An Interdisciplinary Study of Orthodontic, Orthopedic, and Otorhinolaryngological Findings in 12–14-Year-Old Preorthodontic Children

Correspondence to Medical Academy, Lithuanian University of Health Sciences, J. Lukšos-Daumanto 6, 50106 Kaunas, Lithuania E-mail: klopatiene@zebra.lt Introduction The posture of the human body is the result of many types of inputs of sensory information arising from the visual, the vestibular, and the proprioceptive systems, integrated in the complex regulatory system. A poor body posture is primarily a muscular problem. It depends on the body build, general health, sex, psychological state, strength and endurance, demands of the work place, and social as well as cultural traditions. According to literature, the


Introduction
The posture of the human body is the result of many types of inputs of sensory information arising from the visual, the vestibular, and the proprioceptive systems, integrated in the complex regulatory system. A poor body posture is primarily a muscular problem. It depends on the body build, general health, sex, psychological state, strength and endurance, demands of the work place, and social as well as cultural traditions. According to literature, the problem; children who have no sport activities have than children performing sports (1,2). Changes of and posture at work or rest that demand prolonged sitting or prolonged standing with resultant muscular fatigue and inability to sustain adequate support. In the last century, Wachsmann stated that muscular weakness, which is considered to be related to the weakness of the mesoderm, might be the cause of posture. The stomatognathic system plays an important role in postural control, and reciprocally, dental found that alterations of the occlusion affected the head posture, whereas a change of the head posture Malocclusion, the body posture, and the breathing pattern may correlate, but this issue is still controversial. Every year, with a major surge since 2000, new investigations are carried out, and new results about the correlation between the body posture and dental occlusion emerge (11).
Most recent studies concentrate on the relationship between malocclusion and the head posture (12)(13)(14) or on the morphology of the cervical vertebrae (15)(16)(17)(18). Solow and Sandham stated pronounced forward growth rotation of the mandible, increased mandibular prognathism, and a small anterior face height, whereas extension of the head was accompanied by a large anterior face height, backward rotation of the mandible, and maxillary and mandibular retrognathism (19).
Another group of studies evaluated the relation between the whole body posture and malocclusion (20)(21)(22)(23)(24). It is evident that structural orthopedic diseases are associated with occlusal morphology (20,(25)(26)(27)(28). However, there are still controversial results from available studies about the correlation between the poor body posture and dental occlusion. Perrillo tions between the body posture and dental occlusion either in the sagittal or transverse dimensions (24).
Nasopharyngeal pathology causes mouth breathing and affects the postural change. An altered respiration pattern implies necessary adaptive body postures (29). There is a consensus that anterior tilting of the head is the main change. Such individuals anteriorize their heads and extend their necks to results in muscle imbalance and alters the posture.
After evaluating the contradictory results of the previous studies, a decision was made to evaluate the correlation between malocclusion and the orthopedic and the nasopharyngeal pathology in growing patients. Therefore, the aim of this study was to examine the relationship between the type of malocclusion, the body posture, and the nasopharyngeal obstruction in 12-14-year-old children.

