Evaluation of upper and lower pharyngeal airway in ...

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ScienceDirect Tanta Dental Journal 12 (2015) 265e276 www.elsevier.com/locate/tdj

Evaluation of upper and lower pharyngeal airway in hypo and hyper divergent Class I, II and III malocclusions in a group of Egyptian patients Atia Abd Elwareth Abd Elrazik Yousif Orthodontic Department, Faculty of Dentistry, Tanta University, Egypt Received 2 June 2015; revised 29 June 2015; accepted 1 July 2015 Available online 29 September 2015

Abstract Introduction: Significant relationships between the pharyngeal structures and both dento-facial and craniofacial structures have been reported. Hyper-divergent patients may lead to narrower antero-posterior dimensions of the airway. Some authors associated vertical growth pattern with obstruction of the upper and lower pharyngeal airways others associated mouth breathing and Class II malocclusion. So the aim of this study was to assess the upper and lower pharyngeal airway width in different antero-posterior and vertical growth patterns and to evaluate sexual dimorphism in a group of Egyptian patients. Patients and method: A sample of 300 Egyptian patients had divided into (5) groups (each group 60 patients) group 1 Class I, group 2 and 3 Class II division 1 (maxillary prognathism and mandibular deficiency), group 4 and 5 Class III (maxillary deficiency and mandibular prognathism). Each group was divided into three sub groups (hypo-hyper and normal divergent) vertical growth pattern. Each subgroup consists of 10 male and 10 female. The upper and lower pharyngeal airway widths were measured and compared for all groups. Results: Significant differences had exist regarding lower pharyngeal airway between Class I and class II division 1, Class I and Class III mandibular prognathism, Class II and Class III maxillary deficiency, Class II and Class III mandibular prognathism. Significant differences between hypo, hyper and normal vertical growth pattern. Conclusions: In all groups hyper-divergent growth had narrower airway than normal and hypo-divergent growth. Class III had wider airway than Class I malocclusion. Class I had wider airway than Class II division 1 malocclusion. Lower pharyngeal airway in class II division 1 had the narrowest width in all groups. Lower pharyngeal airway in class III mandibular prognathism had the widest width in all groups. Males have wider pharyngeal airway than females. © 2015, Hosting by Elsevier B.V. on behalf of the Faculty of Dentistry, Tanta University.

Keywords: Upper and lower pharyngeal airway width; Skeletal malocclusion; Vertical growth pattern; Cephalometric X ray

1. Introduction E-mail address: [email protected]. Peer review under the responsibility of the Faculty of Dentistry, Tanta University.

Normal respiratory activity influences the growth of maxillofacial structures, favoring their harmonious growth and development [1].

http://dx.doi.org/10.1016/j.tdj.2015.07.001 1687-8574/© 2015, Hosting by Elsevier B.V. on behalf of the Faculty of Dentistry, Tanta University.

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A.A. Elwareth Abd Elrazik Yousif / Tanta Dental Journal 12 (2015) 265e276

Heredity plays an important role in determining the size and shape of the human face and thus of the airway; others reported associations of vertical growth pattern with obstruction of the upper and lower pharyngeal airways concurrently with mouth breathing [2e6]. Significant relationships between the pharyngeal structures and both dento-facial and craniofacial structures have been reported [2,7]. Craniofacial anomalies such as mandibular or maxillary retrognathism, short mandibular body, and backward and downward rotation of the mandible might lead to reduction of the pharyngeal airway space [8]. In addition, different anatomic features of the maxilla and mandible could change the position of the hyoid and soft palate and lead to decreased dimension of posterior airway space [9]. Although a number of studies were performed to investigate the relationship between sagittal skeletal patterns and pharyngeal airway, the relationship between vertical growth patterns and pharyngeal airway using lateral cephalometric films [2,8,10e13], an association between pharyngeal airway dimensions and both sagittal and vertical skeletal patterns was demonstrated. Some authors associated mouth breathing and Class II malocclusion, and others reported associations of vertical growth pattern with obstruction of upper and lower pharyngeal airways concurrently with mouth breathing. If this relationship actually exists, Class I malocclusions and horizontal growth patterns must have natural anatomical airway, other studies have evaluated upper airway dimension of patients with Class II malocclusion [2,3,14] however, controversy surrounds their results. Some articles have assessed the nasal and pharyngeal airway from lateral cephalograms [15e18]. Class II patients have a tendency for a narrower anteroposterior pharyngeal dimension, specifically in the nasopharynx at the level of the hard palate and in the oropharynx at the level of the tip of the soft palate [15]. Skeletal Class II discrepancy with mandibular deficiency is considered as a risk factor for upper airway disorders and oropharyngeal airway deficiencies [19,20]. In order to prevent the potential respiratory problems, Li , (2009) [21] noticed that early orthodontic treatment of mandibular deficiencies in skeletal Class II patients would be beneficial. Thus evaluation of upper and lower airway space which should be an integral part of diagnosis and treatment planning to achieve functional balance and

