Osia Tuma 2015

SummaryBackground: Nasorespiratory function and its relation to cra-niofacial growth are of great interest because of the basic bio-logical relationship between form and function, and the accu-mulating findings of the relationship between mode ofbreathing, craniofacial growth and orthodontic treatment.

Objectives: The aim of this study was to evaluate the effect ofadenoid hypertrophy and sociodemographic variables on theocclusion of children.Methodology: A total of 180 subjects aged 3–12 years wereselected at the Obafemi Awolowo University TeachingHospital Complex, Ile-Ife, Nigeria. Ninety subjects had hyper-trophied adenoids while 90 normal children served as the con-trol group. Orthodontic examinations were carried out andimpressions for study models taken. Occlusion was assessed inthe anterior-posterior, transverse and vertical planes.

Results: Class I relationship was the most prevalent occlusion inboth adenoid and control subjects (55.6% and 72.2%, respec-tively). The occurrence of class II division 1 was significantlyhigher among adenoid than control subjects (P = 0.003).

R�esum�e

Contexte : La fonction nasorespiratoire et sa relation a la crois-sance cranio-faciale sont d’un int�eret certain en raison de laconnexion biologique fondamentale entre la forme et la fonc-tion et les d�ecouvertes toujours plus nombreuses reliant lemode ventilatoire, la croissance cranio-faciale et le traitementorthodontique.Objectifs : Le but de cette �etude �etait d’�evaluer l’effet del’hypertrophie ad�enoıdienne et de variables socio-d�emographiques sur l’occlusion d’enfants au Nig�eria.M�ethodologie : En tout, 180 sujets ag�es de 3 a 12 ans ont �et�es�electionn�es au CHU Obafemi, Ile-Ife, Nig�eria. Quatre-vingt-dix sujets pr�esentaient des v�eg�etations hypertrophi�ees tandisque 90 enfants normaux ont constitu�e le groupe t�emoin. Lesexamens orthodontiques ont �et�e effectu�es et des empreintesont �et�e prises pour r�ealiser des mod�eles d’�etude. L’occlusiona �et�e �evalu�ee dans les sens ant�eropost�erieur, transversal etvertical.R�esultats : Une relation de classe I a �et�e l’occlusion la plusfr�equemment observ�ee dans les deux groupes, ad�enoıdienset t�emoins (55,6 % et 72,2 %, respectivement). L’incidencede relations de classe II, 1 �etait significativement plus �elev�ee

Original articleArticle original

� 2015 CEOPublished by / Edite par Elsevier Masson SAS

All rights reserved / Tous droits reserves

Occlusal characteristics of childrenwith hypertrophied adenoids in Nigeria

Caract�eristiques occlusales des enfantspr�esentant des v�eg�etations hypertrophi�eesau Nig�eria

Vivien Ijeoma OSIATUMAa, Olayinka Donald OTUYEMIa,Kikelomo Adebanke KOLAWOLEa,*, Babatunde Ogunbiyi OGUNBANJOb,Yemisi Bola AMUSAc

aDepartment of Child Dental Health, Obafemi Awolowo University Teaching HospitalsComplex, Ile-Ife, NigeriabDepartment of Child Dental Health, Lagos State University Teaching Hospital, Ikeja, NigeriacOtorhinolaryngology Unit, Department of Surgery, Obafemi Awolowo University, Ile-Ife,Nigeria

Available online: XXX / Disponible en ligne : XXX

*Correspondence and reprints / Correspondance et tir�es a part :

e-mail addresses / Adresses e-mail : [email protected],[email protected] (Vivien Ijeoma OSIATUMA)

International Orthodontics 2010 ; X : 1-17 1http://dx.doi.org/10.1016/j.ortho.2014.12.009

ORTHO 159 1-17

mailto: [email protected]

mailto: [email protected]

http://dx.doi.org/10.1016/j.ortho.2014.12.009

Posterior crossbites occurred significantly more in adenoid sub-jects in the 9–12 years category. In the vertical plane, theoccurrence of deep bite was significantly greater in male thanfemale adenoid subjects. Age had a statistically significant butweak correlation with anterior open bite (r = 0.37). Age andBMI also had significant though weak correlations with poste-rior crossbite in female adenoid subjects (r = 0.39 and r = 0.36,respectively). Regression analysis also showed that age had asignificant effect on the occurrence of anterior open bite, whileBMI had a significant effect on the occurrence of class IIocclusion in adenoid subjects (P < 0.05).

Conclusion: The presence of hypertrophied adenoids affects theocclusion in the three planes. Age and BMI have significanteffects on the occurrence of anterior open bite and class IIdivision 1 malocclusion respectively in adenoid subjects.

� 2015 CEO. Published by Elsevier Masson SAS. All rightsreserved

Key-words

·Adenoid hypertrophy.

·Mouth breathing.

·Occlusion.·Malocclusion.

Introduction

It is established that respiratory needs are the primary deter-minants of the posture of the jaws and tongue and to a lesserextent, of the cranium itself [1]. Therefore, an altered respira-tory pattern due to mouth breathing can cause postural altera-tions such as open lips, lowered or anterior tongue position,and posterior inferior rotation of the mandible in order tostabilize the airway [2,3]. Postural alterations in soft tissueshave been said to change the equilibrium of the pressureexerted on teeth and facial bones, thus altering these struc-tures [3–6]. Nasal obstruction leading to an alteration in modeof breathing can be due to a variety of factors such as enlargedturbinates, hypertrophied adenoids, deviation of the nasalseptum, allergy and chronic inflammation of the membraneswith oedematous nasal mucosa, choanal atresia and tumours ofthe nose and nasopharynx [7–9]. However, enlarged nasopha-ryngeal adenoids have been reported as one of the most fre-quent causes of nasal obstruction [3,9–11]

parmi les sujets ad�enoıdiens que parmi les t�emoins(p = 0,003). Les articul�es crois�es post�erieurs �etaient signifi-cativement plus fr�equents chez les sujets ad�enoıdiens ag�esde 9 a 12 ans. Dans le plan vertical, les supraclusions �etaientsignificativement plus fr�equentes chez les ad�enoıdiens queparmi les ad�enoıdiennes. L’age a affich�e une corr�elation sta-tistiquement significative, quoique faible, avec les b�eancesant�erieures (r = 0,37). L’age et l’IMC ont �egalement montr�edes corr�elations significatives mais faibles avec les articul�escrois�es post�erieurs chez les ad�enoıdiennes (r = 0,39 etr = 0,36, respectivement). L’analyse de r�egression a�egalement montr�e que l’age avait un effet significatif sur lafr�equence des b�eances ant�erieures, alors que l’IMC a eu uneffet significatif sur la fr�equence des occlusions de classe IIparmi les sujets ad�enoıdiens (p < 0,05).Conclusion : La pr�esence de v�eg�etations hypertrophi�eesaffecte l’occlusion dans les trois plans de l’espace. L’age etl’IMC ont un impact significatif sur la fr�equence des b�eancesant�erieures et les malocclusions de classe II, division 1,respectivement, chez les sujets pr�esentant des v�eg�etationshypertrophi�ees.� 2015 CEO. Edite par Elsevier Masson SAS. Tous droitsreserves

Mots-cl�es

·Hypertrophie ad�enoıdienne.

·Respiration orale.

·Occlusion.

·Malocclusion.

Introduction

Il est bien �etabli que les besoins respiratoires sont les�el�ements primordiaux pour la d�etermination de la posturedes machoires et de la langue et, dans une moindre mesure,du crane lui-meme [1]. Il s’en suit qu’unemodification dumoderespiratoire en faveur de la respiration orale peut provoquerdes changements de posture tels que l’�ecartement des l�evres,l’abaissement ou l’avanc�ee de la langue ou la rotation post-�erieure inf�erieure de la mandibule afin de stabiliser les voiesa�eriennes [2,3]. Les alt�erations posturales des tissus mousmodifieraient, selon certains auteurs, l’�equilibre des pressionsqui s’exercent sur la denture et sur les os du visage, remaniantainsi ces structures [3–6]. Les obstructions nasales qui don-nent lieu a unemodification du sch�ema de respiration peuventrelever de plusieurs facteurs : cornets agrandis, v�eg�etationshypertrophi�ees, d�eviation de la cloison nasale, allergies ouinflammation chronique des membranes avec œd�eme de lamuqueuse nasale, atr�esie choanale et tumeurs nasales etnasopharyng�ees [7–9]. Il a �et�e rapport�e, n�eanmoins, que lesv�eg�etations nasopharyng�ees hypertrophi�ees sont l’une descauses les plus fr�equentes de l’obstruction nasale [3,9–11].

2 International Orthodontics 2010 ; X : 1-17

Vivien Ijeoma OSIATUMA et al.

