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ORIGINAL ARTICLE
Year : 2012  |  Volume : 30  |  Issue : 3  |  Page : 242-249
 

Effects of Asthma and Inhalation corticosteroids on the dental arch morphology in children


Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, JSS University, Karnataka, India

Date of Web Publication21-Dec-2012

Correspondence Address:
S S Kumar
Department of Pedodontics and Preventive Dentistry, JSS Dental College and Hospital, SS Nagar, Bannimantap, Mysore, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-4388.105018

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   Abstract 

Background: Hereditary, environmental and developmental factors play an important role in dentofacial development, as well as the initiation of malocclusion disorder. Allergic phenomenon such as asthma that induces an alternative mode of breathing in patients is a contributing factor in development of the dental arch. Aim: Our aim in this study was to evaluate the dentoalveolar morphology in asthmatic children and to analyze the effects of asthmatic medications on the dental arch. Setting and Design : This study is centered on 44 asthmatic children aged between 6-12 years from J.S.S Hospital, Mysore. Selected variables from model analysis of the casts of the asthmatic group were subjected to comparison with those of the non-asthmatic group, which comprised of 44 non-asthmatic children. Selected parameters were arch width, arch length and palatal depth. Materials and Methods : Impressions of upper and lower arches were made with rubber based impression material. A sliding digital caliper was used to measure the casts for arch width and arch length. A palatal depth gauge was used to measure the palatal depth. Statistical Analysis : Differences in arch widths, arch lengths and palatal depths between asthmatics and non-asthmatics groups were evaluated by independent sample t-tests. Chi-square test was applied to assess the frequency of occurrence of malocclusion in the asthmatic children. Result: The results obtained revealed that the arch length and palatal depth of asthmatic group had higher values compared to that of non-asthmatic groups for both age groups (6 to 8-year-old males and females, 10 to 12-year-old males and females). Inter molar width showed a significant lower value in asthmatics in the maxillary arches of 10 to 12-year-old females. Fifty percent of the asthmatic children aged 10 to 12-years had open-bite. Children under regular medication showed significant deviation in the dentoalveolar morphology as compared to those under irregular medication. Conclusion: The present study proves a strong relation between asthma and dentoalveolar morphology.


Keywords: Allergy, asthma, dentoalveolar morphology, inhalation corticosteroids, malocclusion


How to cite this article:
Kumar S S, Nandlal B. Effects of Asthma and Inhalation corticosteroids on the dental arch morphology in children. J Indian Soc Pedod Prev Dent 2012;30:242-9

How to cite this URL:
Kumar S S, Nandlal B. Effects of Asthma and Inhalation corticosteroids on the dental arch morphology in children. J Indian Soc Pedod Prev Dent [serial online] 2012 [cited 2018 Aug 19];30:242-9. Available from: http://www.jisppd.com/text.asp?2012/30/3/242/105018



   Introduction Top


Asthma is considered a chronic inflammatory disorder of the airway similar to allergic rhinitis in that the associated inflammatory reaction is usually Immunoglobulin E (IgE) mediated. In the presence of inflammation, airway hyperactivity develops, resulting in changes in airway tone and thus airflow. When significant narrowing is present, bronchospasm develops and the characteristic wheezing is heard. [1]

It has been reported that 90% of those diagnosed with asthma have allergic rhinitis. The patency of the airway is also considered equally important for the proper growth and the development of the craniofacial and associated nasomaxillary structures. Changes in nasal function induced by rhinitis may lead to the development of bronchial asthma via the loss of the natural filtering mechanism of the nasal passage due the development of edema. [2],[3],[4]

As a consequence of inflammatory response and increased airway resistance in the respiratory system, the subjects suffering from asthma, experience difficulty in breathing. To overcome this difficulty their mode of breathing changes from nasal to oral breathing. This change in function can trigger modulations in the craniofacial growth patterns.

Treatment of acute symptoms is usually with an inhaled short-acting beta-2 agonist (such as salbutamol). Symptoms can be prevented by inhaling corticosteroids.

A few studies have been conducted on the effects of asthma on dentoalveolar arch. However, the conclusions of these studies are contradictory to each other and an in depth research is required to support the existing concept.