Material and Methods
The study was carried out in the Departments of Orthodontics, Orthopedic Traumatology, and Otolaryngology, Medical Academy, the Lithuanian University of Health Sciences, Kaunas, Lithuania. The sample was obtained by approaching consecutive patients who agreed to participate in the study, attending for orthodontic treatment in the Department of Orthodontics. The parents of all the patients were informed about the study and signed a consent form after a full explanation of the aims and the procedures of the study. An approval for the study was obtained from Kaunas Regional Biomedical Research Ethics Committee (No. BE-2-48).
The study group consisted of 76 patients aged 12-14 years (mean age, 12.79 years [SD, 0.98]). There were 35 boys (46.1%) and 41 girls (53.9%). All the patients were examined by the same orthodontist, the same orthopedic surgeon, and the same otorhinolaryngologist in a blind manner.
The main criteria for including the patients into the study group were as follows: age 12-14 years; no previous maxillofacial trauma or surgery, syndromes, clefts, or orthodontic treatment; no previous treatment of orthopedic disorders of the mus-culoskeletal system and no previous injuries to the pelvis, spine, or the long bones of the legs; and no structural orthopedic diseases.
The orthodontic examination consisted of the study model analysis and the cephalometric radiograph analysis. The study model examination consisted of the sagittal examination, where overjet (OJ) was evaluated as normal mm), the transverse examination where the postewas in a cross relationship with 1 or more of the opposite teeth, and the vertical examination, where overbite (OB) was evaluated as normal (1-3 mm), analysis was calculated as the difference between the available space and the necessary space. Crowding was evaluated as mild (lack of space 2-4 mm), mod-Lateral cephalometric radiographs were analyzed using the Dolphin software (version 10.5). The sagittal position of the maxilla (SNA) and the mandible (SNB), the sagittal jaw relationship (ANB), the mandibular plane angle (MP-SN), and maxillary incisors and mandibular incisors inclination (U1-NA and L1-NB, respectively) were used for the analysis of the facial skull. The width of the upper airway (UA) was measured as the distance from the point of the posterior outline of the soft palate to the closest point on the posterior pharyngeal wall. The width of the lower airway (LA) was measured as the distance from the intersection of the posterior border of the tongue and the inferior border of the mandible to the closest point on the posterior pharyngeal wall (35). The parameters used for this study are shown in Fig. 1. For models and the lateral cephalometric analysis, the error margin was determined by repeating the measurements of 6 variables on randomly selected 10 models and radiographs at 2-week intervals with the same operator; the paired sample t test showed The patients were examined from the front, the side, and the back (Fig. 2). From the side, thoracic kyphosis was evaluated (2). If an increased but adjustable asymptomatic thoracic spine curve was observed, the pathology was considered as a kyphotic posture. All the patients underwent testing to rule out Scheuermann's disease and ankylosing spondylitis. The patients were asked to stand upright and brace back the shoulders to produce extension. In cases of postural kyphosis, an increased curvature, which is regular and mobile, was found. From the front, the position of the shoulders, the symmetry of the waist triangles, and the horizontality of the frontal upper iliac crests were examined. From the back, the position of the shoulders, the scapular height, the symmetry of the waist triangles, the iliac crests, and the thoracic rib hump were evaluated. All the patients underwent testing to rule out scoliosis.
Anterior and posterior rhinoscopy and pharyngoscopy were performed to assess the nasal and the pharyngeal tion, the following diagnoses were made: grade 2-3 hypertrophy of the adenoids, when up to two-thirds of the choana were compromised (36); grade 2-4 hypertrophy of the palatal tonsils, when there was <50% of the space between tonsillar pillars (37); the Orthopedic examination A, the evaluation from the front: a) symmetry of the shoulders; b) symmetry of the waist triangles; c) horizontality of the frontal upper iliac crests. B, thoracic kyphosis has to be evaluated from the side. C, the evaluation from the back: a) symmetry of the if the paravertebral muscle roller emerges in the lumbar region and the rib hump in the thoracic region.
A B C D nasal septum deviation, when the failure of the nasal septum in the center was detected; allergic rhinitis, when typical allergy symptoms (nasal congestion, runny nose, sneezing, and watery eyes) were detectresults of the skin prick test was obtained. The statistical analysis was performed using the statistical software package SPSS 20.0 for Windows. The t test, 2 test, and one-way ANOVA test regression analysis were applied to evaluate the association between the orthodontic, the orthopedic, and the nasopharyngeal pathology. The difference was con-P<0.05.
as follows: among the orthopedic anomalies, the kyphotic posture (37 patients, 48.7%) and the rib hump in the thoracic region (42 patients, 55.3%) were prevalent. The asymmetric position of the shoulder line was detected in 21 patients (27.6%), the scapular asymmetry in 21 (27.6%), and the asymmetry of the waist triangles in 5 patients (6.6%).
When evaluating the relationship between the orthodontic and the sagittal orthopedic pathology, a MP-SN and thoracic kyphosis was found, P<0.05 ( Table 1).
The evaluation of the relationship between the orthodontic and the transversal orthopedic pathology (Table 2) demonstrated a correlation between the degree of the overbite and the symmetry of the shoulder line and the position of the scapulae, P<0.05. The deeper overbite correlated with the shoulder and the scapular asymmetry. No relationship between crowding, the posterior cross bite, and the sagittal or the transversal orthopedic parameters was found.
In the study, the relationship between the orthodontic pathology and the hypertrophy of the tonsils or/and the adenoids was evaluated. A statistically SN angle, the decreased width of the upper pharynx, and the hypertrophy of the tonsils or/and the adenoids was found (P<0.05) ( Table 3). No relationship between crowding, the posterior cross bite, or the hypertrophy of the tonsils or/and the adenoids was found.
The evaluation of the relationship between the nasopharyngeal pathology and the sagittal orthopedic pathology showed that thoracic kyphosis was more common among the patients with the nasopharyngeal pathology. The kyphotic posture was diagnosed in 33 patients (55.0%) with the nasopharyngeal pathology and only in 4 patients (25.0%) without such a pathology (P=0.033).
There was no correlation between the nasopharyngeal pathology and the transversal ortho-tion was found between the presence of more than 1 pathology (the hypertrophy of the adenoids, the hypertrophy of the tonsils, the nasal septum deviation, allergic rhinitis, or thoracic kyphosis) and the increased MP-SN angle, the decreased SNB angle, and the increased width of the lower airway, P<0.05 (Table 4).

