International Journal of Pediatric Otorhinolaryngology 78 (2014) 10741079

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International Journal of Pediatric Otorhinolaryngology

journal homepage: www.elsevier.com/locate/ijporl

Facial soft tissues of mouth-breathing children: Do expectations meet

reality?
Bernardo Q. Souki a,b,*, Petrus B. Lopes a, Natalia C. Veloso a, Ricardo A. Avelino a,
Tatiana B.J. Pereira a, Paulo E.A. Souza a, Leticia P. Franco b, Helena M.G. Becker b
a
b

Catholic University of Minas Gerais, School of Dentistry, Orthodontics, Belo Horizonte, Brazil
Federal University of Minas Gerais, Outpatient Clinic for Mouth-Breathers, Belo Horizonte, Brazil

A R T I C L E I N F O

A B S T R A C T

Article history:
Received 13 March 2014
Received in revised form 2 April 2014
Accepted 6 April 2014
Available online 18 April 2014

Objective: To quantify the differences between the facial soft tissue morphology of severely obstructed
mouth breathing (MB) and that of predominantly nasal breathing (NB) children.
Methods: Soft tissue measurements were performed in the lateral cephalograms of 64 severely
obstructed MB children (mean age 6.7  1.6) compared with 64 NB children (mean age 6.5  1.3). Groups
were paired by age, gender, skeletal maturation status and sagittal skeletal pattern. Based on the assumption
of normality and homoscedasticity, comparison of the means and medians of soft tissue measurements
between the two groups was performed.
Results: The facial convexity and anterior facial height ratio of MB were similar to NB children. The upper
lip of MB children was protruded, and its base was thinner compared with NB; however, the length was
not affected. The lower lip was shorter and more protruded in MB children. The nasolabial angle, nasal
prominence, and chin thickness were smaller in MB children.
Conclusions: The facial soft tissue of severely obstructed MB children is different than in NB children.
Changes in lips, nasolabial angle, nasal prominence, and chin thickness are associated with severe airway
obstruction in children.
2014 Elsevier Ireland Ltd. All rights reserved.

Keywords:
Mouth breathing
Face
Cephalometry

1. Introduction
The rst report on the association between mouth breathing
(MB) and facial deformities is now 150 years old [1]. Despite the
knowledge gathered since on the dentoskeletal pattern [26], the
literature on the soft tissue pattern of nasal-impaired children is
scarce and contradictory [4,710].
Anecdotal comments on aberrant facial soft tissue development
have marked the last decades of the 19th century and rst half of
20th century and contributed to the establishment of an adenoid
face stereotype in the minds of health science professionals [11].
Clinical and animal studies thereafter helped to build the concept
that the obstruction of upper airway airow leads to a disrupted
facial muscular framework in mouth breathers. Harvold [12]
studies on monkeys with nasal obstructions demonstrated that

* Corresponding author at: Av. Dom Jose Gaspar, 500 Predio 46 (Colegiado de Pos
Graduacao) Coracao Eucarstico, Belo Horizonte, MG, Brazil CEP 30535-901.
Tel.: +55 31 32455108; fax: +55 31 32455115.
E-mail address: souki.bhe@terra.com.br (B.Q. Souki).
http://dx.doi.org/10.1016/j.ijporl.2014.04.008
0165-5876/ 2014 Elsevier Ireland Ltd. All rights reserved.

under such conditions, upper lips develop a notch due to muscle

activity that keeps the mouth open. However, the response was not
uniform among the animals.
The adenoid face soft tissue prole after the change in the mode
of respiration are clinically described in textbooks. However, these
descriptions are based on clinical aspects without quantitative
measurements. A literature review on this topic showed that soft
tissue evaluations are neglected and that objective data are rare.
The upper lip of MB children was found to be thicker than nasal
breathing (NB) children [13]. No association was found between lip
posture and anterior face height with nasal airow resistance [7],
however lip posture was associated with backwardly rotated face
and larger lower facial height in mouth-breathers [10]. Other
previous publications have concluded that breathing patterns did
not inuence facial soft tissue measurements [8,9]. However,
sampling problems related to size, denition of MB and lacking a
matched control group may explain these results.
At this point, some questions have no objective answers: (1) Is
the facial prole balance of MB different than NB? (2) Is the upper
lip actually shorter, thinner and more protrusive in MB children?
(3) Is the lower lip in MB children longer, thicker and everted? (4) Is

