Facial morphology and obstructive sleep apnea

Alan A. Lowe,* John D. Santamaria,** John A. Fleetham,** and Colin Pr/ce***

Vancouver, British Columbia,

Canada

In a sample of 25 adult male subjects with moderate to severe obstructive sleep apnea, the interaction
among craniofacial, airway, tongue, and hyoid variables was quantified by means of a canonical
correlation analysis. One lateral cephalometric radiograph with the teeth in occlusion was obtained
for each subject together with overnight polysomnographic measurements before the initiation of
therapy. A principal component analysis reduced the data base and one significant canonical
correlation (r, = 0.994) was identified for the 22 variables. Sleep apnea subjects showed a posteriorly
positioned maxilla and mandible, a steep occlusal plane, overerupted maxillary and mandibular
teeth, proclined incisors, a steep mandibular plane, a large gonial angle, high upper and lower facial
heights, and an anterior open bite in association with a long tongue and a posteriorly placed
pharyngeal wall. A multivariate statistical analysis extracted clinically significant associations among
craniofacial, tongue, and airway variables. Subjects with sleep apnea demonstrated several
alterations in craniofacial form that may reduce the upper airway dimensions and subsequently
impair upper airway stability. (AM J ORTHOO DENTOFAC ORTHOP 90: 484-491, 1988.)

Key words: Airway, canonical correlation, cephalometric, sleep apnea, tongue

bstructive sleep apnea (OSA) syndrome is

a relatively common condition caused by recurrent upper airway obstruction during sleep. Patients complain
of a range of symptoms, particularly excessive daytime
sleepiness, and may develop physical complications
that include systemic hypertension, right heart failure,
and cardiac arrhythmias.
The patency of the upper airway is a result of many
interrelated anatomic and physiologic factors .* During
inspiration a negative intrapharyngeal pressure develops
but airway collapse is prevented by the action of the
pharyngeal abductor and dilator muscles. These muscles are activated rhythmically during daytime respiration but, in common with other skeletal muscles, they
become hypotonic during sleep, and airway stability
becomes dependent upon pharyngeal size and pharyngeal tissue compliance. As yet, little is known about
the compliance of the pharyngeal tissues. However,
conditions that reduce airway dimensions result in
OSA. There are reports of OSA in patients with upper
airway tumors, with adenotonsillar hypertrophy,4 and
with conditions associated with macroglossia.7 Airway
size is also affected by craniofacial morphology as reflected in the airway narrowing and sleep apnea observed in patients with significant retrognathia.

From the. University of British Columbia.

Supported by Gram MA-3849 from the Medical Research Council of Canada.
Department of Orthodomics, Faculty of Dentistry.
**Department of Medicine, Health Sciences Centm Hospital.
***Depaament
of Oral Medicine, Faculty of Dentistry.
484

Although the pharynx has been visualized with several techniques including cineradiography,g fiberoptic
bronchoscopy,g acoustic reflectance, and forced expiratory maneuvers, the techniques of CT scanning2s3
and lateral cephalometry4.15 are more commonly used.
While most patients with OSA do not have the pathologic lesions described above, recent reports with CT
scanning have suggested that the airway in such subjects
is narrower than in normal contro1s.2,13Although the
cause of these changes remains obscure, the importance
of craniofacial morphology upon the upper airway dimensions remains undefined.
Traditional cephalometry is used extensively in clinical orthodontics to quantify skeletal and soft-tissue dysplasias before the initiation of therapy.16 Numerous
authors7-1ghave quantified specific airway parameters,
although the obvious limitations of any two-dimensional cephalometric study are recognized. The significant advantages of cephalometry are its easy access,
low cost, and minimal radiation.
The purpose of this study was to investigate the
relationship among craniofacial, airway, tongue, and
hyoid variables obtained from lateral cephalometric radiographs in a sample of 25 adult male subjects with
OSA. In addition, the study was designed to reduce the
number of variables by a principal component analysis
and to test, on the pooled data base, for significant
canonical correlations. Clarification of the interaction
between craniofacial morphology, and airway and
tongue parameters in subjects with OSA could permit
the development of revised postulates with regard to

