10.14639/0392-100X-N1225
Objectives. To evaluate the association between upper airway obstruction and occlusal anomalies in mouth-breathing children.Methods. 356 mouth-breathing children were evaluated by ENT physicians and specialists in orthodontics. ENT examination included nasal endoscopy to assess the adenoidal hypertrophy, tonsillar grading and presence of nasal septum deviation. Clinical orthodontic examination was performed to record occlusal variables. Univariate and multivariable logistic regression were performed to study the association between registered variables. Results. 221 patients (mean age ± sd = 6.2 ± 2.5 years) met inclusion criteria. 81.4% of children presented malocclusion. A significant association between tonsillar grade 2 and the presence of malocclusion, Class II relation and increased overjet was shown. Tonsillar grade 4 showed a significant association with the presence of malocclusion and increased overjet. Adenoidal hypertrophy and nasal septum deviation did not show any association with occlusal findings.Conclusions. A high frequency of orthodontic problems was seen in mouth-breathing children. Our results suggested that severe tonsillar hypertrophy may determine presence of malocclusion and increased overjet. On the other hand, the association between mild tonsillar hypertrophy and many occlusal anomalies in mouth-breathers suggest an important role of malocclusion in the onset of oral breathing in children.
text/xml
1827-675X
1225
en
Angela Galeotti
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
nasal septum deviation
Association between upper airway obstruction and malocclusion in mouth-breathing children
Text.Serial.Journal
https://www.actaitalica.it/
41
Rhinology
2021-11-05
2020-11-04
2021-11-02
2021-11-02
436-442
1
Angela Galeotti
2021/11/05
10.14639/0392-100X-N1225
436
Dentistry Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
1827-675X
nasal septum deviation
en
442
Association between upper airway obstruction and malocclusion in mouth-breathing children
https://www.actaitalica.it/article/download/1225/679
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:436-442; doi: 10.14639/0392-100X-N1225




Rhinology


Association between upper airway obstruction
and malocclusion in mouth-breathing children
Associazione tra l’ostruzione delle vie aeree superiori e le malocclusioni in bambini
con respirazione orale
Paola Festa1,2, Nicola Mansi1, Alfonso Maria Varricchio1, Fabio Savoia3, Camilla Calì3, Carmela Marraudino4,
Giovanni Carlo De Vincentiis5, Angela Galeotti2
1
  Otorhinolaryngology Unit, AORN Santobono-Pausilipon, Naples, Italy; 2 Dentistry Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome,
Italy; 3 Evaluative Epidemiology-Childhood Cancer Registry of Campania, AORN Santobono-Pausilipon, Naples, Italy; 4 Dentistry Unit,
AORN Santobono-Pausilipon, Naples, Italy; 5 Otorhinolaryngology Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy


SUMMARY
Objectives. To evaluate the association between upper airway obstruction and occlusal
anomalies in mouth-breathing children.
Methods. 356 mouth-breathing children were evaluated by ENT physicians and specialists
in orthodontics. ENT examination included nasal endoscopy to assess the adenoidal hyper-
trophy, tonsillar grading and presence of nasal septum deviation. Clinical orthodontic ex-
amination was performed to record occlusal variables. Univariate and multivariable logistic
regression were performed to study the association between registered variables.
Results. 221 patients (mean age ± sd = 6.2 ± 2.5 years) met inclusion criteria. 81.4% of children
presented malocclusion. A significant association between tonsillar grade 2 and the presence
of malocclusion, Class II relation and increased overjet was shown. Tonsillar grade 4 showed        Received: November 4, 2020
a significant association with the presence of malocclusion and increased overjet. Adenoidal        Accepted: April 19, 2021
hypertrophy and nasal septum deviation did not show any association with occlusal findings.
Conclusions. A high frequency of orthodontic problems was seen in mouth-breathing chil-             Correspondence
dren. Our results suggested that severe tonsillar hypertrophy may determine presence of             Paola Festa
                                                                                                    Otorhinolaryngology Unit, AORN Santobono-Pau-
malocclusion and increased overjet. On the other hand, the association between mild tonsil-
                                                                                                    silipon, via M. Fiore 9, 80128 Naples, Italy
lar hypertrophy and many occlusal anomalies in mouth-breathers suggest an important role            E-mail: paolafesta1@gmail.com
of malocclusion in the onset of oral breathing in children.
KEY WORDS: mouth-breathing, malocclusion, adenoids, tonsils, nasal septum deviation                 Funding
                                                                                                    The Authors acknowledge Ferrarelle S.p.a. for partly
                                                                                                    sustaining this research.
RIASSUNTO
Razionale. Valutare l’associazione tra l’ostruzione delle vie aeree superiori e le anomalie         Conflict of interest
occlusali in bambini con respirazione orale.                                                        The Authors declare no conflict of interest.
Metodi. 356 pazienti pediatrici con respirazione orale sono stati valutati in un ambulatorio
multidisciplinare composto da specialisti in otorinolaringoiatria ed ortognatodonzia. La visi-        How to cite this article: Festa P, Mansi N,
ta prevedeva valutazione otorinolaringoiatrica con rinofibroscopia e valutazione ortodontica.         Varricchio AM, et al. Association between
Risultati. 221 pazienti (età media ± dev st = 6,2 ± 2,5 anni) rispondevano ai criteri di              upper airway obstruction and malocclusion
inclusione e sono stati inseriti nel presente studio. L’81,4% dei pazienti presentava una             in mouth-breathing children. Acta Otorhi-
malocclusione. Un’associazione statisticamente significativa è stata evidenziata tra il 2°            nolaryngol Ital 2021;41:436-442. https://doi.
grado di ipertrofia tonsillare e presenza di malocclusione, malocclusione di Classe II e              org/10.14639/0392-100X-N1225
overjet aumentato. L’ipertrofia tonsillare di 4° grado è risultata associata alla presenza di
malocclusione e overjet aumentato. L’ipertrofia adenoidea e la deviazione del setto nasale          © Società Italiana di Otorinolaringoiatria
                                                                                                    e Chirurgia Cervico-Facciale
non sono risultate associate alle variabili occlusali.
Conclusioni. Nei bambini con respirazione orale è presente un’elevata frequenza di ano-
                                                                                                                   OPEN ACCESS
malie occlusali. I nostri risultati suggeriscono che una grave ipertrofia tonsillare può deter-
minare la presenza di malocclusione e aumento dell’overjet. D’altra parte, l’associazione           This is an open access article distributed in accordance with
                                                                                                    the CC-BY-NC-ND (Creative Commons Attribution-Non-
tra una ipertrofia tonsillare di grado lieve e diverse anomalie occlusali suggerisce un ruolo       Commercial-NoDerivatives 4.0 International) license. The
importante della malocclusione nell’insorgenza della respirazione orale nei bambini.                article can be used by giving appropriate credit and mentio-
                                                                                                    ning the license, but only for non-commercial purposes and
PAROLE CHIAVE: respirazione orale, malocclusione, adenoidi, tonsille, deviazione del                only in the original version. For further information: https://
setto nasale                                                                                        creativecommons.org/licenses/by-nc-nd/4.0/deed.en




436
                                                                    Upper airway obstruction and malocclusion in mouth-breathing children