ORTHO 159 1-17

The relationship between hypertrophied adenoids, mouthbreathing, and how it results in peculiar facial characteristicsand malocclusion of either the dental arches or the dentitionhave long been a subject of intense research, studies andcontroversies [3,12,13]. However, previous published litera-ture regarding this relationship has mostly dealt with selectedpatients in the Western world [2–4,8,9]. A search through theliterature suggests that studies in this area are scarce in theNigerian population [14].In experiments that induced oral respiration in primates,Harvold et al. confirmed that environmental impact such assevere airway obstruction can produce major malocclusionsymptoms [15]. Linder-Aronson and others also demonstratedfeatures such as steep mandibular plane angle, narrow max-illary arches and retroclined mandibular incisors in mouth-breathing individuals [16].

According to previous reports, mouth breathing may be asso-ciated with various types of occlusion [4–6]. However, it hasbeen reported that class II malocclusion is somewhat morecommonly associated with patients with hypertrophied ade-noids [3,7,17,18]. In another study of 7-year-olds with atopic(allergic) diseases, mouth-breathers had significantly moreclass II and cusp-to-cusp sagittal molar relationships com-pared with the nose-breathers [19]. Mouth breathing allergicchildren have been shown to have narrower maxillary archescompared with nose-breathers [13].

A sound knowledge of occlusal characteristics plays a majorrole in orthodontics [20]. Occlusal characteristics affects den-tal aesthetics, availability of space, and stability of the denti-tion [20,21]. With increasing awareness of the benefits oforthodontic treatment, patients with enlarged adenoids maypresent for correction of dental irregularities that may beassociated with their condition. It is therefore important thatthe clinician is familiar with occlusal characteristics peculiarto this group of individuals. This study was therefore carriedout to evaluate the effect of adenoid hypertrophy and socio-demographic variables on the occlusion of children and tocompare the findings with that of control subjects.

Materials and methods

The study was carried out in Obafemi Awolowo UniversityTeaching Hospital Complex. (OAUTHC), a tertiary Hospitalin Ile-Ife, South-Western Nigeria. It was a cross-sectionalsurvey whose population consisted of a total of 180 childrenin the primary and mixed dentition between the ages of 3–12 years. The children were divided into experimental andcontrol groups:— experimental/adenoid group: consisted of 90 childrenbetween the ages of 3–12 years, attending the Ear, Nose and

Les liens entre les v�eg�etations hypertrophi�ees, la respirationorale et leurs r�epercussions en termes d’anomalies faciales etde malocclusions des arcades dentaires ou de la denturefont l’objet depuis longue date de recherches, d’�etudes et decontroverses intenses [3,12,13]. Cependant, la litt�eratureexistante concernant ces relations s’est focalis�ee surtout surdes patients dans le monde occidental [2–4,8,9]. Unerecherche de la litt�erature sugg�ere que les �etudes dans cedomaine sur la population nig�eriane sont rares [14].Harvold, Tomer et al. ont r�ealis�e des exp�eriences ou ils ontinduit la respiration orale chez des primates. Ils ont ainsiconfirm�e que des influences environnementales telles qu’uneobstruction s�ev�ere des voies a�eriennes peuvent d�eclencherdes symptomes majeurs de malocclusion [15]. Linder-Aronson et al. ont �egalement soulign�e l’importance, chez lesrespirateurs buccaux, de caract�eristiques telles qu’un angleimportant du plan mandibulaire, l’endognathie maxillaire ou lar�etroversion des incisives mandibulaires [16].Selon diverses �etudes, la respiration buccale serait associ�eea divers types d’occlusion [4–6]. Il a �et�e rapport�e, cependant,que les malocclusions de classe II sont associ�ees plusfr�equemment a des patients pr�esentant des v�eg�etationshypertrophi�ees [3,7,17,18]. Dans une autre �etude portantsur des enfants ag�es de 7 ans atteints de maladies atopiques(allergiques), les respirateurs buccaux pr�esentaient un nom-bre significativement plus �elev�e de classes II et de relationsmolaires sagittales cuspide a cuspide compar�es aux respira-teurs nasaux [19]. Il a �et�e d�emontr�e que les enfants allergi-ques respirateurs buccaux pr�esentent une arcade maxillaireplus �etroite par rapport aux respirateurs nasaux [13].Une bonne connaissance des caract�eristiques de l’occlusionest primordiale en orthodontie [20]. Les caract�eristiquesocclusales influent sur l’esth�etique des dents, l’espace dispo-nible, et la stabilit�e de la denture [20,21]. De plus en plusconscients des avantages du traitement orthodontique, lespatients pr�esentant des v�eg�etations hypertrophi�ees consul-tent parfois pour se faire corriger les anomalies dentaires li�eesa cette affection. Il est donc important que le clinicien soit bieninform�e des caract�eristiques occlusales sp�ecifiques a cegroupe de sujets. Par cons�equent, cette �etude a �et�e r�ealis�eeafin d’�evaluer l’impact de l’hypertrophie ad�enoıdienne et desvariables socio-d�emographiques sur l’occlusion des enfantset de comparer les r�esultats avec ceux de sujets t�emoins.

Mat�eriel et m�ethodes

Cette �etude a �et�e r�ealis�ee au CHU Obafemi Awolowo, hopitaltertiaire situ�e a Ile-Ife au Nig�eria du sud-ouest. Il s’agit d’uneenquete transversale portant sur 180 enfants ag�es de 3a 12 ans en denture primaire ou mixte. Les enfants ont �et�er�epartis en deux groupes, un groupe exp�erimental et ungroupe t�emoin :

— le groupe exp�erimental/ad�enoıdien consistait en 90 enfantsag�es de 3 a 12 ans consultant a la clinique ORL du CHU

International Orthodontics 2010 ; X : 1-17 3

Occlusal characteristics of children with hypertrophied adenoids in NigeriaCaract�eristiques occlusales des enfants pr�esentant des v�eg�etations hypertrophi�ees au Nig�eria

ORTHO 159 1-17

Throat Clinic of Obafemi Awolowo University TeachingHospital Complex (OAUTHC) who had been diagnosed clin-ically and radiographically with hypertrophied adenoids;— the control group: consisted of 90 children aged between3–12 years recruited from patients attending the Child DentalHealth clinic of the OAUTHC. They were interviewed to ruleout any clinical presentations of adenoidal hypertrophy.Each of the study populations was further subdivided intothree age groups based on the stage of dental development.Primary dentition category was made up of 3- to 5-year-olds,early mixed dentition category the 6- to 8-year-olds and thelate mixed dentition/early permanent category was made up of9- to 12-year-olds.All consecutive children presenting in both clinics who metthe inclusion criteria were recruited into the study untilrequired sample size was attained. Sample size was deter-mined as 174 subjects for both groups in order to detect astatistically significant difference of 20% between studygroups, at 80% power where P < 0.05, this was rounded upto 180. The selection of participants was based on the follow-ing criteria: clinical/radiographic diagnosis of enlarged ade-noids, subjects between the ages of 3–12 years, both parentswere Nigerians by nationality and children who had no historyof previous orthodontic treatment. Post-adenoidectomypatients, children with oro-facial developmental anomalies,very ill children and those not consenting to take part in thestudy were excluded.

Ethical approval was sought and obtained from the ObafemiAwolowo University Teaching Hospitals Complex EthicalReview Committee. Informed consent was obtained from theparents or guardians of those subjects willing to participate inthe study. The procedure for the collection of data, the benefitsof the research, the confidentiality of data collected, the risksand discomfort of the procedure were all carefully explained tothe children and their parents or guardians. The voluntaryparticipation of the subjects or withdrawal from the study atany time without prejudice was also assured.

Demographic and anthropometric data were obtained for par-ticipants in both study groups including age, sex and ethnicity.Their weight and height were measured in kilograms andmetres respectively. The body mass index (BMI) was calcu-lated by dividing the weight (kg) by height in meters squared(m2). The BMI values from all participants were grouped intonormal, low, and high values appropriate for age and sex. Thiswas based on the age and sex specific cut off points of BMI forchildren aged 2–18 years provided by Cole et al. [22].

Intra-oral orthodontic examination was performed with themouth open and later with the teeth in occlusion using exam-ination gloves and a mouth mirror.