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485

the cause of this syndrome together with an improved

rationale for treatment.
METHODS

The study group comprised 25 adult male patients

with significant OSA who were considered for corrective upper airway surgery. Two patients with severe
OSA complicated by life-threatening cardiac arrhythmias were excluded and underwent urgent tracheostomies. Edentulous subjects were also excluded as complete cephalometric analyses could not be obtained.
Each subject underwent a single night of polysqmnographic monitoring. Sleep and its various stages
were documented by standard electroencephalographic
(EEG), electro-oculographic (EOG), and electromyographic (EMG) criteria. An EEG record was obtained
with electrodes applied at C3-A2 and C4-Al (according
to the International lo-20 system) and EMG recordings
were obtained from the submental muscles. Bilateral
electro-oculograms were also recorded. Apnea was documented by an infrared CO* analyzer* that recorded
from both the nose and mouth. A single ECG was
monitored to detect cardiac arrhythmias. Arterial oxygen saturation (SaO,) was continually measured with
a ear oximeter (hp 47201A). Transcutaneous COZ
(TcCOJ was monitored with an infrared transducer (hp
47210A) placed on the skin from which the stratum
comeum had been removed. Respiratory effort was
quantitated by respiratory inductive plethysmography. t
All data were recorded on a 15channel polygraphS at
a paper speed of 10 mm per second.
Sleep and respiratory variables were analyzed separately. A microcomputer (IBM PC) continuously monitored and stored airflow, arterial saturation, breathing
pattern, transcutaneous CO*, and heart rate on a mass
storage medium. The entire record was manually scored
for sleep stage and these data were merged with the
respiratory data. The severity of sleep apnea was assessed in terms of the total number of apneas, the apnea
index (apneas per hour of sleep time), and the total
apnea time expressed as a percentage of the total sleep
time, the apnea duration, arterial oxygen saturation, and
transcutaneous CO,.
One lateral cephalometric radiograph was obtained
before the initiation of any form of therapy for each of
the 25 patients. The patients, seated in an upright position with the Frankfort horizontal plane parallel to the
floor, were instructed to lightly contact their baclc teeth.
The dorsum of the tongue was coated with Microtrast
*Beckman Medical Gas Analyzer LB-2, Beckman h:strments,
San Ramon,
Calif.
tRespit.race, Noninvasive Monitoring Systems Inc., Ardsley, N.Y.
SOrass model 78D, Grass Instrument Co., Quincy, Mass.

UPW

\/

Fig. 1. Anatomic points, contours, and planes used to identify

airway, tongue, and hyoid variables. UPW Upper pharyngeal
wall. M/W, Middle pharyngeal wall. VW, Lower pharyngeal
wall. E, Epiglottis. HX Hyoid. 77, Tongue tip. 0, AA-PNS. 0,
PAS. 0, TGL. 0, TGH. 0, MP-H. 8, H-H. 0, C,H. For
complete definitions, see METHODSsection.

Table I. Demographic data for the 25 subjects

Variable

Mean

Age
Weight
Body mass index
Apnea index
Total apnea time
SaO, mean
TcCO* mean

48
91.2
29.2
36.6
28.8
92.2
51.2

+
+
2
2
2
k
+

1 SD

11 yr
13.0 kg
3.2 kg/m
19.1 apneas/hr
17.7% total sleep time
4.3%
4.5 mmHg

Oesophageal Cream* to enhance the outlines of the

tongue and pharyngeal soft tissues. Tracings were constructed of the 25 lateral cephalometric radiographs and
conventional contours and points were digitized. In addition, a number of tongue, pharynx, and hyoid measurements were determined (see Fig. 1). Both x and y
coordinates of the tongue tip (IT), the most inferior
and anterior point of the epiglottis (E), and the most
superior and anterior point on the hyoid bone (H) were
identified. The upper pharyngeal wall (UPW) was a
point on the posterior pharyngeal wall identified by an
extension of the palatal (ANS-PNS) plane.22 The middle
pharyngeal wall (MPW) was a point on the posterior

*Nicholas

Laboratories

Ltd., Slough, United Kingdom.

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Lowe et al.

Am. J. Orthod.

Dent&c.
Orthop.
December 1986

Table II. Summary of the 22 variables used in the canonical correlation analysis
Variable

Interpretation

Craniofacial

SNA
MxUL
SNB
MdUL
ANB
[SNMP + Go A]
[l to NA + 1 to NA mm]
[ADH + MxMH]
[l toNB + 1 toNBmm]
[l to MP mm + MdMH]
SNOP
OB
OJ
UPH
LPH
[PI-H + RH]

Anteroposterior position of maxilla

Maxillary unit length
Anteroposterior position of mandible
Mandibular unit length
Anteroposterior maxilla/mandible discrepancy
Mandibular angulation
Maxillary incisor inclination
Maxillary tooth height
Mandibular incisor inclination
Mandibular tooth height
Occlusal plane angulation
Overbite
Overjet
Upper facial height
Lower facial height
Posterior facial height

Airway

[UPW. + MPW, + LPW.]

