|Year : 2017 | Volume
| Issue : 1 | Page : 8-16
Craniofacial and airway growth in 9–11 years old normal dental occlusion in Iranian adolescents: A longitudinal cephalometric study
Homa Fathi1, Elham Mohammad-Rabei2, Sattar Kabiri3, Alireza A Baghban4, Sepideh Soheilifar5, Mahtab Nouri6
1 Dentist, Tehran, Iran
2 School of Dentistry, Arak University of Medical Sciences, Arak, Tehran, Iran
3 Orthodontist, Tehran, Iran
4 Proteomic Research Center, Department of Basic Sciences, School of Rehabilitation, Shahid Beheshti University of Medical Sciences, Tehran, Iran
5 Department of Orthodontics, Dental Research Center, Hamadan Medical Sciences, Hamadan, Iran
6 Dentofacial Deformities Research Center, Research Institute of Dental Sciences and Orthodontic School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran
|Date of Web Publication||14-Mar-2017|
Shahid Fahmideh Street, Hamadan
Source of Support: None, Conflict of Interest: None
Introduction: The present study was aimed to assess the amount and direction of growth in cranial base, jaws, and soft tissue of airway structures by cephalometric analysis in 9–11-years-old Iranian girls and boys. Materials and Methods: Thirty-four Iranian children with normal occlusion and class I molar relationships were recruited, and 2 lateral cephalograms were obtained from 9 and 11-year-old children Cephalometric variables included variables defining cranial base length and angle, maxillomandibular length and height, dental relationship, head and cervical position, soft palate and tongue, vallecula and hyoid position, and pharyngeal dimension. Normal distribution was confirmed by Kolmogorov–Smirnov analysis (P>0.05). Paired t-test was used for assessing growth changes. P value was set at 0.05. Results: Anterior, posterior, and total cranial base length were increased significantly. The increase in total and upper anterior, total and lower posterior facial heights, ramus height, and palatal inclination were statistically significant. Maxillomandibular length increased significantly with insignificant change in their position. Dental relationship and head and cervical posture were stable. Oropharyngeal and nasopharyngeal anteroposterior dimension did not change. However, hypopharynx sagittal length increased significantly. Nasopharyngeal vertical dimension increased and hyoid moved anteriorly and inferiorly. Conclusion: The results of the present study showed that cranial base and jaws grow anteriorly and inferiorly while maintaining dental occlusion and head posture. Most of the airway structures grow simultaneously with craniofacial components.
Keywords: Airway, Angle class I malocclusion, cephalometrics, growth, growth evaluation
|How to cite this article:|
Fathi H, Mohammad-Rabei E, Kabiri S, Baghban AA, Soheilifar S, Nouri M. Craniofacial and airway growth in 9–11 years old normal dental occlusion in Iranian adolescents: A longitudinal cephalometric study. Dent Hypotheses 2017;8:8-16
|How to cite this URL:|
Fathi H, Mohammad-Rabei E, Kabiri S, Baghban AA, Soheilifar S, Nouri M. Craniofacial and airway growth in 9–11 years old normal dental occlusion in Iranian adolescents: A longitudinal cephalometric study. Dent Hypotheses [serial online] 2017 [cited 2017 Dec 11];8:8-16. Available from: http://www.dentalhypotheses.com/text.asp?2017/8/1/8/202025
| Introduction|| |
Comprehensive understanding of the normal growth of craniofacial structures facilitates realization of significant variations in the growth and development, which is an important part of diagnosis and treatment planning. This helps to predict direction and magnitude of facial growth, which in turn facilitates treatment planning. In addition, post treatment growth in craniofacial and jaw structures would change orthodontic treatment results. Facial growth usually varies with uneven direction and amount. It is claimed that there is a relationship between facial growth and occlusion. This relationship is not necessarily constant and shows considerable interindividual and intraindividual diversity.
Many studies have shown a relationship between craniofacial anomalies and “respiration obstruction syndrome.”,,,,, This term has been used to describe the various conditions associated with chronic obstruction of upper airway in growing children.
