Comparison of sagittal dimension of upper airway space

COMPARISON OF SAGITTAL DIMENSION
OF UPPER AIRWAY SPACE IN
UNOPERATED CLEFT PALATE PATIENTS
AND NON-CLEFT NORMAL SUBJECTS OF
LOCAL POPULATION
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Introduction
Nasal cavity is the usual pathway for
respiratory airflow.
Blockage causes elevation of head.
Head posture changes after therapeutic
measures for improving breathing.
Extension of head causes increase in
pharyngeal airway space.

An increase is seen during pre and
early adolescence.
Lymphatic tissue increases in infancy,
continuous to grow though at a slower
rate until puberty.
A gradual decline is seen later on
(Scammon).

Oral v/s nasal respiration has been a
controversy in the development of face and
occlusion.
Inadequate airway results in certain
deformities.
Compensatory mechanisms is seen by
altered positions of associated parts.
This leads to a shift from nasal to oral
respiration.

In cleft palate individuals, airway space gets
altered due to various causes.
The hypothesis that reduced airway space
due to enlarged adenoids which may cause
certain malocclusion deserves a close study.
This has generated interest in recent years in
measurement of airway space in subjects
with cleft palate.

Children from poor families or rural
background receive minimal or no treatment.
Measurement of nasopharyngeal area in
patients with unoperated cleft palates has not
been reported, to the best of our knowledge.
So, investigation of this dimension in such
patients and comparing them with normal
subjects as well as with studies on operated
cleft palate patients was thought necessary.

Aims & Objectives
To study if there exists a similarity or
difference in the upper airway space,
between unoperated cleft palate
patients, and normal individuals.
To compare the findings of our study on
unoperated cleft patients with those
reported in the literature on operated
cleft palate patients.

Materials & Method
The aim of the study was to compare
upper airway space in patients with cleft
palate and normal individuals.
The subjects were selected at random
from the Department of Orthodontics
and Smile Train Program at the
Craniofacial Unit of S.D.M. College of
Dental Sciences, Dharwad.

All the cleft palate patients had complete
unilateral clefts involving the hard and soft
palate, which were unrepaired (though most
had their lips repaired).
The control group was selected at random
from the Department of Orthodontics.
All the subjects selected were adolescents in
the age group between 11-15 years.

Sample consisted of 30 subjects, of which 15 were
cleft palate patients, and 15 were control group.
The data collected consisted of lateral cephalograms
taken with the subjects at rest in natural head
position.
All the measurements were derived from acetate
tracings of lateral cephalograms.
The upper airway was measured in the study using
the methods proposed by McNamara, Naoko
Imamura et al, T. Wada et al and K. Satoh et al.

Discussion
Present study was aimed at comparing the
upper airway space between cleft palate
group and non-cleft group.
Subjects were taken from Indian population
belonging to both sexes.
The no. of subjects in each group were
sufficient to render the result statistically
significant.
Since the study involved adolescents in the
age range 11-15 years and therefore,
interpretations from the study are applicable
only to that age group.www.indiandentalacademy.com

Methodology:
In McNamara’s method:
Samples were evaluated using an unpaired t-
test.
Mean and standard deviation was done for
airway space and compared between the two
groups.
The airway of cleft subject was significantly
smaller (P<0.05) than the non-cleft subjects.

In Imamura et al’s method:
t-test was carried out on all the parameters
P1, P2, P3, P4 and hPMP by comparing one
group to the other.
All the measurements in the cleft group were
significantly smaller (P<0.05) for the
parameters P1, P2 and P4 than the non-cleft
group.
This finding is similar to that of Imamura et al.

The values of P3 were also smaller in the cleft
group than in the control group.
But the difference was not statistically
significant, unlike in Imamura et al’s study.
The measurement of hPMP in the cleft group
was smaller than the non-cleft group.
The result was not statistically significant
which is similar to that of Imamura et al’s
study.