B.Q. Souki et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 10741079

the nasolabial angle affected? (5) Do nasal prominence and the

chin compensate their forms and positions following a change in
breathing pattern? Knowing the soft tissue morphology of MB
children is an important diagnostic tool for pediatric dentists
because they hold the best position to screen and to indicate
treatment to patients who suffer from upper airway obstruction.
Therefore, this study aimed to quantitatively measure the soft
tissue pattern of severely obstructed children, evaluating if the
expected soft tissue facial morphology of MB meet reality.
2. Materials and methods
Approval for this study was obtained from the Institutional
Review Boards at Pontical Catholic University of Minas Gerais and
at Federal University of Minas Gerais, Belo Horizonte, Minas Gerais,
Brazil. All procedures, possible discomforts or risks, and possible
benets were explained to the parents of all patients involved, and
informed consent was obtained from each parent.
2.1. Population
The sample size of each group was calculated based on an alpha
signicance level of 0.05 and a beta of 0.2 to achieve a power of 80%
to detect a mean difference of 28 or 1 mm between the groups, with
a median estimated standard deviation of 48 or 1.67 mm, according
to Saglam and Gazilerli [14]. The sample size calculation showed
that 63 patients in each group were needed.
The MB population involved 749 children who were consecutively referred by pediatricians or primary care physicians to the
Outpatient Clinic for Mouth-Breathers at the Clinics Hospital from
the Federal University of Minas Gerais, between November 2002
and November 2010. Patients, whose parents presented a chief
complaint of MB, were systematically evaluated in a single visit by
a multidisciplinary team comprising physicians, dentists, and
speech pathologists.
Children in whom MB could not be conrmed, those who had
previous orthodontic treatment, had permanent dentition, had
any craniofacial anomaly, including an Angle Class III malocclusion, were younger than 2 years of age or older than 10 years of
age, had severe dental decay, had behavior limitations precluding
a cephalometric examination, or who had any history of
persistent nger and pacier sucking habits were excluded from
the analysis. To be included, all children were required to have a
high-quality lateral cephalometric radiograph taken at the rst
consultation and severe nasopharyngeal obstruction requiring
adenotonsillectomy to normalize breathing. This evaluation was
based on the clinical and endoscopic ENT examination performed
by two of the authors, who were previously calibrated. Only
severely obstructed children (nasopharynx obstruction 75%
[15] and/or tonsils of Brodsky and Kochs [16] grades 34) with a
surgery indication were included in the present investigation.
Therefore, the MB sample consisted of 64 patient cephalograms.
The mean age of patients in this group was 6 years, 7 months  1
year, 6 months. Thirty-one girls and 33 boys were included. Eleven
MB children had a Class II dental malocclusion, and 53 presented a
Class I pattern.
The corresponding control group was composed of 64
cephalograms from predominantly NB who had been included
in the Pontical Catholic University of Minas Gerais Growth Study
(Ethics Committee approval CAAE 2001/03), and from a pediatric
dentistry private practice at the same city. Their parents were
questioned about the childrens medical history to exclude any
subject with chronic mouth breathing, permanent snoring and
tonsillectomy or adenoidectomy. Nasal breathers with evident
hyperplasia of the tonsils and adenoids on cephalometric lm were
excluded from further analysis. The mean age of the NB children