Soft tissue morphology of the upper airway that can be related to respiration obstruction includes large adenoids, tonsils and soft palates, and narrowed pharyngeal airway.,, Other facial features that are associated with airway obstruction are excessive anterior facial height, incompetent lip posture, protruding maxillary dentition, increased mandibular angle, and posterior dental crossbite.,, Moreover, if left untreated, it may adversely affect the quality of life such as learning disabilities in school and inadequate sleep.,
There are some expensive or unavailable techniques for airway assessment such as computed tomography, fluoroscopy, acoustic reflection, fibrotic pharyngoscopy, and magnetic resonance imaging.
Lateral cephalometric image is a less expensive and available method, which is a useful screening tool for assessing upper airway structures. Although providing two-dimensional view of a three-dimensional (3D) complex, many studies have confirmed the liability of lateral cephalometric measurements for upper airway space, and it has been shown that the measurements were highly correlated with 3D techniques such as computed tomography (CT) and magnetic resonance imaging (MRI).,,,
Some studies have provided reference values for upper airway for adult and children in some races.,, However, no cephalometric norms for upper airway of Iranian children have been established, which makes the present study a novel one. In the present study, normal occlusion children who do not have respiratory problems were selected precisely. Various soft and hard tissue variables were assessed by a computer software. The objective of this retrospective study was to obtain upper airway norms for normal Iranian children and assessing growth changes in craniofacial and airway structures in them.
| Materials and Methods|| |
This retrospective cross-sectional study was conducted among 34 participants. The inclusion criteria consisted of children with normal occlusion and class I molar relationship, normal overjet and overbite, without a history of previous orthodontic treatment or mouth breathing. Research and ethics committee of Shahid Beheshti University of Medical Sciences approved this study. Two cephalograms were obtained in a period of 2 years for 9 and 11-year-old children during 1996–1998 in Qazvin city. Biologic age was assessed by cervical vertebral maturation (CVM) method and was evaluated to be CV2 in all included patients. One X-ray machine (PLANMECA PM 2002 CC PROLINE, Helsinki, Finland) was used to obtain all lateral cephalograms.
Lateral cephalometric radiographs were obtained using a standardized technique, with the jaw in centric relation and the teeth in occlusion, the lips relaxed, and the head in the natural head position.
The landmarks and reference lines used in the analysis are shown in the [Table 1],[Table 2],[Table 3],[Table 4]. The variables for upper airway measurements included 43 linear, 34 angular and 1 area measurements. Cephalometric analysis was carried out using Orthosurger X software. The accuracy of this software has been confirmed in previous studies.,
|Table 4: Airway and retrolinual cephalometric measurements and their definition|
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All lateral cephalometric radiographs were scanned by a radiographic scanner (Microtech Scan Maker 48 bit color, i800). The digitization and measurements were performed separately by two investigators. Intraclass correlation coefficient (ICC) was assessed to be 0.77. The magnification factor was taken into account for each cephalometric radiograph.
Mean and standard deviation (SD) was calculated for each measurement. Data distribution was analyzed with the Kolmogorov–Smirnov tests. All the cephalometric variables were normally distributed (P=0.05). For comparison of statistical changes, paired t-test was used. The data were analyzed using SPSS 20 (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.) with a 5% level of significance (P<0.05).
| Result|| |
A total of 34 patients were recruited, from which 2 were lost to follow up. The results of paired t-test on cephalometric variables are shown in [Table 5] and [Table 6].
|Table 5: Results of paired-t test in craniofacial variables from 9–11 years old|
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|Table 6: Results of paired t test in airway and retrolingual variables from 9–11 years old|
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| Discussion|| |
In the present study, craniofacial and airway growth of 9–11-year-old patients were assessed via cephalometric analysis. It has been proposed that early orthodontic treatment can improve skeletal, muscular, and dentoalveolar abnormalities. Orthodontists usually monitor patients before the onset of adolescence. Therefore, it would be important to determine normal growth of craniofacial structures during this critical period. Therefore, this age range was chosen.