Therefore, the purpose of this study was to evaluate the effects of asthma and its medications on the dentoalveolar morphology. Knowledge about this relationship will help in the interdisciplinary approach in treating asthma and minimizing its effects on the dentofacial system.


   Materials and Methods Top


44 asthmatic children aged between 6-12 years were recruited from the department of pediatrics and department of pulmonology, J.S.S Hospital, Mysore, India. They were classified into subgroups on the basis of age, sex and regularity of medication. Selected variables from model analysis of the casts of the study group were subjected to comparison with those of the non-asthmatic group, which comprised of 44 children. The non-asthmatic subjects for the study were recruited from the outpatient department of the department of pedodontics and preventive dentistry, J.S.S Dental College and Hospital, Mysore who fulfilled our criteria. The children had come for routine dental check-ups. The non-asthmatic subjects were grouped in to subgroups based on age and sex. The child and the parent were informed about the study and their consent was taken [Table 1].
Table 1: Distribution of sample

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Selection criteria

The subjects were included in the non-asthmatic group only if they fulfilled the following selection criteria,

  • Children aged between six to twelve (6-12) years, who have not undergone any orthodontic treatment hitherto.
  • Children without any abnormal Para functional oral habits children with ideal Class 1 Occlusion according to Angle's molar relation.
  • Children with negative history of any respiratory disease.
  • Children presenting with normal physical growth without any gross asymmetry of the face.
  • Children who do not have multiple grossly destructed teeth, or multiple teeth missing, as in such cases occlusion standardization would become difficult.
The subjects included in the study group fulfilled the following criteria for inclusion

  • Age should be between six to twelve (6-12) years.
  • Mild persistent or moderate persistent asthma.
  • Asthmatic patient for about past one to five (1-5) years.
  • Children who do not have any abnormal oral habits.
  • Should not have undergone any orthodontic treatment previously.
  • Children who do not have multiple grossly destructed teeth, or multiple teeth missing, as that would have affected the vertical jaw relations.
  • Children presenting with normal physical growth without any gross asymmetry of the face due to any other cause.
Assessment of dentoalveolar morphology

Impressions of upper and lower arches were made with rubber based impression material. Casts were poured with dental stone. A sliding digital caliper was used to measure the casts for arch width and arch length. A palatal depth gauge was used to measure the palatal depth. [5],[6]

The following measurements were made in millimeters:

  1. Arch width measurements: Maximum rectilinear distance between the lateral incisors, cusp tips of the canines, buccal cusp tips of the premolars and the mesiobuccal cusp tips of the permanent first molars and deciduous second molars. Finally, only inter permanent molar width was considered for statistical analysis to avoid bias in measurements and statistical results which would be created due to exfoliation and eruption phenomenon as we were dealing with mixed dentition, which is transitional in nature [Figure 1].
    Figure 1: Dentoalveolar arch dimensions

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  2. Arch length: The perpendicular distance from the intermolar distance line to the labial surface of the central incisors [Figure 1].
  3. The overjet of the maxillary incisors were measured by placing a scale against the labial surface of the mandibular incisors and taking the reading where the incisal edge of the maxillary incisors touched the scale. In case of unequal protrusion of maxillary incisors, the maximum protrusion was recorded from the incisal edge of left or right maxillary incisors. [6]
  4. The dental casts were held at eye level and a fine horizontal scratch was made on the labial surface of the mandibular central incisors with a chisel. Over-bite was recorded by measuring the mandibular incisors from its edge to the horizontal mark. [6]
  5. Palatal depth: Depth of the palatal vault measured from the intermolar distance line to the palatal vault. [6],[7]
The study casts of 88 children divided were measured under close supervision. All the measurements were made twice. The measurements were repeated in case of an error. The values were subjected to statistical analysis after calculating the mean and statistical significance. The statistical techniques applied was Independent samples t-test for analyzing dental arch morphology and Chi-square test was applied for analyzing frequency of occurrence of malocclusion in asthmatics. All the statistical methods were carried out through the SPSS for Windows (version 16.0).