stability of the results is essential, hence this study is designed and planned to measure the upper and lower pharyngeal airway widths in patients with different antero-posterior (skeletal Class I, II and III malocclusion) and vertical (“hypo-divergent”, “hyper-divergent” and normal divergent) skeletal patterns and search if there is a sexual dimorphism in the pharyngeal airway widths in a group of Egyptian patients. 2. Materials and methods

A sample of 300 patients was selected from orthodontic department, faculty of dentistry, Tanta University according to the following criteria B Patients in the age group of 17e20 years. B Individuals with full complement of teeth up to second molar. B Absence of any pharyngeal pathology. B Patients breathe comfortably through the nose. B No history of repeated common cold or enlarged tonsils. B No history of adenoidectomy and/or tonsillectomy. B Patients with abnormal habits are excluded. B No history of previous orthodontic treatment and/or surgical treatment.

The sample was divided into 5 groups each group consist of 60 patients (30 male and 30 female): Group Group Group Group Group

I: Class I malocclusion. II: Class II division 1 mandibular deficiency. III: Class II division 1 maxillary prognathism. IV: Class III maxillary deficiency. V: Class III mandibular prognathism.

All patients were divided into class I, II and III groups based on the ANB angle (skeletal Class I: 2 ANB 4 , skeletal Class II: ANB > 4 and skeletal class III: ANB 0). Each group was further divided into three subgroups each sub group consist of 20 patients: (10 male and 10 female): Subgroup (A): “hyper-divergent” growth patterns: SN-MP angle 41 ± 3 . Subgroup (B): “hypo-divergent” growth patterns 20 patients: SN-MP angle 23 ± 2 . Subgroup (C): “normal-divergent” growth patterns 20 patients: SN-MP angle32 ± 3 .

Lateral cephalometric radiographs were taken for each subject after obtaining informed written consent from the parents. All the cephalometric radiographs


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were taken using standardized technique with the same cephalometric machine.1 The upper and lower pharyngeal airway was measured manually using acetate tracing paper and pencil and tracing all cephalometric X rays. Each measurement was measured twice with two weeks interval and the mean of the measurements were taken. The following are some Cephalometric points, lines and planes used in this study: PSP: The PNS part of the soft palate. PPW: The posterior pharyngeal wall. HB: The superior margin of the body of the hyoid bone. RL1: Horizontal reference line passing through S point 7 to SN plan. RL2: Vertical reference line passing through S point perpendicular to R1.

Airway Measurements based on McNamara analysis. The pharyngeal airway space was measured at two levels; upper and lower. First a reference lines RL1 and RL2 planes were drawn. Upper Pharyngeal AirWay width (UPAW) is the distance from PSP which is the PNS part of the soft palate to the posterior pharyngeal wall perpendicular to the reference line and the Lower Pharyngeal Airway width (LPAW) the distance between anterior and posterior pharyngeal wall perpendicular to the reference line at the level of the superior margin of the body of the hyoid bone. (Fig. 1). All data were statistically analyzed with statistical package for the social science (SPSS V.16) using mean and standard deviation. Each two groups was compared by student t test and when hypo, hyper and normal divergent pattern was compared f test was used with p value at different levels of significance (p > 0.05 considered non-significant. P < 0.05* considered significant and p < 0.001** considered highly significant). 3. Results Both UPAW and LPAW are wider in Class I than Class II division 1 with mandibular deficiency. The LPAW shows highly significant differences between both groups because the LPAW in Class II division 1 with mandibular deficiency shows the narrowest value in all groups mainly in “hyper-divergent” growth patterns (Table 1). A non-significant difference was found between Class I and Class II division 1 malocclusion with maxillary prognathism and between Class I and Class 1

SironaOrthophosPlus C, Bensheim, Germany.

