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Resumo
Introdução: Os ortodontistas tratam frequentemente crianças com respiração oral.
O objectivo deste estudo foi avaliar, as alterações esqueléticas, das posições
dentárias e da via aérea, em crianças com rinite alérgica crónica e respiração oral,
comparando-as com um grupo de crianças com respiração nasal. Material e
métodos: foram avaliadas setenta crianças do Hospital de Santa Maria, em Lisboa,
entre Setembro de 2009 e Fevereiro de 2013, divididas em dois grupos. Um grupo
de 35 crianças com diagnóstico de rinite alérgica crónica (AR), de ambos os
géneros, idades entre 5 e 14 anos, com reação positiva a aeroalergénios, respiração
bucal e má-oclusão dentária. O grupo de controlo incluiu 35 crianças, saudáveis,
com respiração nasal e má-oclusão dentária. Utilizaram-se as medidas referidas de
Ricketts, Steiner e análise de McNamara. Procedeu-se a análise estatística,
aplicando-se o teste t de Student. Resultados: as crianças respiradoras orais
apresentaram uma maior altura facial anterior da face IFH (p = 0,001), maior ângulo
FMA (p = 0,06) e SN-Opl (p = 0,02). O comprimento da maxila (Co-A, p = 0,006) e
da mandíbula (Co-Gn, p = 0,03) foram menores. Efectuaram-se cinco medidas
lineares para avaliar a via aérea, entre a parede anterior e posterior da faringe e em
quatro delas, as crianças do grupo de estudo têm o espaço aéreo diminuído.
Conclusões: as crianças com respiração oral têm faces mais longas, maxilas e
mandíbulas mais curtas e um espaço aéreo faríngeo menor. Não houve diferenças
estatísticas significativas a nível sagital entre as bases ósseas.
Palavras-chave: rinite alérgica; respiração oral; má-oclusão; tratamento ortodôntico;
crianças.
Abstract
Introduction: Orthodontists frequently treat children with mouth breathing. The aim
of the present study was to examine dental positions, skeletal effects and the airway
space of pharynx of mouth breathing in children with chronic allergic rhinitis
comparing with a control group exhibiting a normal breathing pattern. Methods:
Seventy Caucasian children from Lisbon’s Santa Maria University Hospital were
evaluated, between September 2009 and February 2013. The study group comprised
35 children diagnosed with chronic allergic rhinitis (AR), both gender, age 5-14, with
positive reaction to allergens, mouth breathing and malocclusion. The control group
was 35 same age children, both gender, with nasal breathing and some malocclusion
who went to the orthodontic department to treat their malocclusion. Referred
measures of Ricketts, Steiner and McNamara`s analysis were used. T- Student test
was applied. Results: In comparison with controls AR children exhibited a greater
lower inferior face height IFH (p=0.001), FMA angle (p=0.06) and SN-Opl (p=0.02).
The study group show that the length of the maxilla (Co-A, p=0.006)) and the
mandible (Co-Gn, p=0.03)) were smaller. The overbite is lesser in AR group. Five
linear measures were taken in the upper airway space between the anterior and
posterior wall of the pharynx. The results show that in four of them the study group
had significantly narrowed airway space than control group. Conclusions: Children
with AR and mouth breathing have longer faces, shorter maxillas and mandibles and
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narrowed pharyngeal airway space. There were no statistical differences between
the groups in sagital relationships or in dental inclinations.
Keywords: allergic rhinitis; mouth breathing; malocclusion; orthodontic treatment;
children.
Introduction and literature review
Allergic rhinitis is the most frequent chronic pathology in children.1 It is rarely an
isolated pathology, being associated with asthma,2-5 sinusitis, lymphoid tissue
hypertrophy and obstructive sleep apnea.2-3 There is a prevalence of 75 to 80% of
the patients with asthma, who have simultaneously have allergic rhinitis.5 Many of
these patients have mouth breathing. Rhinitis prevalence increases with age,4,6
presenting variable values between countries and studies. For example, in United
Kingdom asthma has 20% prevalence and allergic rhinitis has a 40% prevalence at
the age of 13-14.3
In A Coruña (Spain), the prevalence is 30.4% at the beginning of school age and
47.3% at the age of 13-14.7 In Portugal, the prevalence of rhinitis is 21,5% among 3
and 5 years old.8 Among patients with malocclusion 48,3% have pathology of the
rhino-pharynges, 40% allergic rhinitis and 16,5% tonsils hyperthrophy.9
According to Moss10 functional matrix theory, craniofacial structures growth is
influenced by the soft tissues. Morphology, position and breathing will condition
craniofacial morphology, however the relationship between nasal obstruction and
craniofacial growth is not evident.11 In a review study, McNamara12 refers that Meyer
(1872), Angle (1907) and Rickets (1968), among others, related nasal obstruction
with complex craniofacial growth functional deviations called “adenoid face”,
characterized by mouth breathing, small nose, thin upper lip and narrow maxilla. In a
study using monkeys, their nasal cavities have been obstructed.13,14 Consequently
they have developed mouth breathing, with increased growth of facial and tongue
muscles. There were also alterations in mandibles morphology, although with
differences in the results; in some monkeys, posterior and inferior rotation of the
mandible occurred with consequent Class II occlusion; in others monkeys there were
anterior rotation and Class II malocclusion.
