obesity reviews

doi: 10.1111/j.1467-789X.2010.00719.x

Diagnostic in Obesity and Complications

Dentofacial characteristics as indicator of obstructive

sleep apnoea-hypopnoea syndrome in patients with
severe obesity
obr_719

105..113

M. E. S. Maciel Santos1, J. R. Laureano Filho1, J. M. Campos2 and E. M. Ferraz2

Summary

Dentistry College of Pernambuco, University

Obstructive sleep apnoea-hypopnoea syndrome (OSAHS) is a complex disease

with a multifactor aetiology. OSAHS is strongly associated with obesity, but there
are many other clinical risk factors, such as the dentofacial characteristics of hard
and soft tissues, hyoid bone position, neck circumference, upper airway spaces
and nasal respiration. A descriptive cross-sectional study was carried out involving 13 patients (one man and 12 women) with severe obesity in order to evaluate
specific physical dentofacial characteristics through a cephalometric examination.
Cephalometry was analysed using 29 measurements of the hard and soft tissues of
the craniofacial structures and dimensions of the upper airways. The demographic
data revealed a mean body mass index of 48 6.26 kg m-2 and cervical circumference of 43 3.69 cm. No patient exhibited important facial asymmetry and
facial types 1 (normal) and 3 (mandible forward) were the most prevalent. Septal
deviation was observed in 46% of patients. The most prevalent modified Mallampati index score was between 3 and 4, while grade 1 was the most prevalent
tonsillar hypertrophy index score (46%). Cephalometry revealed angular and
linear measurements with normally acceptable values for the hard tissues. Obese
patients seem to have a normal craniofacial structure and the risk of developing
OSAHS is especially related to obesity.

Department of Oral and Maxillofacial Surgery,

of Pernambuco, Camaragibe, 2Division of

General Surgery and Obesity Surgery,
University Hospital of the Federal University of
Pernambuco, Recife, PE, Brazil

Received 2 November 2009; revised 18

December 2009; accepted 22 December
2009

Address for correspondence: Dr JR Laureano

Filho, Dentistry College of Pernambuco,
University of Pernambuco, Av. Gal. Newton
Cavalcanti, 1650, Tabatinga, Camaragibe,
Pernambuco, Brazil, CEP 54753-220. E-mail:
laureano@pq.cnpq.br

Keywords: Facial deformity, mandibular advancement, obstructive sleep apnoea.

obesity reviews (2011) 12, 105113

Introduction
Obstructive sleep apnoea-hypopnoea syndrome (OSAHS)
is a common disorder characterized by repetitive episodes
of pharyngeal airway collapse resulting in decreased
airflow despite ongoing respiratory effort during sleep and
can adversely impact longevity and quality of life (1,2).
Despite its multifactor aetiology, the increased upper
airway resistance and airway closure is mainly due to anatomic factors and/or physiologic factors that impair the
function of airway-dilating muscles and increase collapsibility (3,4). There are many clinical risk factors for
obstructive apnoea, such as nasal obstruction, craniofacial

abnormalities, mandibular retrognathia (mandible positioned excessively behind the maxilla), micrognathia (small
maxilla size), narrowed, tapered and short maxillary arch,
overbite (deep bite), long soft palate, modified grade III
or IV Mallampati, macroglossia (large tongue), tonsillar
hypertrophy (large tonsils), increased neck circumference
and obesity (24).
The role of obesity in the pathogenesis of OSAHS has
been well established (49). However, not all patients with
OSAHS are obese and may have another anatomic predisposition to airway collapse. Cephalometric measurements
reveal that OSAHS severity in non-obese patients may be
associated with some types of facial characteristics, such as

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105

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Dentofacial feature in obese patients