   Results Top


From the tables it can be inferred that

  1. The Intermolar width had a lower mean values in asthmatics as compared to the non-asthmatics in 6 to 8-year-old males and 10 to 12-year-old males and females in both the arches. However, a significant higher value (P < 0.05) was observed only for the inter molar width of 10 to 12-year-old females in the maxillary arch where the mean value was 50.06 ± 2.98 in asthmatics and 52.89 ± 2.64 for non-asthmatics. Surprisingly, an increased inter molar width was seen in 6 to 8-year-old female asthmatics in both the arches, and the finding was highly significant in the maxillary arch (P < 0.01) [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10].
    Table 2: Comparison of maxillary arch dimension of asthmatic group and non-asthmatic group (6 to 8-year-old males)

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    Table 3: Comparison of mandibular arch dimension of asthmatic group and non-asthmatic group (6 to 8-year-old males)

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    Table 4: Comparison of maxillary arch dimension of asthmatic group and non-asthmatic group (6 to 8-year-old females)

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    Table 5: Comparison of mandibular arch dimension of asthmatic group and non-asthmatic group (6 to 8-year-old females)

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    Table 6: Comparison of maxillary arch dimension of asthmatic group and non-asthmatic group (10 to 12-year-old males)

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    Table 7: Comparison of mandibular arch dimension of asthmatic group and non-asthmatic group (10 to 12-year-old males)

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    Table 8: Comparison of maxillary arch dimension of asthmatic group and non-asthmatic group (10 to 12-year-old females)

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    Table 9: Comparison of mandibular arch dimension of asthmatic group and non-asthmatic group (10 to 12-year-old females)

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    Table 10: Comparison of maxillary arch dimension among asthmatic children under regular and irregular medication (6 to 8-year-old males)

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  2. The Arch length in asthmatics showed a consistent higher mean values as compared to that of non-asthmatic subjects in both the age group and sexes. This trend was observed in both the maxillary and mandibular arches of asthmatic subjects. However, the values were highly significant (P < 0.01) only in 6 to 8-year-old female asthmatics in both the arches. The mean value was 30.65 ± 3.75 in asthmatics and 24.40 ± 3.33 for non-asthmatics in maxillary arch. The mean value in the mandibular arch was 25.97 ± 3.32 in asthmatics and 21.42 ± 2.18 in non-asthmatics [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10].
  3. A deeper Palate was observed in both the age groups and sexes in asthmatics. (6 to 8-year-old males and females, 10 to 12-year-old males and females). Though the mean value was seen to be increased in all the groups, consistently, the values reached the level of significance only in 6 to 8-year-old male asthmatics (P < 0.05). The mean value was 15.22 ± 1.55 in asthmatics and 13.68 ± 1.38 in non-asthmatics [Table 2], [Table 4], [Table 6], [Table 8].
  4. Decreased Intermolar width, increased Arch length and deeper Palate were consistently observed in asthmatic children undergoing regular medication as compared to those under irregular medication [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17].
    Table 11: Comparison of mandibular arch dimension among asthmatic children under regular and irregular medication (6 to 8-year-old males)

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    Table 12: Comparison of maxillary arch dimension among asthmatic children under regular and irregular medication (6 to 8-year-old females)

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    Table 13: Comparison of mandibular arch dimension among asthmatic children under regular and irregular medication (6 to 8-year-old females)

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    Table 14: Comparison of maxillary arch dimension among asthmatic children under regular and irregular medication (10 to 12-year-old males)

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    Table 15: Comparison of mandibular arch dimension among asthmatic children under regular and irregular medication (10 to 12-year-old males)

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    Table 16: Comparison of maxillary arch dimension among asthmatic children under regular and irregular medication (10 to 12-year-old females)

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    Table 17: Comparison of mandibular arch dimension among asthmatic children under regular and irregular medication (10 to 12-year-old females)

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  5. In the analysis for the frequency of occurrence of malocclusion in asthmatic group, it was observed that 46% percent asthmatics in the age group of 6-8 years had open-bite, 20% had cross-bite and 20% had increased overjet. Fifty percent asthmatics had open-bite, 30% had cross-bite and 10% had increased overjet in the 10-12 year age group. All the children in the asthmatic group had class 1 molar relation. Children under regular medication of inhalation corticosteroids had higher frequency of malocclusion in both the age groups [Table 18], [Table 19], [Table 20] and [Table 21].
    Table 18: Molar relation in asthmatic subjects