Obafemi Awolowo qui avaient �et�e diagnostiqu�es par examenclinique et radiographique avec une hypertrophiead�enoıdienne ;— le groupe t�emoin consistait en 90 enfants ag�es de 3a 12 ans consultant a la clinique de sant�e dentaire du CHUObafemi Awolowo. Ils ont �et�e interview�es pour �ecarter toutepr�esentation d’hypertrophie ad�enoıdienne.Chacune des populations dans l’�etude a �et�e sous-divis�ee entrois groupes d’age en fonction du d�eveloppement dentaire. Lacat�egorie « dentition primaire » comprenait les enfants de 3a 5 ans, la cat�egorie « dentition mixte pr�ecoce » les enfantsde 6 a 8 ans et la cat�egorie « dentition mixte tardive » ou« dentition permanente pr�ecoce » les enfants de 9 a 12 ans.Tous les enfants se pr�esentant de facon cons�ecutive dans lesdeux cliniques et satisfaisant les crit�eres d’inclusion ont �et�erecrut�es dans l’�etude jusqu’a obtention de la tailled’�echantillon requise. Celle-ci a �et�e fix�ee a 174 sujets afin ded�etecter une diff�erence statistiquement significative de 20 %entre les deux groupes avec une puissance de 80 % et unevaleur de p < 0,005. L’�echantillon a finalement �et�e arrondia 180 sujets. La s�election des participants a �et�e bas�ee surles crit�eres suivants : v�eg�etations hypertrophi�ees diag-nostiqu�ees par examen clinique/radiologique, age entre 3 et12 ans, deux parents de nationalit�e nig�eriane, et aucun traite-ment orthodontique ant�erieur. Les patients post-ad�einoıdectomie, les enfants pr�esentant des anomalies ded�eveloppement orofacial, les enfants tr�es malades et ceuxqui ne voulaient pas prendre part a l’�etude ont �et�e exclus.L’autorisation �ethique a �et�e demand�ee et obtenue aupr�es ducomit�e d’�ethique duCHUObafemAwolowo. Un consentementinform�e a �et�e obtenu aupr�es des parents ou des tuteurs dessujets d�esireux de participer a l’�etude. La proc�edure decollecte de donn�ees, les avantages de cette �etude, laconfidentialit�e des donn�ees recueillies et les risques et l’incon-fort associ�es a la proc�edure ont �et�e soigneusement expliqu�esaux enfants ainsi qu’a leurs parents ou tuteurs. Le caract�erelibre de la participation a l’�etude ainsi que la possibilit�e deretrait a n’importe quel moment et sans pr�ejudice ont�egalement �et�e soulign�es.Les donn�ees d�emographiques et anthropom�etriques,comprenant l’age, le sexe et l’origine ethnique, ont �et�e recueil-lies aupr�es des participants dans les deux groupes d’�etude. Lepoids et la taille des sujets ont �et�e relev�es en kilos et enm�etres, respectivement. L’indice de masse corporelle (IMC)a �et�e calcul�e en divisant le poids (kg) par la taille en m�etrescarr�es (m2). Les valeurs IMC de tous les participants ont �et�eregroup�ees selon les valeurs normales, faibles et �elev�eesappropri�ees a leur age et sexe. Ces param�etres �etaient bas�essur les seuils limites sp�ecifiques d’IMC en fonction de l’ageet du sexe d’enfants ag�es de 2 a 18 ans fournis par Coleet al. [22].Un examen orthodontique intraoral a �et�e r�ealis�e a boucheouverte et, plus tard, avec les dents en occlusion utilisantdes gants d’examen et un miroir buccal.



ORTHO 159 1-17

Anterior-posterior arch relationship was determined in thepermanent dentition using the British Standards Institute’sincisor classification [23] with the following classes:

— class I incisal relationship: this was registered when thelower incisors edges occluded with or lay immediately belowthe cingulum plateau of the upper incisors;

— class II incisal relationship: this was registered when thelower incisors occluded posterior to the cingulum plateau ofthe upper. Class II was registered with two subdivisions;

— class II division 1: this was registered when the uppercentral incisors were proclined, and there was an increase inoverjet;— class II division 2: this was registered when the uppercentral incisors were retroclined, and the overjet was minimalor slightly increased;— class III incisal relationship: this was registered when thelower incisors edges occlude anterior to the cingulum plateauof the upper and these teeth met either in an edge to edgerelationship or there was an obvious reverse overjet.

In the primary dentition, it was considered a class I dentalrelationship when the upper primary canine occluded in theembrasure between the lower primary canine and first primarymolar. Class II was registered when the maxillary primarycanine occluded mesial to class I, while class III was regis-tered when the primary maxillary canine occluded distal toclass I.

Vertical relationship was classified as normal, anterior openbite or deep bite.A normal vertical relationship was registered when the upperincisors overlapped one-third or less of the incisal edges of thelower incisors. An open bite was registered in cases thatlacked any overlap or contact between the upper and lowerincisors involving two or more opposing teeth. A deep bite wasregistered when more than half of the labial surfaces of thelower incisors were overlapped by the incisal edges of theupper incisors.

A transverse relationship was classified as either normal orwith posterior crossbite.A normal transverse arch relationship was registered when thebuccal cusps of the upper posterior teeth overlapped the buc-cal cusps of the lower posterior teeth.

Posterior cross bite was registered when two or more posteriormaxillary teeth were in frank lingual cross bite with their lowerantagonists [24].

After intra-oral examination, impressions were made in algi-nate for all participants with disposable trays. Impressionswere rinsed under running water and disinfected with diluted

La relation ant�eropost�erieure des arcades a �et�e d�etermin�eedans la denture permanente a l’aide de la classification desincisives du British Standards Institute [23] et des classessuivantes :— relation de classe I incisive : celle-ci a �et�e enregistr�ee lors-que les bords des incisives inf�erieures �etaient en occlusionavec, ou positionn�ees imm�ediatement en dessous, du platcingulaire des incisives sup�erieures ;— relation de classe II incisive : celle-ci a �et�e enregistr�eelorsque les incisives inf�erieures �etaient en occlusion avec lapartie post�erieure du plat cingulaire sup�erieure. La classe II a�et�e enregistr�ee avec deux sous-divisions ;— classe II, division 1 : celle-ci a �et�e enregistr�ee lorsque lesincisives centrales sup�erieures �etaient en vestibuloversion eten pr�esence d’un overjet excessif ;— classe II, division 2 : celle-ci a �et�e enregistr�ee lorsque lesincisives centrales sup�erieures �etaient en palatoversion et quel’overjet fut minimal ou l�eg�erement augment�e ;— relation incisive de classe III : celle-ci a �et�e enregistr�eelorsque les bords des incisives inf�erieures �etaient en occlusionavec la partie ant�erieure du plat cingulaire et que les incisivesse trouvaient en relation bord a bord ou en pr�esence d’unoverjet invers�e �evident.Pour la denture primaire, nous avons retenu la relation den-taire de classe I lorsque les canines primaires sup�erieures�etaient en occlusion dans l’embrasure entre la canine primaireinf�erieure et la premi�ere molaire primaire. Une classe II a �et�eenregistr�ee lorsque la canine primaire maxillaire �etait enocclusion m�esiale avec la classe I, alors qu’une classe III a�et�e enregistr�ee lorsque la canine primaire maxillaire se trou-vait en occlusion distale avec la classe I.Les relations verticales ont �et�e class�ees en normale, b�eanceant�erieure ou supraclusion.Une relation verticale normale a �et�e enregistr�ee lorsque lesincisives sup�erieures recouvraient d’un tiers ou moins lesbords incisifs des incisives inf�erieures. Une b�eance a �et�eenregistr�ee chez les sujets qui ne pr�esentaient ni recouvre-ment ni contact d’au moins deux dents antagonistes entre lesincisives sup�erieures et inf�erieures. Une supraclusion a �et�eenregistr�ee lorsque plus de la moiti�e des aspects labiaux desincisives inf�erieures �etait recouverte par les bords incisifs desincisives sup�erieures.Les relations transversales ont �et�e class�ees comme �etantnormales ou comme pr�esentant un articul�e crois�e post�erieur.Une relation transversale normale des arcades a �et�eenregistr�ee lorsque les cuspides vestibulaires des dents post-�erieures sup�erieures d�ebordaient les cuspides vestibulairesdes dents post�erieures inf�erieures.Un articul�e crois�e post�erieur a �et�e enregistr�e lorsque deux ouplus des dents maxillaires post�erieures se trouvaient en posi-tion d’articul�e crois�e post�erieur franc par rapport a leurs anta-gonistes inf�erieures [24].Apr�es examen intraoral, des empreintes en alginate ont �et�er�ealis�ees au moyen de porte-empreintes chez tous les parti-cipants. Les empreintes ont �et�e rinc�ees a l’eau courante etd�esinfect�ees avant moulage avec une solution d’hypochlorite



ORTHO 159 1-17

sodium hypochlorite solution before casting. All data werecollected by one investigator (V.I.O).Data analysis: statistical analysis was carried out with SPSSversion 16 (Chicago Inc. 2007). Frequencies and mean values(with their standard deviations) of variables were generated.Association between discrete variables was tested by Chi2.Association between continuous variables was tested usingstudent t-test and analysis of variance. Correlation coefficient(r) was used to test associations between variables. Multipleregression analysis was used to determine the effects of demo-graphic variables (age, sex and BMI) on the occlusion of sub-jects with hypertrophied adenoids. Significance was inferredat P < 0.05.