Cranial base length shows significant changes as anterior, posterior, and total cranial base length were increased from 9-year-old to 11-year-old. This result is in agreement with previous studies. A recent systematic review has shown that anterior cranial base is not a stable structure and its length increases up to adulthood. Remodeling of sella turcica in the backward and downward direction and bone apposition in frontal bone and increase in the size of frontal sinus play a role in this phenomenon., Spheno-occipital synchondrosis grows up to late ages, and posterior cranial base length increases in a backward and downward direction., However, this increase is not reflected in the sella-articular length. Despite the fact that sella point position is somewhat stable in the horizontal plan in this age, sella-basion length increases because of the dorsal displacement of the basion point, where as articular point which is dependent on mandibular position and morphology shows more variation than basion point. Lewis et al. found that cranial base length undergoes growth spurt in both genders., It has been shown that their growth is almost complete approximately in 11–13 years old in females and 15 years old in males. In contrast, some studies have shown that cranial base would not grow after 7 years old. Differences in study design (longitudinal versus cross sectional), landmarks, and sample population may justify these differences. Anterior and posterior cranial base increased in similar increments. Cranial base angle (Ba-S-N and Ar-S-N) was not changed during the study period. Wilhelm et al. reported that cranial base angle decreases significantly from 1 month to 2 years old, however, remained unchanged afterwards.
Sella-ptm length showed insignificant increase during the 2-year follow-up. This is in agreement with the results of previous studies where ptm showed insignificant drift during the treatment.
Vertical analysis showed that total anterior facial height (Na-Gn) and upper anterior facial height (N-ANS) underwent significant increase where as lower anterior facial height increase was insignificant. Moss et al. demonstrated that from 6 to 14 years, the upper anterior facial height increments were larger than lower anterior facial height. In addition, in Snodell et al. study, from 6 to 8 years old, lower anterior facial height was more mature than upper anterior facial height, gaining 75–84% of its length versus 71–82% up to 6 years old. In addition, ramus height (Ar-Go) and posterior facial height (S-Go) increased significantly. Lux et al. stated that ramus height increase is more than mandibular length and mandibular width between 7 and 15 years old. Yavus et al. found that from 10 to 14 years old ramus height increases significantly. Posterior facial height increased significantly in Yoon et al. study. In the present study, anterior facial height increased more than posterior facial height whereas ramus height growth was more than lower anterior facial height.
Palatal plane angle (NSL-NL) increased significantly. This can be attributed to significant increase in upper anterior facial height. This finding is in contrast to the results of previous studies.,, However, in the study by Nanda et al., the palatal plane inclination increased from 6 to 11 years and then decreased from 17 to 23 years old with overall insignificant changes. It appears that palatal plane inclination shows fluctuation during growth, increasing in a period while decreasing in another, causing diversity in results of different studies. Mandibular plane angle decreased insignificantly. This finding reflects the significant increase in ramus height and insignificant increase in anterior facial height. Previous studies have shown that mandibular plane angle decreases significantly., In the study by Sinclair et al., the decrease in the angle was small in both sexes from 9 to 13 years old and was only significant in males. The difference can be attributed to differences in age ranges (9–11 versus 9–13) and the mixed nature of our participants.
Maxillary length (ANS-ptm and ss-ptm), mandibular total length (con-prognathion), mandibular body length (pog-go) increased significantly. This is in agreement with the results of previous studies., As expected, total mandibular length increased more than body length and maxillary length, reflecting the 3-dimensional mandibular growth.
