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Is there a correlation between nasal septum deviation and maxillary transversal deficiency? A retrospective study on prepubertal subjects
International Journal of Pediatric Otorhinolaryngology 83 (2016) 109–112
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Is there a correlation between nasal septum deviation and maxillary transversal deficiency? A retrospective study on prepubertal subjects Ballanti Fabiana, Baldini Alberto *, Ranieri Salvatore, Nota Alessandro, Cozza Paola Department of Orthodontics, University of Rome Tor Vergata, Viale Oxford, 81, 00133 Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 November 2015 Received in revised form 26 January 2016 Accepted 31 January 2016 Available online 6 February 2016
Introduction: Deviated nasal septum may cause a reduction of the nasal airflow, thus, during the craniofacial development, a reduced nasal airflow could originate a chronic mouth-breathing pattern, related with moderate to severe maxillary constriction. The aim of this retrospective study is to analyze the correlation between maxillary transverse deficiency and nasal septum deviation. Methods: Frontal cephalograms were performed on 66 posterior–anterior radiographs of subjects (34M, 32F; mean age 9.95 2.50 years) with maxillary transverse deficiency and on a control group of 31 posterior–anterior radiographs of subjects (13M, 18F; 9.29 2.08 years). Angular parameters of the nasal cavities were recorded and compared between the two groups using a Student’s t-test. Results: Generally all the parameters are very similar between the two groups except for the ASY angle that differs for about the 27%; anyway the Student’s t-test showed no statistically significant differences between the two groups (mostly p > 0.20). Conclusions: This study failed to show an association between transverse maxillary deficiencies and nasal septum deviations. Moreover, no significant differences were found between the mean nasal cavities dimensions in subjects with transverse maxillary deficiency and the control group. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nasal septum Maxillary transverse deficiency Nasal cavities Cephalometry
1. Introduction The septal cartilage is a perpendicular plate with a quadrangular shape that extends from the nasal bone to the bony septum. Two triangular or trapezoidal shaped cartilages flank its upper half fusing with the dorsal septum in the midline. The nasal septum is made up of a vertical lamina that includes two bony parts and a cartilage that is generally slightly deflected respect to its axis. The primitive nasal cavities and the primitive nasal septum are in communication with the oral cavity until the 8th week with the formation of the posterior palate [1]. For these reasons the maxillary bone and the nasal structures have an important anatomical connection starting from their initial growth phases. Moreover, the septal cartilage is rather a center than an area of growth; it deviation in the first years of life,
* Corresponding author at: Centro Medico Polispecialistico Baldini Srl, Via S. Orsola, n. 5, Bergamo 24122, Italy. Tel.: +39 035 271935; fax: +39 035 694280. E-mail addresses: [email protected] (B. Fabiana), [email protected] (B. Alberto), [email protected] (R. Salvatore), [email protected] (N. Alessandro), [email protected] (C. Paola). http://dx.doi.org/10.1016/j.ijporl.2016.01.036 0165-5876/ß 2016 Elsevier Ireland Ltd. All rights reserved.