M. E. S. Maciel Santos et al.

vertical skeletal disharmony (misalignment of teeth and/or

incorrect relation between the teeth of the two dental
arches) (10). A reduced pharyngeal airway space may be
due to structural narrowing of the pharynx and/or the base
of the tongue against the posterior pharyngeal wall (11).
Craniomaxillofacial abnormality is a well-recognized risk
factor for OSAHS and a maxillomandibular deficiency can
result in diminished airway dimensions, leading to obstruction (12). Retrognathism is especially important, as a posteriorly positioned mandible causes the soft tissues of the
tongue and pharynx to be more posteriorly positioned as
well, thereby predisposing an individual to obstruction
during sleep (3). The hyoid bone, located in the anterior
region of the neck above the larynx, is also important as an
anchorage for the tongue muscles and its position partly
affects the shape, size and position of the tongue. Previous
studies have shown that the hyoid bone is more downwardly positioned in individuals with OSAH (13). This
lower position of the hyoid bone gives the tongue a more
upward position, with more tongue mass occupying the
hypopharyngeal area.
The dentofacial characteristics of patients with OSAHS
(whether obese or non-obese) must be evaluated before
the appropriate treatment is offered. This investigation
includes a guided patient history, systematic physical
examination of the head and neck, nasal evaluation and
some kind of imaging evaluation of the airway and dentofacial morphology, with the investigation of hard and soft
tissues (3,14,15).

Obstructive sleep apnoea-hypopnoea

syndrome and craniofacial patterns:
cephalometric findings
A large number of cephalometric studies have been carried
out to investigate the craniofacial architecture of patients
with OSAHS, for which measurements and abnormalities
of the craniofacial structures are well documented.
Changes in the craniofacial parameters and transversal
upper airway area are related to different degrees of
OSAHS severity. Patients with severe OSAHS have a significantly narrower transversal area at the level of uvula
during exhalation as well as more a downwardly positioned hyoid bone, thicker soft palate and larger neck circumference when compared with patients with mild/
moderate OSAHS and control groups (16).
Paoli et al. (17) studied cephalometric abnormalities of
the craniofacial skeleton and airways in a group of 85 men
with OSAHS in relation to their body mass index (BMI).
The patients with normal weight or who were slightly
overweight differed from obese patients in several cephalometric variables: shorter anterior floor of the cranial base
(SNa distance), shorter horizontal ramus of the mandible
(gonionchin distance), more posterior position of the

obesity reviews

mandible (SNB angle) and greater maxillomandibular discrepancy (ANB angle) (Figs 1 and 2). The obese patients,
however, had a craniofacial structure with normal cephalometric values. Thus, the dysfunction seems to be related
to the tissue changes induced by obesity.
Body weight and certain cephalometric parameters are
significant predictors of OSAHS. One study revealed the
existence of craniofacial differences as well as differences in
the soft tissue of the upper airways related to obesity and
the severity of OSAHS among Chinese patients (13). Hyoid
position and soft palate length were significantly different
between normal-weight, overweight and obese patients,
with the hyoid more downwardly positioned and the palate
longer in the obese group. A longer soft palate length, more
downwardly positioned tongue base and increased craniocervical extension were evident in the group with severe
OSAHS.
Tangugsorn et al. analysed different components of
cervico-craniofacial skeleton and morphology of the upper
airway soft tissue among obese and non-obese patients
with OSAHS as well as healthy controls (18). Both OSAHS
groups had cervico-craniofacial abnormalities as well as
abnormalities in the morphology of the upper airway soft
tissue when compared with the controls. The obese patients
had more abnormalities in the morphology of the upper
airway soft tissue as well as head posture and position of
the hyoid bone.
A cephalometric analysis of patients with severe and
non-severe OSAHS revealed that the patients with severe
OSAHS exhibited increased maxillomandibular retrognathism. Craniocervical extension, forward head posture,
downwardly positioned hyoid bone, enlarged, elongated
soft palate and upward tongue postures were more exaggerated as well (19). Morphological differences do appear
to exist between individuals with OSAHS, those who snore
and controls, but most of these differences are in soft tissue
structures (20). Based on it the objective of this study was
find out the association between dentofacial characteristics
of OSAHS in patients with severe obesity.