T. Wada et al and K. Satoh et al’s method
Comparison of airway space between control
and cleft group of our study using T. Wada et
al and K. Satoh et al’s method showed
statistical significance at P<0.05.
This implies that the cleft group has a smaller
airway which agrees with their study.

The airway of operated cleft subjects
was significantly smaller than in
unoperated clefts at P<0.01 for stage-3
study group of K. Satoh et al.
Stage-4 study group showed a smaller
airway at P<0.05.

In comparison with Wada et al, stage-3
study group also showed a smaller
airway at P<0.01.
Stage-4 of Wada et al showed a larger
measurement than our study group.
This was not statistically significant
(P>0.05).

Interpretation of Results and Comparison
with other Studies
The results of this study showed that
the cleft palate subjects tend to have
smaller airway than the normal
individuals.
This is in agreement with other similar
studies.

James A. McNamara
He measured the upper airway space
from lateral cephalograms in all the
subjects in the age group of 6-18 years.
In his study the average airway size, for
both sexes was 17.40mm.

Ours was a comparative study between
normal individuals and unoperated complete
cleft palate subjects.
This is unlike McNamara who had done his
study only on normal individuals.
The subjects in our study were adolescent
children (11-15 years).
The average airway size in normal individuals
of our study was 17.67mm for both sexes,
which is close to the figure reported by
McNamara.

T. Wada et al and K. Satoh et al
T. Wada et al used a study sample of 82
unilateral operated complete cleft lip and
palate patients and 80 non-cleft controls.
In Satoh et al’s study 61 unilateral operated
complete cleft lip and palate patients and 82
non-cleft controls were used.

All the subjects in both the studies were
examined at 4 stages of development.
 Stage-1 at 4 years of age.
Lateral cephalograms were taken with
the subjects at rest.

Stage-3 and Stage-4 of both the studies were
considered, as our sample of adolescents
(11-15 years) lay between these groups.
The results obtained in our study were close
to the previous study at a significant level
(P<0.05).
In one case where control group of T. Wada
et al’s study was compared to our study
group, it showed similarity at P<0.01.

Naoko Imamura et al
Comparison was carried out between two
paired groups (juvenile and adolescent).
Each group was again divided into a cleft
palate juvenile group (CLP/J group) and a
control juvenile group (Control/J group).
Likewise, it was done in the adolescents as
cleft palate adolescent group (CLP/A group)
and a control adolescents group (control / A
group).

The adolescent group consisted of 20
subjects in each group respectively.
The subjects in all the groups were
subjected to lateral cephalograms
which were duly traced.

Their study showed the following results after
doing an analysis of variance. Statistical
significance was established at P<0.05.
Both cleft palate juvenile and cleft palate
adolescent had narrow upper airway in
comparison to controls.
There was no change in hPMP values when
compared between the two groups.

We compared only one group i.e.
adolescent cleft palate patient to
normal individuals in the same age.
A mixed group of males and females were
chosen without differentiation.
As in Imamura et al’s study all the subjects
were subjected to lateral cephalograms for
which tracings were done.

Our results showed a statistical significance
of P<0.05 among the three mean values (P1,
P2 and P3) that were obtained in our study.
This shows a similarity between the two
studies.
Though the values of P3 were lesser in the
cleft group than in the non-cleft group, the
results was not statistically significant.
This is unlike in Imamura et al’s study.

In our study, parameter hPMP is
reduced in the cleft group compared to
non-cleft group.
However, our result did not show any
statistical significance, which is similar
to the above study.

Comparison of unoperated cleft palate
subjects in our study and the operated cleft
palate subjects in the studies of Satoh et al
and Wada et al indicates that the
unoperated cleft palate subjects in our
study group have larger airway
dimensions than the operated cleft
palate subjects in their study group
which is statistically significant (one
comparison at P<0.05 and two at P<0.01).