[AA-PNS + PAS]

Anteroposterior position of posterior pharyngeal wall

Posterior airway space

Tongue

TGL
TGH

Tongue length
Tongue height

Hyoid

[MP-H + H-H]
Cd

pharyngeal wall identified by an extension of a line

between the midpoint of the occlusal surface of the
mandibular molar and the mandibular incisor tip .** The
lower pharyngeal wall (LPW) was a point on the posterior pharyngeal wall identified by an extension of a
line through E drawn parallel to the SN plane.*
Seven linear measurements in the airway, tongue,
and hyoid areas were determined:
AA-PNS = Linear distance between the most anterior point
on the atlas vertebrae and the tip of the posterior nasal
spine.
PAS = POSTERIOR AIRWAY SPACE. Linear distance between a
Point on the base of the tongue and another point on the
Posteriorpharyngeal wall both determined by an extension
of a line from point B through Go.~
TGL = TONGUE LENGTH. Linear distance between E and
TT.**
TGH = TONGUE HEIGHT. Linear distance along the perpendicular bisector of the E-IT line to the tongue dorsum.zz
MP-H = VERTKALPOSITIONOFHYOID.
Lineardistancealong
a Perpendicularfrom H to the mandibular plane (Go-Gn). I4
H-H = VERTICAL POSITION OF HYOID. Linear distance between H and a perpendicular to the C3 (inferior anterior
Position on the third cervical vertebrae) to retrognathion
(most inferior posterior point on the mandibular symphysis)
line .2

Vertical position of hyoid bone

Anteroposterior position of hyoid bone

C,H = ANTEROPOSTERIOR
POSITION
tance between C, and H.z

OF HYOID.

Linear dis-

The data matrix of 25 subjects with 32 cephalometric variables was computed and univariate and multivariate analyses of the data were undertaken. To perform multivariate analysis, it was essential to reduce
the dimensions of the data base by decreasing the number of variables. A principal component analysis (PCA)
can be used to reduce the number of cephalometric
variables when it is known that a set of variables is not
independent. A smaller set of new variables that represent linear combinations of the original variables can
be determined.23 The first principal component is a linear combination of the original variables, which accounts for the largest possible proportion of the variance. The PCA was applied to logical subgroups until
a group was found for which the first principal component explained more than 75% of the variance. All
original values in the raw data matrix were normalized
to determine the principal components and the canonical
correlations.
To investigate the association between craniofacial
variables, and airway, tongue, and hyoid variables, canonical correlations were determined for the normalized

Volume 90
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data matrix for the 25 subjects. By means of this analysis, the dependence between two sets of variables can
be summarized in the correlation between the pair of
canonical variables. The significance of the canonical
correlations can be tested by Bartletts chi-square test.23
If a canonical variable is significant, there is a linear
combination of variables in the first group that is significantly correlated with a linear combination of variables in the second group. Canonical variables can be
interpreted by evaluating the loadings on the original
variables.
RESULTS

Demographic data are provided in Table I. The 2.5

men (mean age, 48 +- 11 years) were generally overweight. Polysomnographic monitoring demonstrated
moderate to severe sleep apnea with an associated impaired gas exchange.
The original 32 variables were reduced to 22 by a
PCA (see Table II). The variables denoted by [ ] represent new linear combination variables; the remaining
variables were not combined. Nine linear combinations
were identified and the interpretation of the final 22
craniofacial, and airway, tongue, and hyoid variables
is provided. The correlation coefficients between the
original variables and the proportion of variance explained by the first principal component for the linear
combinations are indicated in Table III. For example,
the airway variables of AA-PNS and PAS were combined since the first principal component explained
76.9% of the total variance.
A multivariate analysis was undertaken to determine
whether canonical correlations could be determined between linear combinations of variables in the craniofacial group, and the airway, tongue, and hyoid group.24
All original values in the raw data matrix were normalized in terms of standard scores to determine the
principal components and the canonical correlations.
Canonical correlations (and their significance) between
the two groups of variables are given in Table IV. Bartletts test indicates the number of canonical variables
necessary to express the dependency between the two
sets of variables-that
is, the smallest number of
eigenvalues such that the test of the remaining eigenvalues is nonsignificant. At the 0.05 level of significance, one canonical correlation (rl = 0.99416,
P = 0.0055) was identified.
Canonical variable loadings for the craniofacial
variables, and the airway, tongue, and hyoid variables
are provided in Table V. Because 22 canonical variable
loadings were considered concurrently for each set of
canonical variables, correlation coefficients were declared significant at an overall 5% level if their absolute