Results

A total of 180 children were selected for this study based onthe stated criteria. There were 93 (51.7%) boys and 87(48.3%) girls, with a mean age of 6.89 W 2.43 years. Table Ishows the demographic characteristics of the study populationaccording to gender and age groups described. The adenoidpopulation had 45.5% of children in the 3–5-year age groups;37.8% in the 6–8-year groups and 16.7% in the 9–12-year agegroups. The control population had 24.5%, 43.3% and 32.2%,respectively in the various age groups (Table I).

Table II shows the means of weight, height and body massindex (BMI) for both adenoid and control groups according totheir age groups and gender. The Games-Howell multiplecomparison of means demonstrated that significant differ-ences in weight occurred among the subjects in the 3–5-yearand 6–8-year age groups as shown. Differences in height were

de sodium dilu�ee. Toutes les donn�ees ont �et�e recueillies par lememe op�erateur (V.I.O).Analyse des donn�ees : l’analyse statistique a �et�e effectu�eeavec SPSS version 16 (Chicago Incorporation 2007). Lesfr�equences et les valeurs moyennes (avec leurs �ecarts-types)des variables ont �et�e g�en�er�ees. L’association entre les varia-bles discr�etes a �et�e test�ee utilisant le test Chi2. L’associationentre les variables continues a �et�e test�ee utilisant le test-t deStudent et l’analyse de variance. Le coefficient de corr�elation(r) a �et�e utilis�e pour tester les associations entre variables.L’analyse de r�egression multiple a �et�e utilis�ee pour d�eterminerles effets des variables d�emographiques (age, sexe et IMC)sur l’occlusion des sujets pr�esentant des v�eg�etationshypertrophi�ees. La significativit�e a �et�e �etablie a p < 0,05.

R�esultats

Un total de 180 enfants ont �et�e s�electionn�es pour cette �etudeen fonction des crit�eres d�eja d�ecrits. Il y avait 93 (51,7 %)garcons et 87 (48,3 %) filles, avec un age moyen de6,89 W 2,43 ans. Le Tableau I montre les caract�eristiquesd�emographiques des populations �etudi�ees en fonction dusexe et des groupes d’age d�ecrits ci-dessus. La populationad�enoıdienne contenait 45,5 % d’enfants ag�es de 3 a 5 ans,37,8 % d’enfants dans le groupe d’age de 6 a 8 ans et 16,7 %dans le groupe d’age de 9 a 12 ans. La population t�emoincontenait 24,5 %, 43,3 % et 32,2 %, respectivement, dansles divers groupes d’age (Tableau I).Le Tableau II montre les moyennes de poids, de taille etd’indice de masse corporelle (IMC) pour les groupesd’ad�enoıdiens et t�emoin selon leur groupe d’age et leur sexe.La comparaison multiple de moyennes Games-Howell arelev�e des diff�erences significatives de poids parmi les sujetsdans les groupes de 3 a 5 ans et de 6 a 8 ans. Des diff�erences

Table IDemographic characteristics of the study population.

Tableau ICaract�eristiques d�emographiques de la population d’�etude.

Age group (years) / Groupe d’age (ans) Adenoid group / Groupead�enoıdien

Control group / Groupet�emoin

Total

Male /Garcons

Female /Filles

Male /Garcons

Female /Filles

n (%) n (%) n (%) n (%) n (%)

3–5 26 (14.44) 15 (8.33) 14 (7.78) 8 (4.44) 63 (35.0)

6–8 21 (11.67) 13 (7.22) 12 (6.67) 27 (15.0) 73 (40.56)

9–12 8 (4.44) 7 (3.99) 12 (6.67) 17 (9.44) 44 (24.44)

Total 55 (30.56) 35 (19.44) 38 (21.11) 52 (29.0) 180 (100)

Chi2 = 16.02, df = 6, P = 0.013.



ORTHO 159 1-17

also observed in the 3–5-year and 9–12-year age groups(Table II).The mean body mass index (BMI) was 16.49 W 3.00. Themean BMI value of adenoid subjects was significantly lowerthan that of the control subjects (P = 0.006). However therewere no significant differences in BMI when subjects werecategorised into age groups. The majority (75%) of all subjects(adenoid and control) had low BMI, 11.7% had normal and13.3% had high BMI. There was, however, a significant dif-ference in the distribution of adenoid and control subjects intothese categories of BMI (Chi2 = 19.18, P = 0.000). About2.2% of adenoid subjects and 21.1% of control subjects hadnormal BMI, respectively.

Comparisons of occlusal characteristics of both groups in thethree planes of space are shown in Table III. In the anterior-posterior plane, class I incisal relationship was the most prev-alent malocclusion in both adenoid and control groups (55.6%and 72.2%, respectively). However, the frequency of occur-rence was significantly higher in the control group comparedto the adenoid group (P = 0.02). Class II division 1 was sig-nificantly higher in the adenoid subjects compared to thecontrol subjects (P = 0.003). In the vertical and transverseplanes, no statistically significant differences were observedin the occlusal characteristics between both groups (Table III).

de taille ont �egalement �et�e observ�ees dans les groupes ag�esde 3 a 5 et de 9 a 12 ans (Tableau II).L’indice de masse corporelle (IMC) moyen �etait de16,49W 3,00. La valeur IMC moyenne des sujetsad�enoıdiens �etait significativement plus faible que celle dessujets t�emoins (p = 0,006). Cependant, nous n’avons pasrelev�e de diff�erences significatives d’IMC lorsque les sujets�etaient class�es selon leur groupe d’age. La majorit�e (75 %) detous les sujets (ad�enoıdiens et t�emoins) avaient un IMCfaible ; 11,7 % avaient un ICM normal et 13,3 % un ICM �elev�e.Cependant, nous avons observ�e une diff�erence significativeau niveau de la distribution des sujets ad�enoıdiens et t�emoindans ces cat�egories d’IMC (Chi2 = 19,18, p = 0,000).Approximativement 2,2 % des sujets ad�enoıdiens et 20 %t�emoins avaient un IMC normal.Les comparaisons des caract�eristiques des deux groupesdans les trois plans de l’espace sont donn�ees au Tableau III.Dans le plan ant�eropost�erieur, une relation de classe l inci-sive �etait la malocclusion la plus fr�equente dans les deuxgroupes ad�enoıdien et t�emoin (55,6 % et 72,2 %, respecti-vement). Cependant, la fr�equence de cette malocclusion�etait significativement plus �elev�ee dans le groupe t�emoinque dans le groupe d’ad�enoıdiens (p = 0,02). Les classesII division 1 �etaient significativement plus fr�equentes chezles sujets ad�enoıdiens que chez les sujets t�emoin(p = 0,003). Dans les plans occlusal et transversal, aucune

Table IIMeans and standard deviations of demographic variables.

Tableau IIMoyennes et �ecarts-types des variables d�emographiques.

Demographic variables /Variables

d�emographiques

Age group(years) /Groupe d’age

(ans)

Adenoid group / Groupe ad�enoıdien Control group / Groupe t�emoin

Male / Garcons Female / Filles Male / Garcons Female / Filles

n Meana /Moyennea

W SD /W ET

n Meanb /Moyenneb

W SD /W ET

n Meanc /Moyennec

W SD /W ET

n Meand /Moyenned

W SD /W ET

Weight / Poids3–5 26 16.62 2.49 15 16.87 2.26 14 20.36 2.27 8 23.75 6.71

6–8 21 21.71 2.30 13 23.31 5.28 12 25.08 3.96 27 25.81 4.29

9–12 8 31.25 4.06 7 29.00 5.71 12 32.50 5.71 17 33.47 7.22

Height / Taille3–5 26 103.55 9.70 15 105.53 9.26 14 112.71 8.04 8 115.87 6.05

6–8 21 120.62 12.66 13 119.38 8.79 12 122.25 7.81 27 123.89 11.98

9–12 8 137.50 10.11 7 129.00 9.47 12 133.41 13.78 17 138.82 5.98

BMI / IMC

3–5 26 15.58 1.99 15 15.24 2.14 14 16.06 1.31 8 17.46 3.42

6–8 21 15.38 3.72 13 16.71 5.03 12 16.79 2.17 27 16.95 2.73

9–12 8 16.54 1.36 7 17.57 4.23 12 18.47 3.18 17 17.28 2.87

BMI: body mass index. Games-Howell multiple comparison of means: weight: 3–5 years, P < 0.05 ac,ad,bc,bd, 6–8 years, P < 0.05, ac,ad; height: 3–5 years, P < 0.05 ac,ad,bc,bd. 9–12 years, P < 0.05 bd.No statistically significant differences in BMI were observed in all the age groups.