Only the stage-4 subjects of Wada et al had
slightly larger airway dimension than in our
unoperated subjects.
However, these were more advanced in age
(mean age 17 years) than our subjects.
So the comparison cannot be conclusive due
to the added growth in their sample.
Even the stage-4 operated group of Satoh et
al (mean age 17 years) had lesser airway
dimension than the unoperated younger
subjects in our study.

Hence, it may be concluded that a
strong possibility exists that cleft
palate closure further reduces the
airway dimension, which is already
smaller than in the normal individuals.
This needs to be confirmed by conducting a
larger study involving both younger and older
subjects.

Clinical Relevance
It is to be anticipated that cleft palate
patients tend to have a smaller upper
airway size when compared to normal
individuals of the same age group.
Wada et al have opined that the
posterior limit of maxilla is placed more
superiorly and posteriorly in cleft
patients.

A posteriorly placed maxilla may be a
compensation seen in cleft palate
individuals.
Enlarged adenoids along with the
maxillary placement also help in
velopharyngeal closure in cleft palate
patients.

So, adenoidectomy in these patients
should be delayed or not considered as
it may hinder normal speech and
deglutition.
Advancement of maxilla using
orthopedic force or surgery could also
effect speech.

Recommendations for future studies
Since lateral cephalogram is a 2-dimensional
method, it is recommended that a 3-
dimensional method, such as nasal
endoscopy, may be carried out with the help
of an ENT surgery.
The control group, which was selected
randomly, also needs to be scrutinized for the
presence or absence of adenoids and tonsils.

The placement and size of the maxilla
needs to be analyzed, since it is said
that maxilla is usually at fault in cleft
palate patients.
A larger sample of younger and older
group with segregation of gender could
be carried out.

Summary and Conclusion
The purpose of the study was to compare
upper airway space of cleft palate patients
with normal individuals.
The samples for the study were selected at
random from the Department of Orthodontics
and Smile Train Program at the Craniofacial
Unit of S.D.M. College of Dental Sciences,
Dharwad.

All the subjects used in the study were
adolescents in the age group of 11-15 years.
Standardized lateral cephalograms in natural
head position were taken for all the subjects.
McNamara, Imamura et al, K. Satoh et al and
T. Wada et al’s airway space analyses were
done.
All the results were subjected to statistical
analysis.

In McNamara’s method, it did reveal that the
cleft palate individuals have smaller airway
than the normal individuals. (statistical
significance P<0.05).
In Imamura et al’s analyses, three parameters
(P1, P2, P3) showed significance at P<0.05
between the two groups.

The parameter P3 also was smaller in
cleft group, but not significant
statistically.
The parameter hPMP showed that
maxillary placement in relation to
cranium is slightly more posterior in the
study group, than in the control group
though not significant statistically.

In K. Satoh et al and T. Wada et al’s method,
a statistical significance of P<0.01 was seen
indicating a smaller pharyngeal depth in the
cleft group than in the normal group.
When the measurements from our study
(unoperated clefts) were compared with
studies done by others like, Wada et al and
Satoh et al (operated clefts), it indicated a
strong possibility that cleft palate closure
reduces the airway dimension further.

The difference in upper airway space
between cleft palate individuals and normal
individuals, with the space being less in cleft
palate individuals, may be on account of the
following reasons:
 Deficient maxillary growth.
 Posteriorly placed maxilla.
 Presence of adenoids in adolescents, which are
essential in cleft palate patients, since they
facilitate velopharyngeal closure and aid in
speech, and other functions.

Shortcomings of this study
Using a three-dimensional method of studying the
upper airway along with the involvement of an ENT
surgeon.
The control group, which was selected at random,
needs to be clinically examined for the presence or
absence of adenoids and tonsils.
Since the maxilla is usually at fault, the size and
placement of it needs to be studied further.
A larger sample with segregation of gender and of
age needs to be taken.

Comparison of sagittal dimension of upper airway space

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Comparison of sagittal dimension of upper airway space