10.

5005/jp-journals-10021-1101
ORIGINAL ARTICLE
Trilok Shrivastava, Mayuri Thomas

To Determine the Head Posture in Oral

Breathing Children: A Cephalometric Study
1
Trilok Shrivastava, 2Mayuri Thomas

ABSTRACT

Objective: Mouth breathing, being a cause for various orthodontic problems, has been a subject of concern to orthodontists since years. This
study was aimed to analyze the influence, mouth breathing on the head posture and to compare variations in head posture between physiologic
breathing and mouth breathing groups.
Materials and methods: Lateral cephalograms of 25 physiologic breathing (PB) and 25 mouth breathing (MB) children within the age group of
8 to 14 years were analyzed using standard cephalometric parameters. The Student’s t-test was used to determine, if significant cephalometric
differences existed between the MB and the PB children. Values in male and female subjects were determined and expressed as mean and
standard deviation.
Results: The findings revealed that craniofacial morphology in mouth breathers differs profoundly when compared to that of the physiologic
breathers.
Conclusion: There should be an early interception of mouth breathing in growing children as these postural changes, if maintained for long
periods, could lead to severe skeletal deformities.
Keywords: Head posture, Oral breathing, Physiologic breathing, Craniofacial structure, Cephalometry.

How to cite this article: Shrivastava T, Thomas M. To Determine the Head Posture in Oral Breathing Children: A Cephalometric Study. J Ind
Orthod Soc 2012;46(4):258-263.

INTRODUCTION characteristics in mouth breathing children. We wanted to

Obligatory mouth breathing is related to impaired nasal
breathing. The possible causes of impaired nasal breathing
include enlarged adenoids, inadequate nasal airway
development and soft tissue obstructions or swellings like
allergies. 1 Mouth breathing causes various orthodontic
problems and a mouth breather’s face develops aberrantly
because of disruption of functional relationships caused by
chronic airway obstruction.2
Associations have been noted between cranial postures,
the predominant mode of breathing and facial structures.3 It
has been indicated that mode of breathing may influence
craniofacial morphology indirectly through a change in head
position. As a result, natural head posture (NHP) has been
increasingly used as the logical reference position for the
evaluation of craniofacial morphology.4
The purpose of this study was to contribute to our
understanding of the head posture and cephalometric
1
Lecturer, 2Professor and Head
1
Department of Orthodontics, People’s Academy Dental College, Bhopal
Madhya Pradesh, India
2
Department of Orthodontia, Sri Sai College of Dental Surgery
Hyderabad, Andhra Pradesh, India
Corresponding Author: Mayuri Thomas, Professor and Head
Department of Orthodontia, Sri Sai College of Dental Surgery, Hyderabad
Andhra Pradesh, India, e-mail: mayurithomas@hotmail.com
Received on: 9/2/11
Accepted after Revision: 4/4/12
compare variations in head posture between physiologic
breathing and mouth breathing children and analyze the
influence of mouth breathing, not necessarily connected to
an upper airway obstruction, on the head posture in growing
children within the age group of 8 to 14 years.
MATERIALS AND METHODS
The study included, 50 children selected randomly, who were
seen in the Department of Orthodontics and Dentofacial
Orthopedics, Sri Sai College of Dental Surgery. The children
included were between the age group of 8 and 14 years and
were divided into two groups based on the type of breathing
pattern.
1. Physiologic breathing (PB)—25 subjects
2. Mouth breathing (MB)—25 subjects.
Inclusion Criteria
The subjects included in PB group were children with various
orthodontic problems:
1. Without any past history of MB or
2. Without any clinical signs of MB
The subjects included in MB group had:
1. History of MB confirmed by either the parents or their
medical history
2. Incompetent lips
3. Dental crowding in the upper arch
4. ‘Adenoidal facies’ and reduced maxillary transverse
dimension with unilateral or bilateral crossbite

258 JAYPEE
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To Determine the Head Posture in Oral Breathing Children: A Cephalometric Study

5. The breathing pattern showed a diaphragmatic mode of

inhalation and a reduced mobility of the nostrils (a reduced
patency of the upper airway)
6. MB was confirmed by water vapor condensed on the
surface of a mirror placed outside the mouth (mirror fog
test).