1075

was 6 years, 5 month  1 year, 3 months; the sample comprised 32

girls and 32 boys. These children lived in the same city as the MB
group and were matched by gender, age group, sagital dental
relationship (Class I n = 53 vs. Class II n = 11) and skeletal maturation
status (P > 0.05) [17]. Therefore, the total number of children in this
study was 128.
2.2. Cephalometric analysis
Standard lateral cephalometric radiographs were obtained to
evaluate the soft tissue characteristics of the two groups.
Childrens teeth were in centric occlusion, and the lips were
relaxed. Cephalometric landmarks were identied on all radiographs (Figs. 1 and 2) and hand-traced on acetate paper with a
0.3 mm HB lead pencil on a standard light box by one investigator.
Radiographs were scanned and imported into a commercially
available software system (Dolphin Imaging and Management
Solutions, Chatsworth, CA, USA) using a conventional table scanner
(HP Ofcejet J4660 All-in-One Multifunctional Printer, Palo Alto,
CA, USA) with an open lid and room light only. Standard scanning
resolution was set to 300 dots per inch (dpi) gray scale.
Sixteen cephalometric soft tissue measurements were chosen
based on previous publications [8,1821] and their construction is
illustrated in Figs. 1 and 2. They were grouped in 6 evaluation
elds: facial convexity, facial height, nose, lips, sulcus and chin.
2.3. Skeletal maturation status
The maturation status was evaluated based on the appearance
of cervical vertebrae C2, C3 and C4 [17]. All 128 children were in
the prepubertal CS1 stage of maturation.
2.4. Statistical analysis
The data were analyzed using SPSS version 20.0 (SPSS Inc.,
Chicago, IL, USA). Based on the results of the KolmogorovSmirnov
and Levene tests, the assumptions of normality and homoscedasticity were evaluated to decide whether to use parametric
(independent t-test) or non-parametric (MannWhitney) comparison of the means and medians of the two groups. Chi-square test
and independent i-test were used to verify the similarity of MB and
NB samples. A P-value less than 0.05 indicated statistical
signicance.
To determine errors in landmark identication and measurements, 25 randomly selected head lms were retraced, and repeat
measurements were taken by the same orthodontist after an
interval of at least one month. Random error was calculated using
Dahlbergs equation [22]. Systematic error (bias) was assessed
using the paired t-test, for P < 0.05.
The systematic error in measurement did not exceed 0.308 or
0.45 mm. The correlation was higher than 0.938 for all measures;
thus, systematic reading errors were considered to be of no
further importance. The random error ranged between 0.38 and
0.50 mm for the linear measurements and between 0.198 and
0.288 for the angular measurements. There were no statistically
signicant differences between the two measurements in the
error analysis.
3. Results
Figs. 1 and 2 illustrates in red the soft tissue measurements
where signicant differences were found between MB and NB.
Measurements in black are those where no differences were
detected. Fig. 3 illustrates the soft tissue pattern of severely
obstructed MB children. Comparisons between the mean, standard
deviation, medians and range of the soft tissue cephalometric

[(Fig._1)TD$IG]

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B.Q. Souki et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 10741079

Fig. 1. Soft tissue cephalometric landmarks and measurements. Red measures are those where statistically signicant differences were found between MB and NB. Black
measures indicate no difference between groups. Landmarks used were: G, glabela; N0 , soft tissue nasion; FH, Frankfurt horizontal; H Line; Col, columela; Sn, subnasale; UL,
upper lip; LL, lower lip; ST U, upper stomium; ST L, lower stomion; Pg, pogonion; Pg0 , soft tissue pogonion; Me0 , soft tissue menton. (For interpretation of the references to
color in this gure legend, the reader is referred to the web version of this article.)

measurements obtained for the two groups are shown in Table 1.

Soft tissue anterior face height, upper lip thickness at vermillion
and inferior sulcus to H-line did not attend the normality and/or
homoscedasticity; therefore, non-parametric median comparison
[(Fig._2)TD$IG]statistics was employed for those variables. No statistically

signicant differences were observed between Class I and Class

II children within each group (P > 0.05). However, statistically
signicant differences (P < 0.05) were observed between the MB
and NB in 11 of 16 measurements, which can be summarized as
follows.

Fig. 2. Soft tissue cephalometric landmarks and measurements. Red measures are those where statistically signicant differences were found between MB and NB. Black
measures indicate no difference between groups. Landmarks used were: G, glabela; N0 , soft tissue nasion; FH, Frankfurt horizontal; H Line; Col, columela; Sn, subnasale; UL,
upper lip; LL, lower lip; ST U, upper stomium; ST L, lower stomion; Pg, pogonion; Pg0 , soft tissue pogonion; Me0 , soft tissue menton. (For interpretation of the references to
color in this gure legend, the reader is referred to the web version of this article.)

[(Fig._3)TD$IG]

