in ense use o new echnological de ices by he young, such as cell phones and able s, migh con ibu e his lack o subs an ial di e ences in c anio acial hype ex ension. A p e ious s udy ound myo unc ional and c anio acial al e a ions among OB child en be ween he ages o 7---10,23 whe eas he p esen s udy ound hese al e a ions in OB child en wi h a mean age o 12.3 ± 2.0 (G2). The disc ep- ancy may esul om hese s udies ailing o ake he g ow h pa e ns in o accoun . In he p esen s udy, pa ien s wi h an abno mal g ow h pa e n we e excluded based on he c anial and acial index and cephalome ic pa ame- e s, because pa ien s wi h a e ical g ow h pa e n ha e common skele al ea u es, i.e., na owe an e opos e io dimension o he ai way, e usion o he maxilla and he mandible, e ical maxilla y excess, and a highe class II skele al disc epancy.19,28 These pa ien s’ cha ac e is ics migh be a compensa o y mechanism ha could igge he ansi ion om NB o OB. Con e sely, ho izon al g ow h pa - e n is usually cha ac e ized by a mo e an e io mandible. This esul s in a wide lowe pha yngeal ai way, which a o s nasal b ea hing. The e o e, g ow h pa e ns could a ec o bene i physiological espi a o y unc ion.29 I is impo an o be able o de ec pa ien s wi h an OB p edomina ion. Ea ly e e al o he co ec ion o his pa hological unc ion is key o he p e en ion o i egula i- ies in c anio acial de elopmen and o hodon ic p oblems. By elimina ing he g ow h pa e n con ounding in his s udy and compa ing pa ien s acco ding o hei g ow h s age, i was possible o de ec i eal di e ences exis be ween NB and OB child en (G1) and eenage s (G2). This s udy has ce ain limi a ions. Fi s , in a c oss- sec ional s udy, associa ions do no imply causal ela ion- ships. In ac , Shanke e al.28 ound ha se e al child en swi ched be ween o al and nasal espi a o y mode du ing he ou yea s o hei in es iga ion. Howe e , as wi h any ea able o p e en able condi ion, he possibili y o an obse a ional longi udinal s udy wi hou in e ening once OB is de ec ed is p ecluded o e hical easons. Second, he small sample size esul ing om he s ic selec ion c i e ia may ha e limi ed he powe o he analyses o de ec u - he di e ences. Thi d, because his s udy did no ec ui NB as OB pa icipan s, he powe o he analyses may ha e su e ed om his subs an ial di e ence in he sizes o he subg oups being compa ed. Despi e hese limi a ions, hese indings may help medical p o essionals be e man- age pa ien s wi h b ea hing dis u bances, knowing ha his migh indica e a de elopmen al imbalance. The s udy also has i s s eng hs. The highly p ecise selec- ion c i e ia, by including only pa ien s wi h no mal g ow h pa e n, educed he po en ial bias o including child en wi h a gene ic p edisposi ion o OB. In addi ion, occlusal ma u a ion and he physiological dec ease o he adenoids we e aken in o accoun when compa ing he esul s. Finally, a senso ha supplied measu able da a o be e classi y pa ien s’ mode o b ea hing was u ilized. To he bes o he au ho s’ knowledge, his measu emen de ice had ne e been used in his con ex . This combined wi h he ac ha a cons an plane was used as e e ence o he ai way mea- su emen s, may p o e hese da a o be mo e accu a e han hose o much o p e ious esea ch. 128 Chambi-Rocha A e al. Table 1 C anio acial, hyoid posi ion, and head pos u e pa ame e s in nasal and o al b ea hing child en and eenage s. G oup I G oup II NB OB p-Value NB OB p-Value G ow h pa e n 1. FP-MP 66.813◦± 1.13 67.028◦± 3.38 