Materials and methods

The present study was performed at the out-patient clinic
of the Division of General Surgery and Obesity Surgery of
the University Hospital of the Federal University of Pernambuco in association with the Department of Oral and
Maxillofacial Surgery of University of Pernambuco in
Brazil. Between February 2008 and January 2009, 13
patients with severe obesity (Class III obesity) were evaluated with regard to dentofacial characteristics as well as
quality of sleep and nasal respiration.
The study received approval from the Ethics Committee
and all patients gave written informed consent to participate. All patients were submitted to an evaluation protocol

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Dentofacial feature in obese patients

M. E. S. Maciel Santos et al.

107

Figure 1 Cephalometric radiograph of head in profile (a) and respective cephalometric analysis with points, planes and linear measurements used
(b). Bone landmarks: S, centre of sella turcica; Na, nasion, most anterior point of fronto-nasal suture; Orb, lowermost point of orbital floor; ANS, most
anterior point of anterior nasal spine; PNS, posterior nasal spine; apx I, apex of upper central incisor; I, occlusal border of the upper incisor; i,
occlusal border of the lower incisor; apx i, apex of lower incisor; A, point A, subspinale; B, point B, submentale; Me, mental point, lowermost point of
osseous chin; H, forward most and uppermost superior point of hyoid bone; Go, gonion, intersection of mandibular plane and posterior border of the
ramus; C4, centre of corpus of C4 cervical vertebra; T, tip of the uvula; Po, porion, uppermost point of the auditory meatus; Ba, basion, lowermost
point of the basilary process of the occipital bone. Plane definitions: Fr, Frankfort plane, line from Orb to porion; bispinal, line from ANS to PNS; MP,
mandibular plane, line from point Me to Go. Distance measurements: SNa, distance from S to nasion; SBa, distance from S to basion; FLM, facial
length of the middle third of the face; FLI, facial length of the lower third of the face; VPS, velopharyngeal space; LPS, linguopharyngeal space; HPS,
hyopharyngeal space; SPL, soft palate length; HMe, distance from hyoid bone to chin; PNSA, distance from posterior nasal spine to point A;
GoMe, distance from gonion point to mental point; HMP, distance from point H to mandibular plane; HFr, distance from point H to Frankfort plane;
Hbispinal, distance from point H to bispinal plane.

consisting of a guided patient history and systematic physical examination of the head and neck as well as an
anthropometric physical examination (BMI and cervical
circumference) and lateral cephalometric radiography with
cephalometric analysis.
During the anamnesis, patients were asked about the
presence of symptoms related to obesity, such as hypertension, sleep disorders (OSAHS, snoring, daytime somnolence), diabetes, muscle-skeletal disorders and others
comorbidities. All patients selected had a BMI over 40. All
calculations of ideal and excess weight were based on the
metropolitan life foundation table.
The evaluation of head and neck morphology was performed by a facial inspection observing facial asymmetry,
facial type and anthropometric characteristics, chin prominence, anterior rhinoscopy (external nose morphology,
septal deviation and hypertrophy of the lower nasal turbinates), oral evaluation (dental occlusion evaluation, signs

of antero-posterior and/or transversal (maxillomandibular

discrepancies), oropharynx evaluation (using the modified
Mallampati index and tonsillar hypertrophy index) and
cervical circumference at the level of the upper border of
the thyroid cartilage.

Radiographic and cephalometric analysis

Standardized lateral cephalograms were performed with
the patients head secured by a cephalostat and orientated
parallel to the Frankfort plane, with the patient at the
end-expiration phase and not swallowing. Each image was
digitized for subsequent cephalometric analysis. Bone landmarks, angles and linear distances measured were analysed
by the same calibrated operator.
Cephalometric analysis was based on the analysis
described by Paoli et al. (17), with elements from various
methods used in orthodontic and orthognathic routines

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108

Dentofacial feature in obese patients

M. E. S. Maciel Santos et al.

obesity reviews

Figure 2 Cephalometric radiograph of head in profile (a) and respective cephalometric analysis with angles and angular measurements (b). Angles:
SNA, angle between sellanasion line and nasionpoint A; SNB, angle between sellanasion line and nasionpoint B; ANB, angle between ANa and
NaB lines; Tweed, angle between mandibular plane and Frankfort plane; PMA, angle between bispinal plane and mandibular plane; NSH, angle
between nasionsella line and sellapoint H; NSC, angle between nasionsella lines and sellapoint C; AMH, angle between mandibular plane and
Mepoint H; NaSBa, angle between nasionsella line and sellabasion; SNaBa, angle between sellanasion line and nasionbasion; NaBaS,
angle between nasionbasion line and basionsella; I/Fr, angle between Frankfort plane and upper incisor axis; i/PM, angle between mandibular
plane and lower incisor axis; I/i, angle between superior and lower incisive axes; gonial, angle between ascending ramus and mandibular corpus.