Discussion
The present study was based on the assumption that the type of malocclusion, the body posture, and the breathing pattern were interdependent.
The study group consisted of 12-14-year-old orthodontic patients. Such age of the patients was selected on the basis of growth peculiarities. A healthy child at around 7 years of age assumes a normal shape of the spine with physiological lordosis in the cervical and the lumbar areas and physiological kyphosis curves in the thoracic area. The spine grows unevenly, i.e., the longitudinal rate of the growth of the spine is not constant: there is a period of accelerated growth, which occurs at the age between 10.5 and 15.5 years (38), and the peak height velocity averages at an age of 12.2 years in girls and 13.9 years in boys (39). During the peak growth of the spine, the intensive growth of the vertebrae occurs, while the growth of the muscles and the ligaments lags by ~1-2 years. Therefore, during this period, and the shoulder-scapular asymmetry is a normal phenomenon. After the end of the growth spurt, postural defects often disappear spontaneously.
There was a high prevalence of the orthopedic anomalies in the study group. Less than half (48.7%) of the orthodontic patients had kyphotic postures. A study by Lippold et al. revealed orthopedic patho-6.8 years) (20). The prevalence of the nasopharyngeal pathology was also very high in the present study, i.e., it was diagnosed in 78.9% of the patients. According to literature, the prevalence of the hypertrophy of the adenoids and the tonsils -which causes mouth breathing -is high among children, i.e., it varies from 40% to 60% (40,41).
The evaluation of the results of the study showed that the sagittal body posture was related to the vertical craniofacial parameters. The patients with the kyphotic posture had higher MP-SN angles and lower SNB angles, which, of course, was related to the backward rotation of the mandible because of the increasing facial height. According to our re-cantly correlated with the hypertrophy of the tonsils and/or the adenoids. The evaluation of the relationship between the nasopharyngeal pathology and the sagittal orthopedic pathology showed that thoracic kyphosis was more common among the patients with the nasopharyngeal pathology. The ANOVA tween the presence of more than 1 pathology (the hypertrophy of the adenoids, the hypertrophy of the tonsils, the nasal septum deviation, allergic rhinitis, or/and thoracic kyphosis) and the increase in the MP-SN angle and the decrease in the SNB angle. Many previous studies have shown that the nasopharyngeal pathology, which causes mouth breathing, might also cause changes in the head posture, changes in the growth of the mandible (which rotates downward and backward), and an increased lower face height (33). An altered neck posture was observed in 80.0% of the mouth-breathing children in thoracic kyphosis measurements in the group of mouth breathers (32).
When evaluating the body posture in a transversal plane, a correlation was found between a higher overbite and the asymmetry of the shoulders and the body posture, the nasopharyngeal pathology, and crowding in the dental arches or the posterior cross bite, although, in literature, mouth breathing is associated with the narrowing of the upper dental arch and the posterior cross bite (19). This is also in low and Sonnesen, who stated that crowding was associated with the craniocervical posture and greater than 2-mm dental crowding in the dental arches increased the craniocervical angles by 3 o -6 o (13, 14). Whereas Micheloti et al. stated that the unilateral ity and the treatment of this malocclusion to prevent No relationship between the orthodontic parameters and the orthopedic anomalies in the lower thoracic regions was found. Contrary, Lippold et al. discovered that the vertical and the sagittal mandibular position correlated with lower pelvic angles, the pelvic torsion, and the body posture. However, the position of the maxilla did not correlate with studies can be explained, at least in part, by methodological differences of the study design (type of orthopedic evaluation and different age of patients).
In summary, the results of the present study sugbetween the nasopharyngeal pathology, the increase in the MP-SN angle, and the kyphotic posture. The question of causality remains, i.e., which morpho-  (19). This mechanism postulates that the soft tissue layer of the facial skin and the muscles exerts forces on the facial skeleton. In cases of airway obstruction, the head is extended in relation to the cervical column; the soft tissue layer then would be passively stretched. This stretching of the soft tissue of the head and the neck creates a dorsal force, which, in turn, impedes the forward growth of the face, particularly the mandible. From the results of the present study, it is possible to simulate that in cases of airway obstruction not only the posture of the head but also the body posture changes. Therefore, good body posture and the function of the airway is of considerable importance in orthodontics and cannot be overlooked in treatment planning.

Conclusions
The prevalence of the poor body posture and the nasopharyngeal pathology was very high in the present study. In total, 48.7% of the orthodontic patients had the kyphotic posture. The nasopharyngeal pathology was diagnosed in 78.9% of the patients. The evaluation of the correlation between the type of the orthodontic anomalies and the body posture tal position of the mandible (SNB angle) and the mandibular plane angle (MP-SN) and the kyphotic posture, i.e., the patients with the kyphotic posture had higher MP-SN angles and lower SNB angles. A relationship between the nasopharyngeal pathology and the body posture was found, i.e., thoracic kyphosis was more common among the patients with the nasopharyngeal pathology. The study showed no relationship between the degree of crowding, the presence of the posterior cross bite, and the sagittal and the transversal orthopedic parameters.