Fig. 1. UPAW, LPAW and Horizontal and vertical reference planes RL1 and RL2. (Nalbangtil et al., 2005) [22].

III maxillary deficiency regarding both UPAW and LPAW (Tables 2,3). A highly significant difference was found in LPAW between Class I and Class III mandibular prognathism (Table 4) As showed in Table 5 a high significant difference was found between Class II division 1 maxillary prognathism and Class II division 1 mandibular deficiency regarding both UPAW and LPAW. A significant difference between both groups regarding UPAW and highly significant difference between both groups regarding LPAW as it reaches its lowest value in Class II division 1 and reaches its greatest value in Class III mandibular prognathism group. In all groups the “hyper-divergent” growth patterns shows narrower UPAW and LPAW than “hypo-divergent” or normal vertical growth patterns (Tables 6 and 7). A statistically significant difference was found regarding UPAW between Class II division 1 with maxillary prognathism and Class III with maxillary deficiency in “hyper-divergent” growth patterns and LPAW in different types of vertical growth patterns (Table 8). A statistically high significant difference was found in LPAW between Class II division 1 with maxillary prognathism and Class III with mandibular prognathism (Table 9). The UPAW shows greater widths in Class III maxillary deficiency group than Class III mandibular prognathism group while the LPAW shows greater

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Table 1 Comparison between Class I and Class II division 1 with mandibular deficiency regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW

Vertical growth patterns

Class I

Hypo Hyper Normal Hypo Hyper Normal

13.55 12 12.7 12.21 11.77 11.82

Class II division I mand. deficiency

± ± ± ± ± ±

4.89 3.56 3.65 1.97 2.94 2.32

12 11.32 11.54 10.55 9 10

± ± ± ± ± ±

3.12 2.35 2.7 1.98 1.84 1.9

T. test

P. value

1.694 1.013 1.618 3.758 5.053 3.839

0.095 0.316 0.110 0.001** 0.001** 0.001**

P. value < 0.05* (significant) P. value 0.001** (highly significant) UPAW: upper pharyngeal airway LPAW: lower pharyngeal airway.

Table 2 Comparison between Class I and Class II division 1 with maxillary prognathism regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW


Class I


13.55 12 12.7 12.21 11.77 11.82

Class II division I max. prognathism

± ± ± ± ± ±

4.89 3.56 3.65 1.97 2.94 2.32

13.93 12.7 13 12.1 11.59 11.73

± ± ± ± ± ±

1.42 1.21 2.18 2.4 2.6 1.8

T. test

P. value

0.579 1.442 0.553 0.269 0.359 0.239

0.564 0.152 0.586 0.784 0.723 0.813


Table 3 Comparison between Class I and Class III maxillary deficiency regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW


Class I


13.55 12 12.7 12.21 11.77 11.82

± ± ± ± ± ±

4.89 3.56 3.65 1.97 2.94 2.32

Class III max deficiency

T. test

P. value

± ± ± ± ± ±

0.553 1.607 1.103 1.718 1.423 1.634

0.584 0.112 0.274 0.091 0.160 0.109

14.2 13.4 13.7 13.4 12.88 13

2.77 2.16 2.45 3.4 2.65 3.22


Table 4 Comparison between Class I and Class III mandibular prognathism regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW


Class I


13.55 12 12.7 12.21 11.77 11.82

± ± ± ± ± ±

Class III mand. prognathism 4.89 3.56 3.65 1.97 2.94 2.32

14 13 13.4 15.6 14.2 14.8

± ± ± ± ± ±

3.6 2.48 2.8 3.22 1.98 2.3

T. test

P. value

0.364 1.123 0.753 5.048 3.334 4.703

0.717 0.265 0.455 0.001** 0.002** 0.001**



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Table 5 Comparison between Class II division 1 and Class III maxillary deficiency regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW


Class II division I mand. deficiency


12 11.32 11.54 10.55 9 10

± ± ± ± ± ±

3.12 2.35 2.7 1.98 1.84 1.9

Class II division 1 max. prognathism 13.93 12.7 13 12.1 11.59 11.73

± ± ± ± ± ±

1.42 1.21 2.18 2.4 2.6 1.8

T. test

P. value

4.362 4.039 3.534 3.862 6.303 5.123

0.001** 0.001** 0.001** 0.001** 0.001** 0.001**


Table 6 Comparison between class II division 1 and class III maxillary deficiency regarding upper and lower pharyngeal airway malocclusion in different vertical growth patterns.

UPAW

LPAW


Class II division I mand. Deficiency


12 11.32 11.54 10.55 9 10

± ± ± ± ± ±

3.12 2.35 2.7 1.98 1.84 1.9

Class III max. deficiency

T. test

P. value

± ± ± ± ± ±

2.674 3.323 3.014 4.112 6.618 5.542

0.009* 0.002* 0.004* 0.001** 0.001** 0.001**

14.2 13.4 13.7 13.4 12.88 13

2.77 2.16 2.45 3.4 2.65 3.22


Table 7 Comparison between Class II division 1 and Class III mandibular prognathism regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW


Class II division I mand. Deficiency


12 11.32 11.54 10.55 9 10

± ± ± ± ± ±

3.12 2.35 2.7 1.98 1.84 1.9

Class III mand. prognathism 14 13 13.4 15.6 14.2 14.8

± ± ± ± ± ±

3.6 2.48 2.8 3.22 1.98 2.3

T. test

P. value

2.223 2.558 2.476 7.508 10.059 8.592

0.030* 0.013* 0.016* 0.001** 0.001** 0.001**


Table 8 Comparison between Class II division 1 and Class III maxillary deficiency regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW




13.93 12.7 13 12.1 11.59 11.73

± ± ± ± ± ±

1.42 1.21 2.18 2.4 2.6 1.8


T. test

P. value

± ± ± ± ± ±

0.669 2.189 1.653 2.413 2.693 2.674

0.503 0.030* 0.101 0.017* 0.008* 0.009*

14.2 13.4 13.7 13.4 12.88 13

2.77 2.16 2.45 3.4 2.65 3.22


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Table 9 Comparison between Class II division 1 and Class III mandibular prognathism regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW




13.93 12.7 13 12.1 11.59 11.73

± ± ± ± ± ±

1.42 1.21 2.18 2.4 2.6 1.8

Class III mand. prognathism 14 13 13.4 15.6 14.2 14.8

± ± ± ± ± ±

3.6 2.48 2.8 3.22 1.98 2.3

T. test

P. value

0.143 0.839 0.869 6.749 6.189 8.137

0.889 0.401 0.384 0.001* 0.001* 0.001*


for Class II division 1 maxillary prognathism and LPAW for Class II division 1 mandibular deficiency. (Table 11, Fig. 2A and B). The UPAW and LPAW are wider in male than female with significant differences between male and female UPAW in Class II division 1 with maxillary prognathism and LPAW in Class II division 1 with mandibular deficiency (Table 12, Fig. 3A and B).

Widths in Class III mandibular prognathism group than Class III maxillary deficiency group. In all groups the “hyper-divergent” growth patterns shows narrower UPAW and LPAW than “hypo-divergent” or normal vertical growth patterns. A statistically significant difference was found between both groups regarding LPAW in “hypo-divergent” and normal vertical growth patterns (Table 10). In all groups the “hyper-divergent” growth patterns shows narrower pharyngeal airway than normal and “hypo-divergent” growth patterns and “hypo-divergent” growth patterns shows wider pharyngeal airway than normal or “hyper-divergent” growth patterns. A statistically significant difference was found in UPAW

4. Discussion The size of the naso-pharynx is an important factor for determining mode of breathing, i.e. nasal or oral [14]. Since patients with mouth breathing might have

Table 10 Comparison between Class III maxillary deficiency and Class III mandibular prognathism regarding upper and lower pharyngeal airway in different vertical growth patterns.