Maxillomandibular position relative to cranial base did not change from 9 to 11 years. This can be attributed to forward drift of the nasion point, which is accompanied by forward growth of jaws. In addition anterior portion of the mandible and maxilla are resorptive and anterior nasal spine and A point drift inferiorly and posteriorly, which causes insignificant changes in landmarks associated with mandibular and maxillary position.,, Similarly, Bhatia et al. had stated that S-N-Pog remains in almost the same level from 4 to 17 years old. Some studies have shown that maxillomandibular position (indicated by SNA and SNB) to cranial base increases with time., In the study by Chung et al., the participants were followed from 9 to 18 years old. However, in the present study, the follow-up period was assigned to be from 9 to 11 years old. The difference in findings may be attributed to the longer follow-up period. In addition, in the study by Sinclair et al., SNA and SNB angles showed small but statistically significant increase from 9 to 13 years old, whereas these variables changed insignificantly in females. ANB angle was not changed significantly. In our study, both males and females were included and it was not possible to analyze the results separately. This fact may create the difference between findings.
Incisor angulation and anteroposterior position did not change significantly, and consequently, overjet and overbite remained unchanged. Sinclair et al. had shown that from 9–13 years, incisor position remained reasonably stable, except the proclination of lower incisors relative to mandibular plane in males. Others had stated that changes in tooth position is correlated to the amount and direction of craniofacial growth. However, incisor angular positioned remained unchanged, perhaps due to functional stabilization, reflecting the stable position of jaws in present study.
The craniocervical inclination (reflected in CVT-FH, CVT-NL, CVT-NSL, OPT-FH, OPT-NL, OPT-NSL) and cervical inclination to horizontal plan (reflected in CVT-Ho, OPT-Ho) did not change significantly. The results of other studies are the same as ours.
Craniovertical angulation (indicated by NSL-VER, FH-VER, NL, VER) was stable from 9 to 11 years old and this result has been shown in other studies as well. Palatal plane to soft palate angle decreased insignificantly, and this result is similar to those of Akcam et al. in normal population. Thickness of pharyngeal space at the palatal level (pm-UPW) and uvula level (u-MPW) increased insignificantly during the observational period. However, Akcam et al. had stated that the former increases significantly, whereas the later undergoes insignificant changes. Taylor et al. had demonstrated that measurements that include posterior pharyngeal wall show little change from 9–12 years. This is similar to our results and can be attributed to the involution of adenoids in this period. The hypopharynx underwent a significant increase. This can be attributed to the fact that this area lacks adenoids which show involution.
Hyoid bone moved inferiorly and slightly anteriorly. These movements can be attributed to forward displacement of the mandible and vertical growth of cervical vertebrae, respectively. The results of a study has shown that hyoid position is dependent on age and facial type and is independent of obesity. In addition, vallecula moved inferiorly. Kollias et al. found a similar phenomenon in adults aged 22 to 42 years old. This can be attributed to caudally extended tongue mass which in turn can increase tongue length from vallecula to tongue tip, as observed in the present study. Tongue height was increased significantly,which was similar to results of Chavanavesh et al. Vertical growth along with elongation and consequent changes in orientation of vallecula-tongue tip length can explain this change.
The distance between posterior portion of maxilla to the anterior arch of Atlas (lower bony nasopharynx) and Basion (upper bony nasopharynx) showed insignificant decrease which can be attributed to continued elongation of maxillary and palatal length along with forward growth of anterior arch of atlas which compensates spheno-occipital synchondrosis growth. This is in agreement with significant increase in the palatal length observed in present study. Taylor et al. found similar results from 12 to 18 years old. King et al. had proposed that sagittal length of nasopharynx is established in early infancy., Nasopharyngeal height increased significantly, whereas nasopharyngeal depth showed insignificant change.
Finally, it should be mentioned that assessing growth changes in lateral cephalometry poses some shortcoming including 2-dimensional view and difficulty in defining landmarks. In addition, airway evaluation is even more difficult because it is not possible to precisely monitor the respiratory cycle, which may directly affect the airway morphology and size. However, lateral cephalometry is an inexpensive method which provides good assessment of airway elements. Prospective and functional analysis of airway tract is proposed for future studies.
| Conclusion|| |
The present study concludes that among 9–11 years old:
- Cranial base length, maxillomandibular length, and anterior and posterior facial height increased.