B.Q. Souki et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 10741079

1077

3.1. Facial prole and anterior facial height ratio are not different in
MB
Facial prole measurements showed no statistically signicant
difference between MB and NB. Facial convexity angle presented a
P = 0.68 (14.51  5.738 for MB vs. 14.10  5.428 for NB), while soft
tissue facial angle had a P = 0.99 (91.76  4.718 for MB vs.
91.76  4.638 for NB). The soft tissue anterior facial height ratio
was similar in both groups (median = 1 for MB and for NB), with
P = 0.72.
3.2. Upper and lower lips of MB are protruded and nasolabial angle is
smaller
The nasolabial angle in MB children was statistically signicantly smaller (P = 0.02) than in NB children (106.33  10.058 for
MB vs. 110.56  10.158 for NB). The upper lip was protruded in MB.
The upper lip protrusion measurement comparison between MB and
NB showed P < 0.001 (6.22  1.84 mm for MB vs. 4.78  1.59 mm for
NB). The H-angle measurement was also statistically signicantly
greater (P < 0.001) for MB (21.15  3.598 for MB vs. 17.73  3.948 for
NB), and its base is thinner than in NB (12.10  1.60 mm for MB vs.
14.26  1.70 mm for NB), with a P < 0.001. The upper lip sulcus
(subnasale to the H-line) in MB children was deeper than in NB
children (P < 0.001). The upper lip thickness at vermillion (lip tip) of
MB children was not different (P = 0.36) from that of NB children
(median = 12.45 for MB vs. 13.40 for NB). The lower lip of MB was also
protruded compared with NB (lower lip to H-line 1.35  1.51 mm for
MB vs. 0.75  1.56 mm for NB, with P = 0.03); and lower lip
protrusion (4.57  1.97 mm for MB vs. 3.52  1.99 mm for NB, with
P = 0.003). The lower lip sulcus of MB children was shallower than in
NB children (median = 2.70 for MB vs. 3.85 for NB), with P < 0.001.
Fig. 3. Soft tissue pattern of severely obstructed MB children. Red tracing denotes
that measure is smaller in MB in comparison with NB. Yellow tracings indicate that
measure is larger in MB. (For interpretation of the references to color in this gure
legend, the reader is referred to the web version of this article.)

3.3. Upper lip length of MB is similar to NB, but lower lip length is
shorter in MB
The upper lip length in MB children was similar (P = 0.18) to
that of NB children (18.23  1.99 mm for MB vs. 18.75  2.35 mm

Table 1
The mean, median and range of cephalometric measurements of soft tissues in mouth-breathing (MB) and nasal-breathing (NB) children and comparisons between groups.
Cephalometric measures

MB
Mean  SD

Facial convexity
Facial convexity (degree)
Soft tissue facial angle (degree)
Anterior facial height
Soft tissue anterior face height (ratio)
Nose
Nasolabial angle (degree)
Nasal prominence (mm)
Lips
H-angle (degree)
Upper lip protrusion (mm)
Lower lip protrusion (mm)
Lower lip to H-line (mm)
Upper lip thickness at base (mm)
Upper lip thickness at vermillion (mm)
Upper lip length (mm)
Lower lip length (mm)
Sulcus
Subnasale to H-line (mm)
Inferior sulcus to H-line (mm)
Chin
Chin thickness (mm)
SD, standard deviation.
Bold type numbers indicate signicant P-values.

Non-parametric statistics.

NB
Median

Range

14.51  5.73
91.76  4.71

15.20
92.60

29.70
20.00

1.00  0.10

1.00

0.60

106.80
4.00

51.30
14.60

110.56  10.15
7.43  2.69

21.15  3.59
6.22  1.84
4.57  1.97
1.35  1.51
12.10  1.60
12.71  1.97
18.23  1.99
35.48  3.97

20.90
6.30
4.50
1.35
12.00
12.45
18.05
34.90

15.70
7.30
8.80
7.50
8.90
12.10
9.20
18.60

8.31  2.31
2.64  1.06

8.50
2.70

10.61  2.18

10.25

106.33  10.05
4.38  3.26

Mean  SD

P-value
Median

Range

14.10  5.42
91.76  4.63

14.15
91.95

23.60
21.70

1.00  0.09

1.00

0.50

111.05
7.20

44.10
12.00

0.019
0.000

17.73  3.94
4.78  1.59
3.52  1.99
0.75  1.56
14.26  1.70
13.63  2.86
18.75  2.35
40.55  4.63

18.10
4.95
3.45
0.60
14.15
13.40
18.80
40.55

22.80
5.80
9.40
8.20
8.70
14.70
11.50
23.70

0.000
0.000
0.003
0.029
0.000
0.360
0.184
0.000

9.80
4.90

6.42  2.09
3.81  1.50

6.65
3.85

7.90
8.50

0.000
0.000

10.60

12.60  2.52

12.70

10.50

0.000

0.676
0.998
0.719

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B.Q. Souki et al. / International Journal of Pediatric Otorhinolaryngology 78 (2014) 10741079