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    Table 19: Frequency of occurrence of malocclusion

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    Table 20: Frequency of occurrence of malocclusion among asthmatic children under regular and irregular medication (6 to 8-year-old subjects)

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    Table 21: Frequency of occurrence of malocclusion among asthmatic children under regular and irregular medication (10 to 12-year-old subjects)

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   Discussion Top


Asthma may itself influence the general body growth of a child in two ways. First, asthma and its level of control may directly affect growth in the same way as most chronic diseases of childhood. The most commonly observed effect of asthma on growth is a reduction in growth rate, usually towards the end of the first decade of life. Secondly, the severity of asthma may influence the systemic bioavailability of inhaled corticosteroids. Several studies have shown that effects of inhaled corticosteroids are more pronounced in mild and moderate asthma, which is probably due to differences in deposition pattern caused by a smaller airway diameter in patients with more severe disease. The pathogenesis of this growth suppression is complex and not well understood. [7],[8],[9],[10]

Respiratory performance is of great importance for stimulating and maintaining a balance during and after craniofacial development. According to functional and capsular matrix theory of growth, functions like breathing represent natural mechanisms of growth control and any sustained alteration in their performance may lead to the appearance of structural anomalies of the osseous bases. [11]

Adaptation to mouth breathing due to compromised airway may cause permanent changes in the muscular-skeletal relationship and consequently an imbalance between the 'functional matrices' responsible for transformations of size and shape that occur with growth. [11]

Although, there is significant evidence that total or partial obstruction of nasal breathing results in mouth breathing, the latter's effect on craniofacial growth and development still provokes discussion. Clearly, this is a multi-factorial process that involves both genetic and environmental influences. [12]

Many patients with asthma have co-existing allergic rhinitis, mostly as an atopic condition and a swelling of nasal mucosa regularly accompanies the asthmatic attacks. Consequently, these children usually exhibit increased nasal resistance and may constitute a risk group for changes in dentofacial growth and development. [2],[3],[4],[13]

Inhaled steroids, also known as inhaled corticosteroids or ICS for short, have become the mainstay of asthma treatment for persistent asthma in children and adults. These medications work in various ways on the immune system to prevent inflammation of the airways.

For patients with mild, moderate or severe chronic asthma, the first line of prevention is the use of daily inhaled corticosteroids. These inhaled steroids come in different strengths and are generally used once or twice a day.

Long term use of inhaled corticosteroids has been shown to adversely affect growth in children. The investigations and literature on the impact of inhaled corticosteroids on craniofacial and dentoalveolar growth have been insufficient and equivocal.

In this study, consistent lower values were observed for the intermolar width in asthmatics, but it was significant only in the maxillary arches of 10 to 12-year-old females.

According to Brodie, [14] the teeth have a position of equilibrium between two strong musculature namely the buccinators and the muscles of the tongue. [14] The change in equilibrium due to the depressed position of the mandible, induces the buccinators to cause a lateral pressure on the maxillary arch. This pressure is more in the molar area, than in the incisal area which explains the little change in the anterior arch. [6],[14] Angle, Brodie, Moyers and Hawkins agree that muscular imbalance produces a narrow arch in allergic subjects. [15],[16],[17]

The arch lengths of the asthmatics were observed to be longer in this study and the difference reached the level of high significance in both the arches of 6 to 8-year-old female asthmatics. According to a study conducted by Paul and Nanda on 'the effects of mouth breathing on dental occlusion', the reason for lengthening of the maxillary arch was explained on the basis of the lengthening of the arch due to its constriction of its width. [6] However, contrary to this explanation, a longer arch accompanied a broader arch as was the case in the study conducted by Hojensgaard and Wenzel on dentoalveolar morphology of asthmatics. [13]

Based on current results, it is noted that the group diagnosed as having asthma and allergic rhinitis had a significantly deeper palate and there was a tendency to a more accentuated increase of palate depth between the stages of primary and mixed dentition. One of the theories of the influence of mouth breathing on the face is that this respiratory pattern increases pressure in the oral cavity and the nasal cavity. The change in equilibrium due to the depressed position of the mandible, induces the buccinators to cause a lateral pressure on the maxillary arch, which constricts the arch and as a result the depth of the palate would increase. [11],[18],[19]