- Airway analysis revealed an increase in nasopharyngeal height, hypopharyngeal depth, tongue length, and height. Hyoid bone drifted anteriorly and inferiorly.
- No changes in head posture was observed.
- Dental relationship was stable.
Financial support and sponsorship
Conflicts of Interest
There are no conflicts of interest.
| References|| |
Yoon SS, Chung CH. Comparison of craniofacial growth of untreated Class I and Class II girls from ages 9 to 18 years: A longitudinal study. Am J Orthod Dentofac Orthop 2015;147:190-6.
Sinclair PM, Little RM. Dentofacial maturation of untreated normals. Am J Orthod 1985;88:146-56.
Katyal V, Pamula Y, Martin AJ, Daynes CN, Kennedy JD, Sampson WJ. Craniofacial and upper airway morphology in pediatric sleep-disordered breathing: Systematic review and meta-analysis. Am J Orthod Dentofac Orthop 2013;143:20-30.
Flores-Mir C, Korayem M, Heo G, Witmans M, Major MP, Major PW. Craniofacial morphological characteristics in children with obstructive sleep apnea syndrome: A systematic review and meta-analysis. J Am Dent Assoc 2013;144:269-77.
Woodside DG, Linder-Aronson S. The channelization of upper and lower anterior face heights compared to population standard in males between ages 6 to 20 years. Eur J Orthod 1979;1:25-40.
Suntenly JD. Oral respiration: Facial maldevelopment and corrective dentofacial orthopedics. Angle Orthod 1980;50:147-64.
Solow B, Sandham A. Cranio-cervical posture: A factor in the development and function of the dentofacial structures. Eur J Orthod 2002; 24:447-56.
Rubin RM. Mode of respiration and facial growth. Am J Orthod 1980;78:504-10.
Min G, McGrath CP, Wong RW, Hägg U, Yang Y. Cephalometric norms for the upper airway of 12-year-old Chinese children. Head Face Med 2014;10:38.
Arens R, Mcdonough JM, Costarino AT, Mahboubi S, Tayag-Kier CE, Maislin G et al.
Magnetic resonance imaging of the upper airway structure of children with obstructive sleep apnea syndrome. Am J Resp Crit Care Med 2001;164:698-703.
Isono S, Shimada A, Utsugi M, Konno A, Nishino T. Comparison of static mechanical properties of the passive pharynx between normal children and children with sleep-disordered breathing. Am J RespCrit Care Med 1998;157:1204-12.
Zettergren-Wijk L, Forsberg C-M, Linder-Aronson S. Changes in dentofacial morphology after adeno-/tonsillectomy in young children with obstructive sleep apnoea—a 5-year follow-up study. Eur J Orthod 2006;28:319-26.
Deng J, Gao X. A case-control study of craniofacial features of children with obstructed sleep apnea. Sleep Breath 2012;16:1219-27.
Solow B, Sonnesen L. Head posture and malocclusions. Eur J Orthod 1998;20:685-93.
Fenemore B, Potter P. A survey of perceived and confirmed allergy in children with learning disabilities and hyperactivity. Curr Allergy Clin Immunol 2002;15:24-8.
Haponik EF, Smith PL, Bohlman ME, Allen RP, Goldman SM, Bleecker ER. Computerized Tomography in Obstructive Sleep Apnea: Correlation of Airway Size with Physiology during Sleep and Wakefulness 1–3. Am Rev Resp Dis 1983;127:221-6.
Suratt PM, Dee P, Atkinson RL, Armstrong P, Wilhoit SC. 2015 Fluoroscopic and Computed Tomographic Features of the Pharyngeal Airway in Obstructive Sleep Apnea 1–3. Am Rev Resp Dis 1983;127:487-92.
Bradley TD, Brown IG, Grossman RF, Zamel N, Martinez D, Phillipson EA et al.