Results differ in terms of posture: some studies conclude that there are no
differences between head and neck posture among mouth and nasal breathers,15
others refer that those patients with mouth breathing show a greater head extension,
with an anterior projection towards cervical column, and a higher lordosis.16 Patients
with vertical patterns17 have a similar respiratory volume but quantitatively less nasal
breathing than “mesofacials”. Mouth breathers presents: bigger facial height,18-20
more retrognate maxilla,19-21 higher palate,20,22,23 retrognate mandible,19 anterior
open-bite and Class II malocclusion,21,24 posterior crossed bite,23,24 normal upper
intermolar and intercanine distance,22 decreased perimeter of superior and inferior
arch,23,25 vestibular tilting of the upper incisors,15 retro-inclination of inferior
incisors,15,20 and greater dental crowding.25
For the reasons here, the aim of this study was to analyze the facial pattern of both
groups (mouth and nasal breathers) and compare if there are vertical or sagital
alterations of bone structures between them or the cranial basis, to determine if there
are alterations in dental tilting and compare the width of the upper and lower
pharyngeal airway in mouth and nasal breathing.
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Material and methods
Seventy Caucasian children from Lisbon’s Santa Maria University Hospital were
evaluated, between September 2009 and February 2013, and divided in two groups.
The study was approved by de Ethics Committee of the Hospital. In both groups
were excluded children that were submitted to previous tonsil and adenoid surgery,
that had finger or dummy suction habits beyond three years of age, or that presented
any genetic syndromes. Allergic group (G1) comprehended 35 children (24 boys and
11 girls), mean-age of 10 years and 2 months old, with chronic allergic rhinitis proved
by positive tests to breathing allergens, mouth breathing confirmed by a
questionnaire with standard questions and by another test where every child was
asked to breath trough their nose. If they could breathe through their nose for more
than one minute they were excluded from the group, even if questionnaire indicates
that they might have oral breath. Every child had to have any malocclusion that
required orthodontic treatment, as it was impossible to submit them to a
teleradiograph, by the ethic committee standards. Control group (G2) comprised 35
children (17 boys and 18 girls), median age of 11 years and 5 months old, that went
to the orthodontic appointment of the same hospital. Inclusion criteria were nasal
breathing, the absence of allergic pathology or otorhinolaringology problems and
presence of malocclusion. Children were submitted to an orthodontic study, based on
a digital profile teleradiography, taken in the Hospital’s radiological department,
always using the same Rx digital machine.
Cephalogram measurements: referred measures of Rickets, Steiner and McNamara
were taken (fig.1, fig. 2). Different data analysis were made (table I), particularly
those that don’t change with age. For the airway space analysis the distances
between the anterior and posterior pharyngeal walls were measured, in five different
heights (fig.3).
Inserir figura 1, 2 e 3 e tabela 1 aqui
Measurements were taken by a single professional (HAA), using the Nemoceph
studio computer program. Twenty radiographs of the children were compared and no
system errors were found. Statistical analysis was made with a software program
(SPSS, version 17), and Student t-test was used for groups comparison. Significance
level of p<0.05 was considered.
Results
Skeletal, dental and soft tissues relationships, as well as airway space are described
in tables II and III.
Inserir as tabelas 2 e 3 aqui.
A statistically relevant FMA alteration (p=0.006) between the two groups was
observed, being the allergic individuals more verticals. Also at the SN.OPL and
Ans.Xi.Pm (IFH) level there are statistically significant differences of respectively
p=0.02 and p=0.001, showing mainly an increase of the inferior facial height. It was
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also observed that G1 presented smaller maxillas Co-A (p=0.006) and mandibles CoGn (p=0.03).