(Figs 1 and 2). All 21 cephalometric points and 29 measurements selected allow the exploration of the craniofacial
skeleton and dentofacial characteristics. With these landmarks, the following linear and angular measurements are
taken into account: the anterior cranial base length (SNa
distance), positions of the maxilla and mandible in the
sagittal direction (SNA and SNB angles), maxillomandibular discrepancies (ANB angles), facial height and divergence measurements (Tweed and gonion angles), and
airway measurements, including width of the three levels
of the pharynx (velopharyngeal, linguopharyngeal and
hyopharyngeal spaces). Special attention was given to the
position of the hyoid bone, which was established in
several ways both in the vertical and antero-posterior
directions.

6.26 kg m-2 and mean cervical circumference of

43 3.69 cm. For this sample a mean of ideal weight
(59.6 4.34) revelled an excess weight of 66.2 18.52 kg.
None of the patients exhibited facial asymmetry and the
most prevalent facial types was types 1 and 3 (46.15%
each). Mean overjet and overbite were similar
(2 1.3 mm). Septal deviation was observed in six patients
(46.15%). In the oropharynx evaluation, the modified Mallampati index revealed a greater prevalence of grades 5 and
6 (38.4% and 46.1%, respectively). The opposite occurred
for the tonsillar hypertrophy index, which revealed a
greater prevalence of grades 1 and 2.
Table 2 displays the 29 specific cephalometric measurements, with angular and linear measurements representing
the morphology of the hard and soft tissues of the head
and neck.

Results
The descriptive data are summarized in Table 1. The
sample was made up of one man and 12 women with a
mean age of 34 10.82 years, mean BMI of 48

Further discussion
The pathogenesis of OSAHS is complex and not yet fully
understood. Obesity has been confirmed to play an impor-

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Dentofacial feature in obese patients

Table 1 Clinical examination measurements (data are expressed as

mean value [SD] and number [%])
Mean (SD)
Demographic data
Gender
Male
Female
Age (years)
Weight (kg)
Height (m)
BMI (Wt/Ht2)
Ideal weight (kg)
Excess weight (kg)
Cervical circumference (cm)
Dentofacial and nasal analysis
Facial asymmetry
Yes
No
Facial type
Type 1
Type 2
Type 3
Overjet (mm)
Overbite (mm)
Intercanthal distance (mm)
Interlip distance (mm)
Alar base (mm)
Nasal height (mm)
Nostrils (mm)
Right height
Right width
Left height
Left width
Septal deviation
Yes
No
Oropharynx evaluation
Mallampati index
Grade 1
Grade 2
Grade 3
Grade 4
Tonsillar hypertrophy
Grade 1
Grade 2
Grade 3
Grade 4

(10.82)
(20.66)
(0.07)
(6.26)
(4.34)
(18.52)
(3.69)

0 (0)
13 (100)
6 (46.15)
1 (7.6)
6 (46.15)
2
2
32
2
36
45

(1.39)
(1.36)
(3.90)
(0.78)
(3.45)
(2.22)

9
10
7
10

(1.98)
(1.20)
(1.56)
(1.68)

109

Table 2 Cephalometric values with angular and linear measurements

(data are expressed as mean value [SD])

n (%)

1 (7.7)
12 (92.3)
34
126
1.62
48
59.6
66.2
43

M. E. S. Maciel Santos et al.

Mean (SD)
Angular measurements (degrees)
SNA
SNB
ANB
Tweed
PMA
NSH
NSC
AMH
NaSBa
SNaBa
NaBaS
IFr
i/MP
I/i
Goniac
Linear measurements (mm)
SNa
SBa
FLM
FLI
VPS
LPS
HPS
SPL
HMe
PNSA
GoMe
HMP
HFrankfort
Hbispinal

86.13
83.24
2.89
22.83
25.99
91.71
116.93
22.84
132.76
18.01
29.23
120.41
82.97
120.07
126.46

(4.66)
(3.14)
(4.22)
(4.19)
(4.63)
(4.95)
(6.02)
(6.24)
(4.18)
(2.11)
(2.49)
(5.18)
(6.51)
(7.87)
(5.74)

66.97
42.36
47.71
64.55
11.38
14.59
32.48
34.53
49.33
50.77
70.70
18.93
84.89
61.97