Introduction                                                     The consent of parents and children was obtained as appro-
                                                                 priate, after explanation of the purpose of the examination.
The main causes of mouth-breathing in children are aller-
gic rhinitis, adenoidal hypertrophy, enlarged palatal tonsils
                                                                 ENT examination
and obstructive deviation of the nasal septum 1. The asso-
                                                                 An interview was performed with the children’s parents, or
ciation between mouth-breathing and dental malocclusions
                                                                 caregivers, to confirm the chief complaint of mouth-breath-
has been previously reported 2-4. Oral breathing is associ-
                                                                 ing. According to Yamaguchi et al. 10, we defined a subject
ated with a downward position of the mandible and subse-
                                                                 as a mouth-breather if the parents reported 2 or more posi-
quently lower position of the tongue that may result in al-
                                                                 tive items of the 3 following items during daytime: “breathes
tered craniofacial growth 5,6. The reported effects on dental
                                                                 with mouth ordinarily,” “mouth is open ordinarily,” and
occlusion are increased overjet, reduced overjet, anterior
                                                                 “mouth is open when chewing” or 2 or more positive items
or posterior crossbite, open bite and displacement of con-
                                                                 among the following 3 items during nighttime: “snoring,”
tact points 4. The skeletal features associated with mouth-
                                                                 “mouth is open during sleeping,” and “mouth is dry when
breathing are reduction in transversal growth of the upper
                                                                 your child gets up”. Evaluation of tonsillar hypertrophy
arch with posterior crossbite, anterior open bite due to in-
                                                                 grading was performed by an ENT specialist with more than
crease of the anterior lower facial height and development
                                                                 10 years of working experience according to Brodsky and
of Class II malocclusion 5. On the other hand, the influence
                                                                 Koch 11 as follows: grade 0, tonsils limited to the tonsillar
of adenoidal and tonsillar hypertrophy on dental occlusion
                                                                 fossa; grade 1, tonsils occupying up to 25% of the space be-
in children is controversial 2,7,8 and the association between
                                                                 tween the anterior pillars in the oropharynx; grade 2, tonsils
malocclusion and nasal septum deviation has rarely been
                                                                 occupying 25-50% of the space between the anterior pillars;
investigated 9. Therefore, the aim of this study is to evalu-
                                                                 grade 3, tonsils occupying 50-75% of the space between the
ate the association between severity of the obstruction by
                                                                 anterior pillars; and grade 4, tonsils occupying 75-100% of
adenoidal and palatal tonsillar hypertrophy or the presence
                                                                 the space between the anterior pillars. Nasal endoscopy was
of nasal septum deviation and occlusal variables in mouth-
breathing children to investigate the role of cause-effect be-   performed to evaluate adenoidal hypertrophy in 4 grades 12:
tween upper airways obstruction and malocclusion.                grade 1 describes the adenoids occupying less then 25% of
                                                                 the choanal area, grade 2 adenoids occupy 25% to 50% of
                                                                 the choanal area, grade 3 adenoids occupy 50% to 75% of
Materials and methods                                            the choanal area, grade 4 adenoids occupy 75% to 100% of
This study was conducted in accordance with the princi-          the choanal area. The presence of nasal septum deviation
ples of the Helsinki Declaration of 1975, as revised in 1983     was assessed when a mucosal contact point between septal
and approval of the Ethics Committee was obtained (no.           crest and inferior turbinate was seen at nasal endoscopy.
1186_OPBG_2016).
                                                                 Dental examination
Population                                                       All children underwent a specific dental examination by
Three-hundred fifty-six patients referred to Otorhinolar-        two specialists in orthodontics with more than 10 years of
yngology Unit of Bambino Gesù Children’s Hospital,               working experience.
IRCCS (Rome, Italy) and Otorhinolaryngology Unit of              The following occlusal variables were evaluated:
Santobono-Pausilipon Children’s Hospital (Naples, Ita-           • Primary canine relation: Class I, II, or III according to
ly) between July 2017 and February 2020 with the chief             Angle classification. Due to the small number of chil-
complaint of mouth-breathing for at least 6 months were            dren with an asymmetric canine relation, they were com-
evaluated by a multidisciplinary team comprised of ENT             bined as Class II or Class III canine relation.
physicians and specialists in orthodontics in a collegiate       • Posterior crossbite: present, absent. A posterior crossbite
medical examination. Exclusion criteria were: age young-           was recorded if the buccal cusp of at least one upper pri-
er than two years old, genetic syndromes, recent acute in-         mary or permanent molar tooth occluded lingually to the
fections of the upper airways or acute otitis media in the         buccal cusp of the corresponding lower tooth.
last 10 days, previous history of orthodontic treatment or       • Open bite: present, absent. It was considered as present
an adenoidectomy and/or tonsillectomy, acute and chron-            if the overlap of the lower incisors by upper incisors in
ic pathologies of the lower airways, congenital malfor-            the vertical plane is less than 1 mm.
mations of the airways, chronic rhinosinusitis with nasal        • Deep bite: present, absent. It was considered present if
polyposis, dental anomalies or missing teeth in deciduous          the overlap of the lower incisors by upper incisors in the
dentition.                                                         vertical plane is more than 3 mm.