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After categorizing into the various age groups, there weresignificant differences in the AP plane only in the 3–5-yearage groups. While the occurrence of class I incisal relation-ship was significantly greater in the control group (P = 0.006),class II division 1 was significantly higher in the adenoidgroup (P = 0.001). In the transverse plane the occurrence ofposterior cross bites was significantly higher in the 9–12-yearadenoid group compared with their counterpart control group(P < 0.001).

Table IV shows the comparisons of occlusal characteristics ofadenoid subjects across age groups. There were no statisticallysignificant differences in occlusal characteristics in the ante-rior-posterior and vertical occlusal planes across the agegroups (P > 0.05). In the transverse plane, the occurrenceof posterior crossbite differed significantly across the agegroups (P < 0.01). Gender comparisons were done in theanterior-posterior, vertical and transverse planes of male

diff�erence statistiquement significative n’a �et�e observ�eeentre les deux groupes au niveau des caract�eristiques occlu-sales (Tableau III).Apr�es classement des sujets en plusieurs groupes d’age,nous avons relev�e des diff�erences significatives dans le planA-P uniquement dans le groupe d’age de 3 a 5 ans. Alors quela fr�equence des relations de classe I incisive �etait significati-vement plus �elev�ee dans le groupe t�emoin (p = 0,006), lesclasses II, division 1 �etaient significativement plus fr�equentesdans le groupe d’ad�enoıdiens (p = 0,001). Dans le plan trans-versal, la fr�equence des articul�es crois�es post�erieurs �etaitsignificativement plus �elev�ee dans le groupe d’ad�enoıdiensag�es de 9 a 12 ans par rapport au groupe t�emoin �equivalent(p < 0,001). Dans le plan transversal, la fr�equence des articu-l�es crois�es post�erieurs a affich�e des diff�erences significativespour tous les groupes d’age (p < 0,01).Le Tableau IV montre les comparaisons en fonction du sexeont �et�e r�ealis�ees dans les plans ant�eropost�erieur, vertical ettransversal de tous les sujets, garcons et filles, ad�enoıdiens ett�emoins. Dans le plan ant�eropost�erieur, la fr�equence desclasses II, division 1 �etait statistiquement plus �elev�ee chezles garcons ad�enoıdiens par rapport aux garcons t�emoins(p = 0,03). Parmi les filles, aucune diff�erence statistiquementsignificative n’a �et�e observ�ee. Dans les plans vertical et

Table IIIComparison of occlusal characteristics of adenoid and controlsubjects.

Tableau IIIComparaison des caract�eristiques occlusales chez les sujetsad�enoıdiens et t�emoin.

Occlusal characteristics /Caract�eristiques occlusales

Adenoid group (n = 90) /Groupe ad�enoıdien (n = 90)

Control group (n = 90) /Groupe t�emoin (n = 90)

Chi2 P-value /Valeur de p

n (%) n (%)

Anteroposterior incisal relationship /Relation incisive ant�eropost�erieure

Class I / Classe I 50 (55.6) 65 (72.2) 5.42 0.020b

Class II division 1 / Classe II division 1 35 (38.8) 17 (18.9) 8.76 0.003b

Class II division 2 / Classe II division 2 0 (0) 2 (2.2) 0.497a

Class III / Classe III 5 (5.6) 6 (6.7) 0.00 1.000

Vertical relationship / Relation verticale

Normal overbite / Recouvrement normal 33 (36.6) 29 (32.2) 0.39 0.530

Anterior open bite / B�eance ant�erieure 19 (21.2) 23 (25.6) 0.49 0.481

Deep bite / Recouvrement excessif 38 (42.2) 38 (42.2) 0.00 1.000

Transverse relationship / Relation transversale

Normal relationship / Relation normale 80 (89.9) (92.2) 0.58 0.445

Posterior crossbite / Articul�e crois�e A-P 10 (11.1) (7.8) 1.91 0.633a Fishers Exact Test.b Statistically significant.



ORTHO 159 1-17

and female adenoid and control subjects. In the anterior-pos-terior plane, the frequency of occurrence of class II division 1was statistically significantly higher in male adenoid subjectscompared to male control subjects (P = 0.03). Between thefemale subjects, no statistically significant differences wereobserved. In the vertical and transverse planes, no significantdifferences were observed in the occlusal characteristics ofmale and female adenoid and control subjects (Table IV).Male and female adenoid subjects were also compared(Table V), in the anterior-posterior plane, the frequency ofoccurrence of class I was statistically significantly higher infemale adenoid subjects compared to the males (P = 0.016).The reverse was observed with class II division 1 which wasstatistically significantly higher in the male subjects(P = 0.003). In the vertical plane, the frequency of occur-rence of normal overbite was significantly more in femaleadenoid subjects while deep bite was significantly higher inthe male subjects (P < 0.05). In the transverse plane, nostatistically significant differences were observed in theocclusal characteristics between male and female adenoidsubjects.

transversal, aucune diff�erence significative n’a �et�e relev�eepour les caract�eristiques occlusales des sujets garcons etfilles, ad�enoıdiens et t�emoins (Tableau IV).

Une comparaison a �et�e r�ealis�ee (Tableau V) des sujetsad�enoıdiens garcons et filles relative au plan ant�eropost�erieur.La fr�equence des classes l �etait significativement plus �elev�eechez les filles ad�enoıdiennes par rapport aux garcons(p = 0,016). L’inverse �etait observ�e concernant les classes IIdivision 1, qui �etaient significativement plus fr�equentes chezles garcons ad�enoıdiens. Dans le plan vertical, la fr�equencedes recouvrements incisifs normaux �etait significativementplus �elev�ee chez les filles ad�enoıdiennes, alors que lesrecouvrements incisifs excessifs �etaient significativement plusfr�equents chez les garcons (p < 0,05). Dans le plan transver-sal, aucune diff�erence statistiquement significative n’a �et�etrouv�ee relative aux caract�eristiques occlusales chez lesgarcons et les filles ad�enoıdiens (Tableau V).

Table IVComparison of occlusal characteristics across age groups inadenoid subjects.

Tableau IVComparaison des caract�eristiques occlusales chez les sujetsad�enoıdiens dans les diff�erents groupes.


3–5 years(n = 41) /3–5 ans(n = 41)

6–8 years(n = 34) /6–8 ans(n = 34)

9–12 years(n = 15) /9–12 ans(n = 15)


n (%) n (%) n (%)

Anteroposterior (incisal) relationship /Relation (incisive) ant�eropost�erieure

Class I / Classe I 24 (58.5) 15 (44.1) 11 (73.3) 0.38 0.146

Class II division 1 / Classe II division 1 15 (36.6) 16 (47.1) 4 (26.7) 2.02 0.372a

Class II division 2 / Classe II division 2 0 (0) 0 (0) 0 (0)

Class III / Classe III 2 (4.9) 3 (8.8) 0 (0) 2.34 0.378a


Normal overbite / Recouvrement normal 15 (36.6) 10 (29.4) 8 (53.3) 2.51 0.284a

Anterior open bite / B�eance ant�erieure 10 (24.4) 7 (20.6) 2 (13.3) 0.86 0.648a

Deep bite / Recouvrement excessif 16 (39.0) 17 (50.0) 5 (33.3) 1.50 0.472


Posterior crossbite / Articul�e crois�e A-P 4 (9.8) 4 (11.8) 2 (13.3) 2.91 0.000a,,b

a Fishers Exact Test.b Statistically significant.



ORTHO 159 1-17

Spearman’s correlation tests of the relationship between age,BMI and occlusal characteristics in male and female adenoidsubjects showed that age had a statistically significant(P = 0.03), but weak correlation with anterior open bite(r = 0.37) and posterior cross bites (P = 0.02, r = 0.39) inthe female adenoid subjects (Table VI).

BMI had an inverse but strong correlation with class II divi-sion 1 in adenoid subjects, this correlation however was notstatistically significant. BMI also showed a statistically sig-nificant (P = 0.03) but weak correlation (r = 0.36) with poste-rior crossbite in the female adenoid subjects.

Table VII shows the multiple regression analysis of the effectof age, gender and BMI on the occlusion of adenoid subjects.Results showed that age had a statistically significant effect(P = 0.005) on the occurrence of anterior open bite in adenoidsubjects. However, the relative association with this occlusaltrait is weak (b = 0.24). BMI also had significant but weakassociation with the occurrence of class II occlusion in ade-noid subjects (P < 0.05).