(3.86)
(3.33)
(2.67)
(5.38)
(3.95)
(5.51)
(4.95)
(3.58)
(5.37)
(3.23)
(5.54)
(4.74)
(6.56)
(7.63)

6 (46.15)
7 (53.84)

1
1
5
6

(7.6)
(7.6)
(38.4)
(46.1)

6
5
2
0

(46.1)
(38.4)
(15.3)
(0)

BMI, body mass index; SD, standard deviation.

tant role because of fatty deposition around the pharyngeal

walls, which contributes towards the narrowing and collapsibility of the airway (58). However, not all patients
with OSAHS are obese and therefore different features that
cause nocturnal upper airway obstruction in obese and
non-obese patients are expected (18). Moreover, 25% of
severely obese patients have no improvement in the apnoeahypopnoea index (AHI) following bariatric surgery and
weight loss (9). There are two main theories to explain this:

the patients exhibit other anatomic factors that cause collapsibility (e.g. maxillomandibular deficiencies, mandibular
retrognathia, large tongue, etc.) (2); or it could be secondary
to extrathoracic obstruction or physiologic lung mechanisms (9). In fact, the AHI should not be considered the only
criterion of surgical success (21), as the clinical assessment of
mean oxygen saturation, blood pressure, sleep quality and
Epworth Sleepiness Scale are also important (2,9).
Based on craniofacial morphology, dysmorphosis in the
group of non-obese or slightly obese patients with OSAHS
is common and important. This may be related to a genetic
predisposition or a growth disorder during childhood
(22,23). As obese patients have a craniocervical structure
with normal cephalometric values, the dysfunction seems
to be related to the changes around of the upper airway soft
tissues induced by obesity (14,17,20). Cephalometric
studies have demonstrated that there are craniofacial
differences as well as differences in upper airway soft
tissues related to obesity and the severity of OSAHS. These
anatomic deviations are usually confined to cervicocraniofacial skeletal structures in non-obese OSAHS

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110 Dentofacial feature in obese patients

M. E. S. Maciel Santos et al.

patients, whereas obese patients with OSAHS have been

found to have more abnormalities in the morphology of
upper airway soft tissues as well as head posture and hyoid
bone position (13,16,17,20,24).
In the present study, only patients with severe obesity
were analysed, as obesity has been found to be a contributing factor to the occurrence and severity of OSAHS
(59). However, according to Fogel et al. (25), the correlation between obesity and OSAHS severity is not consistent
and other clinical assessments are necessary for this kind of
patient. It is therefore important to investigate other clinical factors that can predispose an individual to developing
OSAHS and we propose a specific head and neck clinical
and radiographic evaluation that includes investigations of
dentofacial deformities, neck circumference, tongue and
tonsil size and quality of nasal respiration. For example,
neck circumference is considered one of the best specific
predictors of the presence and severity of OSAHS.
The mean neck circumference in the present study
(43 3.69 cm) was similar to that described in other
studies (14). On the other hand, no patient in the present
study exhibited facial asymmetry and the most common
facial types were types 1 and 3, which are traditionally not
as related to a predisposition to OSAHS as type 2 (mandibular retrognathism). Moreover, overjet/overbite values
were normal, thereby denoting good incisor dental occlusion and good skeletal relationship between the jaws. These
data are in agreement with studies that found that no
abnormalities in the facial skeleton were associated with
OSAHS in patients with severe obesity (14).
Septal symmetry is considered an important clinical
factor for nasal respiration quality and a severe deviation is
a predictor of poor nasal respiration or mouth breathing
(26). In the present study, the anterior rhinoscopic septal
deviation was observed in six patients (46.15%), but we
found equivalent values regarding anterior nose morphology in relation to the right and left height and width of the
nostrils. Based on these findings, we agree with Duchna
et al. (27), who reports that septal devation and increased
nasal resistance have no clinically relevant importance in
patients with OSAHS.
The evaluation of dental occlusion was very difficult to
measure because of the large number of partially edentulous patients in the sample. Nearly all the patients were
analysed based on canine occlusion, which revealed a
prevalent Angle Class I occlusion. The good occlusion referenced by molar and canine Angle Class I occlusion represents bite equilibrium and harmonic occlusion without
discrepancies, whereas Angle Classes II and III suggest
dental and/or maxillofacial antero-posterior discrepancies.
The modified Mallampati index and tonsillar hypertrophy index are considered predictors of the occurrence and
severity of OSAHS (28,29). The link to a physical examination of patients with OSAHS is simple, as a high Mal-