                                                                                                                                    437
P. Festa et al.




• Reduced overjet (OVJ): present, absent. It was consid-        Table I. Prevalence of ENT and dental findings.
   ered if the distance between upper and lower incisors in      Variable                                n                                %
   the horizontal plane is less than 1 mm.                       Sex
• Increased overjet (OVJ): present, absent. It was consid-          M                                        130                         58.8
   ered if the distance between upper and lower incisors in         F                                        91                          41.2
   the horizontal plane is more than 3 mm.                       Adenoidal hypertrophy
The presence of malocclusion was assessed when one or
                                                                    1                                        26                          11.8
more occlusal parameters were altered.
The measurements were taken manually using a calibrated             2                                        79                          35.7
calliper and the other variables were assessed by direct in-        3                                        64                          29.0
spection.                                                           4                                        52                          23.5
                                                                 Tonsillar grading
Statistical analysis                                                1                                        45                          20.4
The analysis was performed using the STATA software ver-            2                                        100                         45.2
sion 14.2 (StataCorp LP, College Station, TX, USA). The             3                                        54                          24.4
statistical significance was set at P < 0.05.
                                                                    4                                        22                          10.0
All the categorical variables were summarised by absolute
                                                                 Nasal septum deviation
frequencies and percentage. The Spearman correlation co-
efficient (rho) was used to test the strength of association        No                                       186                         84.2
between age and adenoidal hypertrophy and between age               Yes                                      35                          15.8
and tonsillar grading.                                           Presence of malocclusion
Multivariable and univariate logistic regression models             No                                       41                          18.6
were developed to assess independent variables associated           Yes                                      180                         81.4
with occlusal findings. The independent ENT variables ex-        Class
amined were adenoidal hypertrophy, tonsillar grading and
                                                                    I                                        140                         63.3
nasal septum deviation. In multivariable analysis, the re-
sults were adjusted by age and sex.                                 II                                       67                          30.3
For the purpose of statistical analysis, the dependent vari-        III                                      14                          6.3
able of malocclusion was both binarily grouped both ana-         Posterior cross-bite
lysed by multinomial logistic regression model.                     No                                       148                         67.0
                                                                    Yes                                      73                          33.0
Results                                                          Open bite
                                                                    No                                       157                         71.0
Two hundred and twenty-one patients (130 boys (58.8 %)
and 91 girls (41.2%), mean age ± SD = 6.2 ± 2.5 years)              Yes                                      64                          29.0
were included. One-hundred and thirty-five children were         Deep bite
excluded due to exclusion criteria.                                 No                                       141                         63.8
The absolute frequencies (n) and percentage (n/N x 100%)            Yes                                      80                          36.2
of ENT variables and occlusal findings is shown in Table I.      Reduced overjet
The results showed a significant negative correlation               No                                       197                         89.1
between age and adenoidal hypertrophy (P < 0.001;
                                                                    Yes                                      24                          10.8
rho = -0.27) and between age and tonsillar grading
                                                                 Increased overjet
(P < 0.001; rho = -0.23) (Tab. II).
A significant association between tonsillar grade 2 and             No                                       151                         68.3
the presence of malocclusion was found by univari-                  Yes                                      70                          31.7
ate (OR = 2.30, p = 0.05) and multivariable (OR = 2.86,         Number of children (n) and prevalence given in percentage (n/N x100%).
p = 0.03) analyses. Furthermore, tonsillar grade 4 and the
presence of malocclusion showed a significant association       p = 0.03) between tonsillar grading 2 and Class II rela-
in multivariable analysis (OR = 4.58, p = 0.05).                tion. Furthermore, tonsillar grade 2 showed a significant
The results of univariate and multivariable analyses showed     association with increased overjet in univariate (OR = 5.56,
a significant association (OR = 2.78, p = 0.02 and OR = 2.66,   p = 0.00) and multivariable analyses (OR = 5.46, p = 0.00).