Exclusion Criteria
Exclusion criteria for both groups included previous or
ongoing orthodontic treatment, vestibular or equilibrium
problems, visual, hearing or swallowing disorders, and facial
or spinal abnormalities (i.e. torticollis, scoliosis or kyphosis).

METHOD
A lateral cephalogram was taken of each subject (50 in total)
in the NHP as in ‘self-balancing method’. Informed consent
was obtained from the parents of all subjects and the Fig. 1: The cephalometric and craniocervical landmarks
procedures were conducted in accordance with the ethical
standards of the Committee on Human Experimentation of
the institution in which the experiments were done. The
radiographs were taken from motorized, vertical adjustable
Planmeca Proline 2002 series, with an anode X-ray source of
0.8 mm focus. The vertical adjustability of the machine permits
the recording of standing subjects. The transverse adjustment
of the head in the cephalostat is facilitated by a light source
projecting a horizontal line through the plane of the ear rods
and a vertical line through the median plane of the head holder.
The focus-median plane distance was 150 cm and the film
median plane distance was 10 cm for the lateral cephalometric
film with an enlargement of 5.6%. A wedge shape collimator
made up of lead is used for the passage of radiation for image
quality.

Cephalometry
All the lateral cephalograms were traced manually for each
subject.
The cephalometric and craniocervical landmark points
taken were (Fig. 1) as follows:
• A—the most posterior point on the anterior contour of
the upper alveolar process
• ANS (anterior nasal spine)—the tip of the bony anterior
nasal spine of the maxilla
• B—deepest point on the anterior contour of the lower
alveolar process
• Ba (basion)—median point of the anterior margin of the
foramen magnum
• Go (gonion)—constructed point of the intersection of the
ramus plane and the mandibular plane
• N (nasion)—the most anterior point of the frontonasal
suture in the median plane
• S (sella)—the midpoint of the pituitary fossa
• PNS (posterior nasal spine)—the tip of the bony posterior
nasal spine
Fig. 2: The cephalometric and craniocervical planes and angles
• Gn (gnathion)—the most anterior-inferior point on the
bony chin in the midsagittal plane
• Hy—most superior and anterior point on the body of the
hyoid bone
• CV2ip—most inferior and posterior point on the second
cervical vertebra corpus
• CV2tg—the tangent point at the superior posterior
extremity of the odontoid process of the second cervical
vertebra
• CV4ip—most inferior and posterior point on the fourth
cervical vertebra corpus
• Ris—the most posterior and superior point on the condyle
• Rli—the most posterior and inferior point on the
ascending ramus.

The Journal of Indian Orthodontic Society, October-December 2012;46(4):258-263 259