Mouth breathing is believed to be the primary factor in development of class 2 division 1 malocclusion. However, in this study all asthmatics were observed to have class 1 molar relation. This was explained by various authors. Angle and Moyers reported that mouth breathing was associated with all classes of malocclusion. According to Salzmann, the occurrence of various types of malocclusion in allergic and mouth breathing subjects does not indicate mouth breathing itself as a primary cause. [15],[16],[17],[20],[21],[22],[23],[24]

In the analysis for the frequency of occurrence of malocclusion in asthmatic group, it was observed that a large group of asthmatic children presented with anterior open-bite. This finding was in concordance with the findings of Vig, who found that there was an increase in anterior open bites, lower face height, and a tendency to hold the head higher in patients with mouth breathing. [25] In a mouth breather, the extended head posture, soft tissue stretching and the tongue lowered from contact with the palate and protruded to provide a greater oral airway is seen in response to an obstructed or resistant airway. All of these cause slight backward and downward forces exerted by the soft tissue layer on the facial skeleton thereby restraining the forward and increasing the downward component of the maxillary and mandibular growth relative to the cranial base, leading to a hyper divergent type of growth of upper and lower jaws leading to an open-bite. [25]

The occurrence of cross-bites in this study concurs with that of the study conducted by Hojensgaard and Wenzel. [13] Venitidou also proved the same in his study on incidence of malocclusion in asthmatic children. [26] The occurrence of increased overjet coincides with the findings of Paul and Nanda, who studied the effects of mouth breathing on dental occlusion. The reason for increased overjet is due to the loss of lip tone. In mouth breathers, the upper lip is short and hypotonic. Therefore, there would be no force applied on the upper anteriors. [6]

Children under regular medication of inhalation corticosteroids were observed to have narrower arch, deeper palate and higher frequency of open-bite and cross-bite as compared to those under irregular medication. These findings cannot be ignored, though the values were not significant. The relationship between corticosteroids and dentolveolar development has yet to be understood with further investigations in this field with higher sample size, standardization of drug dosage, frequency and the type of corticosteroid used.

Narrow, constricted arches and posterior cross-bites can be corrected by methods like rapid maxillary expansion. This may also help reduce nasal airway resistance, as told by Timms in his study on 'the effect of rapid maxillary expansion on nasal airway resistance'. [27] Children can also be taught various lip exercises and deep breathing exercises to overcome habitual mouth breathing.


   Conclusion Top


It can be summarized that the changes seen in the dentoalveolar morphology may be a result of a complex combination of the effects of the disease, medication and associated mouth-breathing. This study mainly throws light on the existence of the problem. The studies relating to growth are always intricate due to the multifactorial nature of growth. Further research is necessary to elucidate and put facts about growth, asthma and inhaled corticosteroids into perspective.

Asthma takes a toll on psychological and physical health of a person. Feelings of social stigma and embarrassment are common amongst children and adolescents. Moreover, the esthetic implications of malocclusion would deepen the psychological wound further. These findings from our study are clinically relevant to the pedodontist in intercepting malocclusions at early stages. The pedodontist along with the pulmonologist, otolaryngologist and orthodontist together can help a suffering child have a happy, healthy and active childhood.

 
   References Top

1.Steinbacher DM, Glick G. The dental patient with asthma. JADA 2001;132:1229-39.  Back to cited text no. 1
    
2.Preston B, Lampasso J, Tobias PV. Cephalometric Evaluation and measurement of the upper airway. Semin Orthod 2004;10:3-15.  Back to cited text no. 2
    
3.Sacre JA. Allergic rhinitis-Co-existent diseases and complications. A Review and analysis. Rev Alerg Mex 2006;53:9-29.  Back to cited text no. 3
    
4.Cooper BC. Nasorespiratory function and orofacial development. Otolaryngol Clin North Am 1989;22:413-41.  Back to cited text no. 4
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5.Bishara SE, Jakabsen J. Changes in tooth size-arch length relationships from early adolescence to early adulthood. Am J Orthod Dentofac Orthop 1989;95:46-59.  Back to cited text no. 5
    