Les tests de corr�elation de Spearman portant sur la relationentre l’age, l’IMC et les caract�eristiques occlusales des sujetsad�enoıdiens, garcons et filles, ont montr�e que l’age avait unecorr�elation significative quoique faible (p = 0,03) avec lab�eance ant�erieure (r = 0,37) ainsi qu’avec les articul�es crois�espost�erieurs (p = 0,02, r = 0,39) chez les filles ad�enoıdiennes(Tableau VI).L’IMC a montr�e une corr�elation oppos�ee mais forte avecles classes II division 1 chez les sujets ad�enoıdiens.Cependant, cette corr�elation n’�etait pas statistiquementsignificative. L’IMC a �egalement montr�e une corr�elation sta-tistiquement significative (p = 0,03) quoique faible (r = 0,36)avec les articul�es crois�es post�erieurs chez les fillesad�enoıdiennes.Le TableauVIImontre l’analyse de r�egressionmultiple concer-nant l’impact de l’age, du sexe et de l’IMC sur l’occlusion chezles sujets ad�enoıdiens. Les r�esultats montrent que l’age avaitun effet statistiquement significatif (p = 0,005) sur lafr�equence des b�eances ant�erieures chez les sujetsad�enoıdiens. N�eanmoins, l’association relative de cette car-act�eristique occlusale �etait faible (b = 0,24). L’IMC a�egalement affich�e une association significative mais faibleavec la fr�equence des occlusions de classe II chez les sujetsad�enoıdiens (p < 0,05) (Tableau VII).

Table VComparison of occlusal characteristics in male and femaleadenoid subjects.

Tableau VComparaison des caract�eristiques occlusales des sujetsad�enoıdiens garcons et filles.


Male (n = 55) /Garcons (n = 55)

Female (n = 35) /Filles (n = 35)


n (%) n (%)

Anteroposterior (incisal) relationship /Relation (incisive) ant�eropost�erieure

Class I / Classe I 25 (45.5) 25 (71.4) 5.84 0.016b

Class II division 1 / Classe II division 1 28 (50.9) 7 (20.0) 8.59 0.003b

Class II division 2 / Classe II division 2 0 (0) 0 (0)

Class III / Classe III 2 (3.6) 3 (8.8) 0.373a


Normal overbite / Recouvrement normal 15 (27.3) 18 (51.4) 5.37 0.020b

Anterior open bite / B�eance ant�erieure 12 (21.8) 7 (20.0) 0.04 0.837

Deep bite / Recouvrement excessif 28 (50.9) 10 (28.6) 4.37 0.036b


Normal relationship / Relation normale 50 (90.9) 30 (85.7) 0.58 0.445

Posterior crossbite / Articul�e crois�e post�erieur 5 (9.1) 5 (14.3) 1.28 0.845a Fishers Exact Test.b Statistically significant.



ORTHO 159 1-17

Discussion

This study was carried out to evaluate the occlusal character-istics in patients with hypertrophied adenoids and comparethe findings with control subjects. Dental inter-arch relation-ship in the three planes of space is the basic clinical parameterin understanding the patient’s occlusion and its behaviourwhen exposed to unbalanced muscular activities. Generally,the triad of class II malocclusion, anterior open bite andposterior cross bite has been described as the occlusal patternfor mouth-breathers [13,25,26]

Discussion

Cette �etude �et�e r�ealis�ee afin d’�evaluer les caract�eristiquesocclusales chez des patients pr�esentant des v�eg�etationshypertrophi�ees et de comparer les r�esultats avec des sujetst�emoins. Les relations inter-arcades dans les trois plans del’espace fournissent des param�etres cliniques fondamentauxpour mieux comprendre l’occlusion des patients ainsi que lecomportement de celle-ci lors d’une exposition prolong�eea des activit�es musculaires non-�equilibr�ees. En g�en�eral, latriade form�ee par une malocclusion de classe II, une b�eance

Table VICorrelations of age, BMI and occlusal characteristics in maleand female adenoid subjects.

Tableau VICorr�elations d’age, d’IMC et les caract�eristiques occlusaleschez des sujets ad�enoıdiens garcons et filles.

Anterior-posterior incisal relationship / Relation(incisive) ant�eropost�erieure

Vertical relationship /Relation verticale

Transverse relationship /Relation transversale

Class I /Classe I

Class IIdivision 1 /Classe II

division 1


division 2

Class III /Classe III

Normaloverbite /Recouvrement

normal

Anterioropen bite /B�eance

ant�erieure

Deep bite /Recouvrement

excessif

Posteriorcrossbite /Articul�e crois�e

post�erieur

Adenoid subject (n = 90) / Groupe ad�enoıdien (n = 90)

Age / Age

Coefficient (r) �0.07 0.02 0.04 0.12 0.02 0.10 �0.08 0.12

P-value / Valeur de p 0.531 0.890 0.742 0.258 0.872 0.367 0.477 0.278

BMI / IMC

Coefficient (r) 0.17 �0.90 0.05 0.15 0.05 0.06 �0.14 0.13

P-value / Valeur de p 0.104 0.402 0.061 0.159 0.611 0.564 0.480 0.210

Male adenoid subjects (n = 55) / Groupe ad�enoıdien garcons (n = 55)

Age / Age

Coefficient (r) �0.08 0.10 – �0.05 0.22 �0.07 �0.15 �0.04

P-value / Valeur de p 0.571 0.490 – 0.721 0.100 0.601 0.281 0.771

BMI / IMC

Coefficient (r) 0.22 �0.14 – �0.17 0.26 �0.04 �0.24 �0.39

P-value / Valeur de p 0.114 0.312 – 0.134 0.057 0.083 0.784 0.813

Female adenoid subjects (n = 35) / Groupe ad�enoıdien filles (n = 35)

Age / Age

Coefficient (r) �0.05 �0.15 0.072 0.30 �0.28 0.37 0.60 0.39

P-value / Valeur de p 0.770 0.390 0.704 0.08 0.100 0.032a 0.734 0.021a

BMI / IMC

Coefficient (r) 0.18 �0.11 0.10 �0.05 �0.14 0.24 �0.09 0.36

P-value / Valeur de p 0.307 0.518 0.56 0.76 0.438 0.167 0.621 0.032a

BMI: body mass index.a Statistically significant.



ORTHO 159 1-17

Themajority of adenoid and control subjects had low BMI, thisis similar to the report of Adegoke et al. in the same environ-ment [27]. The authors found that 77.8% of schoolchildrenstudied were underweight with BMI less than 18.50. Thegreatest differences in height and weight between adenoidand control subjects were observed among the 3–5-year agegroups. Somatic growth impairment due to abnormal growthhormone secretion documented in patients with enlarged ade-noids probably shows its greatest effect early in life [28].Studies have however found that normalization and catch upsomatic growth may occur as respiratory obstruction isrelieved [28,29].

The prevalence of class II division 1 was found to be signifi-cantly higher in the adenoid subjects as in previous studies inpatients with hypertrophied adenoids [7,18,30]. This can be

ant�erieure et un articul�e crois�e post�erieur a �et�e d�ecrite commele sch�ema occlusal des respirateurs oraux [13,25,26].La majorit�e des sujets ad�enoıdiens et t�emoin avaient un IMCbas, r�esultat similaire a celui obtenu dans l’�etude d’Adegoke etal. et dans le meme environnement [27]. Ces auteurs onttrouv�e que 77,8 % des enfants d’age scolaire �etaient ensous-poids avec un IMC inf�erieur a 18,50. Les diff�erencesles plus marqu�ees de taille et de poids entre les groupesad�enoıdiens et t�emoin ont �et�e observ�ees dans le grouped’age des 3 a 5 ans. Une insuffisance de la croissance soma-tique due a une s�ecr�etion anormale des hormones de crois-sance document�ee chez les patients pr�esentant une hyper-trophie ad�enoıdienne se manifeste probablement de faconmaximale pendant les premi�eres ann�ees de la vie [28].Cependant, des �etudes ont montr�e que la normalisation et lerattrapage de la croissance somatique peuvent se r�ealiserlorsque l’obstruction respiratoire est lev�ee [28,29].Nos r�esultats, similaires a ceux d’�etudes ant�erieures sur despatients avec des v�eg�etations hypertrophi�ees [7,18,30], ontmontr�e une pr�evalence significativement plus �elev�ee des

Table VIIMultiple regression analysis of age, gender, BMI andocclusion of adenoid subjects.

Tableau VIIAnalyse de r�egression multiple de l’age, du sexe, de l’IMC etde l’occlusion des sujets ad�enoıdien.

Anteroposterior incisal relationship /Relation incisive ant�eropost�erieure

Vertical relationship / Relationverticale

Transverse relationship /Relation transversale

Class I /Classe I


division 1


division 2

Class III /Classe III

Anterioropen bite /B�eance

ant�erieure

Deep bite /Supraclusion

Posteriorcrossbite /Articul�e crois�e

post�erieur

Age / Age

95% CI / IC95 % �0.03 to 0.08 �0.09 to 0.004 �0.004 to 0.031 �0.03 to 0.03 �0.10 to 0.01 �0.08 to 0.04 �0.09 to 0.02

b-coefficient 0.12 0.25 0.21 0.04 0.24 0.10 0.15

P-value / Valeur de p 0.391 0.084 0.144 0.753 0.005a 0.481 0.317

Gender / Sexe


b-coefficient 0.18 0.19 0.21 0.11 0.12 0.23 0.15

P-value / Valeur de p 0.121 0.091 0.068 0.302 0.309 0.058 0.192

BMI (low) / IMC (faible)


b-coefficient 0.32 0.26 0.17 0.25 0.05 0.01 0.032

P-value / Valeur de p 0.021a 0.047a 0.221 0.057 0.711 0.085 0.186

BMI (high) / IMC (�elev�e)


b-coefficient 0.18 0.23 0.09 0.03 0.17 0.19 0.15

P-value / Valeur de p 0.094 0.045a 0.382 0.793 0.133 0.042 0.201

BMI: body mass index.a Statistically significant.