UPAW

LPAW


Class III max. deficiency


14.2 13.4 13.7 13.4 12.88 13

± ± ± ± ± ±

Class III mand. prognathism

2.77 2.16 2.45 3.4 2.65 3.22

14 13 13.4 15.6 14.2 14.8

± ± ± ± ± ±

3.6 2.48 2.8 3.22 1.98 2.3

T. test

P. value

0.203 0.539 0.362 2.104 1.784 2.034

0.845 0.589 0.720 0.042* 0.082 0.048*


Table 11 Comparison between hypo, hyper and normal divergent vertical growth patterns in different antero-posterior skeletal relationships.

UPAW

LPAW

Different antero-posterior mal-relations

Hypo

Class Class Class Class Class Class Class Class Class Class

13.55 12 13.93 14.2 14 12.21 10.55 12.1 13.4 15.6

I II division I mand. deficiency II division I max. prognathism III max deficiency III mand. prognathism I II division I mand. deficiency II division I max. prognathism III max deficiency III mand. prognathism

Hyper ± ± ± ± ± ± ± ± ± ±

4.89 3.12 1.42 2.77 3.6 1.97 1.98 2.4 3.4 3.22

12 11.32 12.7 13.4 13 11.77 9 11.59 12.88 14.2

Normal ± ± ± ± ± ± ± ± ± ±

3.56 2.35 1.21 2.16 2.48 2.94 1.84 2.6 2.65 1.98

P. value < 0.05* (significant) UPAW: upper pharyngeal airway LPAW: lower pharyngeal airway.

12.7 11.54 13 13.7 13.4 11.82 10 11.73 13 14.8

± ± ± ± ± ± ± ± ± ±

3.65 2.7 2.18 2.45 2.8 2.32 1.9 1.8 3.22 2.3

F. test

P. value

1.768 1.536 4.121 1.327 1.385 0.985 3.632 1.354 0.851 1.662

0.214 0.312 0.013* 0.389 0.375 0.358 0.024* 0.279 0.395 0.106


A

UPA

14.5

271

14 13.5 13 12.5 12 11.5 11

Class I

Class II div. 1 Class II div. 1 mand. max. deficiency prognathism

Hypo

Hyper


Class III mand. Prognathism

Normal

B LPA

16.5 15.5 14.5 13.5 12.5 11.5 10.5 9.5 8.5

Class I

Class II div. 1 mand. Deficiency

Class II div.1 max prognathism

Hypo

Hyper


Class III mand. Prognathism

Normal

Fig. 2. A: UPAW in different vertical and antero-posterior growth patterns. B: LPAW in different vertical and antero-posterior growth patterns.

decreased airway dimension, only children with normal nasal breathing were included in this study to eliminate the interfering factors. Ashwin Kumar et.al. (2014) stated that the pharyngeal airway dimensions are subjected to change with different malocclusion [23]. The relationship between airway patency and craniofacial development is highly controversial not only having academic implications but also having considerable clinical consequences. It can influence the

orthodontist's decision on diagnosis and treatment planning [24]. Many previous studies have shown that adenoid or tonsillar obstruction of the airway might cause abnormal maxillofacial development [25e27]. Kim et al. (2010) [28] studied upper airway dimension of children in this 9e11 year age group. In this age, maxillo-mandibular growth rate is steady and constant before the adolescent growth spurt [28]. King, (1952) [29] stated that nasopharyngeal depth is established early

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Table 12 Comparison between UPAW and LPAW in male and female in different antero-posterior skeletal relationships. Different antero-posterior mal-relations

UPAW

LPAW

Male

Female

Mean ± SD Class Class Class Class Class

I II division I mand. deficiency II division I max. prognathism III max deficiency III mand prognathism