Trilok Shrivastava, Mayuri Thomas
Reference Lines and Angular Measurements
Linear
• SN (anterior cranial base length)—line joining sella to
nasion
• NSL (anterior cranial base)—extended line from N to S
• NL (palatal plane)—extended line from ANS to PNS
• VER—line drawn parallel to the vertical plane of the
cephalogram
• ML (mandibular plane)—line joining Gn to Go
• HOR—line drawn perpendicular to VER
• RL—line joining Ris and Rli
• Hy-NL–line perpendicular from the most anterior and
superior point on the hyoid to palatal plane
• Hy-ML–line perpendicular from the most anterior and
superior point on the hyoid to mandibular plane
• CVT (posterior tangent cervical)—an extended line from
CV2tg to CV4ip
• OPT–line connecting the tangent point at the superior,
posterior extremity of the odontoid process of CV2tg and
the most inferior/posterior point on the corpus of CV2ip
(Fig. 2).
Linear Measurements
1. S-N
2. Hy-NL
3. Hy-ML (see Fig. 2)
The Angular Measurements
1. N-S-Ba—inner angle formed by the line joining nasion
to sella to basion
2. NL/ML (basal plane angle)—angle between ML and NL
3. ML/RL (mandibular gonial angle)—angle between ML
and RL
4. S-N-A—inner angle formed by the connection of the
sella, nasion and A point
5. S-N-B—inner angle formed by the connection of the
sella, nasion and B point
6. A-N-B—the difference of the angles SNA and SNB,
indicating the amount of jaw dysplasia.
For head posture, the angular measurements (cranio-
cervical postural variables) taken were (see Fig. 2) as
follows:
• Craniovertical
7. NSL/VER—the angle between NSL and VER
8. NL/VER—the angle formed by the intersection of NL
and VER
• Craniocervical
9. NSL/OPT—head position in relation to the second
cervical vertebra, intersection of NSL and OPT
10. NL/OPT—head position in relation to the palatal plane,
intersection of NL and OPT
• Craniohorizontal
11. OPT/HOR—cervical inclination, the angle between OPT
and HOR
12. CVT/HOR—cervical inclination, the angle between CVT
and HOR (see Fig. 2).
260
Craniofacial Measurements
The above given 12 angular and three linear measurements
that formed the basis of the postural and craniofacial analysis5
were manually calculated for each subject.
Method Errors
In the postural recording method, the radiographs were taken
with the subject standing in NHP as described by Sahin Saglam
and Uydas.6 All linear and angular variables measured on the
lateral cephalometric radiographs that were taken 2 weeks
apart, were determined by two orthodontists independently
and no significant differences were found for any of the
craniofacial variables in the two data sets. The measurement
error was calculated using 20 radiographs (10 each randomly
chosen from MB and PB).
Statistical Method
Cephalometric variables were presented as mean, standard
deviation (SD), and the lowest and highest values. The Student’s
t-test was used to determine if significant cephalometric
differences existed between the MB and PB children. Values
in male and female subjects were determined and expressed
as mean and standard deviation.
Statistical Software
The statistical software namely SPSS 11.0 and Systat 8.0 were
used for the analysis of the data. All variables were tested for
statistical significance by a paired t-test. The level of
significance was determined at p < 0.05.
RESULTS
Cephalometric and Hyoid Variables
(Angular Values)
1. The mean N-S-Ba in the MB group increased compared to
the PB (p < 0.063).
2. In MB group the mean NL/ML was increased (p < 0.001).
3. Mean ML/RL in the MB group increased and also NL/ML
(p = 0.017).
4. The difference of mean for S-N-A of PB and MB group
was little (p = 0.289).
5. The S-N-B mean between PB and MB was significant
(p = 0.017).
6. The mean A-N-B difference of the two groups was
significant statistically (p = 0.016) (Table 1).
Cephalometric and Hyoid Variables (Linear Values)
1. The difference of mean for S-N of PB and MB was not
significant (p = 0.875)
2. The mean for Hy–ML was increased in MB (p = 0.545)
3. The Hy-NL increased in MB (p = 0.088) (Table 2).
JAYPEE
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To Determine the Head Posture in Oral Breathing Children: A Cephalometric Study

Table 1: Cephalometric variables—angular

Variables Group Mean SD p-value

N-S-Ba (°) Physiologic breather 126.00 3.96 0.063

Mouthbreathers 128.12 3.91
NL/ML (°) Physiologic breather 21.00 5.07 <0.001
Mouthbreathers 26.64 4.35
ML/RL (°) Physiologic breather 121.08 6.27 0.017
Mouthbreathers 125.24 5.54
S-N-A (°) Physiologic breather 82.56 3.94 0.289
Mouthbreathers 81.44 3.43
S-N-B (°) Physiologic breather 79.60 3.59 0.017
Mouthbreathers 77.36 2.74
A-N-B (°) Physiologic breather 3.00 1.15 0.016
Mouthbreathers 4.04 1.72

Table 2: Cephalometric and hyoid variables—linear

Variables Group Mean SD p-value

S-N (mm) Physiologic breather 72.20 3.43 0.875

Mouthbreathers 72.04 3.72
Hy-ML (mm) Physiologic breather 10.92 3.28 0.545
Mouthbreathers 11.44 2.72
Hy-NL (mm) Physiologic breather 54.24 6.05 0.088
Mouthbreathers 57.36 6.59