438
                                                                                                Upper airway obstruction and malocclusion in mouth-breathing children




Table II. Correlation coefficient between age and adenoidal hypertrophy and                  In this study, the occlusal variables showed a high frequen-
between age and tonsillar grading.                                                           cy of malocclusion in mouth-breathing children similar to
                  Adenoidal hypertrophy             Tonsillar grading                        data from a recent study in children with obstructive sleep
                         (1, 2, 3, 4)                  (1, 2, 3, 4)
                                                                                             apnea 14. This confirms that malocclusion is more frequent
                          Rho                    P           Rho               P
                                                                                             in mouth-breathing children compared to nasal breathers as
    Age                  -0.27             < 0.001           -0.23          < 0.001          reported previously 4,14.
Rho: Spearman correlation coefficient.                                                       No association was seen between adenoidal hypertrophy
                                                                                             and occlusal variables in this study. This suggests that
                                                                                             adenoidal hypertrophy does not determine an increase of
Moreover, tonsillar grade 4 showed a significant association
                                                                                             malocclusion in children with mean age of 6 years. Similar
with increased overjet in univariate (OR = 8.00, p = 0.00)
                                                                                             results were reported by Sidlauskiene et al. 15 who found no
and multivariable analyses (OR = 10.17, p = 0.00).
                                                                                             significant association between the presence of orthodontic
On the other hand, adenoidal hypertrophy and nasal septum
                                                                                             characteristics and otorhinolaryngologic pathology (hyper-
deviation did not show any association with occlusal variables.
                                                                                             trophy of adenoids or tonsils, nasal septum deviation and
No association was seen between adenoidal hypertrophy,
                                                                                             allergic rhinitis) in their sample and by Souki2 who reported
tonsillar grading and nasal septum deviation and posterior
                                                                                             adenoids/tonsils hyperplasia have no association with the
crossbite, open bite or deep bite.
                                                                                             prevalence of class II relation, anterior open bite and pos-
The results of univariate and multivariable analyses are
presented in Tables III, IV and V.                                                           terior cross-bite.
                                                                                             On the other hand, some cephalometric studies have sug-
                                                                                             gested an association between reduced upper nasopharyn-
Discussion                                                                                   geal width and skeletal anomalies such as mandibular verti-
The objective of this study was to evaluate the association                                  cal growth evaluated in children of similar age 16,17.
between severity of the obstruction by adenoidal and tonsil-                                 The absence of association between adenoidal hypertrophy
lar palatal hypertrophy, the presence of nasal septum devia-                                 and occlusal variables might also be related to the young
tion and the occlusal findings in mouth-breathing children.                                  age of patients (about 6 years old) in our study: it is con-
Firstly, we found the severity of adenoidal hypertrophy                                      ceivable that the malocclusion develops at a later age since
and tonsillar grading decreased with age, as reported to be                                  the respiratory deficit due to adenoidal hypertrophy takes
physiologically normal 13.                                                                   a few years before determining any dental changes. Cheng


Table III. Results of univariate and multivariable logistic regression analysis between grouped malocclusion (dependent variable) and the ENT independent vari-
ables.
 Variable                                      Malocclusion
                                                  NO                       YES
                                             (n = 41, 19%)           (n = 180, 81%)            Univariate analysis                    Multivariable analysis
                                                 n     %              n        %      OR            95% CI           p value    OR           95% CI            p value
    Adenoidal hypertrophy
      1                                           5   19.2            21      80.8
      2                                          12   15.2            67      84.8    1.33       0.42      4.21       0.63     0.91      0.25      3.35         0.89
      3                                          13   20.3            51      79.7    0.93       0.30      2.95       0.91     0.61      0.16      2.27         0.46
      4                                          11   21.2            41      78.8    0.89       0.27      2.89       0.84     0.50      0.12      2.05         0.34
    Tonsillar grading
      1                                          13   28.9            32      71.1
      2                                          15   15.0            85      85.0    2.30       0.99      5.37      0.05*     2.86      1.14       7.17       0.03*
      3                                          10   18.5            44      81.5    1.79       0.70      4.58      0.23      2.58      0.90       7.38       0.08
      4                                           3   13.6            19      86.4    2.57       0.65     10.20      0.18      4.58      0.99      21.33       0.05*
    Nasal septum deviation
      No                                         37   19.9           149      80.1
      Yes                                         4   11.4           31       88.6    1.92       0.64      5.79       0.24     2.53      0.77      8.30         0.13
*
    statistically significant, p value ≤ 0.05.