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explained by the fact that prolonged mouth breathing can leadto proclination of the upper anterior incisors as the equilib-rium effect from the lips on the position of the teeth is lostwhen the lips are habitually left apart [1,30]. It could also bedue to the retroclination of mandibular incisors and retro-gnathic mandible previously documented for these subjectswhen they were compared to healthy control subjects[2,20,31].

This study found that the prevalence of class II division 1malocclusion was more in the 3–5-year age groups comparedto other age groups. This is similar to the report of Souki et al.[25]. This could be because, as the child grows, the nasophar-ynx also increases in size and concurrently the mass of ade-noid lymphoid tissues reduces in size [7,32]. Therefore, theeffect of obstruction may not be as severe as a child growsolder. This early onset of the development of class II division 1malocclusion can also be related to the early presentation ofadenoid hypertrophy in this environment as congenital ade-noid hypertrophy has been documented [14].

In spite of the significant association between the presence ofclass II division 1 malocclusion and hypertrophied adenoids,which was established, it was not found to be the most prev-alent relationship in the anterior-posterior plane. Most of theadenoid children showed class I incisal relationship. This maybe because anterior-posterior dental inter-arch relationship ismostly determined by heredity [7,8,25]. Mouth breathingresulting from enlarged adenoids therefore acts as a secondaryaetiological factor. Even in the presence of obstructed airflow,the force of unbalanced muscular activities due to mouthbreathing may not be enough to shift a genetically determinedclass I occlusion into class II.

The results of this study did not indicate any difference in theoccurrence of anterior open bite between adenoid and controlsubjects which had earlier been described by Souki et al. in2009 as one of the occlusal traits seen in mouth breathingchildren [25]. They found an overall increased occurrence ofanterior open bite in all samples of mouth breathing subjectsconsidered. A reason for this discrepancy may be due todifferences in the definition of open bites. They registeredanterior open bite in all cases where the subjects lacked anyover bite regardless of the amount, and the number of teethinvolved. However, in this study, anterior open bite was reg-istered when there was no vertical overlap or contact betweenat least two anterior teeth. Vertical dental relationship also hasheredity as the major determinant but environmental factorssuch as non-nutritive sucking habits and mouth breathing canact as secondary causes of anterior open bite [2,33–35]. Wehowever noted that the presence of deep bite was significantlymore among male than female adenoid subjects in this study

classes II division 1 dans le groupe de sujets ad�enoıdiens.Cela s’explique par le fait que la respiration orale prolong�eepeut induire la proclination des incisives ant�erieuressup�erieures puisque l’�equilibration entretenue par les l�evressur la position des dents est perdue lorsque les l�evres sonthabituellement maintenues en position �ecart�ee [1,30]. Ceph�enom�ene s’explique aussi par la r�etroinclinaison des inci-sives mandibulaires et par une r�etrognathie mandibulaire quiont d�eja �et�e retrouv�ees chez cette cat�egorie de patientscompar�es a des sujet t�emoins sains [2,20,31].Cette �etude a montr�e une plus grande pr�evalence des mal-occlusions de classe II division 1 chez les 3 a 5 ans par rapportaux autres groupes d’age. Ce r�esultat est similaire auxdonn�ees de Souki et al. [25]. Cela est peut-etre du au faitque, pendant la croissance de l’enfant, le nasopharynxs’accroıt en parall�ele a la diminution de la masse de tissusad�enoıdo-lymphoıdes [7,32]. Par cons�equent, l’obstruction vapeut-etre diminuer d’importance a mesure que l’enfant grand-ira. Par ailleurs, des cas d’hypertrophie ad�enoıdienne con-g�enitale ont �et�e rapport�es [14], ce qui sugg�ere que la survenuepr�ecoce du d�eveloppement d’une malocclusion de classe IIdivision 1 est peut-etre li�ee a la pr�esentation pr�ecoce d’unehypertrophie ad�enoıdienne.Malgr�e l’�etablissement d’une association significative entre lapr�esence de malocclusions de classe II division 1 et lesv�eg�etations hypertrophi�ees, cette relation ne s’est pas etrer�ev�el�ee etre la relation la plus fr�equente dans le plan ant�ero-post�erieur. La majorit�e des enfants ad�enoıdiens ont pr�esent�eune relation incisive de classe I, peut-etre du fait que les rela-tions dentaires inter-arcades ant�eropost�erieures sont surtoutd�etermin�ees par l’h�er�edit�e [7,8,25]. La respiration orale duea des v�eg�etations hypertrophi�ees repr�esente, par con-s�equent, un facteur �etiologique secondaire. Meme enpr�esence d’un flux respiratoire obstru�e, la force des activit�esmusculaires, non-�equilibr�ees en raison de la respiration orale,peut suffire pour transformer une occlusion de classe Ig�en�etiquement d�etermin�ee en classe II.Les r�esultats de cette �etude n’ont pas r�ev�el�e de diff�erencesentre les sujets ad�enoıdiens et les t�emoins concernant lafr�equence des b�eances ant�erieures, pourtant d�ecrites parBernardo Souki et al. en 2009 comme l’une des caract�eris-tiques de la respiration orale enfantine [25]. Ces auteurs onttrouv�e une augmentation globale de l’incidence des b�eancesant�erieures chez tous les �echantillons de respirateurs oraux�etudi�es. Cette disparit�e est peut-etre due a des d�efinitionsdivergentes de ce qui constitue une b�eance. Souki et al. ontenregistr�e des b�eances ant�erieures chez tous les sujetspr�esentant un manque de recouvrement incisif, ind�ependam-ment de la quantit�e et du nombre de dents impliqu�ees. Dans lapr�esente �etude, au contraire, une b�eance ant�erieure a �et�eenregistr�ee en l’absence de recouvrement vertical ou decontact entre au moins deux dents ant�erieures. Par ailleurs,l’h�er�edit�e constitue le d�eterminant principal des relations den-taires verticales bien que des facteurs environnementaux telsque la succion non-nutritive et la respiration orales puissentintervenir comme causes secondaires de b�eances ant�erieures



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Regarding the presence of posterior cross bites, the findings inthis study showed some similarity with the aforementionedstudy of Souki et al. [25]. The occurrence of posterior crossbites was significantly more in the adenoid than the controlgroup in the 9–12-year-old groups. Intragroup comparisonsamong the adenoid population also showed that occurrence ofposterior crossbite differed significantly across the age groups.The older adenoid subjects exhibited a greater tendencytowards posterior cross bites. These show that transverse den-tal relationship can be influenced by environmental factorssuch as mouth breathing. Thus, early normalization of nasalairflow passage in younger children may be beneficial from anorthodontic point of view.

In the female subjects, the occurrence of class II division 1malocclusion was inversely correlated with age of the patientbut this was not a significant relationship. However, withrespect to anterior open bite, and posterior cross bites, thefemale adenoid subject could be said to have a 37% (r = 0.37)and 39% (r = 0.39) chance of developing an anterior open biteand a posterior cross bite respectively as she increases in age.Further study would be required to either confirm or disputethis.

Although not statistically significant, a strong negative corre-lation was found to exist between BMI and class II division 1occlusion in all adenoid subjects while a significant but weakrelationship was also observed between BMI and posteriorcross bites in the female adenoid subjects. BMI also showedsignificant but weak associations with the occurrence of classII occlusion in adenoid subjects on regression analysis. Thesefindings suggest that an association between BMI and certainocclusal characteristics cannot be ruled out in patients withadenoid hypertrophy. The increased tendency to class II mal-occlusion and posterior cross bites have also been previouslydocumented for OSAS patients [24,35].