Morphology

and sleep apnea

487

Table III. Nine linear combinations (accounting

for more than 75% of the total variance)

identified by means of a principal
component analysis

Linear

combination

Craniofacial
[SNMP + Go A]
[l toNA
+ 1 toNAmm]
[ADH +
[I toNB
[I to MP
[PFH +

MxMH]
+ 1 toNBmm]
mm + MdMH]
RH]

Airway
[UPW,
+ MPW,
+ LPW,]
UPW. vs. MPW,
UPW, vs. LPW,
MPW, vs. LPW,
[AA-PNS
+ PAS]
Hyoid
[MP-H
+ H-H]

Correlation
coejjicient

Proportion
explained

of variance
by first PC
(%)

0.6963
0.8015

84.07
89.57

0.7163
0.7968
0.7829
0.7666

85.81
89.55
89.15
88.89
79.11

0.7766
0.4629
0.7475
0.5348

76.92

0.4112

89.41

value was larger than 0.3994. Canonical variable loadings less than 0.400 were neglected.
The first (and only significant canonical correlation
at the 0.05 level of significance) showed a linear combination of negatively loaded variables-SNA,
SNB
and OB-with positively loaded variables-[SNMP
+
GoA], [ 1 to NA + 1 to NA mm], [ADH + MxMH],
[l toNB + 1 toNBmm],
[I toMPmm + MdMH],
SNOP, UFH, and LFH-for the craniofacial group, and
a linear combination of negatively loaded variables[UPW, + MPW, + LPWJ-and
a positively loaded
TGL variable in the airway, tongue, and hyoid group.
The eigenvalue for the first canonical correlation (see
Table IV) indicated that approximately 98.8% of the
variation in the first craniofacial variable could be accounted for by an interdependence with the first airway
and tongue soft-tissue variable. A diagrammatic representation of this craniofacial type is provided in
Fig. 2. Subjects with OSA demonstrated a posteriorly
positioned maxilla and mandible, a steep occlusal
plane, overerupted maxillary and mandibular teeth,
proclined maxillary and mandibular incisors, a steep
mandibular plane, a large gonial angle, an anterior open
bite, and high upper and lower facial heights in association with a long tongue and a posteriorly positioned pharyngeal wall. The second through sixth
canonical correlations for this sample of 25 adult subjects with OSA were not significant at the 0.05 level,

488

Lowe

Am. .I. Orthod.

et al.

Dentofac. Orthop.
December 1986

Table IV. Canonical correlations (and their significance) between the craniofacial variables and the airway,

tongue, and hyoid variables

Bartletts
Eigenvalue

Canonical
correlation

0.98835
0.81242
0.14173
0.63861
0.43202
0.31440

0.99416
0.93404
0.86124
0.79913
0.65729
0.56071

No. of
eigenvalue

test for

remaining

Chi-square

DF

127.74
69.86
43.09
25.49
12.26
4.91

90
70
52
36
22

1
2
3
4
5

eigenvalues
Tail
probability
0.0055
0.4823
0.8059
0.9039
0.9518
0.8973

10

Table V. Canonical variable loadings for the craniofacial variables, and the airway, tongue, and
hyoid variables*
Canonical
Variable
Craniojacial

SNA
MxUL
SNB
MdUL
ANB
[SNIyfP + Go A]
[l toNA + 1 toNamm]
[ADH + MxMH]
[l toNB + 1 toNBmm]
[l toMPmm + MdMH]
SNOP
OB
OJ
uw
LFH
[PFiH + RH]

pizq

-0.125

-0.257

-0.281

0.026

-0.285

variable

loadings

-0.093

0.286

0.058

-0.259
-0.095
0.273
0.237
-0.147
-0.147
-0.077
0.128
0.093
0.003
0.078

0.242
0.468
El-0.617
-0.003
0.042
-0.104
-0.227
0.124
0.069
0.019
-0.321
0.233

z
-0.014

0.190
pYzq

0.119
1-0.5451

0.283
-0.260

0.114

0.160
-0.088
0.187
-0.216
0.387
0.201
-0.114

0.164
z

PI
0.71
-0.511
0.051
-0.087

0.217
-0.023
0.145
0.181

0.101
0.123
0.011
0.211
0.282

-0.041
-0.138
-0.267
-0.219
0.188
0.223
-0.093

-0.029

(0.4851
-0.263
-0.095
pXio.4481
-0.285
-0.373
-0.128
-0.130
0.247
0.286
0.120
0.061