13.6 12 13.8 14.4 14.3

± ± ± ± ±

3.6 2.5 2.5 2.8 3.7

T

P

1.332 1.269 2.714 1.528 0.991

0.188 0.207 0.008* 0.133 0.329

Mean ± SD 12.5 11.2 12.7 13.2 13.3

± ± ± ± ±

3.8 3.1 1.9 2.1 2.6

Male

Female

Mean ± SD 12.3 10.6 12.1 13.5 15.3

± ± ± ± ±

2.4 1.9 2.6 3.5 3.1

T

P

1.653 2.043 1.817 0.732 1.623

0.102 0.045* 0.071 0.471 0.113

Mean ± SD 11.5 9.8 11.3 12.8 14

± ± ± ± ±

1.9 1.6 2.2 2.5 1.8

P. value < 0.05* (significant) UPAW: upper pharyngeal airway LPAW:lower pharyngeal airway.

in life, and then it usually remains the same. Therefore, the age group of the present study selected between 17 and 20 to avoid any probability of growth changes. Graure et al. (2009) [30] in their study, using Cone Beam Computerized Tomography (CBCT) reported that the volume of the lower part of upper airway has a significant relation with antero-posterior position of mandible. Although the ANB angle might be affected by the antero-posterior position of the nasion relative to the maxilla and mandible, [31e34] it was the most

commonly used cephalometric measurement to determine sagittal relationship of the jaws [30,32,34,35]. Thus, decided to use the ANB angle to define the sagittal relationship of the jaws. Ishikawa et al. (2000) [36] reported that it is reliable for determining the antero-posterior relationship of the jaws so the sample in the present study was divided into skeletal class I, II and III based on ANB angle. Cephalometric measurements were used for assessing airway dimensions in the present study. Although caphalometric films give two-dimensional

UPAW

A

ClassClass I II division I mand. Class II deficiency division I max. prognathism Class III max deficiency Class III mandprognathism

Male

Female

B

LPAW

16 15 14 13 12 11 10 9 8 Class I

Class II div. I mand. deficiency

Class II div. I max. prognathism

Male


Class III mand prognathism

Female

Fig. 3. A: UPAW in male and female in different antero-posterior growth patterns. B: LPAW in male and female in different antero-posterior growth patterns.


picture of a three-dimensional object, Malkoc et al. (2005) [17] stated that cephalometric film were reliable in determining airway dimensions and Aboudara et al. (2009) [37] found a significant positive association between nasopharyngeal airway size on cephalometric films and its true volumetric size on CBCT (cone beam computerized tomography) scan in adolescents. On the other hand, lateral cephalometry has the advantages of wide availability, simplicity, low cost and ease of comparison with other studies [38]. Since it is reported that patients with vertical growth pattern have narrower upper airway [8,39], so children with normal growth pattern were included in this study as control group for “hypo-divergent” and “hyperdivergent” growth pattern. The results of the present study showed, both UPAW and LPAW are narrower in “hyper-divergent” growth patterns than normal vertical growth pattern or “hypo-divergent” growth pattern in different anteroposterior skeletal jaws relations. This difference is statistically insignificant except LPAW in class II division 1 group which shows significant difference between “hypo, hyper and normal” vertical growth patterns which come in accordance with the finding of Kerr WJ (1985) [4] who found smaller naso-pharynx in patients with long face than short face. Also Gupta PS and Ravi MS, (2014) [40] found significant difference between upper and “oropharyngeal” widths and facial skeletal pattern. Subjects with vertical skeletal pattern have significantly narrower upper airways than those with horizontal skeletal pattern. This finding is in agreement with those of Marcos Roberto de Freitas et al., (2006) [2] who had conducted a similar study earlier. This finding is further supported by a study according to which higher and shallower pharyngeal dimension were found in individuals with dolicho-cephalic growth patterns [24]. Pharyngeal airway width shows lowest values in the high-angle group. Another explanation for the airway differences among the groups might be the retruded mandible in the high-angle group. According to Kim et al. (2010) [28] children with retruded mandibles had decreased total pharyngeal airway volumes. Also Grauer et al. [30] found that subjects in the low-angle group had the largest bizygomatic width and this factor may be a possible explanations as to why patients in the low-angle group had larger pharyngeal airway volumes than patients in the high- and normalangle groups. Similar results were obtained by King EW (1952) [29] who stated that there were no significant differences in the inferior, superior, and total airway