                                                                                                                                                                  439
P. Festa et al.




Table IV. Results of univariate and multivariable multinomial logistic regression analysis between classes of malocclusion (dependent variable) and the ENT in-
dependent variables.
                                                                                      Univariate analysis                     Multivariable analysis
                          Variable                       n         %         OR            95% CI          p Value      OR            95% CI         p Value
    Class I        Adenoidal hypertrophy
    (n = 140, 64%)
                     1                                  17        12.1
                     2                                  51        36.4
                     3                                  42        30.0
                     4                                  30        21.4
                   Tonsillar grading
                     1                                  34        24.3
                     2                                  58        41.4
                     3                                  34        24.3
                     4                                  14        10.0
                   Nasal septum deviation
                     No                                 119       85.0
                     Yes                                 21       15.0
    Class II       Adenoidal hypertrophy
    (n = 67, 30%)
                     1                                   6        9.0
                     2                                  25        37.3       1.39      0.49       3.96      0.54       1.10       0.35      3.50       0.87
                     3                                  19        28.4       1.28      0.44       3.76      0.65       1.18       0.36      3.93       0.78
                     4                                  17        25.4       1.61      0.53       4.85      0.40       1.31       0.37      4.62       0.67
                   Tonsillar grading
                     1                                   8        11.9
                     2                                  38        56.7       2.78      1.16       6.66      0.02*      2.66       1.07      6.59      0.03*
                     3                                  14        20.9       1.75      0.65       4.71      0.27       1.60       0.56      4.55      0.38
                     4                                   7        10.4       2.12      0.65       6.99      0.21       1.92       0.54      6.90      0.32
                   Nasal septum deviation
                     No                                 57        85.1
                     Yes                                10        14.9       0.99      0.44       2.25      0.99       1.03       0.43      2.45       0.95
    Class III      Adenoidal hypertrophy
    (n = 14, 6%)
                     1                                   3        21.4
                     2                                   3        21.4       0.33      0.06       1.81      0.20       0.48       0.06      3.62       0.48
                     3                                   3        21.4       0.40      0.07       2.21      0.30       0.54       0.07      3.94       0.54
                     4                                   5        35.7       0.94      0.20       4.45      0.94       1.24       0.16      9.43       0.84
                   Tonsillar grading
                     1                                   3        21.4
                     2                                   4        28.6       0.78      0.16       3.70      0.76       1.29       0.21      7.76       0.78
                     3                                   6        42.9       2.00      0.46       8.66      0.35       3.41       0.57      20.54      0.18
                     4                                   1        7.1        0.81      0.08       8.46      0.86       1.97       0.13      29.37      0.62
                   Nasal septum deviation
                     No                                 10        71.4
                     Yes                                 4        28.6       2.27      0.65       7.90      0.20       1.81       0.42      7.79       0.43
*
    statistically significance, p value ≤ 0.05.




440
                                                                                         Upper airway obstruction and malocclusion in mouth-breathing children




Table V. Results of univariate and multivariable logistic regression analysis between reduced or increased OVJ (dependent variable) and the ENT independent
variables.
 Variable                                    Reduced OVJ
                                                   NO                YES
                                             (n = 197,89%)      (n = 24,11%)            Univariate analysis                     Multivariable analysis
                                                 n     %        n        %     OR            95% CI           p Value    OR            95% CI            p Value
    Adenoidal hypertrophy
      1                                          23   88.5      3       11.5
      2                                          72   91.1      7       8.9    0.75       0.18      3.12       0.69     0.58       0.11      2.92         0.51
      3                                          59   92.2      5       7.8    0.65       0.14      2.94       0.58     0.43       0.08      2.36         0.33
      4                                          43   82.7      9       17.3   1.60       0.40      6.52       0.51     1.11       0.21      5.94         0.91
    Tonsillar grading
      1                                          41   91.1      4       8.9
      2                                          91   91.0      9       9.0    1.01       0.30      3.48       0.98     1.09       0.29      4.16         0.90
      3                                          45   83.3      9       16.7   2.05       0.59      7.17       0.26     2.14       0.53      8.65         0.28
      4                                          20   90.9      2       9.1    1.03       0.17      6.08       0.98     0.98       0.14      6.81         0.99
    Nasal septum deviation
      No                                     166      89.2      20      10.8
      Yes                                    31       88.6       4      11.4   1.07       0.34      3.35       0.91     1.28       0.36      4.52         0.70
    Variable                                           Incresed OVJ
                                                   NO               YES
                                             (n = 151, 68%)    (n = 70, 32%)            Univariate analysis                     Multivariable analysis
                                                 n     %        n        %     OR            95% CI           p Value    OR            95% CI            p Value
    Adenoidal hypertrophy
      1                                          21   80.8       5      19.2
      2                                          48   60.8      31      39.2   2.71       0.93      7.95       0.07     2.18       0.64      7.49         0.21
      3                                          46   71.9      18      28.1   1.64       0.54      5.02       0.38     1.62       0.45      5.90         0.46
      4                                          36   69.2      16      30.8   1.87       0.60      5.83       0.28     1.32       0.35      5.02         0.68
    Tonsillar grading
      1                                          40   88.9       5      11.1
      2                                          59   59.0      41      41.0   5.56       2.02     15.29      0.00*      5.46      1.91      15.65       0.00*
      3                                          41   75.9      13      24.1   2.54       0.83      7.77      0.10       2.87      0.88       9.32       0.08
      4                                          11   50.0      11      50.0   8.00       2.29     27.93      0.00*     10.17      2.59      39.89       0.00*
    Nasal septum deviation
      No                                     125      67.2      61      32.8
      Yes                                    26       74.3       9      25.7   0.71       0.31      1.61       0.41     0.81       0.33      1.97         0.64
*
    statistically significant, p value ≤ 0.05.