Pharyngeal size in snorers, nonsnorers, and patients with obstructive sleep apnea. N Eng J Med 1986;315:1327-31.
Remmers J, Sauerland E, Anch A. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol 1978;44:931-8.
Rodenstein DO, Dooms G, Thomas Y, Liistro G, Stanescu DC, Culee C et al.
Pharyngeal shape and dimensions in healthy subjects, snorers, and patients with obstructive sleep apnoea. Thorax 1990;45:722-7.
Major MP, Flores-Mir C, Major PW. A ssessment of lateral cephalometric diagnosis of adenoid hypertrophy and posterior upper airway obstruction: Asystematic review. Am J Orthod Dentofac Orthop 2006;130:700-8.
Pepin J, Ferretti G, Veale D, Romand P, Coulomb M, Brambilla C et al.
Somnofluoroscopy, computed tomography, and cephalometry in the assessment of the airway in obstructive sleep apnoea. Thorax 1992;47:150-6.
Riley RW, Powell N. Maxillofacial surgery and obstructive sleep apnea syndrome. Otolaryngol Clin North Am 1990;23:809-26.
Pirilä-Parkkinen K, Löppönen H, Nieminen P, Tolonen U, Pääkkö E, Pirttiniemi P. Validity of upper airway assessment in children: A clinical, cephalometric, and MRI study. Angle Orthod 2011;81:433-9.
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 Dentofac Orthop 2009;135:468-79.
McNamara JA. A method of cephalometric evaluation. Am J Orthod 1984;86:449-69.
Samman N, Mohammadi H, Xia J. Cephalometric norms for the upper airway in a healthy Hong Kong Chinese population. Hong Kong Med J 2003;9:25-30.
Nouri M, Garazhian A, Boghozian A. Assessing the cephalometric norms of children aged 9-11 years in Qazvin-1997. J Dent Sch 2002;20:404-17.
Nouri M, Mokhtari M, Jabouri M, Einollahi A, Hassani N. Longitudinal cephalometric growth of 9-11 years normall occlusion Iranian children. J Qazvin Univ Med Sci 2003;27:65-77.
JM XX Jr, Brudon W. Orthodontic and orthopedic treatment in the mixed dentition. Ann ArborNeedham Press 1993:3-6.
Afrand M, Ling CP, Khosrotehrani S, Flores-Mir C, Lagravere-Vich MO. Anterior cranial-base time-related changes: A systematic review. Am J Orthod Dentofacial Orthop 2014;146:21-32 e6.
Arat ZM, Türkkahraman H, English JD, Gallerano RL, Boley JC. Longitudinal growth changes of the cranial base from puberty to adulthood. Angle Orthod 2010;80:725-32.
Franchi L, Baccetti T, Stahl F, JAM XX Jr. Thin-plate Spline Analysis of Craniofacial Growth in Class I and Class II Subjects. Angle Orthod 2007;77:595-601.
Arat M, Koklu A, Ozdiler E, Rubenduz M, Erdogan B. Craniofacial growth and skeletal maturation: A mixed longitudinal study. Eur J Orthod 2001;23:355-61.
Arat ZM, Rübendüz M, Akgül AA. The Displacement of Craniofacial Reference Landmarks During Puberty: A Comparison of Three Superimposition Methods. Angle Orthod 2003;73:374-80.
Björk A. Cranial base development: A follow-up X-ray study of the individual variation in growth occurring between the ages of 12 and 20 years and its relation to brain case and face development. Am J Orthod 1955;41:198-225.
Lewis AB, Roche AF. Elongation of the cranial base in girls during pubescence. Angle Orthod 1972;42:358-67.
Lewis AB, Roche AF. Cranial base elongation in boys during pubescence. Angle Orthod 1974;44:83-93.
Lewis AB, Roche AF, Wagner B. Pubertal spurts in cranial base and mandible. Comparisons within individuals. Angle Orthod 1985;55:17-30.
Krogman W. Biological timing and the dento-facial complex. ASDC J Dent Child 1968;35:328-41.