can determine a distortion of the maxillary bone with a dislocation of the septum toward the deviated site [2,3]. Septal deviations could be related to childhood traumas or to a disharmonic development of the near structures (ethmoid bone, nasal bone, vomer bone, maxillary bone). This disharmonic growth could be related with an excessive compression of the nasal and maxillary structures given by an incorrect position of the fetus. This compression is often asymmetric and this can determine in the maxillary bone, palatal deformities or modification of one of the nasal cavities floor. Maxillary transverse constriction is one of the most frequent skeletal deformities in the craniofacial region [4]. This deformity usually causes unilateral or bilateral posterior crossbites, dental crowding, high palatal vault, elevation of the nasal floor and mouth breathing [5]. Some studies correlate the maxillary transverse deficiency with small nasal cross sectional areas [6,7]. It was published that skeletally expanding the maxillary bone brings to an improvement of the breathing pattern [8,9] and a reduction of the nasal airway resistance increasing significantly the lower nasal volume, nasal floor width and nasal lateral width [10–12]. Some studies showed that subjects with cleft palate have a nasal septum deviation toward the cleft side [13,14]. In the scientific literature it
B. Fabiana et al. / International Journal of Pediatric Otorhinolaryngology 83 (2016) 109–112
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is stated that deviated nasal septum may cause a reduction of the nasal airflow, thus, during the craniofacial development, a reduced nasal airflow could originate a chronic mouth-breathing pattern, related with moderate to severe maxillary constriction [5,15]. 1.1. Aim of the study The aim of this retrospective study is to analyze the correlation between maxillary transverse deficiency and nasal septum deviation. There are no published studies that evaluate their potential association. 2. Materials and methods 2.1. Subjects A retrospective evaluation was performed on 66 posterior– anterior radiographs of subjects (34M, 32F; mean age 9.95 2.50 years) with maxillary transverse deficiency clinically diagnosed by an expert orthodontist were selected according to the following criteria: maxillary transverse constriction with monolateral or bilateral molar crossbite, no history of orthodontic treatment, prepubertal age, high quality standardized posterior–anterior radiographs. A control group of 31 posterior–anterior radiographs of subjects (13M, 18F; 9.29 2.08 years) were selected according to the following criteria: absence of maxillary transverse constriction, no history of orthodontic treatment, prepubertal age, high quality standardized posterior–anterior radiographs. All the subjects were free from congenital anomalies and syndromes. Informed consent agreement was signed by patients allowing their data to be used for research purposes.
Fig. 1. Representation of posterior–anterior cephalometric measurements analyzed in the study. NC, right nasal cavity angle; NC0 , left nasal cavity angle; NSm, nasal septum median; NSi, nasal septum inferior; ANS, anterior nasal spine.
2.2. Data
2.3. Statistical analysis
Posterior–anterior radiographs were taken by a single trained radiographer with the bipupillar plane parallel to the ground floor and a specific support in order to ensure a standardized position. The same operator manually traced each frontal cephalogram (Fig. 1) and a second operator checked landmarks and anatomic contours. In case of disagreement the cephalograms were retraced reaching a mutual satisfaction of both the operators. The following anatomical points and lines were traced according to Kyrkanides et al. [14]:
A Shapiro–Wilk test was conducted in order to demonstrate the normal distribution of the data. A Student’s t-test was used to analyze the differences between the two groups. The significance level was set at p < 0.05.
– Lo (and Lo0 ): latero-orbital, defined as the intersections between the lateral margin of the orbits and ‘‘cranial linea innominata’’ (oblique line). – NSm: nasal septum median, the most median central point of the nasal septum. – NSi: nasal septum inferior, the most inferior central point of the nasal septum. – LoL: the latero-orbital line, connecting Lo–Lo0 . – VML: the vertical midline, perpendicular to LoL passing trough the midpoint of LoL line (Lom).
3. Results The posterior–anterior cephalometric data of both groups are shown in Table 1 with the results of the Student’s t-test. Generally all the parameters are very similar between the two groups except for the ASY angle that differs for about the 27%; anyway the Student’s t-test showed no statistically significant differences between the two groups (mostly p > 0.20). The Student’s t-test showed the absence of statistically significant differences between the mean age of the two groups (p = 0.18).
Table 1 Descriptive statistical analysis and Student’s t-test p-values. AGE
CV
NC
NC0
NS inf NS med ANS
ASY
Study Mean group SD
9.95 2.50
38.6 3.3
19.1 2.1
19.5 2.0
0.8 1.4
1.1 1.8
0.7 1.1
1.5 1.8
Control
Mean SD
9.29 2.08
37.1 6.3
18.3 3.5
18.6 2.5
0.8 1.3
1.2 1.8
0.6 1.1
1.1 1.6
T-test
p-Value 0.180 0.221 0.285 0.078 0.899 NS NS NS NS NS
0.676 NS
0.619 0.217 NS NS
The following angles were calculated: – – – – – – –
NC: right nasal cavity angle, nc-VML. NC0 : left nasal cavity angle, nc0 -VML. CV: nasal cavity angle, nc–nc0 . NSm angle: SNm-VML angle (absolute value). NSi angle: SNi-VML angle (absolute value). ANS angle: ANS-VML anterior nasal spine angle. ASY: asymmetry of the two nasal cavities, difference between NC and NC0 (absolute value).