0.001
0.027
f--?i3q

Airway

[UPX. + MPW, + LPW,]

[AA-PNS + PAS]
Tongue

TGL
TGH

0.081
10.541)

pmij
-0.174

[0.5691
0.191

0.216

-0.001

0.076
-0.072

-0.341
pxq

0.238
0.340

0.237
-0.420

-0.172
-0.214

El

Hyoid

[MP-H + H-H]
CsH

0.013
-0.165

pEi%j
0.007

0.036
0.365

-0.288
~0.710(

0.530
0.786

*Significant loadings larger than 0.400 (absolute values) are enclosed in boxes.

although variable loadings greater than 0.400 were

identified.
DISCUSSION

The number of cephalometric variables was reduced

to a smaller set of composite variables with a minimal

loss of information by means of the PCA. The combination of variables was carefully designed so that the
first principal components could be easily interpreted
from a biologic viewpoint. Usual statistical methods are
often inappropriate in this setting because the measured
variables are numerous and often interrelated so that

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Morphology

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499

SNA

SLEEP

APNEA

r so.994

n= 25

Fig. 2. Diagrammatic representation of the variable loadings for the first canonical correlation. For a
complete description of each variable, see RESULTS section.

individual correlations may be meaningless. Furthermore, it is often more convenient to describe a pattern.
Canonical correlation analyses have been applied
to evaluate the complexity of relationpreviously zz23~25
ships between craniofacial and soft-tissue structures.
However, prior to this report, a multivariate approach
has not been undertaken in a sample of adult subjects
with OSA. Factor analytic methods have been used
extensively to extract the latent components that account for observable craniofacial morphology and to
summarize its overall characteristics. The influence of
many interrelated and confounding variables can be
minimized and a group of important or major variables
defined. Unlike prediction equations, which produce
normal values, the results from multivariate analysesin this case canonical correlations-are used to describe
the data and the interconnections in an objective
manner.
The results from this study demonstrate an interaction between craniofacial morphology and pharyngeal
soft tissues. A previous reportz2 quantified an association between a forward tongue posture and an anterior
open bite, a large overjet, a steep mandibular plane,
and large gonial angle. In the current sample, a posterior
position of the pharyngeal wall and a lengthening of
the tongue occurred with the following craniofacial features: a posterior maxilla and mandible, a clockwiserotated mandible, a steep occlusal plane, an increased
height of the lower and upper face, extruded teeth,
proclined incisors, and an open bite. These findings

may have important implications for the pathogenesis

of obstructive sleep apnea.
In recent years many studies have contributed to
our knowledge of the physiology of the upper airway
and the factors that are responsible for airway patency. 2,4~4~17~9,28
Obstruction of the upper airway is primarily prevented by the action of the pharyngeal dilator
and abductor muscles contracting in phase with respiration. Sleep reduces the activity of all these muscles
so that the pharynx becomes narrower and airway resistance increases.26 An abnormal skeletal pattern that
reduces resting airway dimensions could predispose to
upper airway obstruction during sleep.
The genioglossus muscle is the largest and best studied of the upper airway muscles.27 It is attached to the
hyoid bone and to the mandible such that conditions
that retract the mandible result in a posterior movement
of the tongue and a narrowing of the airway. This has
been documented in clinical conditions of depressed
consciousness in which airway obstruction is overcome
by moving the jaw forward.28
The balance between the pharyngeal musculature
and the negative intrapharyngeal pressure of inspiration
determines the patency of the upper airway. A structural
narrowing of the airway eventually hinders the muscular
component of the balance even at rest. A recent report2
describes a test of overall airway stability. With a face
mask securely applied, a negative pressure is generated
within the pharynx. Such pressures have no effect upon
normal subjects, but result in upper airway obstruction

490

Lowe et al.