Wilhelm BM, Beck FM, Lidral AC, Vig KWL. A comparison of cranial base growth in Class I and Class II skeletal patterns. Am J Orthod Dentofacial Orthop 2001;119:401-5.
Moss ML. Vertical growth of the human face. Am J Orthod 1964;50:359-76.
Snodell SF, Nanda RS, Currier GF. A longitudinal cephalometric study of transverse and vertical craniofacial growth. Am J Orthod Dentofacial Orthop 1993;104:471-83.
Lux CJ, Conradt C, Burden D, Komposch G. Three-dimensional analysis of maxillary and mandibular growth increments. Cleft Palate Craniofac J 2004;41:304-14.
Yavuz I, Ikbal A, Baydas B, Ceylan I. Longitudinal posteroanterior changes in transverse and vertical craniofacial structures between 10 and 14 years of age. Angle Orthod 2004;74:624-9.
Ochoa BK, Nanda RS. Comparison of maxillary and mandibular growth. Am J Orthod Dentofacial Orthop 2004;125:148-59.
Bjork A, Skieller V. Growth of the maxilla in three dimensions as revealed radiographically by the implant method. Br J Orthod 1977;4:53-64.
Nanda RS, Merrill RM. Cephalometric assessment of sagittal relationship between maxilla and mandible. Am J Orthod Dentofacial Orthop 1994;105:328-44.
Chung C-H, Mongiovi VD. Craniofacial growth in untreated skeletal Class I subjects with low, average, and high MP-SN angles: A longitudinal study. Am J Orthod Dentofacial Orthop 2003;124:670-8.
Graber LW, Vanarsdall RL Jr, Vig KW. Orthodontics: Current principles and techniques. 5th edn. Philadelphia: Elsevier Health Sciences; 2012. 229-38.
Björk A, Skieller V. Postnatal growth and development of the maxillary complex. Factors affecting the growth of the midface. Monograph 1976;6:61-99.
Enlow DH, Harris DB. A study of the postnatal growth of the human mandible. Am J Orthod 1964;50:25-50.
Bhatia S, Leighton B. Manual of facial growth: A computer analysis of longitudinal cephalometric growth data. Oxford University Press; 1993.
Solow B, Siersb˦k-Nielsen S. Cervical and craniocervical posture as predictors of craniofacial growth. Am J Orthod Dentofacial Orthop 1992;101:449-58.
Akcam MO, Toygar TU, Wada T. Longitudinal Investigation of Soft Palate and Nasopharyngeal Airway Relations in Different Rotation Types. Angle Orthod 2002;72:521-6.
Taylor M, Hans MG, Strohl KP, Nelson S, Broadbent BH. Soft tissue growth of the oropharynx. Angle Orthod 1996;66:393-400.
Pae E-K, Quas C, Quas J, Garrett N. Can facial type be used to predict changes in hyoid bone position with age? A perspective based on longitudinal data. Am J Orthod Dentofacial Orthop 2008;134:792-7.
Kollias I, Krogstad O. Adult craniofacial and pharyngeal changes-a longitudinal cephalometric study between 22 and 42 years of age. Part II: morphological uvulo-glossopharyngeal changes. Eur J Orthod 1999;21:345-55.
Chavanavesh J, Petdachai S, Chuenchompoonut V. Cephalometric corrlation among pharyngeal airway dimensions and surrounding structures in growing Thai orthodontic patients with normodivergent facial pattern. CU Dent J 2015;38:37-52.
King EW. A roentgenographic study of pharyngeal growth 1. Angle Orthod 1952;22:23-37.
Handleman CS, Osborne G. Growth of the Nasopharynx and Adenoid Development from One to Eighteen years. Angle Orthod 1976;46:243-59.
Abramson Z, Susarla S, Troulis M, Kaban L. Age-related changes of the upper airway assessed by 3-dimensional computed tomography. J Craniofac Surg 2009;20:657-63.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]