NC, right nasal cavity angle; NC0 , left nasal cavity angle; CV, nasal cavity angle; NSm angle (absolute value); NSi angle (absolute value); ANS angle, anterior nasal spine angle; ASY, asymmetry of the two nasal cavities (absolute value).
B. Fabiana et al. / International Journal of Pediatric Otorhinolaryngology 83 (2016) 109–112
4. Discussion The maxillary bone and the nasal structures have an important anatomical connection starting from their initial growth phases [1,3]. In fact, maxillary transverse constrictions, which are one of the most frequent skeletal deformities in the craniofacial region, are characterized by high palatal vault, elevation of the nasal floor and mouth breathing [4,5]. Many studies [8,16,17] found changes in nasal volume after rapid maxillary expansion, but some authors stated that these variations are not clinically significant [18,19]. Farronato et al. [1] found that rapid maxillary expansion is able to reduce a nasal septum deviation in contrast with the findings of Altug-Atac et al. [6] but Aziz et al. [2] in their systematic review found some weaknesses in their works concluding that is still not clear the influence of this orthopedic treatment on nasal septum. In this retrospective study posterior–anterior radiographs were analyzed tracing frontal cephalograms [14] in order to find differences in nasal septum structures associated with transverse maxillary deficiency. Literature lacks of studies that analyze the possible association between transverse maxillary deficiency and nasal septal deviation. Nasal breathing is a prerequisite for a proper growth of the craniofacial complex. Thus should be supposed that moderate to severe nasal septal deviation can cause clinically significant reduction of the nasal airflow resulting in irreversible repercussions on the growth and development of craniofacial structures [2,15]. In this study, no significant differences were found between the septum nasi angles of the two groups denying the existence of this correlation. Some studies [20,21] concluded that anterior and inferior septal deviations increase nasal resistance more than posterior and superior septal deviations. Different nasal airflow reductions could differently interfere with the maxillary growth. In this study we analyzed the absolute value of the medium and inferior septum nasi angles in subjects with transverse maxillary deficiency compared with a control group. This two-dimensional analysis is unable to evaluate the position of the septal deviation on the sagittal plane that could interfere with the related nasal airflow reduction. Thus a detailed analysis of the tridimensional position of the nasal septal deviation, of its severity and of its consequent nasal airflow could bring to different results in order to show its potential association with transverse maxillary constrictions. In this study, according with Baraldi et al. [7] the dimensions of the nasal cavities showed similar values between the two groups as confirmed by the absence of statistically significant differences. Similarly was not statistically significant the considerable difference between the nasal cavity asymmetry mean values of the two groups. Baraldi et al. [7] reported that a maxillary deficiency in the transverse dimension could be correlated with small posterior nasal cross-sectional areas measured by acoustic rhinometry but, surprisingly, he did not find statistically significant correlations with the anterior