The current understanding of OSAS supports the existence of adynamic imbalance in upper airway function that results froma combination of alterations in structural and anatomical char-acteristics, protective reflexes and neuromotor function of theupper airway [36]. In obese children, the effects of fat depo-sition in the pharyngeal muscles and extra-pharyngeal com-pression from superficial subcutaneous fat further decreasesthe pharyngeal lumen and increases pharyngeal collapsibility[37]. Furthermore, abdominal fat causes an upward displace-ment of the diaphragm when supine and this leads to reducedchest wall compliance: it also reduces ventilatory efforts, lungvolumes and oxygen reserves [36]. This reduced lung volumes

[2,33–35]. Nous avons observ�e, cependant, que la pr�esenced’un recouvrement incisif excessif �etait significativement plusfr�equente parmi les sujets ad�enoıdiens garcons que parmi lesfilles dans cette �etude.En ce qui concerne la pr�esence d’articul�es crois�es post-�erieurs, les r�esultats de nos recherches ont montr�e une cer-taine similarit�e avec l’�etude de Souki et al. d�eja mentionn�ee[25]. Parmi les sujets ag�es de 9 a 12 ans, les articul�es crois�espost�erieurs avaient une pr�evalence significativement plus�elev�ee dans le groupe ad�enoıdien que dans le groupe t�emoin.La comparaison intra-groupe parmi la populationad�enoıdienne a �egalement montr�e que l’incidence d’articul�escrois�es post�erieurs variait beaucoup d’un groupe d’age a unautre. Les sujets ad�enoıdiens plus ag�es affichaient une ten-dance plus marqu�ee aux articul�es crois�es post�erieurs, ce quimontre que la relation dentaire transversale peut etremodifi�eepar des facteurs environnementaux tels que la ventilationorale. Ainsi, la normalisation pr�ecoce du passage d’air dansles voies respiratoires nasales chez les enfants plus jeunespeut etre b�en�efique du point de vue orthodontique.Parmi les filles, la fr�equence des malocclusions de classe IIdivision 1 a montr�e une corr�elation invers�ee avec l’age de lapatiente, mais sans que la relation soit significative.Cependant, au sujet des b�eances ant�erieures et des articul�escrois�es post�erieurs, l’on pourrait conclure que les sujetsad�enoıdiens f�eminins avaient, en grandissant, 37 %(r = 0,37) et 39 % (r = 0,39) de chances de d�evelopper, respec-tivement, une b�eance ant�erieure ou un articul�e crois�e post-�erieur. Des �etudes suppl�ementaires seraient n�ecessaires pourvalider cette conclusion.Quoique statistiquement non-significative, une corr�elationn�egative forte entre l’IMC et les occlusions de classe II, division1 a �et�e not�ee chez tous les sujets ad�enoıdiens tandis qu’unecorr�elation faiblement significative a �egalement �et�e observ�eeentre l’IMC et les articul�es crois�es chez les sujets ad�enoıdiensde sexe f�eminin. Par ailleurs, l’analyse de r�egression a r�ev�el�edes associations faiblement significatives entre l’IMC et la sur-venue d’occlusions de classe II chez les sujets ad�enoıdiens.Ces r�esultats sugg�erent qu’une association entre l’IMC et cer-taines caract�eristiques occlusales ne peuvent etre exclue chezles patients pr�esentant une hypertrophie ad�enoıdienne. Unetendance accrue a des malocclusions de classe II et a desarticul�es crois�es post�erieurs a �egalement �et�e rapport�ee chezdes patients souffrant du SAOS [24,35].Nos connaissances actuelles au sujet du SAOS plaident enfaveur de l’existence d’un d�es�equilibre dynamique au niveaudu fonctionnement des voies a�eriennes sup�erieures d�ecoulantd’une combinaison demodifications de caract�eristiques struc-turelles et anatomiques, de r�eflexes de protection et de lafonction neuromotrice des voies a�eriennes sup�erieures [36].Chez les enfants ob�eses, les effets du d�epot de graisse dansles muscles pharyng�es et la compression extra-pharyng�eeprovoqu�ee par la graisse sous-cutan�ee superficielle r�eduisentencore plus la lumi�ere pharyng�ee et augmentent le risque d’uneffondrement du pharynx [37]. Par ailleurs, la graisse abdo-minale provoque un d�eplacement ascendant du diaphragme



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cause a reflexive decrease in the size of the pharyngeal airwayexacerbating the respiratory compromise [38]. A recent paperhas also discussed the potential role of leptin, a potent respi-ratory stimulant and central chemoreceptor modulator as alink between obesity and OSAS [37].

One of the limitations in this study was that the participantshad their dental occlusion evaluated, but their nasorespiratoryfunction, age of occurrence of nasal obstruction and degree ofobstruction were not evaluated. Each of these could also affectthe extent to which the occlusion would be altered [2,3,12,13].It has been established that the size of the nasopharynx variesconsiderably in different individuals [39,40] and that thisvariation provides an important explanation for the varyingeffects which large adenoids have on passage of air and con-sequently on the development of malocclusion. Further workwhere degree of obstruction, duration of obstruction, and sizeof the pharyngeal airway in relation to the size of the enlargedadenoid are assessed with follow up after surgery would behighly desirable.

Conclusions

From the findings in this study, the following conclusions aredrawn:— a significant association between the presence of a class IIdivision 1malocclusion and hypertrophied adenoid was estab-lished. The occurrence of class II division 1 was higher in theadenoid than control group;

— class II division 1 was a significant occurrence in the 3–5-year adenoid groups and in male more than in female adenoidsubjects;

— in the vertical plane, the frequency of occurrence of deepbite was significantly more in male than female adenoidsubjects;— posterior crossbite occurred significantly more in adenoidthan control subject in the 9–12-year age groups. Among theadenoid subjects the occurrence of post crossbite increasedwith age;

— BMI has significant associations with the occurrence ofclass II occlusion in all adenoid subjects and with posteriorcrossbites in the female adenoid subjects;

— age has a statistically significant effect on the occurrenceof anterior open bite in all adenoid subjects and on anterioropen bite and posterior cross bites in the female adenoidsubjects.

en position allong�ee sur le dos, ce qui a pour r�esultat der�eduire la compliance des parois thoraciques et r�eduit aussil’effort ventilatoire, les volumes pulmonaires et les r�eserves enoxyg�ene [36]. Cette r�eduction des volumes pulmonairesd�eclenche une diminution des dimensions des voiesa�eriennes pharyng�ees, exacerbant ainsi le compromis respir-atoire [38]. Une �etude r�ecente a �egalement discut�e le rolepotentiel de la leptine, un stimulant respiratoire puissant etmodulateur ch�emor�ecepteur central, comme lien entre leSAOS et l’ob�esit�e [37].Une des limitations de cette �etude provient du fait qu’une�evaluation a �et�e faite de l’occlusion dentaire des participantsmais non pas de leur fonction nasorespiratoire, de l’age desurvenue de l’obstruction nasale et de l’importance del’obstruction. Chacun de ces �el�ements aurait pu �egalementaffecter la port�ee de l’occlusion [2,3,12,13]. Il a �et�e �etablique les dimensions du nasopharynx varient consid�erablementchez des sujets diff�erents [39,40] et que cette variation fournitune explication importante des divers effets impos�es par lesv�eg�etations sur le passage de l’air et, par cons�equent, sur led�eveloppement de la malocclusion. De nouvelles recherchesseraient tr�es souhaitables pour �evaluer, avec suivi post-chir-ugical, l’�etendue de l’obstruction, la dur�ee de l’obstruction etles dimensions des voies a�eriennes pharyng�ees par rapporta l’importance des v�eg�etations hypertrophi�ees.

Conclusions

Les r�esultats de cette �etude nous permettent de tirer lesconclusions suivantes :— une association significative a pu etre �etablie entre lapr�esence d’une malocclusion de classe II division 1 et dev�eg�etations hypertrophi�ees. La survenue de classes II division1 �etait plus �elev�ee dans le groupe des ad�enoıdiens que parmiles t�emoins ;— les classes II division 1 ont montr�e une fr�equence signifi-cative plus �elev�ee chez les 3 a 5 ans dans le groupead�enoıdien et chez les garcons ad�enoıdiens que chez les fillesad�enoıdiennes ;— dans le plan vertical, la fr�equence des recouvrements inci-sifs excessifs �etait significativement plus �elev�ee chez lesgarcons ad�enoıdiens que chez les filles;— les articul�es crois�es post�erieurs �etaient significativementplus fr�equents chez les sujets ad�enoıdiens que chez lest�emoins dans le groupe d’age de 9 a 12 ans. Parmi les sujetsad�enoıdiens, la survenue d’articul�es crois�es post�erieurs aug-mentait avec l’age ;— l’IMC montre des associations significatives avec la surve-nue des occlusions de classe II chez tous les sujetsad�enoıdiens et avec les articul�es crois�es post�erieurs chezles filles ad�enoıdiennes ;— l’age a un effet statistiquement significatif sur la survenuedes b�eances ant�erieures chez tous les sujets ad�enoıdiens etsur les b�eances ant�erieures et les articul�es crois�es post�erieurschez les filles ad�enoıdiennes.



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Disclosure of interest

The authors declare that they have no conflicts of interestconcerning this article.

D�eclaration d’int�erets

Les auteurs d�eclarent ne pas avoir de conflits d’int�erets enrelation avec cet article.

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