et al. 18 noted that the younger a subject is, at the time of                         upper airways obstruction. Some authors2 have highlighted
evaluation, the less the ‘‘adenoid’’ type of facial character-                        the important role of heredity in mouth-breathing children
istics is expressed.                                                                  as a secondary etiological factor to Class II development.
Furthermore, our results showed an association between                                Finally, our study showed a very strong association be-
tonsillar grading 2 and several orthodontic anomalies: the                            tween tonsillar Grade 4 and the presence of malocclusion
presence of malocclusion, Class II relation and increased                             (OR = 4.58) and increased overjet (OR = 10.17). This is
overjet. These results indicate that mouth-breathing chil-                            interesting because it suggests that severe tonsillar hyper-
dren with mild tonsillar hypertrophy often present ortho-                             trophy may have an aetiologic role in the development of
dontic problems. Our hypothesis is that in patients with                              malocclusion. On the other hand, Diouf et al. 8 showed that
mild tonsillar grading the presence of breathing problems is                          tonsillar Grade 4 was strongly associated with molar Class
due more to craniofacial anomalies than to the presence of                            II relation and posterior crossbite with functional lateral de-



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P. Festa et al.




viation of the mandible in a sample of children with mean                    3
                                                                                  Zicari AM, Albani F, Ntrekou P, et al. Oral breathing and dental
                                                                                  malocclusions. Eur J Paediatr Dent 2009;10:59-64.
age of about 9 years. We suppose that the difference in the                  4
                                                                                  Grippaudo C, Paolantonio EG, Antonini G, et al. Association between
mean age (6.2 ± 2.5 years) of our study compared to the                           oral habits, mouth breathing and malocclusion. Acta Otorhinolaryn-
higher mean age (9.0 ± 1.9 years) of the aforementioned                           gol Ital 2016;36:386-394. https://doi.org/10.14639/0392-100X-770
study 8 may explain the different results.                                   5
                                                                                  Chung Leng Muñoz I, Beltri Orta P. Comparison of cephalometric
Therefore, this study highlights the importance of a multi-                       patterns in mouth breathing and nose breathing children. Int J Pedi-
                                                                                  atr Otorhinolaryngol 2014;78:1167-1172. https://doi.org/10.1016/j.
disciplinary approach to children suffering from breathing                        ijporl.2014.04.046
disorders, such as reported in the Italian Ministry of Health                6
                                                                                  Al Ali A, Richmond S, Popat H, et al. The influence of snoring,
guidelines on the diagnosis and management of children                            mouth breathing and apnoea on facial morphology in late childhood:
                                                                                  a three-dimensional study. BMJ Open 2015;5:e009027. https://doi.
with obstructive sleep apnoea 19.                                                 org/10.1136/bmjopen-2015-009027
                                                                             7
                                                                                  Gois EGO, Ribeiro Junior HC, Vale MPP, et al. Influence of nonnutri-
Conclusions                                                                       tive sucking habits, breathing pattern and adenoid size on the devel-
                                                                                  opment of malocclusion. Angle Orthod 2008:78:647-654. https://doi.
The strengths of the study are: 1) few previous studies exam-                     org/10.2319/0003-3219(2008)078[0647:IONSHB]2.0.CO;2
ined association between the examined variables in a large
                                                                             8
                                                                                  Diouf JS, Ngom PI, Sonko O, et al. Influence of tonsillar grade on
                                                                                  the dental arch measurements. Am J Orthod Dentofacial Orthop
sample of children with age from 2 years; 2) no papers in                         2015;147:214-220. https://doi.org/10.1016/j.ajodo.2014.10.028