nasal cross-sectional areas nasal width in subjects. Thus, frontal cephalometric evaluation could be not enough sensitive to reveal alterations that involve only the posterior nasal structures. The frontal cephalometric evaluation of posterior anterior radiographs is an excellent method for the analysis of face transverse deformities and asymmetries [7,22,23]. There are no studies that analyzed the reliability of the frontal cephalometric evaluation in the diagnosis of the nasal septal deviations, but some studies previously used this method in the analysis of the influences of the maxillary expansion techniques on the nasal septum and cavities [1,6,7,24]. Future studies with larger samples should be done to elucidate the argument. Furthermore, looking at the etiology of the potential association between nasal septal deviations and maxillary
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transverse deficiency, the analysis of a group of subjects with septal deviations, even with different methods, could bring to different and clearer results. 5. Conclusions This study failed to show an association between transverse maxillary deficiencies and nasal septum deviations. Moreover, no significant differences were found between the mean nasal cavities dimensions in subjects with transverse maxillary deficiency and the control group. References [1] G. Farronato, L. Giannini, G. Galbiati, C. Maspero, RME: influences on the nasal septum, Minerva Stomatol. 61 (2012) 125–134, http://www.ncbi.nlm.nih.gov/ pubmed/22441415. [2] T. Aziz, K. Ansari, M.O. Lagravere, M.P. Major, C. Flores-Mir, Effect of non-surgical maxillary expansion on the nasal septum deviation: a systematic review, Prog. Orthod. 16 (2015) 15, http://dx.doi.org/10.1186/s40510-015-0084-y. [3] J. Delaire, A. Gaillard, J. Billet, H. Landais, Y. Renaud, Considerations sur les synostoses pre´mature´es et leurs consequences au crane et a` al face, Rev. Stom. 64 (1963) 97. [4] J.A. Mcnamara, Maxillary transverse deficiency, Am. J. Orthod. Dentofac. Orthop. (1998) 567–570, S0889540600040920 [pii]. [5] T. Laptook, Conductive hearing loss and rapid maxillary expansion: report of a case, Am. J. Orthod. 80 (1981) 325–331, http://www.ncbi.nlm.nih.gov/pubmed/ 7025649. [6] A.T. Altug-Atac, M.S. Atac, G. Kurt, H.A. Karasud, Changes in nasal structures following orthopaedic and surgically assisted rapid maxillary expansion, Int. J. Oral Maxillofac. Surg. 39 (2010) 129–135, http://dx.doi.org/10.1016/j.ijom.2009. 11.013. [7] C.E. Baraldi, S.M. Pretto, E. Puricelli, Evaluation of surgically assisted maxillary expansion using acoustic rhinometry and postero–anterior cephalometry, Int. J. Oral Maxillofac. Surg. 36 (2007) 305–309, http://dx.doi.org/10.1016/j.ijom.2006.10.016. [8] F. Ballanti, R. Lione, S. Viarani, E. Fanucci, P. Cozza, Post-retention effects of rapid maxillary expansion on nasal cavity and on periodontal structures, Oral Implantol. (Rome) 1 (2008) 95–103, http://www.ncbi.nlm.nih.gov/pubmed/23285345. [9] A. Baldini, A. Nota, C. Santariello, V. Assi, F. Ballanti, P. Cozza, Influence of activation protocol on perceived pain during rapid maxillary expansion, Angle Orthod. 85 (2015) 1015–1020, http://dx.doi.org/10.2319/112114-833.1. [10] H.G. Hershey, B.L. Stewart, D.W. Warren, Changes in nasal airway resistance associated with rapid maxillary expansion, Am. J. Orthod. 69 (1976) 274–284, http://www.ncbi.nlm.nih.gov/pubmed/766643. [11] J. Zeng, X. Gao, A prospective CBCT study of upper airway changes after rapid maxillary expansion, Int. J. Pediatr. Otorhinolaryngol. 