Table 3: Craniocervical postural variables

Variables Group Mean SD p-value

CV NSL/VER Physiologic breather 95.04 3.34 <0.001

Mouthbreathers 102.04 3.62
NL/VER Physiologic breather 90.32 3.69 <0.001
Mouthbreathers 94.88 3.15
CC NSL/OPT Physiologic breather 93.28 6.35 0.044
Mouthbreathers 96.68 5.18
NL/OPT Physiologic breather 89.44 5.82 0.012
Mouthbreathers 93.36 4.67
CH OPT/HOR Physiologic breather 94.40 8.33 0.704
Mouthbreathers 95.20 6.33
CVT/HOR Physiologic breather 89.24 7.73 0.768
Mouthbreathers 89.84 6.52

Craniocervical Values (Angular Measurements)
1. The mean NSL/VER and NL/VER was higher in MB group
(p < 0.001).
2. The mean NSL/OPT was higher in MB group (p = 0.044).
3. The mean NL/OPT in PB group was higher (p = 0.012).
4. The mean OPT/HOR difference in both groups was not
significant (p = 0.704).
5. The mean CVT/HOR difference in both groups was not
significant (p = 0.768) (Table 3).
DISCUSSION
Respiratory needs are the primary determinants of the posture
of the jaws and tongue (and of the head itself, to a lesser
extent). Therefore an altered respiratory pattern, such as
breathing through the mouth rather than the nose, could change
the posture of the head, jaw and tongue.7 Oral respiration alters
the muscle forces exerted by the tongue, cheeks and lips upon
the maxillary arch, leading to a narrow maxillary arch with a
high palatal vault, a posterior crossbite, a Class II or III dental
malocclusion, and an anterior open bite. An abnormal posture
of the head changes the load in several joints of the
craniovertebral region, resulting in unfavorable dentofacial and
craniofacial growth. Thus, 50 subjects in the age group of 8 to
14 years were selected for this study.
The purpose of the study was to assess whether there was
a relationship between MB and variables of head posture in
children before these same variables might influence their
development. Several studies have shown that MB is connected
with a variation in the head posture and with an increased
craniocervical extension8 in order to increase the dimension
of the airway9 and the oropharyngeal permeability5 with
mandibular and lingual postural modifications, and of the soft
palate as well.

The Journal of Indian Orthodontic Society, October-December 2012;46(4):258-263 261