for NB), while lower lip length was signicantly smaller (P < 0.001) in
MB children (35.48  3.97 mm for MB vs. 40.55  4.63 mm for NB).
3.4. Nasal prominence is smaller, and the chin is thinner in MB
children
The nasal prominence of MB children was statistically smaller
(P < 0.001) than that of NB children (4.38  3.26 mm for MB vs.
7.43  2.69 mm for NB), while the chin was thinner (10.61  2.18 mm
for MB vs. 12.60  2.52 mm for NB, with P < 0.001).
4. Discussion
Growing awareness of children with obstructive sleep apnea in
recent decades motivated the development of a MB cohort study in
our University Hospital-based Outpatient Clinic for Mouthbreathers in 2002 [23]. Soon afterwards, the assistant professionals
involved with MB care realized that some expectations regarding
MB were unsubstantiated. Therefore, a series of studies have been
conducted to investigate a population of severely obstructed
children to determine if expectations based on previous data were
well-founded [2325].
The adenoid face has long been cited as an MB characteristic [7].
Addressing adenoid and/or severe tonsil obstruction led to the
belief that this facial stereotype was likely to have a high
prevalence. However, after observing that the majority of MB
children did not present such a facial deformity, the present
authors contributed to the literature that sought evidence for soft
tissue changes after a switch from a nasal to oral breathing mode.
Aside from anecdotal reports from a century ago, little has been
published on this subject [4,79].
The present investigation reported the rst comprehensive
quantitative measurements of facial soft tissue patterns of young
MB children with severe upper airway obstructions. Compared
with a matched sample of nasal breathers, signicant differences
were observed, and interesting conclusions were made. Some
ndings are in agreement with previous concepts, but others were
contrary to what was expected.
Despite previous studies showing that MB children have a
higher prevalence of Class II malocclusion than NB [22], the soft
tissue facial convexity was not different between the two groups in
the present investigation. Our ndings are in accordance with
Jakobsone, Urtane and Terauds [9], who also did not nd a
difference in the prole of impaired nasal breathing adolescents.
Compared with previously reported data [26] for pre-adolescents,
the soft tissue facial angle found in our sample (91.768 for MB and
NB) was slightly higher, while the facial convexity angle in our
sample was slightly smaller. This suggests that our children, both
MB and predominantly NB, had a mandible positioned more
anteriorly than the other study sample, with no Class II facial
prole.
Dental anterior open bite is reported to be more prevalent in MB
[23], and the lower anterior face height to total anterior face height
ratio is higher in MB than in NB children [24]. Based on these data, we
expected to nd a different soft tissue anterior facial height ratio in
MB than NB children, but our results showed that the ratio of soft
tissue lower and upper anterior measurements were the same in MB
and NB children, which was observed also by Hartgerink and Vig [7].
Therefore, the clinical examination of MB children regarding facial
convexity and the anterior facial height ratio may not be a reliable
tool to discriminate these children from NB children. This contradicts a classic expectation for mouth breathers.
However, the nasolabial angle, nasal prominence and chin are
signicantly smaller in MB than in NB children. The acute
nasolabial angle in MB might be associated with a protruded
upper lip. Such protrusion can be explained by the compensatory

forward lip position to facilitate airow and also by the movement

of the upper incisors. The last assumption was not investigated in
our study. In MB children, a reduction of upper lip thickness at its
base and increase in the sulcus was observed. The upper lip
vermillion thickness is not affected after MB. Small nasal
prominence and chin thickness may be explained by the reduced
functionality of nasal complex and perioral muscles in MB.
We expected that the upper lip length would be shorter in MB
than NB children. This was not found. Both groups presented the
same upper lip length. We found a shorter lower lip in MB than NB
children and a shallow inferior sulcus to H-line measurement. The
lower lip was also protruded. A protruded lower lip was not a
surprising nding, but a shorter lower lip length was not expected.
It appears that during MB, the lower arch soft tissue does not
develop as much as in NB because the necessity of keeping the
mouth open may limit functional muscular activity.
It was not the aim of this paper to suggest the use of
cephalometric measurements in the daily clinical evaluation of
soft-tissue pattern following the change in the mode of breathing,
but to bring a contribution to the understanding of what might be
associated with the nasal obstruction and the facial balance. The
use of standardized facial photography, especially the 3D
photography [27] might add additional contribution to this topic
and should be considered in future investigations. Future research
should also evaluate the electromyographic and functional
behavior of facial soft tissues, as additional information to this
topic. At this moment, however, there are evidences that there is
no relationship between the electromyography of the superior
orbicularis oris muscle and the breathing mode [28].
5. Conclusions
Based on this studys results, the following conclusions can be
made:
1. There are signicant soft tissue differences between severely
obstructed MB and predominantly NB children.
2. The upper lip of MB is protruded and thinner at its base, but the
length is not affected; the lower lip of MB children is protruded
and has a reduced length.
3. The nasolabial angle is smaller in MB children; and the nasal
prominence is smaller and chin is thinner in MB children.
4. Facial convexity and anterior facial height ratio are not different
in MB.

Acknowledgment
We thank Ms. Luana Ferro Fialho Araujo for her contribution on
Figures artwork.
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