in patients with OSA, demonstrating that the airway in

these patients is relatively unstable even at rest.
Recent evidence suggests that most patients with
OSA have a narrowed airway. For example, CT scans
of the upper airway in patients with OSA have shown
that the cross-sectional area of the pharynx is reduced
at multiple levels2~3and complete airway obstruction
has been observed. Acoustic reflectance techniques
have confirmed these findings.15 The cause of these
changes remains unknown; Suratt and associatesI suggested that fatty infiltration of the pharynx was not
responsible because the tissue densities of the pharynx
on CT scans were not consistent with adipose tissue.
Rivlin and associates,15 on the other hand, documented
with acoustic reflectance a widening of the pharyngeal
cross-sectional area in one patient who lost 68 kg in
weight, which suggests that peripharyngeal deposition
of fat may have contributed to the sleep apnea.
Alterations in facial skeletal morphology may also
be responsible for the airway abnormality as the pharyngeal musculature is intimately related to the bony
structure. Such changes have been described previously, although infrequently. Riley and co-workersI
found that in a group of ten patients with OSA, six had
abnormal lateral cephalometric radiographs, which suggest mandibular deficiency. In these subjects the airway
behind the mandible was narrowed significantly. Similarly, Rivlin and associates5 noted in nine patients with
OSA that the mandible was posteriorly displaced and
that the number of apneas correlated with the total posterior displacement. Therefore, abnormal craniofacial
morphology would appear to be more common than
previously described.
In this study we were able to examine many aspects
of craniofacial morphology and to describe a relationship between skeletal patterns and airway boundaries.
More posterior boundaries of the pharynx were noted
in association with specific craniofacial variables. Such
interactions are not haphazard and a spectrum of severity was observed. The features included a retropositioned maxilla, extrusion of the maxillary and mandibular teeth, proclination of upper and lower incisors,
and an open bite. The mandible was positioned posteriorly, and a large gonial angle and steep mandibular
plane were noted. The posterior wall of the pharynx
was more posterior and the tongue length increased.
Although these measurements do not describe the upper
airway in toto, they provide a more representative
model than a single posterior airway size measurement.14 Caution must be exercised in the interpretation
of these results because, although the coexistence of
certain variables can be established, direct cause-and-

Am. J. Orthod.

Dentofac. Orthop.
December 1986

effect relationships cannot be proved. However, documentation of the interaction among specific variables
does enhance our understanding of the possible interplay between craniofacial variables, and airway,
tongue, and hyoid variables in subjects with OSA.
The interactions described in this report may have
important implications for treatment of OSA. Uvulopalatopharyngoplasty is effective in treating many patients with OSA3 but relatively contraindicated in patients with marked retrognathia. Recently, it has been
suggested that patients in whom the PAS measurement
is abnormal should also have a mandibular advancement
performed to correct the skeletal abnormality.31 In view
of the results described herein, the mandibular changes
may be the result of other bony abnormalities for which
specific therapy may be required. For example, consideration of a maxillary advancement procedure may
be indicated in some subjects in whom a posteriorly
placed maxilla is documented.
On the basis of the findings in this report, it is
hypothesized that patients with obstructive sleep apnea
have several atypical craniofacial structures. These abnormalities, which may be associated with several aberrations in craniofacial form rather than just a deficient
mandible, reduce the upper airway dimensions and impair upper airway stability. A further analysis, based
on CT scans of OSA patients to create three-dimensional reconstructions of craniofacial, airway, and
tongue structures is underway that could provide a better understanding of the interaction among these factors.
The authors thank Drs. J. Petkauand K. Takadafor their
advice and assistancewith the statistical analysis, Mr. R.
DeCou for his assistancein figure preparation, and Mrs. B.
Crockford for typing the manuscript.
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8. Conway WA, Bower CG, Barnes ME: Hypersomnolence and

intermittent upper airway obstruction: occurrence caused by micrognatbia. JAMA 237: 2740-2742, 1977.
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Reprint requests:
Dr. Alan A. Lowe
Department of Grthodontics
Faculty of Dentistry
University of British Columbia
2199 Wesbrook Mall
Vancouver, B.C.
V6T 127

AA0 MEETING CALENDAR

1987--Montreal, Canada, May 10 to 13, Le Palais des Congressde Montreal
1988-New Orleans, La., April 29 to May 4, New Orleans Convention Center
1989-Anaheim, Calif., May 14 to 17, Anaheim Convention Center
1990-Washington,
D.C., May 8 to 9, Washington Convention Center
1991-St. Louis, MO., May 5 to 8, St. Louis Convention Center
1992-Seattle, Wash., May 9 to 13, Seattle Convention Center