Trilok Shrivastava, Mayuri Thomas
Some authors have evaluated the patency of the upper
airways using cephalometric techniques and established a
connection between the reduction of the nasopharyngeal space
and the increase in craniocervical angle.10
An increased ANB and intermaxillary divergence (ANS-
PNS/Go-Me) were prevailing in MB patients. This finding is
similar to other studies on mouth breathing and its influence
on dentofacial structures. These skeletal measurements
indicate a tendency for MB children to present with a
dolichofacial Class II skeletal pattern.5
Cephalometric Variables
The angle between the palatal plane to mandibular plane (NL/
ML) is significantly increased (p < 0.001) in MB group
(Table 1). This suggests that in MB there was downward and
backward rotation of the mandible in concurrence with the
study done by Cuccia AM et al 2008.5
The angle between the mandibular plane and the ascending
ramus (ML/RL) is also increased significantly (p=0.017) in
MB (mean—125.24°), when compared to the PB (mean-
121.08°). This indicates an opening of the gonial angle in
mouth breathers on account of a down and back rotation of
the mandibular base. Further study is required to evaluate the
changes in the values of both the upper and lower gonial angles
and the Bjork sum.
The S-N-A did not show any statistically significant change
(p=0.289) in MB when compared to the PB. S-N-B reduced
(p=0.017) in MB in comparison to PB, indicating a down and
back rotated mandible. Angular measurement of SN to ANS–
PNS and also inclination angle would have provided better
insight into the maxilla and its role in the opening of the ML/
RL and can be incorporated in future studies.
The N-S-Ba angle did not increase (p=0.063) in MB when
compared to PB. This finding is similar to the study by Ang et
al 200411 (p=0.129). Cuccia AM et al 20085 found the mean
N-S-Ba to be increased in MB when compared to the PB
(p=0.717), which is similar to the present study.
S-N did not show any significant variation in the MB and
PB groups (p=0.875). This finding is similar to the finding by
Ang et al 200411 (p=0.352).
Hyoid Variables
The hyoid bone is located at a lower position in MB patients.
Some studies12,13 found a correlation between a lower hyoid
bone position in relation to the mandibular plane and increase
in craniocervical extension. Bibby14 supported the stability of
the hyoid position which should not be influenced by the
postural anomalies of mouth breathers. Extension of the head
by 10° does not significantly affect upper airway resistance.14
The increased caudal position of hyoid bone is a frequent
finding in previous studies15-17 and this is confirmed in the
present investigation.
The hyoid variable, Hy-NL, the linear length from the
maxilla to the hyoid, indicates a more caudally positioned hyoid
262
bone in MB (57.36 mm) when compared to the PB (54.24
mm) (Table 2). The linear length from the hyoid to the
mandible, Hy-ML; value also indicates toward a lowered hyoid
position in mouth breathers when compared to the PB.
Craniocervical Postural Variables
The craniocervical angles may be useful as a diagnostic or
monitoring measurement in subjects with MB because it
represents both head posture and cervical vertebral
compensatory changes. Extreme extension of both the head
and cervical column, however, may represent an overactive
compensatory mechanism that ultimately leads not to
reduction of airway resistance, but rather has an adverse effect
on airway patency that further compounds the obstructive
problem.
Craniovertical
NSL/VER increased in the MB when compared to the PB in
this study (Table 3), suggesting a change in the head posture in
MB attributed to the upward and backward tilting of the head.
NL/VER—the palatal plane to the true vertical was
increased (p<0.001) in MB indicating an upward tilting of the
head leading to an increased inclination of the palatal plane.
Craniocervical
NSL/OPT: This craniocervical angulation is representative of
both the head posture and forward inclination changes of the
cervical column. This angle was found increased which was
statistically significant (p=0.044) in the MB (mean=96.68°)
when compared to the PB (mean=93.28°). This increased value
indicates that there is an upward and backward rotation of the
head and a cervical flexion, which is in accordance to the
findings in the study by Ang et al11 in 2004.
NL/OPT: This angle was also found increased in the MB
(93.36°) when compared to the PB (89.44°) which was
statistically significant (p=0.012), indicating a backward
flexion of the cervical column.
Craniohorizontal
OPT/HOR and CVT/HOR were found increased in the MB
when compared to the PB.
The findings in the present study seems to suggest that
craniofacial morphology in subjects with MB differ profoundly
when compared to that of the PB. The lower jaw was found
more retrognathic as shown by SNB when compared to the
upper jaw. This reflects toward a tendency to skeletal Class II
malocclusion, increased ANB angle. The head was also found
to be tilted backward as illustrated with a caudal hyoid bone
position. The gonial angles were found to increase, showing a
downward and backward rotation of mandible.
However, some of the findings could not be concluded
well and there lies a need to investigate those variables with a
bigger sample size which was a limitation of the present study.
JAYPEE

To Determine the Head Posture in Oral Breathing Children: A Cephalometric Study
Moreover, further clinical studies are necessary to evaluate
this parameter with larger samples and methodological
refinements.
The findings in the present study indicates toward an early
interception of mouth breathing habit in growing children,
because if these postural changes are maintained for a longer
duration they could definitely lead to skeletal and dental
malocclusions.
This further stresses the role of general dental
practitioners, pedodontists and orthodontists to identify the
mouth breathing habit at the earliest possible age to prevent
the impending changes associated with it.
SUMMARY AND CONCLUSION
The following can be concluded with this study performed on
50 subjects (25 MB and 25 PB) to assess variations in head
posture:
1. NL/ML is significantly increased in MB when compared
to the PB, indicating a downward and backward rotation of
the mandible.
2. ML/RL is also increased significantly in MB which
indicates an opening of the gonial angle.
3. A-N-B is also significantly increased in MB, when
compared to the PB. This shows a tendency toward skeletal
Class II malocclusion.
4. The S-N-B angle was statistically reduced in MB in
comparison to the PB, indicating downward and backward
rotated mandible.
5. NSL/VER value was found increased in the MB when
compared to the PB, which indicates an upward and
backward tilting of the head.
6. NSL/OPT angle is found increased in the MB when
compared to the PB. The increased value indicates that
there is upward and backward rotation of the head and a
cervical flexion.
7. NL/OPT angle was also found increased in the MB,
indicating a backward flexion of the cervical column.
The Journal of Indian Orthodontic Society, October-December 2012;46(4):258-263
JIOS
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