literature reporting the association of all variables we exam-               9
                                                                                  D’Ascanio L, Lancione C, Pompa G, et al. Craniofacial growth in
ined in mouth-breathing children in the same study; 3) no                         children with nasal septum deviation: a cephalometric comparative
                                                                                  study. Int J Pediatr Otorhinolaryngol 2010;74:1180-1183. https://doi.
previous studies have reported an association between nasal                       org/10.1016/j.ijporl.2010.07.010
septum deviation and orthodontic occlusal variables.                         10
                                                                                  Yamaguchi H, Tada S, Nakanishi Y, et al. Association between mouth-
Finally, this study showed association between severe ton-                        breathing and atopic dermatitis in japanese children 2-6 years old: a
sillar hypertrophy and the presence of malocclusion and                           population-based cross-sectional study. PLoS One 2015;10:e0125916.
                                                                                  https://doi.org/10.1371/journal.pone.0125916. eCollection 2015
increased overjet. On the other hand, mild tonsillar hyper-                  11
                                                                                  Brodsky L, Koch RJ. Anatomic correlates of normal and diseased
trophy was significantly associated with the presence of mal-                     adenoids in children. Laryngoscope 1992;102:1268-1274. http://doi.
occlusion, Class II relation and increased overjet in mouth-                      org/10.1288/00005537-199211000-00013
breathers. These results suggest that malocclusion may have
                                                                             12
                                                                                  Cassano P, Gelardi M, Cassano M, et al. Adenoid tissue rhinopharyn-
                                                                                  geal obstruction grading based on fiberendoscopic findings: a novel
a dual role: it may be a determining factor in the onset of                       approach to therapeutic management. Int J Pediatr Otorhinolaryngol
mouth-breathing in children with mild upper airway obstruc-                       2003;67:1303-1309. https://doi.org/10.1016/j.ijporl.2003.07.018
tion, while on the other hand it may be an effect due to severe              13
                                                                                  Mattila PS, Tarkkanen J. Age-associated changes in the cellular com-
                                                                                  position of the human adenoid. Scand J Immunol 1997;45:423-427.
palatal tonsil hypertrophy. Therefore, this study confirms the                    https://doi.org/10.1046/j.1365-3083.1997.d01-417.x
importance of the multidisciplinary team for diagnosis and                   14
                                                                                  Galeotti A, Festa P, Viarani V, et al. Prevalence of malocclusion
treatment of children with breathing disorders.                                   in children with obstructive sleep apnoea. Orthod Craniofac Res
                                                                                  2018;21:242-247. https://doi.org/10.1111/ocr.12242
                                                                             15
                                                                                  Šidlauskienė M, Smailienė D, Lopatienė K, et al. Relationships be-
Acknowledgements                                                                  tween malocclusion, body posture, and nasopharyngeal pathology in
                                                                                  pre-orthodontic children. Med Sci Monit 2015;21:1765-1773. https://
The authors acknowledge all colleagues of Otorhinolar-                            doi.org/10.12659/MSM.893395
ingology Unit and Dentistry Unit of Bambino Gesù Chil-                       16
                                                                                  Sousa JB, Anselmo-Lima WT, Valera FC, et al. Cephalometric assess-
dren’s Hospital and AORN Santobono-Pausilipon for their                           ment of the mandibular growth pattern in mouth-breathing children. J
                                                                                  Pediatr Otorhinolaryngol 2005;69:311-317. https://doi.org/10.1016/j.
contribution to this study.                                                       ijporl.2004.10.010
                                                                             17
                                                                                  Galeotti A, Festa P, Viarani V, et al. Correlation between cephalometric
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