77 (2013) 1805–1810, http://dx.doi.org/10.1016/j.ijporl.2013.07.028. [12] C. Santariello, A. Nota, A. Baldini, F. Ballanti, P. Cozza, Analysis of rapid maxillary expansion effects on nasal soft tissues widths, Minerva Stomatol. 63 (2014) 307– 314, http://www.ncbi.nlm.nih.gov/pubmed/25308568 (accessed 05.11.14). [13] K. Mølsted, E. Dahl, Asymmetry of the maxilla in children with complete unilateral cleft lip and palate, Cleft Palate J. 27 (1990) 184–190, discussion 190-2, http:// www.ncbi.nlm.nih.gov/pubmed/2340639. [14] S. Kyrkanides, R. Bellohusen, J.D. Subtelny, Skeletal asymmetries of the nasomaxillary complex in noncleft and postsurgical unilateral cleft lip and palate individuals, Cleft Palate. Craniofac. J. 32 (1995) 428–433, http://dx.doi.org/10.1597/ 1545-1569(1995)032<0428:SAOTNC>2.3.CO;2. [15] T. Baccetti, L. Franchi, C.G. Cameron, J.A. McNamara, Treatment timing for rapid maxillary expansion, Angle Orthod. 71 (2001) 343–350, http://dx.doi.org/ 10.1043/0003-3219(2001)071<0343:TTFRME>2.0.CO;2. [16] T. Smith, A. Ghoneima, K. Stewart, S. Liu, G. Eckert, S. Halum, et al., Threedimensional computed tomography analysis of airway volume changes after rapid maxillary expansion, Am. J. Orthod. Dentofac. Orthop. 141 (2012) 618– 626, http://dx.doi.org/10.1016/j.ajodo.2011.12.017. [17] C. Baratieri, M. Alves Jr., E.F. Sant’anna, M.da C. Nojima, L.I. Nojima, 3D mandibular positioning after rapid maxillary expansion in Class II malocclusion, Braz. Dent. J. 22 (2011) 428–434, http://www.ncbi.nlm.nih.gov/pubmed/22011901. [18] G. Ceroni Compadretti, I. Tasca, G. Alessandri-Bonetti, S. Peri, A. D’Addario, Acoustic rhinometric measurements in children undergoing rapid maxillary expansion, Int. J. Pediatr. Otorhinolaryngol. 70 (2006) 27–34, http://dx.doi.org/ 10.1016/j.ijporl.2005.05.004. [19] C.L. Marcus, L.J. Brooks, K.A. Draper, D. Gozal, A.C. Halbower, J. Jones, et al., Diagnosis and management of childhood obstructive sleep apnea syndrome, Pediatrics 130 (2012) e714–e755, http://dx.doi.org/10.1542/peds.2012-1672. [20] G.J.M. Garcia, J.S. Rhee, B.A. Senior, J.S. Kimbell, Septal deviation and nasal resistance: an investigation using virtual surgery and computational fluid dynamics, Am. J. Rhinol. Allergy 24 (2010) e46–e53, http://dx.doi.org/10.2500/ ajra.2010.24.3428. [21] T. Liu, D. Han, J. Wang, J. Tan, H. Zang, T. Wang, et al., Effects of septal deviation on the airflow characteristics: using computational fluid dynamics models, Acta Otolaryngol. 132 (2012) 290–298, http://dx.doi.org/10.3109/00016489.2011. 637233.
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[22] N.J. Betts, R.L. Vanarsdall, H.D. Barber, K. Higgins-Barber, R.J. Fonseca, Diagnosis and treatment of transverse maxillary deficiency, Int. J. Adult Orthod. Orthognath. Surg. 10 (1995) 75–96, http://www.ncbi.nlm.nih.gov/pubmed/9082002. [23] K. Mølsted, E. Dahl, V. Brattstro¨m, J. McWilliam, G. Semb, A six-center international study of treatment outcome in patients with clefts of the lip and palate:
evaluation of maxillary asymmetry, Cleft Palate Craniofac. J. 30 (1993) 22–28, http://dx.doi.org/10.1597/1545-1569(1993)030<0022:ASCISO>2.3.CO;2. [24] D.L. Cross, J.P. McDonald, Effect of rapid maxillary expansion on skeletal, dental, and nasal structures: a postero-anterior cephalometric study, Eur J. Orthod. 22 (2000) 519–528, http://www.ncbi.nlm.nih.gov/pubmed/11105408.