6.Paul JL, Nanda RS. Effects of mouth breathing on dental occlusion. Angle Orth 1973;43:201-6.  Back to cited text no. 6
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7.Balfour-Lynn L. Growth and childhood asthma. Arch Dis Child 1986;61:1049-55.  Back to cited text no. 7
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8.Fergusson AC, Murray AB, Tze WJ. Short stature and delayed skeletal maturation in children with allergic disease. J Allergy Clin Immunol 1982;69:461-5.  Back to cited text no. 8
    
9.Sprock A. Growth pattern in 200 children with asthma. Ann Allergy 1965;23:608-11.  Back to cited text no. 9
    
10.Pedersen S. Do inhaled corticosteroids inhibit growth in children? Am J Respir Crit Care 2001;164:521-35.  Back to cited text no. 10
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11.Frietas De, Bastos P, Primo SG. Evaluation of the palatal dimensions of patients with perennial allergic rhinitis. Int J Pediatr Dent 2001;11:365-71.  Back to cited text no. 11
    
12.Ricketts RM. Respiratory Obstruction Syndrome. Am J Orthod Dentofac Orthop 1968;54:495-507.  Back to cited text no. 12
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13.Hojensgaard E, Wenzel A. Dentoalveolar morphology in children with asthma and perennial rhinitis. Euro J Orthod 1987;9:265-70.  Back to cited text no. 13
    
14.Brodie AG. Muscular factors in diagnosis and treatment of malocclusion. Angle Orth 1953;23:71-7.  Back to cited text no. 14
    
15.Angle EH. In: Treatment of malocclusion of the teeth. 7 th ed. Philadelphia: S.S. White Dental Mfg.co; 1907. p. 111-7.  Back to cited text no. 15
    
16.Moyers RE. Development of dentition and occlusion. In: Marshal DK, editor. Handbook of orthodontics. 4 th ed. Chicago: The Year Book Inc; 1958. p. 122-6.  Back to cited text no. 16
    
17.Hawkins AC. Mouth breathing as the cause of malocclusion and other facial abnormalities. Texas Dent J 1965;83:10-5.  Back to cited text no. 17
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18.Moreira M, de Paira LA. Evaluation of the palatal depth and width in mouth breathers with primary dentition. Int J Orofacial Myology 1989;15:19-24.  Back to cited text no. 18
    
19.Proffit WR, Fields HW. Development of orthodontic problems. In: Contemporary Orthodontics. 3 rd ed. Boston: Mosby publication; 2000. p. 127-34.  Back to cited text no. 19
    
20.Bresolin D, Shapiro PA. Mouth breathing in allergic children: Its relationship to dentofacial development. Am J Orthod Dentofac Orthop 1983;83:334-40.  Back to cited text no. 20
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21.Ballard CF. Mouth breathing. Proc Roy Soc Med 1958;51:282-5.  Back to cited text no. 21
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22.Brash JC. The etiology of irregularity and malocclusion of teeth. London: Dental Board of UK; 1929. p. 212-26.  Back to cited text no. 22
    
23.Salzmann JA. In: Orthodontic principles and prevention. Philadelphia and Montreal: J. B. Lippincott co; 1957.  Back to cited text no. 23
    
24.Hartsook JT. Mouth breathing as a primary aetiology factor in production of malocclusion. J Dent Child 1946;13:91-4.  Back to cited text no. 24
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25.Vig KW. Nasal obstruction and facial growth: The strength of evidence for clinical assumption. Am J Orthod Dentofac Orthop 1998;113:603-11.  Back to cited text no. 25
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26.Venetidou A. Incidence of malocclusion in asthmatic children. J Clin Pediatr Dent 1993;17:89-94.  Back to cited text no. 26
    
27.Timms DJ. The effect of rapid maxillary expansion on nasal airway resistance. Br J Orthod 1986;13:221-8.  Back to cited text no. 27
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    Figures

  [Figure 1]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14], [Table 15], [Table 16], [Table 17], [Table 18], [Table 19], [Table 20], [Table 21]


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