0.864a67.056◦± 1.91 67.000 ± 2.71◦0.958a Facial heigh 2. FCNA 58.438◦± 1.87 57.639◦± 4.48 0.635a57.833◦± 2.76 59.962◦± 3.05 0.111a 3. Xi-ANS-Pm 44.250◦± 3.47 43.917◦± 3.93 0.838a42.278◦± 3.30 46.346◦± 3.69 0.015a Maxilla 4. SNA 79.438◦± 3.38 81.750◦± 4.57 0.214a78.944◦± 2.57 77.115◦± 4.63 0.298a 5. ANS-PNS-FHP −1.750◦± 3.13 −1.056◦± 3.85 0.659a0.56◦± 3.98 −2.000◦± 2.82 0.171a 6. ANS-PNS 44.125 ± 3.90 mm 44.667 ± 3.59 mm 0.733a46.222 ± 2.63 mm 49.269 ± 3.75 mm 0.049a Mandible 7. SNB 77.500◦± 4.50 77.353◦± 3.81 0.892a77.688◦± 2.65 74.250◦± 3.18 0.082b 8. MP-FHP 26.563◦± 2.61 26.000◦± 5.54 0.788a28.000◦± 4.19 28.192◦± 3.73 0.911a 9. Go-FC 51.000 ± 4.62 mm 50.528 ± 4.11 mm 0.797a57.167 ± 3.26 mm 58.077 mm ± 6.57 mm 0.706a 10. Xi-Pm 58.875 mm ± 4.12 mm 56.722 mm ± 1.97 mm 0.81a63.833 mm ± 3.29 mm 63.769 mm ± 6.59 mm 0.979a Maxilla-mandible 11. ANB 2.063◦± 2.88 4.250◦± 2.49 0.60a1.833◦± 1.67 2.192◦± 3.12 0.757a Hyoid bone 12. H-MP 9.500 mm ± 1.61 7.765 ± 3.73 mm 0.683b8.563 ± 3.58 mm 12.100 mm ± 6.06 mm 0.017b C anioce ical pos u e 13. OPT-SN 83.813◦± 9.94 83.361◦± 12.15 0.928a79.944◦± 9.26 85.808◦± 9.72 0.172a 14. CVT-SN 105.875◦± 7.94 106.194◦± 10.75 0.941a101.444◦± 7.48 108.115◦± 10.22 0.11a Bold alues ep esen he s a is ically signi ican di e ence. NB, nasal b ea hing; OB, o al b ea hing. aS uden ’s - es . bMann---Whi ney U- es . B ea hing mode in luence on c anio acial de elopmen 129 Table 2 Ai way pa ame e s in nasal and o al b ea hing child en and eenage s. G oup I G oup II NB OB p-Value NB OB p-Value Ai way Nasopha ynx 1. ad1-Ba 23.833 ± 5.57 mm 21.529 ± 7.07 mm 0.261b21.611 ± 3.87 mm 22.192 ± 5.54 mm 0.789a 2. ad2-S0 22.750 ± 3.17 mm 21.417 ± 3.41 mm 0.358a21.625 ± 4.07 mm 20.800 ± 6.28 mm 0.647b 3. P V-Ad 11.500 ± 3.76 mm 10.000 ± 3.69 mm 0.724b14.556 ± 6.00 mm 13.692 ± 4.99 mm 0.717a O opha ynx 4. USP 12.688 ± 2.01 mm 11.333 ± 2.72 mm 0.221a14.222 ± 3.98 mm 12.577 ± 3.38 mm 0.309a 5. MPP 11.000 ± 2.46 mm 8.765 ± 2.15 mm 0.030b10.000 ± 2.34 mm 9.346 ± 2.60 mm 0.554a 6. IT 10.063 ± 2.51 mm 10.472 ± 1.89 mm 0.650a10.167 ± 4.13 mm 11.077 ± 2.72 mm 0.539a 7. MPp10.500 ± 2.34 mm 9.972 ± 2.69 mm 0.637a9.056 ± 2.81 mm 10.731 ± 3.94 mm 0.287a Hypopha ynx 8. C3P 9.938 ± 2.77 mm 9.86 ± 3.63 mm 0.958a8.444 ± 3.14 mm 10.692 ± 3.82 mm 0.162a Bold alue ep esen s he s a is ically signi ican di e ence. NB, nasal b ea hing; OB, o al b ea hing. aS uden ’s - es . bMann---Whi ney U es . A e examining child en and eenage s wi h a no - mal g ow h pa e n, his s udy shows ha he e a e cephalome ic di e ences be ween indi iduals wi h o al b ea hing and nasal b ea hing modes. Compa ed o nasal b ea he s, a lowe an e opos e io dimension o he ai way in o al b ea hing child en is ound; whe eas in eenage o al b ea he s, he e is a g ea e lowe an e io acial heigh , a longe pala e, and a lowe posi ion o he hyoid bone ela i e o he mandibula plane. These indings a e o p ac ical in e es o clinicians when diagnosing, ea ing, and/o e e ing pa ien s o specialis s o b ea hing dis u bances- ela ed issues. As hese issues migh indica e a de elopmen imbalance, ea ly diagnosis is impo an o co ec o amelio a e any nega i e e ec s wi h imely ea men . Fu u e esea ch examining la ge samples o pa ien s wi h same selec ion c i e ia as used he e is needed in o de o examine hei c anio acial de elopmen acco ding o mode o b ea hing, while aking in o accoun g ow h pa - e n, age, and gende . 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