Contents lists available at ScienceDirect
International Journal of Pediatric Otorhinolaryngology journal homepage: www.elsevier.com/locate/ijporl
Is there a correlation between nasal septum deviation and maxillary transversal deficiency? A retrospective study on prepubertal subjects Ballanti Fabiana, Baldini Alberto *, Ranieri Salvatore, Nota Alessandro, Cozza Paola Department of Orthodontics, University of Rome Tor Vergata, Viale Oxford, 81, 00133 Rome, Italy
A R T I C L E I N F O
A B S T R A C T
Article history: Received 24 November 2015 Received in revised form 26 January 2016 Accepted 31 January 2016 Available online 6 February 2016
Introduction: Deviated nasal septum may cause a reduction of the nasal airflow, thus, during the craniofacial development, a reduced nasal airflow could originate a chronic mouth-breathing pattern, related with moderate to severe maxillary constriction. The aim of this retrospective study is to analyze the correlation between maxillary transverse deficiency and nasal septum deviation. Methods: Frontal cephalograms were performed on 66 posterior–anterior radiographs of subjects (34M, 32F; mean age 9.95 2.50 years) with maxillary transverse deficiency and on a control group of 31 posterior–anterior radiographs of subjects (13M, 18F; 9.29 2.08 years). Angular parameters of the nasal cavities were recorded and compared between the two groups using a Student’s t-test. Results: Generally all the parameters are very similar between the two groups except for the ASY angle that differs for about the 27%; anyway the Student’s t-test showed no statistically significant differences between the two groups (mostly p > 0.20). Conclusions: This study failed to show an association between transverse maxillary deficiencies and nasal septum deviations. Moreover, no significant differences were found between the mean nasal cavities dimensions in subjects with transverse maxillary deficiency and the control group. ß 2016 Elsevier Ireland Ltd. All rights reserved.
Keywords: Nasal septum Maxillary transverse deficiency Nasal cavities Cephalometry
1. Introduction The septal cartilage is a perpendicular plate with a quadrangular shape that extends from the nasal bone to the bony septum. Two triangular or trapezoidal shaped cartilages flank its upper half fusing with the dorsal septum in the midline. The nasal septum is made up of a vertical lamina that includes two bony parts and a cartilage that is generally slightly deflected respect to its axis. The primitive nasal cavities and the primitive nasal septum are in communication with the oral cavity until the 8th week with the formation of the posterior palate [1]. For these reasons the maxillary bone and the nasal structures have an important anatomical connection starting from their initial growth phases. Moreover, the septal cartilage is rather a center than an area of growth; it deviation in the first years of life,
* Corresponding author at: Centro Medico Polispecialistico Baldini Srl, Via S. Orsola, n. 5, Bergamo 24122, Italy. Tel.: +39 035 271935; fax: +39 035 694280. E-mail addresses: [email protected] (B. Fabiana), [email protected] (B. Alberto), [email protected] (R. Salvatore), [email protected] (N. Alessandro), [email protected] (C. Paola). http://dx.doi.org/10.1016/j.ijporl.2016.01.036 0165-5876/ß 2016 Elsevier Ireland Ltd. All rights reserved.
can determine a distortion of the maxillary bone with a dislocation of the septum toward the deviated site [2,3]. Septal deviations could be related to childhood traumas or to a disharmonic development of the near structures (ethmoid bone, nasal bone, vomer bone, maxillary bone). This disharmonic growth could be related with an excessive compression of the nasal and maxillary structures given by an incorrect position of the fetus. This compression is often asymmetric and this can determine in the maxillary bone, palatal deformities or modification of one of the nasal cavities floor. Maxillary transverse constriction is one of the most frequent skeletal deformities in the craniofacial region [4]. This deformity usually causes unilateral or bilateral posterior crossbites, dental crowding, high palatal vault, elevation of the nasal floor and mouth breathing [5]. Some studies correlate the maxillary transverse deficiency with small nasal cross sectional areas [6,7]. It was published that skeletally expanding the maxillary bone brings to an improvement of the breathing pattern [8,9] and a reduction of the nasal airway resistance increasing significantly the lower nasal volume, nasal floor width and nasal lateral width [10–12]. Some studies showed that subjects with cleft palate have a nasal septum deviation toward the cleft side [13,14]. In the scientific literature it
B. Fabiana et al. / International Journal of Pediatric Otorhinolaryngology 83 (2016) 109–112
110
is stated that deviated nasal septum may cause a reduction of the nasal airflow, thus, during the craniofacial development, a reduced nasal airflow could originate a chronic mouth-breathing pattern, related with moderate to severe maxillary constriction [5,15]. 1.1. Aim of the study The aim of this retrospective study is to analyze the correlation between maxillary transverse deficiency and nasal septum deviation. There are no published studies that evaluate their potential association. 2. Materials and methods 2.1. Subjects A retrospective evaluation was performed on 66 posterior– anterior radiographs of subjects (34M, 32F; mean age 9.95 2.50 years) with maxillary transverse deficiency clinically diagnosed by an expert orthodontist were selected according to the following criteria: maxillary transverse constriction with monolateral or bilateral molar crossbite, no history of orthodontic treatment, prepubertal age, high quality standardized posterior–anterior radiographs. A control group of 31 posterior–anterior radiographs of subjects (13M, 18F; 9.29 2.08 years) were selected according to the following criteria: absence of maxillary transverse constriction, no history of orthodontic treatment, prepubertal age, high quality standardized posterior–anterior radiographs. All the subjects were free from congenital anomalies and syndromes. Informed consent agreement was signed by patients allowing their data to be used for research purposes.