obesity reviews

lampati index and/or tonsillar hypertrophy index score is

associated with a greater probability of sleep-disordered
breathing because the oral airway is smaller. Moreover,
individuals with partial or total nasal obstruction must
breathe through the mouth and, if the oral airway is also
narrowed (e.g. high Mallampati and tonsillar hypertrophy
index scores), breathing during sleep may be compromised
(28,29). In the present study, the most prevalent modified
Mallampati scores were 3 and 4 (38.4% and 46.1%,
respectively), but hypertrophy of the palatine tonsils scores
revealed normal findings. Thus, as no patients had any
history of surgeries in these anatomic structures, we suspect
that the size of the tongue (as measured by the modified
Mallampati index) can be also increased by obesity regardless of any pathology and the size of the palatine tonsils is
generally a hereditary trait or pathologic condition. We
also believe that larger tongue and palatine tonsil sizes can
predispose an individual to obstruction of the upper
airways, especially in the oropharynx. However, Martinho
et al. (14) found that these two altered measurements had
no have correlation to the occurrence and severity of
OSAHS.
The cephalometric values in the present study are of
interest. Maxillomandibular discrepancies can predispose
individuals to OSAHS and many cephalometric measurements can suggest this condition. Cranial base length (SNa
and SBa distances) and cranial base flexure angles (Na
SBa angles) have been studied in patients with OSAHS, as
a shorter length of the cranial base causes a retroposition
of the maxilla, which is often not evidenced by the SNA
angle. Regarding these measurements, we found a shorter
cranial base length (SNa of 66.97 3.86 and SBa of
42.36 3.33 mm) than that described in previous studies
(17). However, the cranial base flexure angles had no
abnormal cephalometric values and the possible retroposition of the maxilla related to the shorter cranial base was
not associated with a reduced posterior velopharyngeal
space (velopharyngeal space of 11.38 3.95 mm). Retroposition of the maxilla or mandible is also usually
assessed by the SNA (position of the maxilla in relation to
the cranial base) and SNB angles (position of the mandible
in relation to the cranial base), which are widely used in
orthodontics, with normal values ranging from 81 to 83
and 79 to 81, respectively. We found higher mean measurements of these angles. However, as a result of the standard
deviation, we cannot affirm that there was evidence of
maxillomandibular discrepancies and the ANB angle
(maxillanasionmandible angle) also had normally
acceptable values. Retroposition of the maxilla or mandible
may also be associated with the size of the maxilla and
mandible. The PNSA and GoMe values in the present
study were within the normal range.
It is assumed that the hyoid bone is more downwardly
positioned than normal in relation to the mandibular plane

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Dentofacial feature in obese patients

in obese patients with OSAHS. However, the position of

the hyoid bone in the present sample was slightly different
from that found in the literature. In the vertical direction,
the distances from the hyoid to the mandibular
plane (HMP of 18.93 4.74 mm), Frankfort plane
(HFrankfort of 84.89 6.56 mm) and palatal plane
(Hbispinal of 61.97 7.63 mm) were all less than those
described by Paoli et al. (17) and Battagel et al. (20). Thus,
the hyoid bone in the severely obese patients of the present
study was higher and more forwardly positioned than the
mean values found by the authors cited.
In relation to gender, according to Tsai et al. (30), there
are obvious differences in the craniofacial skeletal characteristics that contribute to OSAHS severity and different
anthropometric and cephalometric measurements should
be used for men and women. Although male patients are at
greater risk factor of developing more severe OSAHS than
women, the present sample was predominantly composed
of women (92.3%) and the differences in relation to gender
were considered non-significant.
Cephalometry has a number of advantages, such as its
reproductibility, low cost, easy access, minimal radiation
exposure and non-invasive nature (2). According to some
authors, radiographic examination of the face and airways
has received considerable attention because of its merit of
being simpler and more readily available than CT scanning
or magnetic resonance imaging techniques (1720,24).
However, there are limitations to cephalometric investigations inherent to examining a three-dimensional object
using two-dimensional techniques. The differing transversal dimensions of the airways cannot be seen and therefore
the image obtained is incomplete. Other limitations of
cephalometric studies include the use of different landmarks, measurements and tracing analyses, which hinders
the comparison of the results. We agree that cephalometric
studies have a number of disadvantages, but this method is
still employed in some countries (e.g. orthodontic and
orthognathic treatment of dentofacial deformities) and
the results, despite not being the best, adequately reveal the
anatomy of the head and neck anatomy as well as the
morphology of the upper airway morphology and can be
correctly interpreted by experienced professionals.
Some authors (31) have reported morphological differences in three-dimensional soft tissues and craniofacial
structures of the pharyngeal airway between positional and
non-positional OSAHS patients. Patients with positional
OSAHS have wider lateral airways, lower facial height and
a more backward position of the lower jaw, which may
explain the differences in the maintenance of pharyngeal
airway patency in the lateral sleep position. It was not
within the scope of the present study to evaluate and
compare positional or non-positional OSAHS and the
results revealed no significant discrepancies in relation to
the position of the jaws.