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volumes among the long, short, and normal groups of no growing patients. Celikoglua M et al. (2014) [41] stated that nasopharyngeal airway volume in the high-angle group was significantly lower than that of the low-angle group and the normal-angle group “oropharyngeal” airway volume was highest in the low-angle group this come in accordance with the result of the present study. According to a study, subjects with Class I and Class II malocclusions and vertical growth patterns have significantly narrower upper pharyngeal airways than those with Class I and Class II malocclusions and normal growth patterns [2]. When compared pharyngeal airway in Class I and Class II division 1 malocclusion a highly significant difference was found regarding LPAW which reach its lowest value in subgroup “hyper-divergent” class II division 1 this came in accordance with Kirjavainen et al. (2007) [42]. Ceylan I and Oktay H, (1995) [14] who reported that oro-pharyngeal area was smaller in skeletal Class II patients. In the present study UPAW shows non-significant difference between Class I and Class II division 1 malocclusion this come in accordance with Soheilifar S and Sara AS, (2014). [43]. Ceylan I and Oktay H, (1995) [14] reported that oropharyngeal area was smaller in skeletal Class II patients; however, the sagittal measurements of oropharynx were not affected by the ANB angle. Kim et al. (2010) [28] performed three-dimensional analysis of pharyngeal airway, reported that the mean total airway volume in patients with retro-gnathia was significantly smaller than in patients with a normal antero-posterior skeletal relationship. Also the results of the present study come in accordance with Mergen DC, (1970) [3] also selected the patients based on the occlusion and reported that nasopharyngeal depth was significantly narrower in patients with Class II malocclusion than in normal occlusion; furthermore, they performed their study on (13 years old) patients. In accordance with our results previous studies by Dunn, (1973) [44] Ackerman, (1981) [45] & Proffit WR et al., (2007) [46] showed that subjects with Class I and Class IImalocclusions and vertical growth patterns had significantly narrower upper pharyngeal airways than Class I and Class II subjects with normal growth patterns. Freitas et al. (2006) [2] compared upper and lower pharyngeal widths in patients with untreated Class I and Class II malocclusions and normal and vertical growth patterns. His results showed that subjects with Class I and Class II malocclusions and vertical growth

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patterns have significantly narrower upper pharyngeal airways than those with Class I and Class II malocclusions and normal growth patterns which come in accordance with the present study. In contrast to our findings Sosa et al. (1982) [47] study the relationship of adenoids and type of malocclusion of Class I and Class II, Division 1 malocclusions and their results showed that airway space did not appear to vary with the type of malocclusion. In the present study when pharyngeal airway in Class I and Class III was compared the pharyngeal airway of Class III showed wider measurements than Class I with no significant difference between both groups but a highly significant difference exist regarding LPAW between Class I and Class III mandibular prognathism this come in accordance with Muto T et al. (2008) [48] who found that the pharyngeal airway diameter was largest in the group with mandibular prognathism. These results indicated that the antero-posterior dimension of the PAS is affected by different skeletal patterns of the mandible. In the present study Class III had wider pharyngeal airway than Class I and Class II malocclusion this come in accordance with Alves M Jr et al. (2012) [32] Oz U et al. (2013) [33] and Claudino LV et al. (2013) [34] Iwasaki T et al. (2009) [49] also reported that the lower pharyngeal widths of girls with Class III malocclusion were significantly larger than that of girls with Class I malocclusion, while there was no significant difference in the upper pharyngeal width evaluated by cone-beam computed tomography this came in accordance with the results of the present study which shows non-significant difference regarding UPAW and LPAW between Class I and Class III maxillary deficiency but high significant difference between Class I and Class III mandibular prognathism regarding LPAW. Also in accordance with our results Takemoto Y et al. (2011) [50] reported that the lower pharyngeal airway of prognathic girls was wider than that of girls with normal occlusion. When compared the pharyngeal airway measurements between male and female the male group show wider pharyngeal airway than female group but the difference was non-significant except LPAW in Class II division 1 group which shows weak but significant difference between male and female group. This came partially in accordance with Grauer D et al. (2009) [30] Zheng ZH et al. (2014) [35] Solow B et al. (1984) [51] and EL H, Palomo JM, (2011) [31] all reported no significant gender difference in pharyngeal airway measurements [28,32].

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