Fig. 1. Representation of posterior–anterior cephalometric measurements analyzed in the study. NC, right nasal cavity angle; NC0 , left nasal cavity angle; NSm, nasal septum median; NSi, nasal septum inferior; ANS, anterior nasal spine.
2.2. Data
2.3. Statistical analysis
Posterior–anterior radiographs were taken by a single trained radiographer with the bipupillar plane parallel to the ground floor and a specific support in order to ensure a standardized position. The same operator manually traced each frontal cephalogram (Fig. 1) and a second operator checked landmarks and anatomic contours. In case of disagreement the cephalograms were retraced reaching a mutual satisfaction of both the operators. The following anatomical points and lines were traced according to Kyrkanides et al. [14]:
A Shapiro–Wilk test was conducted in order to demonstrate the normal distribution of the data. A Student’s t-test was used to analyze the differences between the two groups. The significance level was set at p < 0.05.
– Lo (and Lo0 ): latero-orbital, defined as the intersections between the lateral margin of the orbits and ‘‘cranial linea innominata’’ (oblique line). – NSm: nasal septum median, the most median central point of the nasal septum. – NSi: nasal septum inferior, the most inferior central point of the nasal septum. – LoL: the latero-orbital line, connecting Lo–Lo0 . – VML: the vertical midline, perpendicular to LoL passing trough the midpoint of LoL line (Lom).
3. Results The posterior–anterior cephalometric data of both groups are shown in Table 1 with the results of the Student’s t-test. Generally all the parameters are very similar between the two groups except for the ASY angle that differs for about the 27%; anyway the Student’s t-test showed no statistically significant differences between the two groups (mostly p > 0.20). The Student’s t-test showed the absence of statistically significant differences between the mean age of the two groups (p = 0.18).
Table 1 Descriptive statistical analysis and Student’s t-test p-values. AGE
CV
NC
NC0
NS inf NS med ANS
ASY
Study Mean group SD
9.95 2.50
38.6 3.3
19.1 2.1
19.5 2.0
0.8 1.4
1.1 1.8
0.7 1.1
1.5 1.8
Control
Mean SD
9.29 2.08
37.1 6.3
18.3 3.5
18.6 2.5
0.8 1.3
1.2 1.8
0.6 1.1
1.1 1.6
T-test
p-Value 0.180 0.221 0.285 0.078 0.899 NS NS NS NS NS
0.676 NS
0.619 0.217 NS NS
The following angles were calculated: – – – – – – –
NC: right nasal cavity angle, nc-VML. NC0 : left nasal cavity angle, nc0 -VML. CV: nasal cavity angle, nc–nc0 . NSm angle: SNm-VML angle (absolute value). NSi angle: SNi-VML angle (absolute value). ANS angle: ANS-VML anterior nasal spine angle. ASY: asymmetry of the two nasal cavities, difference between NC and NC0 (absolute value).
NC, right nasal cavity angle; NC0 , left nasal cavity angle; CV, nasal cavity angle; NSm angle (absolute value); NSi angle (absolute value); ANS angle, anterior nasal spine angle; ASY, asymmetry of the two nasal cavities (absolute value).