M. E. S. Maciel Santos et al.

111

Although skeletal differences have been reported in nonobese patients with OSAHS (13,18), this condition is not
confirmed in obese patients with OSAHS, for whom the
dysfunction seems to be related to the changes in the soft
tissues induced by obesity. These differences have physiopathogenic, diagnostic and therapeutic consequences for
the management of patients with OSAHS (17).
Continuous positive pressure in the upper airways
during sleep (CPAP) and weight loss should be recommended for all overweight patients with sleep-disordered
breathing, as it results in the improvement of OSAHS.
However, CPAP imposes a heavy burden on patients and
losing weight is not an easy task, resulting in high rates of
failure and relapse. CPAP, for example, has a rejection rate
of 1824% among patients with OSAHS (32). For severely
obese patients, bariatric surgery is the best option for lowering weight and maintaining it at much lower levels as well
as for the resolution of associated comorbidities, including
OSAHS (69). Improvement in OSAHS symptoms with a
reduction in AHI in severely obese patients after bariatric
surgery is well documented (59,33).
Surgical treatment of OSAHS is principally aimed at
enlarging the airway dimensions while decreasing airway
collapsibility. Maxillomandibular advancement (MMA)
surgery is currently regarded the most effective and acceptable surgical treatment for OSAHS (34,35). In a previous
study, we reviewed the importance of this technique to the
improvement of OSAHS in obese or non-obese patients
with or without maxillofacial discrepancies (5). MMA
involves advancing the maxilla and mandible, increasing
the antero-posterior and lateral dimensions at all the levels
of the upper airways as well as improving the tension and
collapsibility of the suprahyoid and velopharyngeal musculature as a result of the upward and forward movement
of the hyoid bone (2,11,34). Traditionally, the indication of
MMA surgery for OSAHS is based on the severity of the
disease and/or cephalometric determination of an important dentofacial deformity, but patients currently do not
need to have skeletal deficiencies to undergo MMA and the
benefit for those patients with a particularly severe disease,
including those with a significantly high BMI, has been
established (3638).
For this reason, the examination and assessment of the
upper airway anatomy plays a central role in patient evaluation and can help guide treatment. Furthermore, as
OSAHS has a multifactor aetiology, obesity and differing
craniofacial characteristics among these patients are only
part of the equation and the altered pathophysiology of the
airways in these conditions must be recognized (13). This
preliminary research requires further discussion and we
aim to acquire a larger number of patients in future studies
in order to compare these data with a healthy control group
as well as the same measurements following bariatric
surgery. Thus, one of the purposes of this study is to make

2010 The Authors

obesity reviews 2010 International Association for the Study of Obesity 12, 105113

112 Dentofacial feature in obese patients

M. E. S. Maciel Santos et al.

this evaluation protocol clear and accessible so that it may

be routinely used in different health fields, especially by
internists and endocrinologists during the evaluation of
obese patients with OSAHS. We believe that severely obese
patients are strongly susceptible to developing OSAHS
because of the obesity altering the soft tissue anatomy
around the upper airways and a multidisciplinary approach
is important for a more effective management of these
patients.

Conflict of Interest Statement

No conflict of interest was declared.

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