There are no statistically significant alterations of sagital relationships between
groups, although the G1 has a higher ANB value than G2.
There are no statistically relevant changes of the relationships between incisors and
skeletal basis, being used for each arcade two angular measurements and one linear
measurement.
There is a statistically significant alteration on overbite as children in the study group
have an open bite tendency.
In the airway space it was observed a statistically significant decrease in Pns-Pp1
distance (p=0.028), Npa-Npp (p=0.013), Ppm-Pp2 (p=0.02) and Hpa-Pp3 (p=0.036).
Discussion
For ethical reasons (presence of radiations) it is not possible to study and compare
every child with mouth or nasal breathing, but only the ones that present
malocclusion and consequently need of cephalometric study.
Therefore, the aim of this study was to compare pure cephalometric alterations in
children with malocclusion who presented different types of breathing. Another big
limitation in the sample gathering was the fact that many children with allergic
problems also have tonsil and adenoid pathology, and many of the children observed
had already been submitted to tonsil or adenoid removal, so they were excluded.
Many times children with skeletal Class II are referred as mouth breathers but some
studies don’t specify if it is caused by vestibular tilting of the upper incisors that do
not allow the lip seal, leading to mouth breathing, or not. 33,34 In our study it was
observed an increased ANB angle, but not statistically significant. In many studies
mouth breathers have increased upper incisors tilting and retroposition of the lower
incisors, but we have not verify that in our study. Possibly it was because we have
rejected every child with suction habits beyond the age of 3, which may be present
on those studies and lead to different results. Our aim by excluding those children
was to evaluate only the way of breathing.
Mouth breathing children are skeletically more vertical, confirming previous studies
18,20,26, suggesting that a narrower airway space may lead to a more vertical growth.
This growth along with posterior rotation of the mandible, secondary leads to a
reduction of the overbite, which was statistically significant, as in previous
studies13,16.
It was also observed a smaller maxilla and mandible length, as in another previous
study22. Pharynx was evaluated in five different heights. The purpose was to evaluate
if there were specific areas of bigger or smaller dimension. It was not found a
statistically significant difference in the Bfa-Bfp measurements as it is demonstrated
in some studies28,29 showing that there are no correspondence between vertical
growth and airway space in that area.
We can speculate if this measurement is not decreased, in opposition to others that
are increased due to a more forward position of the tongue in the mouth breathers.
It was found a statistically significant difference on the ENp-Pp1 and Nfa-Nfp
measurements showing a narrower nasopharynx in mouth breathers, as in previous
studies30,31,32. The distance between ppm-PP2 is also smaller, showing that there is a
reduced space between the anterior and posterior wall, as well as in the inferior
portion of the pharynx, where the narrower space was found between the anterior
and posterior part, at the C3 level.
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Conclusions
This study showed that:
1) Children with allergic rhinitis and mouth breathing are skeletally more vertical,
with an open bite tendency;
2) They have a smaller maxilla and mandible than the nasal breathing children;
3) There are no sagital base alterations although there is an increase tendency in
a skeletal Class II;
4) There is a reduced airway space in all its extension, except between the
posterior wall of the tongue and the posterior pharynx wall, probably due to an
anterior position of the tongue in children that may present an obstruction.
Figure. 1 Vertical skeletal cephalometric variables: 1, FMA; 2, SN.Gn; 3,
Ricketts axis; 4, SN.Opl; 5, Opl.GoGn; 6, Ricketts palatal angle; 7, IFH (inferior
face height).
Figure. 2 Sagital skeletal and dental cephalometric variables: 8, SNA; 9, SNB;
10, ANB; 11, A-Nperp; 12, Pg-Nperp; 13, Co-A; 14, Co-Gn; 15, 1.SN; 16,
1.NA; 17; 1-NA; 18; 1-NB; 19, 1.NB; 20, IMPA; 21, 1.1;
Figure. 3 Pharyngeal airway spaces variables: A, distance between PNS and
posterior wall of pharynx in ANS-PNS plane; B, superior McNamara airway
space taken on half superior of soft palate, and measured on the narrowed
space between soft palate and posterior wall of pharynx; C, distance between
inferior soft palate point (Ppm) and posterior wall of pharynx in a line parallel
to oclusal plane; D, inferior McNamara airway space measured from
intersection of posterior border of tongue and inferior border of mandible to the
closer point on posterior pharyngeal wall; E, hipopharyngeal airway space, the
narrowed space found from anterior to posterior wall of pharynx below the
mandible border.
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