B. Fabiana et al. / International Journal of Pediatric Otorhinolaryngology 83 (2016) 109–112
4. Discussion The maxillary bone and the nasal structures have an important anatomical connection starting from their initial growth phases [1,3]. In fact, maxillary transverse constrictions, which are one of the most frequent skeletal deformities in the craniofacial region, are characterized by high palatal vault, elevation of the nasal floor and mouth breathing [4,5]. Many studies [8,16,17] found changes in nasal volume after rapid maxillary expansion, but some authors stated that these variations are not clinically significant [18,19]. Farronato et al. [1] found that rapid maxillary expansion is able to reduce a nasal septum deviation in contrast with the findings of Altug-Atac et al. [6] but Aziz et al. [2] in their systematic review found some weaknesses in their works concluding that is still not clear the influence of this orthopedic treatment on nasal septum. In this retrospective study posterior–anterior radiographs were analyzed tracing frontal cephalograms [14] in order to find differences in nasal septum structures associated with transverse maxillary deficiency. Literature lacks of studies that analyze the possible association between transverse maxillary deficiency and nasal septal deviation. Nasal breathing is a prerequisite for a proper growth of the craniofacial complex. Thus should be supposed that moderate to severe nasal septal deviation can cause clinically significant reduction of the nasal airflow resulting in irreversible repercussions on the growth and development of craniofacial structures [2,15]. In this study, no significant differences were found between the septum nasi angles of the two groups denying the existence of this correlation. Some studies [20,21] concluded that anterior and inferior septal deviations increase nasal resistance more than posterior and superior septal deviations. Different nasal airflow reductions could differently interfere with the maxillary growth. In this study we analyzed the absolute value of the medium and inferior septum nasi angles in subjects with transverse maxillary deficiency compared with a control group. This two-dimensional analysis is unable to evaluate the position of the septal deviation on the sagittal plane that could interfere with the related nasal airflow reduction. Thus a detailed analysis of the tridimensional position of the nasal septal deviation, of its severity and of its consequent nasal airflow could bring to different results in order to show its potential association with transverse maxillary constrictions. In this study, according with Baraldi et al. [7] the dimensions of the nasal cavities showed similar values between the two groups as confirmed by the absence of statistically significant differences. Similarly was not statistically significant the considerable difference between the nasal cavity asymmetry mean values of the two groups. Baraldi et al. [7] reported that a maxillary deficiency in the transverse dimension could be correlated with small posterior nasal cross-sectional areas measured by acoustic rhinometry but, surprisingly, he did not find statistically significant correlations with the anterior nasal cross-sectional areas nasal width in subjects. Thus, frontal cephalometric evaluation could be not enough sensitive to reveal alterations that involve only the posterior nasal structures. The frontal cephalometric evaluation of posterior anterior radiographs is an excellent method for the analysis of face transverse deformities and asymmetries [7,22,23]. There are no studies that analyzed the reliability of the frontal cephalometric evaluation in the diagnosis of the nasal septal deviations, but some studies previously used this method in the analysis of the influences of the maxillary expansion techniques on the nasal septum and cavities [1,6,7,24]. Future studies with larger samples should be done to elucidate the argument. Furthermore, looking at the etiology of the potential association between nasal septal deviations and maxillary
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transverse deficiency, the analysis of a group of subjects with septal deviations, even with different methods, could bring to different and clearer results. 5. Conclusions This study failed to show an association between transverse maxillary deficiencies and nasal septum deviations. Moreover, no significant differences were found between the mean nasal cavities dimensions in subjects with transverse maxillary deficiency and the control group. References [1] G. Farronato, L. Giannini, G. Galbiati, C. Maspero, RME: influences on the nasal septum, Minerva Stomatol. 61 (2012) 125–134, http://www.ncbi.nlm.nih.gov/ pubmed/22441415. [2] T. Aziz, K. Ansari, M.O. Lagravere, M.P. Major, C. Flores-Mir, Effect of non-surgical maxillary expansion on the nasal septum deviation: a systematic review, Prog. Orthod. 16 (2015) 15, http://dx.doi.org/10.1186/s40510-015-0084-y. [3] J. Delaire, A. Gaillard, J. Billet, H. Landais, Y. 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